Chadley Uekman

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)

Happy New Year from all of us at the Arkansas Geriatric Education Collaborative! I hope everyone had a wonderful holiday season and ready to begin a new year. As we ended 2018, the Health Resources and Services Administration (HRSA) gifted us with the next grant cycle requirements, better known as the NOFO (Notice of Funding Opportunity). Therefore, AGEC staff and partners have been busily putting together the proposal for new programs and activities for the next five year cycle! We are excited about this opportunity but of course always apprehensive about the uncertainty of grants! I want to thank each of you who are helping or are contributing to this proposal, it is certainly broad and comprehensive!

Looking back at the last quarter of 2018, we had a very successful 4 day train-the-trainer program on Stanford’s Chronic Pain Self-Management program (CPSMP) where 22 individuals were trained to be lay trainers. They can now go to their perspective audiences and hold CPSMP classes. We also hosted our fall webinar which featured Dr. Rhonda Mattox who presented on Insomnia: a golden opportunity to address psychiatric disorders. Attendance was great (over 75) as were the responses from participants! In November, we also worked with Circle of Life Hospice in northwest AR to provide a 3 day CE Event. We had 111 attendees and over 1500 total CE hours were awarded! In addition to these programs, we also had partners continue to provide Dementia Experiences, Certified Dementia Classes, Family Caregiver Workshops and a plethora of educational forums.

As we look to this first quarter, we have just sponsored Geriatric Grand Rounds at the end of January with Dr. Brody, from Brain Matters Research with over 120 attendees, and have begun to plan our spring webinars. We are also very excited about our upcoming Opioid Forum in April. An interprofessional team is planning the forum and the presenters will include the AR Drug Director, Kirk Lane; Michael Mancino, MD, UAMS Center for Addiction Services; Teresa Hudson, PharmD; Michael Cassat, MD; Jonathan Goree, MD and Masil George, MD. The audience will be 50-60 older adults and community leaders who are interested in opioid issues and chronic pain in older adults. The agenda includes a panel discussion with experts about: understanding opioid medication, recognizing possible opioid addiction, and chronic pain management. This will be followed by interactive patient simulation experience sessions and a discussion of medical and non-medical treatment options by the experts. We will also provide support for the Geriatric Forum at Hendrix College scheduled in April where experts will discuss needs identified by an older adults needs assessment survey completed earlier in the year. More information will be available on these forums at a later date.

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.

Screening for Dementia

By Kevin Rowell, Ph.D.
Department of Psychology and Counseling, University of Central Arkansas

It seemed to Karen that her 78 year-old mother was having more trouble remembering people’s names, recalling the right words to use in a conversation, and driving with some confusion about which routes to take. Karen noted that her mother’s difficulties began occurring gradually over the past two years, and now she wondered if this is a part of normal aging or if it could be signs of Alzheimer’s disease. On two different occasions, Karen addressed her concern with her mother but was met both times with her mother’s refusal to discuss the matter.

Such a scenario is quite common in families, and with the Baby Boomer generation now in their 60’s and 70’s, it is becoming a reality to millions of Americans. When an elderly person begins to experience noticeable decline in memory, sense of direction, and other cognitive abilities, the concern is whether these are due to normal, age-related changes or due to a disease process like Alzheimer’s, the most common type of dementia. Receiving a diagnosis of dementia is certainly troubling and disconcerting, much like a cancer diagnosis, because some forms have no cure and are fatal within a few years of onset. As with most diseases, early detection leads to early intervention which even if not curable, can at least slow down the progression or assist in preserving cognitive function for a longer period of time.

While most of us are familiar with the terms Alzheimer’s disease and dementia, there is some confusion about their meaning. Dementia is a class of disorders that usually occurs after age 60 with abnormal decline in memory being the first symptom to be noticed. Other cognitive deficits include difficulty recalling names of people or objects, carrying out multiple step tasks, solving complex problems, and maintaining visual-spatial accuracy. Alzheimer’s disease is by far the most common type of dementia and represents approximately 60-70% of cases. Other common types include vascular dementia, dementia due to Parkinson’s disease, and Lewy Body dementia (American Psychiatric Association, 2013).

Determining whether or not an elderly family member has dementia usually involves some type of cognitive exam to measure the degree of function that is lost and may also include a brain scan such as a CT scan or MRI to evaluate the brain’s structural changes that have occurred. In both types of examination, the results from the current patient are compared to a large sample of people his or her age to determine if the changes are significantly below average, that is, if these changes are much greater than expected for the patient’s age group.

Cognitive examinations vary in terms of complexity and time: very brief scales have only a few items and take less than five minutes, intermediate tests require 30 minutes to an hour, and more comprehensive neuropsychological assessments involve several hours of testing. The kind of test administered depends upon the health care provider who is seen. Their choice of assessment will be based upon how much time they can allocate for the testing and the kind of assessment training that they have received.

Most people will make an initial appointment with their primary care provider (PCP) rather than with a psychiatrist, neurologist, or psychologist. PCP’s typically have very limited time to conduct an assessment, and they usually receive training on administering brief screening tests instead of more complex scales. If results of the screening test indicate a problem with memory or other kinds of cognitive functioning, the PCP may give a tentative dementia diagnosis but will typically refer the patient for more in-depth assessment by a psychiatrist, neurologist, or psychologist in order to confirm the diagnosis (Yokomizo, Simon, & de Campos Bottino, 2014).

Because of their common medical education and training, psychiatrists and neurologists often provide similar kinds of assessments. These tests usually require approximately 30 minutes to complete and involve several cognitive tasks such as memory, attention span, naming common objects, copying geometric figures, verbal ability, and orientation to time/date, place, and person. Each task is assigned a very limited number of points, usually ranging 0-3, and a total score is derived by summing all of the points. This total score is then compared to a normal range of scores expected for someone with the same age, and in some cases, with similar education. Psychiatrists and neurologists very often refer the patient for a CT scan or MRI which will help determine the specific type of dementia given that the cognitive testing indicates a significant level of impairment and warrants a diagnosis of dementia (Del Sole, Malaspina, & Biasina, 2016; Tsoi, Chan, Hirai, Wong, & Kwok, 2015).

Psychologists who specialize in geriatric assessment, typically receive the greatest amount of training in test administration. Whereas they often utilize the kinds of intermediate tests used by psychiatrists and neurologists, neuropsychologists may want to use more in-depth, more complex tests to precisely evaluate a person’s memory, attention span, and the other cognitive abilities measured in the intermediate tests. Similar to the other tests mentioned, the results are compared to a normative sample to determine the severity of impairment (Fields, Ferman, Boeve, & Smith, 2011).

If a family member begins to experience noticeable memory loss or problems in other kinds of cognitive tasks, it is advisable to seek a cognitive examination because it is critical to have this kind of information in determining whether or not the individual has dementia. These results can then be used to track changes in their cognitive abilities as they age which will be highly useful in determining the optimal type of intervention for them.

References.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5^th ed.). Washington, DC: Author.

Del Sole, A., Malaspina, S., & Biasina, A. (2016). Magnetic resonance imaging and positron emission tomography in the diagnosis of neurodegenerative dementias. Functional Neurology, 31, 205-215.

Fields, J. A., Ferman, T. J., Boeve, B. F., & Smith, G. E. (2011). Neuropsychological assessment of patients with dementing illness. Nature Reviews. Neurology, 7, 677-687. doi: 10.1038/nrneurol.2011.173.

Tsoi, K. F., Chan, J. C., Hirai, H. W., Wong, S. S. & Kwok, T. Y. (2015). Cognitive tests to detect dementia. A systematic review and meta-analysis. JAMA Internal Medicine, 175, 1450-1458. doi: 10.1001/jamainternmed.2015.2152.

Yokomizo, J. E., Simon, S. S., & de Campos Bottino, C. M. (2014). Cognitive screening for dementia in primary care: A systematic review. International Psychogeriatrics, 26, 1783-1804. doi: 10.1017/S1041610214001082.

Tech and Aging

By Jessica Camp, MSN, APRN, AGCNS-BC
College of Nursing & Health Professions, Arkansas State University

It appears that more older adults are using technology in their daily lives (Davis, 2019). According to a study by AARP, mobile devices and computers are the primary technology used by this population (Anderson, 2017, p. 3). To a lesser extent, older adults reported managing their healthcare and learning with this technology. Another study by PEW Research Center Older Adults and Technology Use (Smith, 2014) found that:

Six in ten seniors now go online
Just under half are broadband adopters
Younger, higher-income, and more highly educated seniors use the internet and broadband at rates approaching—or even exceeding—the general population
Internet use and broadband adoption each drop off dramatically around age 75
27% of older adults use social networking sites such as Facebook, but these users socialize more frequently with others compared with non-SNS users
E-readers are as popular as smartphones

Sadly, however, Davis (2019) points out that the design of technology used by older adults rarely focuses on them. This article aims to shed a bit of light on some of the technology that may be useful or even helpful for older adults and technology that is actually designed for the older adult.

Interestingly enough, these are not the only technology-based items, nor services, available to older adults. Currently, there is a multitude of technological products marketed specifically for older adults. Nextavenue contributing write Patricia Corrigan shared an overview on several tech items that can help older adults who serve to maintain their independence, such as:

Wearable battery-operated emergency alert systems (such as Philips Lifeline), which detect falls and summon help
The Apple watch (Series 4), which monitors your heart rhythm and detects falls
Some cell phones (such as GreatCalla), which offer emergency response buttons
Voice-controlled devices (such as LifePod), which work with “smart” speakers to remind you when to take your medication or head to a medical appointment
Cameras, microphones and motion sensors (Evermind makes one version), which monitor your regular activity — or signal a lack of it to your caregiver (2018, para. 2)Surprising to this author, there is a company offering transportation normally available through the use of technology to older adults. One company provides transportation for older adults by turning traditional on-demand transportation systems (like Uber, for example) already in place into senior-friendly transportation. Older adults can call an eight-hundred-number and press a few buttons once registered, to obtain a ride, and even return home all the while sharing information with the family about their activity through messaging communication. This service charges twenty-seven cents per minute currently in addition to the service rate charged by the transportation company for the travel. Unfortunately, it is not yet available in all parts of Arkansas. However, the zip code 72002 for Little Rock provided the following rates (from their website):
Not surprising, there is more than one company that markets cell phones, including smartphones, to our older adults. One such company touts that they are the home of the “original easy-to-use cell phone” (Greatcall, 2019a, para. 1). They also offer a family caregiving device that includes a wearable communicator designed for two-way communication, fall detection, and GPS locating features that are reportedly waterproof. Further, they offer a version of this that tracks fitness and looks similar to the traditional wearable device providing the same features (Greatcall, 2019b). Another company offers more conventional cell phones with some additional services designed for urgent and emergent communication around the clock (Snapfon, 2019, para. 1-3).

Ride Fare:
$3.60 base fare + $0.76 per mile + $0.15 per minute (with a minimum fare of $7.60)

and
Concierge Fee:
$0.27 per minute

* Please note that during periods of high demand, our vendors may include a surge charge (gogograndparent.com, 2018)

Despite older adults still reporting skepticism regarding technology, the trend is up on use for most aspects. This article shows that there is no shortage of new ways technology is being garnered to help out older adults. Let this article encourage you to learn more about how technology can assist your older adult patients, your family or even yourself.

Smith, (2014). PEW report. Older Adults and Technology Use. PEW Research Center. Retrieved on January 14^th, 2019 from http://www.pewinternet.org/2014/04/03/older-adults-and-technology-use/

Anderson, M., & Perrin, A. (2017). PEW Report. Technology Use Among Seniors. PEW Research Center. Retrieved on January 14^th, 2019 from http://www.pewinternet.org/2017/05/17/technology-use-among-seniors/

Abrahms, S. (2015). 3 Must-have cell phones for seniors. Retrieved on January 17^th, 2019 from https://www.forbes.com/sites/nextavenue/2015/06/17/3-must-have-cell-phones-for-seniors/#238490ce6cce

Greatcall. (2019a). About us. Retrieved on January 17^th, 2019 from https://www.greatcall.com/about-us

Greatcall. (2019b). Feel safer on the go. Retrieved on January 17, 2019 from https://www.greatcall.com/devices/lively-mobile-medical-alert-system

Snapfon & Excellcious Communications LLC. (2019). Easy to use features. Retrieved on January 17, 2019 from https://www.snapfon.com/big-button-cell-phone/

Snapfon & Excellus Communications LLC. (2019). sosPlus mobile emergency management services. Retrieved on January 17, 2019 from https://www.snapfon.com/sos-plus/

GoGoGrandparent. (2018). How it works. Retrieved on January 17, 2019 from https://gogograndparent.com/

Corrigan, P. (2017). Technology can help us age in place, if we let it. Nextavenue: Where Grown-ups Keep Growing. Retrieved on January 14^th, 2019 from https://www.nextavenue.org/technology-age-in-place/

Anderson, G.O. (2017). Technology Use and Attitudes Among Mid-life and Older Adults. AARP Research. Retrieved on January 14^th, 2019 from https://www.aarp.org/content/dam/aarp/research/surveys_statistics/technology/info-2018/atom-nov-2017-tech-module.doi.10.26419%252Fres.00210.001.pdf

It’s not all sunshine and roses: Closing the rehab gap

By Christopher S. Walter, PT, DPT, PhD
AGEC Geriatric Fellow
Assistant Professor
Department of Physical Therapy
University of Arkansas for Medical Sciences – Fayetteville

Have you ever considered that your current treatment of drug therapies is not working for you? If you have, you aren’t alone. In fact, the top-ten highest grossing drugs in the United States only benefit 4-33% of the people who take them¹. Unfortunately, research suggests that motor rehabilitation therapies are no different².

Rehabilitation is the action of restoring someone to health or normal life through therapy after an injury, illness, or disease process. Generally speaking, we know that rehab works. For example, an individual who gets therapy following an injury (e.g., fractured hip, stroke, etc.) is more likely to improve faster, and to a greater extent, than someone who does not get therapy. This is good news for those getting therapy and those in the rehab field. However, a closer, individualized look at the process shows that it’s not all sunshine and roses. Some individuals have very good results after rehabilitation, while others show little to no improvement². This problem is made worse by the fact that the rehab clinician (i.e., physical therapist, occupational therapist, and/or other allied healthcare provider) is unable to predict who might or might not respond to therapy.

The problem is clear; the solution is not. Science has yet to develop a process that predicts who will respond to therapy and who will not respond. We do know that age is a factor. The older the patient, the less they respond to the given therapies^3-5.

There is good news, though. Just because an individual does not respond to one intervention does not mean he/she will not respond to all interventions. To put this into perspective, consider the following example. If a medication prescribed by your doctor to lower your cholesterol does not have the desired effect, your doctor could 1) prescribe a larger dose of that medication, or 2) choose a different drug all together. The goal to lower cholesterol is the same only the method has changed. Rehabilitation is no different.

There are steps that rehab therapists and professionals can take to ensure that therapy is successful for as many people as possible. First, our treatments should only be selected after thoughtful examination of the patient’s individual characteristics. Further, it is important that our interventions are evidence based with documented effectiveness. This is where we need your help. You can help by signing up to be a participant in rehab research trials. Reach out to the local university to see if there is an open study for people like yourself. Additionally, ARresearch.org is a secure website that allows the community a first-hand look at the research being conducted at UAMS. Volunteers can provide their information if interested in participating in research. The researchers are then able to contact potential volunteers for their studies.

The goal of rehabilitation is to restore health and quality of life following an injury. To meet this goal, rehab professionals must work to identify characteristics that separate those who will respond to therapy from those who will not. With passionate professionals and an enthusiastic community willing to volunteer, we can close the gap on rehab success.

Schork NJ. Personalized medicine: Time for one-person trials. Nature. 2015;520:609-611.
Winstein C. Translating the Science into Neurorehabilitation Practice: Challenges and Opportunities (The Kenneth Viste, Jr. MD Lecture). American Society of Neurorehabilitation Annual Meeting. Washington, DC.2013.
Dobkin BH, Nadeau SE, Behrman AL, et al. Prediction of responders for outcome measures of locomotor Experience Applied Post Stroke trial. J Rehabil Res Dev. 2014;51:39-50.
Rodeghero JR, Cleland JA, Mintken PE, Cook CE. Risk stratification of patients with shoulder pain seen in physical therapy practice. J Eval Clin Pract. 2017;23:257-263.
Walter CS, Hengge CR, Lindauer BE, Schaefer SY. Declines in motor transfer following upper extremity task-specific training in older adults. Exp Gerontol. 2018;116:14-19.

High-Risk Over-the-Counter Medications for Older Adults

By Katie Cummins, PharmD Candidate 2019 and Lisa Hutchison, PharmD, MPH, BCPS, BCGP, FCCP
Donald W. Reynolds Institute on Aging at UAMS

As our patients age, their bodies undergo physiological changes that alter their responses to many drugs. Kidney and liver function decline so that some drugs stay in the body longer or accumulate to dangerous levels. Body composition changes – muscle decreases while the proportion of fat increases – can lead to the need for smaller doses or longer dosing intervals. In addition, older adults are generally more sensitive to many drugs, especially those that affect the central nervous system. Patients are sensitive to both the effects the drugs are designed for as well as their negative side effects.¹

Medications that are “potentially inappropriate” for older adults are detailed in the Beers’ Criteria. The Beers’ list is a tool for providers to help identify medications that could be problematic for older patients. It can also be used as a guide for future drug selection. Some of the concerns outlined in the 2015 Beers’ criteria include adverse events like: dizziness, drowsiness, constipation, confusion, bleeding risk, orthostatic hypotension, and delirium.²

However, these side effects are not limited to prescription drugs; the over-the counter (OTC) section of the pharmacy contains medications that may be inappropriate or even dangerous to older adults. Though they may appear to be safer options since they are widely available, they are not without risk for harm. Some of these potentially inappropriate OTC medications are:

Diphenhydramine: also known as Benadryl³
1. Commonly found in products branded as PM or Nighttime – Tylenol PM, Advil PM, Unisom, ZzzQuil, Delsym Cough+Cold Nighttime, Theraflu Nighttime Severe Cold and Cough
2. Used as sleep aid or anti-histamine for allergies
3. Side effects: confusion, drowsiness, dizziness, delirium, dry mouth, constipation
Oxybutynin: also known as Oxytrol for Women⁴
1. Topical patch marketed for overactive bladder
2. Side effects: drowsiness, delirium, dizziness, dry mouth, constipation
Meclizine: also known as Dramamine Less Drowsy, Bonine⁵
1. Commonly found in products marketed for motion sickness or vertigo
2. Side effects: dizziness, drowsiness, dry mouth, constipation, can worsen dementia symptoms
NSAIDs (non-steroidal anti-inflammatory drugs): ibuprofen, naproxen,
1. Common brand names: Motrin, Advil, Aleve
2. May increase risk of GI bleeding, cardiac events²
  1. Take extra caution if taking daily aspirin or prescription blood thinners or anti-platelets like warfarin, clopidogrel (Plavix), prasugrel (Effient), apixaban (Eliquis), dabigatran (Pradaxa)
PPIs (proton pump inhibitors): such as omeprazole, lansoprazole
1. Common brand names: Prilosec, Prevacid
2. May contribute to bone loss with long-term use which increases fracture risk with a fall
3. Can increase risk of bacterial C. difficile infections – symptoms include severe diarrhea²

This is not to say that older adults should avoid all OTC products in the community but rather to show that it is important to for providers to ask if they are taking these products. Documenting this information can prevent the need for additional prescriptions to treat side effects that may be caused by an OTC product – halting a prescribing cascade in its tracks.

References

Hajjar ER, Gray SL, Slattum Jr PW, Hersh LR, Naples JG, Hanlon JT. Geriatrics. In: DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey L. eds. Pharmacotherapy: A Pathophysiologic Approach, 10e New York, NY: McGraw-Hill; http://accesspharmacy.mhmedical.com/content.aspx bookid=1861&sectionid=146077984. Accessed July 26, 2018.
American Geriatrics Society 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. Journal of the American Geriatrics Society. 2015;63(11):2227-2246. doi:10.1111/jgs.13702.
Diphenhydramine. Lexi-Drugs. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL. Available at: http://online.lexi.com. Accessed July 26, 2018.
Oxybutynin. Lexi-Drugs. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL. Available at: http://online.lexi.com. Accessed July 26, 2018.
Meclizine. Lexi-Drugs. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL. Available at: http://online.lexi.com. Accessed July 26, 2018.

Geriatric Student Scholars Selected for FY 2019

It is with great pleasure that the Arkansas Geriatric Education Collaborative (AGEC) announces its 2019 selection for the Geriatric Student Scholars program – Samantha Pennington, a third-year College of Pharmacy student; Taylor Bennett, a third-year College of Medicine student, Holly Bennett, a second-year College of Health Professions student and Larreasha Adams from the College of Nursing Adult-Geriatric Primary Care Program.

The purpose of the Student Scholars program (sponsored by AGEC) is to increase health professions students’ interest and exposure to older adults, to improve knowledge of older adults and the specialized care they need and to promote interprofessional collaboration among health professions students.

We are so excited to announce the Geriatric Student Scholars for FY 2019 to support emerging health professionals education and participation surrounding specialized needs for older adults, and to foster interprofessional collaboration in academic and clinical geriatrics. The goal of the Geriatric Workforce Enhancement Program (GWEP) is to enhance the quality of health care for elderly Arkansans through research, education and training. The Geriatric Student Scholars program is an excellent way to achieve this goal and mentor future healthcare team members. – AGEC Director, Robin McAtee, Ph.D., RN., FACHE

UAMS’ Arkansas Geriatric Education Collaborative is a program of the University Of Arkansas for Medical Sciences – Department of Geriatrics. The collaborative is funded by a Health Resources and Services Administration grant of $3.2 million for a Geriatrics Workforce Enhancement Program.

Mitigating Risk of Intracranial Hemorrhage while using Blood Thinners

UAMS logo

By Hope Quattlebaum, PharmD candidate and Lisa C Hutchison, PharmD, MPH
Donald W. Reynolds Institute on Aging at UAMS

Blood thinners, such as novel oral anticoagulant agents (NOACs), reduce the risk of developing an emboli (clot) in conditions such as atrial fibrillation (afib), deep venous thrombosis (DVT), and other cardiovascular conditions. The NOACs include apixaban (Eliquis), rivaroxaban (Xarelto), dabigatran (Pradaxa), and edoxaban (Savaysa). Using blood thinners prevent clots of all kinds, even ‘good’ clots. When ‘good’ clots are inhibited serious bleeding can occur, such as intracranial hemorrhage (ICH).

Clinicians sometimes mitigate risk by choosing to use aspirin in place of a NOAC since it is thought to have a lower risk of ICH. However, studies show that apixaban 5 mg twice daily did not increase ICH compared to aspirin therapy in afib patients⁶. Based on this, apixaban is a better choice than aspirin since it poses no additional risk and is more effective. However, it was not known if this conclusion could be applied to other disease states. A meta-analysis published in 2018 attempted to answer this question.

The meta-analysis included five major randomized controlled trials (RCTs) with the purpose to assess the risk of ICH with NOACS versus aspirin in all indications⁵. The researchers looked for RCTs that compared apixaban and rivaroxaban to aspirin for 3 or more months. The primary endpoint was rates of ICH in NOACs versus aspirin. The table provides information on the age, disease state and comparison groups in each of the five studies.

Trial name	Mean age (years)	Disease state	Treatment groups
AVERROES⁶, 2014	70	Atrial fibrillation	5mg apixaban twice daily v. aspirin 81-324 mg
NAVIGATE ESUS¹, 2018	67	Embolic stroke of undetermined source	15 mg rivaroxaban once daily v. aspirin 100mg
EINSTEIN CHOICE⁴, 2017	58.5	Venous thromboembolism	20mg or 10 mg daily rivaroxaban v. aspirin 100mg
COMPASS², 2017	68.2	Stable cardiovascular disease	5 mg rivaroxaban twice daily v. aspirin 100 mg
COMPASS³, 2017	67.8	Stable peripheral or carotid artery disease	5 mg rivaroxaban twice daily v. aspirin 100 mg

After pooling evidence, the researchers determined that the risk of ICH with rivaroxaban 10-20mg daily is 3.31 times higher than aspirin. Lower doses, 10 mg daily or 5 mg twice daily, were not associated with higher risk of ICH. Apixaban did not show an increased risk. Researchers calculated that 15-20 mg rivaroxaban can cause an additional 3 hemorrhages per 1000 patients compared to aspirin or apixaban. Evaluation of the secondary endpoint showed that rivaroxaban 15-20 mg increased the rate of fatal bleeding by 2.37 times compared to aspirin and apixaban 5mg twice daily. Also, the same dose is associated with 2.64 times higher risk for major bleeding compared to aspirin, while apixaban showed no increase in risk.

This meta-analysis provides substantial evidence that rivaroxaban at higher doses (15-20 mg daily) increases risk of ICH and fatal bleeding in many patients needing anti-thrombotic therapy. These doses are equivalent to those recommended in afib, DVT treatment, but higher than the recommended dose for DVT prevention, 10 mg daily. Apixaban 5 mg twice daily and rivaroxaban 10mg were not associated with these increased risks. Unfortunately, no direct comparisons could be made between aspirin and dabigatran or edoxaban.

References

¹ Hart RG, Sharma M, Mundl H, et al; NAVIGATE ESUS Investigators. Rivaroxaban for stroke prevention after embolic stroke of undetermined source. N Engl J Med. 2018;378(23):2191-2201. doi: 10.1056/NEJMoa1802686
² Eikelboom JW, Connolly SJ, Bosch J, et al; COMPASS Investigators. Rivaroxaban with or without aspirin in stable cardiovascular disease. N Engl J Med. 2017;377(14):1319-1330. doi:10.1056/NEJMoa1709118
³ Anand SS, Bosch J, Eikelboom JW, et al; COMPASS Investigators. Rivaroxaban with or without aspirin in patients with stable peripheral or carotid artery disease: an international, randomised, double-blind, placebo-controlled trial. Lancet. 2017;S0140-6736(17)32409-1.
⁴ Weitz JI, Lensing AWA, Prins MH, et al; EINSTEIN CHOICE Investigators. Rivaroxaban or aspirin for extended treatment of venous thromboembolism. N Engl J Med. 2017;376(13): 1211-1222. doi:10.1056/NEJMoa1700518
⁵ Huang W, Singer DE, