Monique F. Miller, PharmD Candidate

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.

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

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.

Healthy brain initiative. CDC website. cdc.gov/aging/healthybrain/index.htm. Updated August 29, 2019. Accessed February 16, 2020.

Promoting brain health: be a champion! make a difference today! CDC website.cdc.gov/aging/pdf/cognitive_impairment/cogImp_genAud_final.pdf. Updated February 2011. Accessed February 18, 2020.

Compton MT. Clinical Manual of Prevention in Mental Health. 1st ed. Washington, DC: American Psychiatric Association Publishing; 2010.

Brodziak A, Wolińska A, Kołat E, Różyk-Myrta A. Guidelines for prevention and treatment of cognitive impairment in the elderly. 

. 2015;21:585-597. doi: 10.12659/MSM.892542.

Lane CA, Barnes J, Nicholas JM, et al. Associations between blood pressure across adulthood and late-life brain structure and pathology in the neuroscience substudy of the 1946 British birth cohort (Insight 46): an epidemiological study. 

 2019;18(10):942-952. doi: 10.1016/S1474-4422(19)30228-5.

Alber J, Alladi S, Bae HJ, et al. White matter hyperintensities in vascular contributions to cognitive impairment and dementia (VCID): knowledge gaps and opportunities. 

 (N Y). 2019;5:107-117. doi: 10.1016/j.trci.2019.02.001.

Andrade C, Radhakrishnan R. The prevention and treatment of cognitive decline and dementia: an overview of recent research on experimental treatments. 

 2009;51(1):12-25. doi:10.4103/0019-5545.44900

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

Along with other factors necessary to sustain human life, including food, oxygen, and water, sleep is a biological requirement and an important contributor to overall health.

On average, sleep occupies 20% to 40%, or 5 to 10 hours, of a person’s day.

 Sleep is so essential that many people ask their health care professionals what amount of sleep is adequate. The 2019 

® reported that pharmacists make 925,105 recommendations monthly for patients who require sleep aids.

Understanding sleep’s importance requires knowledge of the downstream effects of either insufficient duration or poor quality of sleep. Healthy sleep involves various factors, including an absence of sleep disorders, adequate duration, good quality, proper timing, and regularity.

 The American Academy of Sleep Medicine recommends that adults get at least 7 hours of sleep nightly to promote optimal health.

 provides tips for obtaining this recommended amount.

The CDC reports that adults categorized as short sleepers—those accruing fewer than 7 hours of sleep per 24-hour period&mdash;were more likely to report chronic health conditions than those who obtained adequate sleep.

These conditions include cardiovascular disease, depression, diabetes, and hypertension.

 Investigators hypothesize that short duration and fragmented sleep interfere with the body’s restorative process that usually occurs during sleep.

 The lack of or interference with this process may lead to dysregulation of various body functions and, down the line, chronic conditions.

Because of sleep’s impact on appetite-regulating hormones, its effects extend to the ability to maintain a healthy diet. Researchers report that sleep alters levels of ghrelin and leptin, which regulate hunger and satiety, respectively.

 Sleep deprivation increases ghrelin, contributing to overeating behaviors and triggering greater neuronal activation to food stimuli, increasing the likelihood of eating foods that are high in fat and sugar.

Lack of sleep also leads to dysregulation of the release of hormones, including cortisol.

 A study reported that chronic sleep deprivation in healthy volunteers led to increased appetite, blood pressure, and evening cortisol levels.

 The presence of too much cortisol may suppress the body’s proinflammatory responses and compromise immune defenses, weakening the immune system.

 Findings have shown that sleep-deprived patients have increased susceptibility to infectious illnesses, including upper respiratory

Sleep deprivation can lead to cardiovascular disease, diabetes, inflammation, lower mortality, and weight gain.

 Insufficient sleep is also associated with cardiovascular disease, as it raises risks of hypertension, hypercholesteremia, atherosclerosis, acute myocardial infarction, and heart failure.

In addition, short sleep duration impairs neurocognitive function. As sleep time decreases, attentional lapses increase in a dose-dependent manner. A night of minimal rest can affect executive function, processing speed, and working memory the next day. Investigators note that sleep is critical to maintaining alertness, sustaining attention, and thinking clearly.

 Patients who are sleep deficient experience delayed reaction times and increased lapses in attention.

 Some may use caffeine to mitigate these issues, but caffeine has no effect on executive function.

Investigators have found that insufficient sleep may contribute to atypical, impulsive behavior and that chronically sleep-restricted patients exhibit more risk-taking behaviors and manifest deficiencies in reasoning, arriving at conclusions before evaluating an entire problem.

