Chadley Uekman

Promoting Safe Driving Among Older Adults Using Driving Simulation Technology

By Amanda Mohler, OTD, OTR/L
Department of Occupational Therapy
Arkansas State University

Driving is a dynamic task requiring the active engagement of an individual’s sensory, perceptual, cognitive, and motor systems. However, as individuals age, the systems are at risk of declining, resulting in poorer accuracy of driving performance. Research shows the effects of aging on physiologic systems often result in decreased muscle strength, coordination, and motor control. The aging systems can result in a slowing of emergency maneuvers and increased breaking time (Karthaus & Falkenstein, 2016). Furthermore, age-related degeneration of the peripheral sensory receptors results in decreased postural control of the lower limbs and decreased force production for pedal reaction (Lacherez, Wood, Anstey, & Lord, 2014; Woolnough et al., 2013). Researchers found cognitive functions relevant for safe driving decline with age as well. Imperative executive function skills such as the ability to visually scan the driving field or shift attention decreases with age. The changes in executive function result in the decreased ability to monitor the environment, react appropriately, and manage multiple tasks, therefore, resulting in an increased risk of accidents or traffic violations (Karthaus & Falkenstein, 2016; Hahn, Wild-Wall, Falkenstein, 2011; Richardson & Marottoli, 2003).

There is a misconception that stricter driving rules and policies for aging adults would resolve the behind the wheel risks.. However, research shows increased monitoring, such as undergoing medical or vision tests to renew one’s license, does not result in increased safe driving or decreased fatal accidents (Karthaus & Falkenstein, 2016). Some proponents of harsher driving laws have even recommended retracting a drivers’ license after a specific age. However, decreased access to driving often encourages individuals to use less safe methods of mobility, such as walking or driving without a license. Therefore, regulating older adult drivers with harsher policies is not the answer. Rather, the solution lies in finding strategies to promote safe driving designed explicitly for the aging population.

To address the growing population of older adults still driving, students from the Department of Occupational Therapy at Arkansas State University (AState) partnered with community civic agencies to promote older adult safe driving using driving simulation technology. Driving simulation is an evolving technology consisting of computer-aided technology to mimic real-life driving scenarios. Trained professionals use driving simulation for assessment and intervention purposes. The simulation technology allows professionals the capacity to assess one’s ability to drive, including physical and cognitive factors. The driving simulation produces real-world and evidence-based results that professionals can review with clients via a report or video replay to provide education and training on their changing needs related to aging and driving.

Because of the flexibility of driving simulation technology, all individuals benefit from it no matter age, gender, disease, or injury. At AState, educated students and faculty use the technology to assess specific human functions related to driving, aging, and older adult diseases. Common assessments include, but are not limited to, physical ability to sustain driving, reaction time, hazardous perceptions, memory, planning, safety, attention, and vehicle control. Each of the driving skills are relevant in assessing and enhancing cognitive, sensory, and motor skills. Following each drive, the health professional reviews the results with clients and provides feedback and recommendations on maintaining safe driving. If clients require additional training, they have the option to participate in a driving program using the simulator. During the driving program, clients receive education on specific impairments and safe driving skills including basic vehicle control skills (e.g., steering wheel, or gas and brake pedal), progressive roadway and driving tasks (e.g., construction zone or metropolitan city), and advanced driving safety and performance skills (e.g., defensive driving or hazard detection).

Since the simulation occurs in a controlled environment, it offers many benefits. One benefit is the ability to provide safe, objective, reliable, and repeatable performance measures (Classen & Brooks, 2014; Be ́dard, Parkkari, Weaver, Riendeau, & Dahlquist, 2010). Second, professionals can present situations that would not otherwise be available or may be too risky for the client at the time of the assessment. The simulator operator can control the simulation settings, including external conditions (e.g., weather, traffic, road surface), exposure to hazards such as school zones or pedestrians, and control the driving situations (e.g., suburban or rural).

Driving is an everyday and automatic task. For many older adults, driving is a way to remain independent and mobile. Losing the ability to drive puts one at risk for depression, isolation, and decreased health. Therefore, restricting or revoking an older adults’ ability to drive has the potential to increase the national economic burden and decrease one’s overall quality of life. It is not a matter of changing policies or restricting one’s license. Instead, professionals and policymakers should focus on educating older adults on safe driving and addressing their changing skills associated with the natural age-related process.

References

Be ́dard, M., Parkkari, M., Weaver, B., Riendeau, J., & Dahlquist, M. (2010). Brief Report— Assessment of driving performance using a simulator protocol: Validity and reproducibility. American Journal of Occupational Therapy, 64, 336–340.

Classen, S. & Brooks, J. (2014). Driving Simulators for Occupational Therapy Screening, Assessment, and Intervention. Occupational Therapy in Health Care, 28(2), 154-162. doi: 10.3109/07380577.2014.901590

Hahn, M., Wild-Wall, N., & Falkenstein, M. (2011). Age-related differences in performance and stimulus processing in dual task situation. Brain Research, 1414, 66–76.

Lacherez, P., Wood, J.M., Anstey, K.J., & Lord, S. (2014). Sensorimotor and postural control factors associated with driving safety in a community-dwelling older driver population. Journals of Gerontology Series A: Biological Sciences & Medical Sciences, 69 (2), 240–244. Retrieved from http://dx.doi.org/10.1093/gerona/glt173

Richardson, E.D. & Marottoli, R.A. (2003). Visual attention and driving behaviors among community-living older persons. Journal of Gerontology: Series A, 58, M832–M836.

Woolnough, A., Salim, D., Marshall, S.C., Weegar, K., PorterM.M., Rapoport, M.J., Man Son-Hing, M.,…Vrkljan, B. (2013). Determining the validity of the AMA guide: A historical cohort analysis of the assessment of driving related skills and crash rate among older drivers. Accident Analysis & Prevention. 61, 311–316. Retrieved from: http://dx.doi.org/10.1016/j. aap.2013.03.020

What’s New in the 2019 Guidelines for Community-Acquired Pneumonia?

By Blaze Calderon, Juliana Oguh, and Lisa C. Hutchison, PharmD, MPH, BCPS, BCGP
University of Arkansas for Medical Sciences (UAMS) College of Pharmacy

Several factors increase the frequency of infection and pneumonia in older adults including lowered immune function, the presence of comorbid conditions, and nursing home residence.¹ Community-acquired pneumonia (CAP) is defined as an acute infection of the pulmonary tissue that is acquired outside of a health care setting.² CAP is a leading cause of morbidity and mortality worldwide. The clinical presentation of CAP ranges from mild pneumonia, characterized by fever, cough, and shortness of breath, to severe pneumonia, characterized by sepsis and respiratory distress.²In 2019 the American Thoracic Society (ATS) and Infectious Disease Society of America (IDSA) released an update to their 2007 guidelines on CAP.³ This marks the first update in over a decade. This update is especially important to geriatrics because CAP is one of the most common and fatal infectious diseases seen in this patient population.⁴

Major changes introduced in the new guidelines:

Instead of defining severe CAP based on the location of treatment (inpatient or ICU), the new guidelines have introduced a validated definition in which 3 or more minor or 1 major criteria must be met in order to classify the diagnosis as severe CAP. Minor criteria are: respiratory rate ≥ 30 breaths/min, PaO2/FiO2 ratio ≤ 250, multilobar infiltrates, confusion/disorientation, blood urea nitrogen level ≥ 20 mg/dl, leukopenia, thrombocytopenia, hypothermia, and hypotension requiring aggressive fluid resuscitation. Major criteria are septic shock with need for vasopressors and respiratory failure requiring mechanical ventilation.
Sputum and blood cultures should be obtained if possible for patients with severe disease (without delaying antibiotic therapy), but the new guidelines expand this recommendation to include inpatients empirically treated for MRSA or Pseudomonas aeruginosa.
Macrolide monotherapy (i.e, azithromycin, clarithromycin) may be used for outpatients, but only in areas where pneumococcal resistance to macrolides is reported to be less than 25%.
The new guidelines do not recommend procalcitonin levels to decide if antibiotic therapy should be initiated. These are reserved for identifying when to discontinue antibiotics in hospital acquired or ventilator associated pneumonia.
Corticosteroids are not recommended, but may be considered in patients with refractory septic shock.
The healthcare associated pneumonia (HCAP) category was introduced in 2005. The most recent recommendations are to stop using this categorization to determine if extended-spectrum antibiotics should be used. Instead, the presence of local epidemiology and risk factors decide if MRSA or P. aeruginosa coverage is needed for CAP. There is an emphasis on de-escalation of antibiotic therapy based on culture results.
In the previous guidelines, empiric therapy for severe CAP was a beta lactam + macrolide or beta lactam + fluoroquinolone. Now a beta lactam + macrolide is preferred. This is due to the increase risks identified with fluoroquinolone therapy.
Finally, follow up chest imaging is not recommended for patients who are improving.¹

The approach to diagnosis and management of pneumonia in older adults is generally the same as in the general population, although older adults are more often afflicted with severe disease or sepsis.¹ The fact that most patients with community-acquired pneumonia can still be treated with tried-and-tested regimens like macrolides or macrolides and beta lactam antibiotics that have been used for decades is encouraging in the face of concerns over increasing antibiotic resistance. When treating older adults, the use of broader empiric treatment initially is common due to increased risk of drug resistance, and higher incidence of severe forms of pneumonia. The new guidelines may improve tailored antibiotic use in older adults with the change in definition of severe CAP, and focus on de-escalation of therapy when possible.

References:

Mody, L. Approach to infection in the older adult. In: UpToDate, Schmader, K.E. & Givens, J., UpToDate. Waltham, MA, 2019.
Ramirez, J.A. Overview of community-acquired pneumonia in adults. In: UpToDate, File Jr., T.M. & Bond, S., UpToDate. Waltham, MA, 2019.
Metlay, J. P., Waterer, G. W., Long, A. C., Anzueto, A., Brozek, J., Crothers, K., … & Griffin, M. R. (2019). Diagnosis and Treatment of Adults with Community-acquired Pneumonia. An Official Clinical Practice Guideline of the American Thoracic Society and Infectious Diseases Society of America. American Journal of Respiratory and Critical Care Medicine, 200 (7), e45-e67.
Niederman, M. S., & Ahmed, Q. A. (2003). Community-acquired pneumonia in elderly patients. Clinics in geriatric medicine, 19(1), 101-120.

Geriatric Student Scholars Selected for 2020

By Whitney Thomasson, MAP
Research Assistant
UAMS Arkansas Geriatric Education Collaborative

It is with great pleasure that the UAMS Arkansas Geriatric Education Collaborative (AGEC) announces its 2020 selection for the Geriatric Student Scholars program: Abbey Belote (Doctorate of Physical Therapy student), Caitlyn Crowder (Doctorate of Audiology student), Serena Van (Doctorate of Pharmacy student), Rebekah Ward (Physician Assistant student), and Sarah Wilson (Hendrix College Pre-Medical undergraduate).

The purpose of the Student Scholars program is to increase health professions students’ interest in and exposure to older adults, to improve knowledge of older adult health issues and the specialized care they need, and to promote interprofessional collaboration among health professions students. Throughout the program, the scholars are required to attend a minimum number of academic and community programs focused on older adults, and write reflections on their experiences. The scholars will also work collaboratively on a team project this spring, which will focus on a current geriatric-related issue.

We at AGEC are proud to support our second annual cohort of geriatric scholars. While keeping academic and community program participation at the center of the student experience, we made a couple of modifications to this year’s program for a more immersive learning opportunity. First, we extended the program from 4 months (spring semester) to 6 months (mid-fall and spring semester). This is in an effort to allow for more time for all the students to properly meet each other, to participate in more academic and community programs, and to fully plan and execute an interprofessional “capstone” project. As well, this was our first year accepting five student scholars instead of four. In fostering our partnership with Hendrix College, we accepted undergraduate applicants from the college for a fifth slot on our Student Scholars program for 2020. We are excited to see how an undergraduate perspective from another college will shape the interprofessional approach of the scholars.

To read more about our scholar selection, please visit our 2020 Student Scholar page. In addition, Hendrix College recently released a wonderful article about our undergraduate scholar Sarah Wilson, which you can read here.

We look forward to an exciting 2020 with our Geriatric Student Scholars!

From The Director’s Desk

By Robin McAtee, PhD, RN, FACHE, Director, Arkansas Geriatric Education Collaborative (AGEC), a Geriatric Workforce Enhancement Program (GWEP) at the University of Arkansas for Medical Sciences (UAMS) Donald W. Reynolds Institute on Aging (DWR IOA)

Fall 2019

Hello everyone from the Arkansas Geriatric Education Collaborative (AGEC), the Geriatric Workforce Enhancement Program for Arkansas. Summer of 2019 is over and we are beginning one of the busiest times of the year. Summer was very eventful for us as we started our new grant and began working to bring new partners and collaborators on board with the AGEC!

We have been very busy this fall with community and health professional programming. We had our first fall professional continuing education program featuring our newest AGEC member Leah Tobey, PT, DPT and Morgan Storey, APRN who presented a two-hour webinar entitled Urological Issues in Older Adults & Pelvic Floor Physical Therapy Interventions. This event focused on improving the attendees’ awareness of urological and non-invasive pelvic floor PT services, and evidence-based treatment options for urinary urgency management. They also reviewed potential medication causes of urinary incontinence and best suited options for treatment. Stay tuned for our upcoming continuing education events on our website at agec.uams.edu. We have started new fall community programs with our partner Arkansas AARP. We are conducting lunch and learns in several rural locations across the state with topics ranging from pain management to family caregiving for loved ones with dementia.

Our academic partners are also busy this fall. UCA just completed their annual Inter Profession Education forum on October 15 with over 400 students in attendance from OT, PT, Nursing, Health Sciences, Exercise and Sport Sciences, Addiction Studies, Communication Sciences and Disorders, Family and Consumer Sciences and Psychology. Students were able to learn how each profession would contribute to the health and wellbeing of a real patient who served as a ‘live’ client. Nine clients and caregivers discussed their case with inter professional groups of students that then offered suggestions on how they would assist the client in their care. ASU faculty are updating curriculum and clinical experiences in areas that impact older adults and have many nurse practitioner students involved in projects such as screening for osteoporosis, colorectal cancer, and depression.

In other exciting news, we had 20 stellar applications for 5 Geriatric Student Scholar positions! After much hard decision making, we have named our 5 new scholars for this year and will be announcing them soon – stay tuned!

We continue to seek new ways to reach and teach all audiences and if you have any suggestions, please let us know.

Leakage – Is it a Normal Part of Aging?

By Leah R. Tobey, PT, DPT
Clinical Coordinator
UAMS Arkansas Geriatric Education Collaborative

First and foremost, having a candid conversation with your healthcare provider is the very best way to manage leakage, whether it be urine or bowel. But, do keep reading this article for your personal and professional knowledge. According to the National Association for Continence (NAFC). bladder control problems affect about 25 million Americans, and 85% of them are women. But this is rarely talked about. Probably one of the hardest things for patients is to bring up the topic of urinary leakage to their healthcare providers due to the private nature of this topic. As a general statistic, women wait about 6.5 years to talk to their doctor about urinary leakage. Although the statistic is moving in the right direction, from about 10 years, that’s still too long to live with symptoms when there are proven, evidence-based treatments available. The Women’s Preventive Services Initiative (WPSI) disseminates evidence-based clinical recommendations for women’s preventative healthcare services in the United States. The WPSI estimates 55% of women with urinary incontinence did not report symptoms to their healthcare providers because of embarrassment, stigma, or acceptance as normal. Starting the conversation and using appropriate screens for urinary incontinence could help identify these patients who might be uncomfortable initiating the conversation.

The National Institute on Aging (NIA) defines urinary incontinence as leaking urine by accident. Earlier this month, the AGEC had the pleasure of hosting a webinar on “Urological Issues in Older Adults & Pelvic Floor Physical Therapy Interventions.” Let’s test your knowledge of pelvic health and aging. Is incontinence a natural part of aging? Is incontinence after childbirth normal? Is it normal to wake up to urinate every night? The answer to each of these questions is no. They are all myths for which we might have at one time believed to be a part of the aging process. According to the NIA and International Continence Society (ICS) weak bladder or pelvic floor muscles can cause leakage as can damage to the nerves that control the bladder from Parkinson’s disease or diabetes, for example. Associated with aging, diseases like arthritis can make it difficult to get to the bathroom in time or blockage from an enlarged prostate in men can cause urinary leakage. The NIA reports incontinence can happen to anyone and it is more common in older people, especially women; but this doesn’t have to be the case. For the dedicated patient, incontinence can be significantly reduced or cured with the help of behavioral, lifestyle, pharmacologic and nonpharmacological treatment, including physical therapy treatment. Pelvic floor muscle exercises (also known as Kegels) when performed correctly can effectively strengthen the core and pelvic floor, allowing the muscles to more strongly hold urine and prevent leakage. A physical therapist with certification in pelvic floor therapy can help educate and teach patients about Kegels, timed voiding, lifestyle changes and evaluate other related back or hip problems which could make urinary leakage worse. For more information visit the National Association for Continence www.nafc.org.

Leah R. Tobey is a doctor of physical therapy, and has been treating patients with incontinence for over 10 years.

To Sleep or Not to Sleep? Management of Insomnia and the Elderly

By Sarah Albanese, PharmD and Lisa Hutchison, PharmD, MPH, BCPS, BCGP
University of Arkansas for Medical Sciences (UAMS) College of Pharmacy

Approximately, 50% of older adults report trouble falling and staying asleep.¹ As people age, sleep cycle changes, chronic medical conditions, and medications decrease total sleep time, increase awakenings, and decrease time in deep sleep.¹ Insomnia increases the risk of depression, cognitive impairment, hypertension, heart disease, chronic fatigue, diabetes, and falls. Non-pharmacological treatments are recommended first including cognitive behavioral therapy for insomnia (CBT-I) with sleep hygiene and controlling stimuli that make sleeping difficult. CBT-I has shown long-term improvements in insomnia over pharmacological options.^1,3,4

Information on the most common medications used for insomnia in elderly patients is listed in Table 1. Although low cost, benzodiazepines, non-benzodiazepines sedatives, and diphenhydramine are not recommended for treatment of insomnia in the elderly due to their minimal effectiveness and numerous side effects.^1,4-7 Preferred agents based upon efficacy and safety include doxepin at doses of 6 mg or less, ramelteon and suvorexant. However, these agents are higher cost, making affordability an issue. Suvorexant, like benzodiazepines and non-benzodiazepines, is a schedule IV controlled substance, which indicates a potential for abuse and affects accessibility to the drug when prescriptions expire or need refills. The higher doses of doxepin, while low cost, are not recommended as side effects increase significantly. Trazodone has pronounced side effects and benefits are short term. Mirtazapine showed significant benefit with insomnia treatment, but data is limited to patients with depression.^1,3-7 Melatonin has shown minor benefits for insomnia treatment, decreasing sleep onset by 5-7 minutes. However, melatonin has become a favorite option for insomnia treatment in elderly individuals due to its benign side effect profile, accessibility, and low cost.

Insomnia is a major problem in the elderly population, with many negative effects if left untreated. Pharmacological options provide some benefit for insomnia, but a majority of products have major side effects. Non-pharmacological treatments like CBT-I are recommended for insomnia treatment in elderly people over pharmacologic options due to the long-term efficacy and lack of negative effects.^1-7

Table 1: Medications for Insomnia Treatment ^1,3-8

Medication Class and Examples

Advantages

Disadvantages

Cost

Benzodiazepines

Temazepam

Triazolam

Side effects: Drowsiness, falls, fractures, cognitive impairment, delirium, increased accidents, tolerance, rebound insomnia

Minimal effectiveness

Not for long-term use

Schedule IV controlled substance – potential for abuse

$ – $$

Non – Benzodiazepine Sedatives

Zolpidem

Zaleplon

Eszopiclone

Short half-life-less hangover

Fewer side effects at low doses

Side effects: same as benzodiazepines, plus sleep -walking, -eating, -driving, rebound insomnia

Not for long-term use

Schedule IV controlled substance – potential for abuse

Antidepressants Doxepin

Trazodone

Mirtazapine

Improvement significant

Doxepin: Minimal side effects at doses ≤ 6 mg

Side effects: drowsiness, dizziness, constipation

Doxepin: Pronounced side effects at doses >6 mg including dry mouth, rebound insomnia, orthostatic hypotension, cognitive impairment

Trazodone: Beneficial effects subside after 1 week; Other side effects: arrhythmias, orthostatic hypotension, falls

Mirtazapine: Indicated for insomnia if also treating depression; Other side effects: hyponatremia, weight gain, dry mouth

Except:

Doxepin

3-6 mg $$$

Antihistamines

Diphenhydramine

Available over-the-counter

Side effects: drowsiness, dizziness, cognitive impairment, falls, constipation, tolerance

Melatonin Receptor Agonists
Ramelteon, Melatonin

Minimal side effects

No rebound insomnia

Ramelteon:

Significant improvement

Melatonin:

Available over-the-counter

Side effects: Headache, nausea, vomiting, upper respiratory infection, runny nose, dizziness

Melatonin: Dietary supplement with lack of standardization

Ramelteon $$$

Melatonin $

Orexin Receptor Antagonist

Suvorexant

Well-tolerated

Side effects: drowsiness

Schedule IV controlled substance – potential for abuse

$$$

$ = cost <$1/day; $$ = Cost $1-2/day; $$$ = cost $3-10/day

References:

Patel D, Steinberg J, Patel P. Insomnia in the elderly: a review. J Clin Sleep Med 2018;14:1017-24.
Vaz Fragoso C, Gill TM. Sleep complaints in the community – living older adults: a multifactorial geriatric syndrome. J Am Geriatr Soc 2007;55:1853-66.
Kamel NS, Gammack JK. Insomnia in the elderly: cause, approach, and treatment. Am J Med 2006;119:463-69.
McCall WV. Sleep in the elderly: burden, diagnosis and treatment. Prim Care Companion J Clin Psychiatry 2004;6:9 – 20.
Reynolds AC, Adams RJ. Treatment of sleep disturbance in older adults. J Pharm Pract Res 2019;49:296-304.
Sateia MJ, Buysse DJ, Krystal AD, Neubauer DN, Heald JL. Clinical practice guidelines for pharmacological treatment of chronic insomnia in adults: an American academy of sleep medicine clinical practice guidelines. J Clin Sleep Med 2017l;13:307-49.
2019 American geriatrics society beers criteria update expert panel. American geriatric society 2019 updated AGS beers criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc 2019;67:674-94.
Good Rx Inc. Available at: https://www.goodrx.com/ .

Physical Activity for Older Adults

By Stacy Harris, DNP, APRN
School of Nursing
University of Central Arkansas

Being physically active is one of the most important lifestyle habits people of all ages can take to improve their health. Recently, the United States Department of Health and Human Services (2018), released new physical activity guidelines. The new guideline recommends adults try to achieve a minimum of 150 minutes (2 hours and 30 minutes) of moderate activity or 75 minutes (1 hour and 5 minutes) of intensive activity each week. The new guideline highlights special populations, including recommendations for the older adult. Older adults should try to achieve the adult recommendations along with balance training and muscle strengthening activities. In addition, the guideline states that older adults with chronic conditions or disabilities should engage in physical activity according to their abilities, explaining that any activity level is better than being sedentary.

As adults age and chronic conditions become common, patients may feel becoming physical fit and more active is unrealistic and not beneficial. However, numerous studies have shown older adults benefit from physical activity. Lövdén, Xu and Wangy (2013) published a critique of a meta analysis that linked increased aerobic physical activities with enhance cognition in sedentary adults. In a randomized control trial of Tai Chi training in adults (mean age 77) with mild cognition issues 30 minutes of Tai Chi three times a week over 12 months resulted in a 4% lower conversion to dementia compared to 17% for the control group (Lövdén, Xu and Wangy, 2013). Tai Chi is a low impact activity practiced as a graceful form of exercise involving a series of movements performed in a slow, focused manner accompanied by deep breathing.

Older adults may be overwhelmed or intimidated when a health care provider uses the word “exercise.” The word exercise suggests a level of activity that may be unattainable for older adults. Patients may be more likely to relate to leisure activities such as gardening, dancing or walking. Evidence suggests that leisure activities are beneficial to cardiovascular health. Mensink, Ziese and Kok (2009) found older adults who participated in leisure activities at 1-2 hours per week, had lower systolic blood pressure, heart rate and body mass than sedentary adults.

Besides improving cardiovascular health, physical activity is also proven to improve orthopedic issues. Half of all older adults have knee and hip pain and may worry that increasing physical activity will worsen already achy joints (Peterson, Osterloh and Graff, 2019). The good news is that this idea has been disproven by multiple scientific trials. The American College of Rheumatology and the Osteoarthritis Research Society International recommends activity as first line treatment for knee and hip pain. Activities such as water aerobics, land-based (i.e. walking) and Tai Chi are appropriate activities.

At the University of Central Arkansas (UCA), the Department of Exercise and Sport Science, developed an exercise program for older adults who reside at College Square Apartments, a retirement community on the UCA campus. A faculty member and students meet with participating residents who have been cleared by their primary care provider. Before exercise begins, the students conduct a motivational interview with the participant and create mutual agreed upon goals. The students administer the Senior Fit Test, interpret the results, then prepare and lead the participants through 6-8 weeks of exercise. At the end of the program students administer the Senior Fit Test again, and then review and debrief with the participant.

Older adults may think participating in a fitness program or purchasing expensive equipment is needed to improve fitness. Home-based items such as lifting full milk gallon jugs or carrying laundry baskets up steps are ways to increase strength. Stretch bands are low-cost items that can be used to help with flexibility and strength, too. Any physical activity is worthwhile and helps cardiovascular, joint and mental health. Just move!

References

Lövdén, M., Xu, W. & Wangy, H. X. (2013). Lifestyle change and the prevention of cognitive decline and dementia. Current Opinions in Psychiatry 26 (3): 239-243.

Mesink, B. M., Ziese, T. & Kok, F.J. (2009). Benefits of leisure-time physical activity on the cardiovascular risk profile at older age. International Journal of Epidemiology (28): 659-666.

Peterson, N. E., Osterloh, K. D., & Graff, M. N. (2019). Exercises for older adults with knee and hip pain. The Journal for Nurse Practitioners, (15) 263-267.

S. Department of Health and Human Services (2018). Physical activity guidelines advisory committee scientific report, 2ⁿ^d Ed. Retrieved from https://health.gov/paguidelines/second-edition/report/

Special Focus Facility Programs for the Aging Population

Dr. Angela Stone Schmidt, Professor Emeritus
College of Nursing & Health Professions
Arkansas State University

The “Special Focus Facility” (SFF) program, is implemented by Centers for Medicare and Medicaid Services (CMS) for the aging and others requiring the need for long term nursing care. The purpose of this initiative is to keep the public, healthcare providers and consumers, informed when discussing long term care options. The SFF report is a result of state agency inspections resulting in what that agency is doing to improve quality of care for the aging after deficiencies have been cited. There are specific areas reviewed to determine quality and these reports are available online. Those long term care facilities, identified as a “Special Focus Facility”, are identified and include measures of quality, or lack of, with available evidence, identifying high and low performing nursing homes.

In June 2019, the release of a list of 400 nursing homes across the country by the Senate Committee on Aging was deemed to have persistently poor survey inspection results. Policy makers took note and responded, directing attention to the quality issues of long term care. CMS gave the list to Senator Robert P. Casey (D-Pa.), a member of the special committee on aging, which included 6 from Arkansas. A subsequent announcement was made by CMS of how the list is being sorted for possible inclusion in its SFF Program. David Gifford, Senior Vice President of Quality and Regulatory Affairs, American Health Care Association (AHCA), supported making relevant, transparent information available to families and consumers so they could make informed care decisions for selecting a quality facility.

(https://www.aging.senate.gov/imo/media/doc/SFF%20List%20with%20Cover%20Letter%20051419%20-%20Casey.pdf )

CMS and state agencies have inspected nursing homes on a regular basis to determine if they are providing the quality of care that Medicare and Medicaid require to protect and improve residents’ health and safety. When nursing homes do not meet CMS’ health care or fire safety standards, these instances are cited as deficiencies, and CMS requires that the problems be corrected. Most nursing homes have some deficiencies identified, as reported by CMS, with the average being 6-7 deficiencies per inspection.

“Skilled nursing facilities (SNFs) and nursing facilities (NFs) are required to be in compliance with the requirements in 42 CFR Part 483, Subpart B, to receive payment under the Medicare or Medicaid programs. To certify a SNF or NF, a state surveyor completes at least a Life Safety Code (LSC) survey, and a Standard Survey. The State has the responsibility for certifying a SNF’s or NF’s compliance or noncompliance, except in the case of State-operated facilities. However, the State’s certification for a skilled nursing facility is subject to CMS’ approval. “Certification of compliance” means that a facility’s compliance with Federal participation requirements is ascertained. In addition to certifying a facility’s compliance or noncompliance, the State recommends appropriate enforcement actions to the State Medicaid agency for Medicaid and to the regional office for Medicare.” (https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/NHs.html )

Some nursing homes make unsustainable improvements to correct an identified problem on inspection but as a result, have repeated cycles of serious deficiencies because of not addressing the underlying systemic problems that contributed to the needed improvement to improve quality of care. These facilities identified as a SFF had a compliance history which posed risks to residents’ health and safety. The methodology for identifying facilities for the SFF program is based on the same methodology used in the health inspection domain of The Five-Star Quality Rating System. CMS calculates a total weighted health inspection score for each facility. Results from over three cycles (approximately three years) of inspections are converted into points based on the number of deficiencies cited and the scope and severity level of those citations, including any repeat visits. The more deficiencies that are cited, and the more cited at higher levels of scope and severity, the more points are assigned. Note that a lower survey score corresponds to fewer deficiencies and revisits, and thus better performance on the health inspection domain. (Five Star Rating System for Special Focused Facility, updated 9/25/19, https://www.cms.gov/Medicare/ProviderEnrollment-and-Certification/CertificationandComplianc/downloads/usersguide.pdf)

The Nursing Home Compare Five Star Quality Rating System design was developed by CMS with leading researchers in the long-term care field and contributions by consumers and provider groups. The rating system features an Overall Quality Rating of one to five stars based on nursing home performance on three domains, each of which has its own ratings. The three domains include:

1) Health Inspection measures derived from outcomes from state health inspections that are based on the number, scope, and severity of deficiencies identified during the three most recent annual inspection surveys, as well as substantiated findings from the most recent 36 months of complaint investigations.

2) Staffing measures that are based on nursing home staffing levels with ratings on the staffing domain including at least two measures: Registered nurse (RN) hours per resident day; and total nurse staffing (the sum of RN, licensed practical nurse (LPN), and nurse aide) hours per resident per day.

3) Quality Measures based on MDS and claims-based quality measures (QMs), reflect performance on 17 of the QMs that are currently posted on the Nursing Home Compare website. These include ten long-stay measures and seven short-stay measures. Quality Domain information for all measures are available at: https://www.cms.gov/medicare/quality-initiatives-patient-assessmentinstruments/nursinghomequalityinits/nhqiqualitymeasures.html.

Therefore, the facilities with the most points in a State become candidates for the SFF program. The number of nursing homes on the candidate list is based on five candidates for each SFF slot, with a minimum candidate pool of five nursing homes and a maximum of 30 per State. State agencies use this list to select nursing homes to fill the SFF slot(s) in their state. Once a State selects a facility as an SFF, the State Survey Agency, conducts a full, onsite inspection of all Medicare health and safety requirements every six months and makes recommendations. These may include fines, denial of Medicare payment, or other measures, until the nursing home either (1) graduates from the SFF program; or (2) is terminated from the Medicare and/or Medicaid program(s). Once an SFF graduates or is terminated, each State then selects a new SFF from a monthly list of candidates. CMS also informs candidate nursing homes of their inclusion on the SFF candidate list in the monthly preview of the Five-Star Quality Rating System.

The Center for Medicare Advocacy looked at information on Nursing Home Compare for each of the 21 SFF graduates on CMS’s May 16, 2019 list. Four facilities had new names on Nursing Home Compare: https://www.medicare.gov/nursinghomecompare/search.html . According to their study, standards for graduation from SFF were vague. CMS describes graduates as SFFs that have “made significant improvements in quality of care – and those improvements are continued over time.” CMS does not reflect the many recent graduates that continue to have serious deficiencies, multiple complaint surveys, and inadequate nurse staffing. Some facilities even change their name to avoid recognition and avoid scrutiny. This Center’s analysis is consistent with The New York Times report in July 2017, which found that 52% of 528 SFFs that graduated before 2014 were cited with serious harm or jeopardy in the years after they graduated. More than one-third of the facilities received the lowest federal rating for health and safety.( https://www.medicareadvocacy.org/cma-alert-june-20-2019/ )

This information of the SFF Program is necessary for discharge planners seeking nursing home placement and other healthcare providers, as well as consumers in response to advocacy for our aging population. When admission to a nursing home is considered, use the comparison website to determine results of the survey process for quality and performance. Compare website information about the nursing home’s star ratings, staffing, quality measures, and inspection results at: https://www.medicare.gov/nursinghomecompare/search.html . Even as a healthcare provider making recommendations for placement, visit the nursing home and talk to staff, residents, physicians, and other families, to assist families to make informed decisions. Call the state survey agency (agency contact information is posted on Nursing Home Compare) to find out more about the nursing home. If the nursing home is an SFF, look at the length of time that the nursing home has been on the SFF list. This has importance if the nursing home has been an SFF nursing home for more than 18 to 24 months, since such nursing homes are closer to either graduating (due to improvements) or ending their participation in Medicare and Medicaid. CMS reports that most of the nursing homes in the SFF program significantly improve their quality of care within 18-24 months after being selected, while about 10% tend to be terminated from Medicare and Medicaid. Lists are provided by state at: https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/downloads/sfflist.pdf

From The Director’s Desk

Summer 2019

I begin this letter with some exciting news. It was announced on June 10 that we were successful in our quest for renewing our grant! We were fully funded from Health Resources and Services Administration (HRSA) with a five year $3.74M grant to continue and expand the work of the Arkansas Geriatric Education Collaborative. Therefore as we wind-up the activities of fiscal year 2019, we are excited to get started on all of our new and continued activities for the new grant period!

First, to recap the last three months of fiscal year 2019, we were very busy. In April, we had two major events. April 2, UAMS AGEC in collaboration with Hendrix College, sponsored an “Aging in Arkansas Symposium” in Conway where the results of an older adult needs assessment were discussed by a panel of experts. April 12 we has a forum, Combating the Opioid Crisis and Chronic Pain, in partnership with the Clinton School of Public Service. This forum was focused on older adults in Arkansas managing chronic pain issues. Panelist included UAMS experts Michael Mancino, M.D.; Teresa Hudson, Pharm.D., Ph.D.; Masil George, M.D.; Heejung Choi, M.D.; Kristin Garner, M.D., Leah Tobey, D.P.T., and Kirk Lane, Arkansas drug director. To supplement this presentation and program, the AGEC and the UAMS Center for Health Literacy developed a Chronic Pain Book for patients. The book has been reviewed by the UAMS IMPACT group and many others. It was unveiled at the forum and has been extraordinarily well received. A link can be found on our website for more information on the books: https://agec.uams.edu/chronic-pain-book-and-addiction-resources/
Books can be ordered by emailing agec@uams.edu. The forum was followed by the posting of the AGEC produced video of an opioid addiction story on the UAMS Facebook page and it has received over 18,000 views!

On April 22, we had our second spring CE Webinar entitled Beers Criteria Update and Evidenced Based Alternatives featuring Lisa C. Hutchison, Pharm.D., MPH, BCPS, FCCP and Janna Hawthorne, Pharm.D., MA, Ed. This was followed on May 8 by a live Facebook event with Alzheimer’s Arkansas entitled: Understanding Respite Care in partnership with Alzheimer’s Arkansas where we had over 750 views on Facebook.

Starting in June, the AGEC crew started production for our First Responder Dementia Training Distance Learning Program. This program should be ready for viewing soon! Stay tuned!

At the end of May, we were privileged to have a presentation from our first cohort of Geriatric Scholars. They presented to the AGEC leadership on the activities from this semester including their interdisciplinary project and helped us discuss ways to improve the program. This program will be continued in the new grant!

We were also active with our community based partners with several programs and activities. In addition, we also partnered with the Oaklawn Center on Aging in response to a request from Mental Health America of Middle Tennessee who had heard about the AGEC’s First Responder Training. Kathy Packard MS, M.Ed., LPC, CDP, and I trained first responders to be Certified Dementia Practitioners and in Elder Abuse and Neglect identification and reporting. The program was extremely well received.

Thank you for all you do for older adults in Arkansas and we look forward to continuing to partner with many of you to expand and improve services and programs.

Helping Your Patients with the Medicare Maze

By Kathy Packard, MS, M.Ed., LPC
Oaklawn Center on Aging

As a healthcare professional, you may be asked questions regarding Medicare. If your patients are approaching their 65^th birthday or currently enrolled Medicare, they may be receiving daily mail with Medicare information, supplemental insurance and prescription drug plans (Part D). With open enrollment in October you may want to keep Medicare information available for your patients. The information being mailed out to your patients can be overwhelming and very confusing for someone who does not know how to navigate the Medicare system. This is the reason it is called the Medicare maze. As their provider, patients may feel comfortable asking you questions regarding their Medicare coverage. Therefore, you need to be prepared to help them navigate this maze.

There may be special programs for some patients. Older individuals who have difficulty affording medications, may qualify for a federal program, extra help, a state program, or a Medicare Savings Program. These programs are based on financial need and can assist paying Medicare and prescription drugs costs, premiums, deductibles, coinsurance and copayments for Part A, B and D. Arkansas uses the baseline federal income and resource limits. If you think your patient may qualify, have them call the Senior Health Insurance Information Program (SHIIP) office (1-800-224-6330) and they will direct the caller to a counselor who is trained to make application for them.

Remember: October 15, 2019-December 7, 2019, is open enrollment for all parts of Medicare. To research the Medicare part D plans in your patients’ area of the state, they can go online to www.medicare.gov to view and compare available plans. To research parts A, B & C (Medicare Advantage plans) they can go online to www.insurance.arkansas.gov or call SHIIP counselors at 1-800-224-6330.

In addition to the maze of decisions, Medicare recently changed the format of their card to protect against identity theft. Most new Medicare beneficiaries turning 65 will apply for Medicare by going online to www.ssa.gov or by calling their local Social Security office. After the application is complete, Medicare cards will be received prior to or the month of their 65^th birthday. The new Medicare card has a unique number for each recipient, they no longer use Social Security numbers as the identifying number. All Medicare beneficiaries have until December 31, 2019 to obtain the new card and will be required to use the new Medicare card no later than January 2020. Most medical practices and healthcare facilities began taking the new Medicare card this year. Current Medicare beneficiaries should have received their new Medicare card by now, but if they haven’t, they should call 1-800-Medicare to order one.

Assisting Medicare beneficiaries has a positive health benefit. By taking away the stress of making these confusing decisions by themselves, you may well decrease their blood pressure and improve their health and health services!