Sleep is a necessity, and any lack of or shortened duration of sleep may impair numerous bodily functions. Pharmacists can counsel patients who have trouble sleeping or report inadequate sleep. The figure

 displays common OTC pharmacist-recommended medications and their accompanying frequencies, as reported in the OTC Guide®. These should be used only short term. Refer patients who still have trouble sleeping to their prescribers.

 2017;12(1):1-22. doi:10.1016/j.jsmc.2016.10.012.

Pharmacist recommendations—sleep aids. 

®. otcguide.net/recommendations/sleep-aids. Published 2019. Accessed December 2, 2019.

Watson NF, Badr MS, Belenky G, et al. Recommended amount of sleep for a healthy adult: a joint consensus statement of the American Academy of Sleep Medicine and Sleep Research Society. Sleep. 2015;38(6):843-844. doi: 10.5665/sleep.4716.

Frank S, Gonzalez K, Lee-Ang L, Young MC, Tamez M, Mattei J. Diet and sleep physiology: public health and clinical implications. 

 2017;8:393. doi: 10.3389/fneur.2017.00393.

Are you getting enough sleep? cdc.gov/features/sleep/index.html. CDC website. Updated March 18, 2019. Accessed December 2, 2019.

Worley SL. The extraordinary importance of sleep: the detrimental effects of inadequate sleep on health and public safety drive an explosion of sleep research. 

McEwen BS. Sleep deprivation as a neurobiologic and physiologic stressor: allostasis and allostatic load. 

. 2006;55(10 suppl 2):S20-S23. doi: 10.1016/j.metabol.2006.07.008.

Chattu VK, Manzar MD, Kumary S, Burman D, Spence DW, Pandi-Perumal SR. The global problem of insufficient sleep and its serious public health implications. 

 (Basel). 2018;7(1):pii:E1. doi: 10.3390/healthcare7010001.

Lack of or shortened duration of this biological necessity may impair numerous bodily functions.

Sleep Contributes Greatly to Overall Health

Blepharitis is an inflammation of the eyelids. Demodex blepharitis is specific to infections caused by the parasites Demodex folliculorum or Demodex brevis that inhabit both hair follicles and sebaceous glands.

These parasites are commonly found on the skin of older adults and less commonly, young children.

Health care professionals must be aware of current treatment recommendations as well as potential treatments that are effective against certain conditions. 

Infected individuals can present either with symptoms or asymptomatically. Symptoms include itching, redness, burning, and level of tearing.

Common treatments for Demodex blepharitis include single dose ivermectin, taken twice with each dose 2 weeks apart, metronidazole treatment for 10 days, and topical tea tree oil.

 However, according to the results of recent studies, all of these treatments may be ineffective for Demodex blepharitis. Patients who received ivermectin and tea tree oil only experienced a 6% rate of mite eradication.

Researchers have been looking into permethrin as potential treatment of Demodex blepharitis.

 Permethrin, an insecticide of the pyrethroid family, is used against mites, ticks, and other insects.

A recent study evaluated 21 patients with this condition over a 6-month period—treatment of this condition takes months.

 The researchers determined the efficacy of permethrin 5% cream being applied to each patients’ eyelashes for 6 months. Of significance, researchers noticed an improvement in parasite burden and blepharitis symptoms.

the study lacked a decrease in ocular surface disease index (OSDI) score, which is used to estimate patients’ experiences of ocular irritation and dry eye. This may have been due to permethrin not being able to penetrate to the location of the ectoparasite Demodex brevis, which tends to migrate deep within the sebaceous glands.

Permethrin is usually only effective against Demodex folliculorum, which is found mostly in the eyelash follicle.

Hecht I, Melzer-Golik A, Sadi Szyper N, Kaiserman I. Permethrin cream for the treatment of demodex blepharitis. 

 2019 Jun 3. doi:10.1097/ICO.0000000000002013. [Epub ahead of print]

Damian D, Rogers M. Demodex infestation in a child with leukemia: treatment with ivermectin and permethrin. 

Hirsch-Hoffmann S, Kaufmann C, Bänninger PB, Thiel MA. Treatment options for demodex blepharitis: patient choice and efficacy. 

Kabata&#351; N, Do&#287;an A&#350;, Kabata&#351; EU, et al. The Effect of demodex infestation on blepharitis and the ocular symptoms. 

Permethrin, an insecticide of the pyrethroid family, is used against mites, ticks, and other insects.

Evaluating Efficacy of Permethrin Cream for Demodex Blepharitis

Chlamydia affects as many as 131 million people worldwide each year, which equates to about 1.7% of the global population. According to the CDC, chlamydia is the most common sexually transmitted disease in the United States. Due to the large number of people affected, chlamydia has become a global health concern.

Acknowledging the tremendous burden imposed by the common infection, an author from the University of Alabama at Birmingham has published a comprehensive review in the journal 

. In it, she stresses that talking about chlamydia may be difficult, but every member of the health care team needs to increase patient awareness.

, and is transmitted through various routes such as vaginal, anal, and oral sex.

Risk factors for this infection include multiple sex partners, history of sexually transmitted infections (STIs), presence of another STI, and lack of barrier contraception.

 Most infected individuals are asymptomatic, but chlamydia may cause urethritis and epididymitis in men, and cervicitis and pelvic inflammatory disease in women.

To treat chlamydia, prescribers encourage expedited partner therapy, treating both patients and their sexual partners. Recommended medications include a single dose of azithromycin and 7 days of doxycycline.

Health care professionals, including pharmacists, can help promote health awareness of this infection and prevention strategies involved. They can also recommend annual screening to patients they believe are at increased risk, including the following

Sexually active women age 25 years and younger

Women older than age 25 years that are at high risk

Health care professionals should also inform their patients about prevention strategies including

Proper use of barrier contraception (condoms)

If receiving treatment for chlamydia, patients should also be counseled to abstain from sexual activity for 7 days after the completion of treatment. This will prevent spread of infection to partners.

is a 2020 PharmD candidate at the University of Connecticut in Storrs.

 2019 Jun 10:2165079919853590. doi: 10.1177/2165079919853590. [Epub ahead of print].

Centers for Disease Control and Prevention (2017). 

https://www.cdc.gov/std/chlamydia/hedis.htm

Malhotra, Meenakshi et al. Genital chlamydia trachomatis: an update.

Due to the large number of people affected, chlamydia has become a global health concern.

Health Care Professionals Can Help Prevent Chlamydia Infections 

The National HIV/AIDS Strategy (NHAS) has sought to reduce HIV transmission in the United States. To complete this task, the NHAS established 3 prevention goals in 2010

Increasing the percentage of people living with HIV aware of their serostatus to 90%

Of these 3 goals, none were achieved. The United States only achieved a 15% decrease in HIV transmission rate between years 2010 and 2015,

and new infections fell by only a 17.7% reduction by 2015. As a result, the federal government decided to find new ways of effectively targeting the HIV transmission rate.

In a comprehensive review recently published in the 

Journal of Acquired Immune Deficiency Syndromes,

the authors record HIV transmission rates between years 2010 and 2015, including both the goals implemented and numbers achieved.

Achieving these goals would require additional measures, including a rise in the utilization of HIV treatment and an increase in both diagnostic and prevention services.

 Health care professionals, including pharmacists and nurse practitioners, play a critical role in attaining these goals. They must raise awareness of HIV and prevention of transmission, the author suggests.

Recent work by researchers suggests that high levels of retention in care (at least 90%) and reengagement in care (at least 70%) are critical to halving HIV incidence by 2025, highlighting the importance of improving the HIV care continuum.

Health care providers should use the tracking systems built into their computer systems to monitor their patients who have HIV. By considering this additional insight, health care professionals may contribute to increased awareness and decreased transmission of HIV.

Prevention would involve encouraging the use of pre-exposure prophylaxis, post-exposure prophylaxis, condoms, and antiretroviral therapy (ART).

The CDC refers to ART as “treatment as prevention,” because ART is effective in causing an undetectable viral load. By reducing the amount of virus, it will also lead to a decrease in transmission to others.

In supporting HIV prevention, health care professionals should routinely engage patients in conversations regarding prevention steps that can be taken and are currently being taken to reduce their risks.

To target this issue effectively, health care professionals must address the needs of those most commonly affected. This high-risk population includes men who have sex with men, African American and Hispanic individuals, and transgender women.

Diagnostic services are also necessary in monitoring this epidemic. Researchers recommend HIV testing be completed at least annually in high risk populations, including people using injectable drugs.

Health care professionals may also play a role in encouraging high risk individuals to get tested.

CDC Analysis Underscores Need for More HIV Testing

Senate Bill Proposes Expansion of PrEP Access

is a 2020 PharmD Candidate he University of Connecticut in Storrs.

Bonacci, RA, Bradley H, Rosenberg ES, Holtgrave DR. Evaluating the Impact of the US National HIV/AIDS Strategy, 2010-2015. 

JAIDS Journal of Acquired Immune Deficiency Syndromes. 

Published May 28, 2019 [epub ahead of print] doi: 10.1097/QAI.0000000000002113

Bazazi AR, Vijay A, Crawford FW, et al. HIV Testing and awareness of HIV status among people who inject drugs in greater Kuala Lumpur, Malaysia. 

Centers for Disease Control and Prevention (2019). 

https://www.cdc.gov/hiv/risk/art/index.html

Health care professionals, including pharmacists and nurse practitioners, play a critical role in attaining goals for reducing HIV transmission. 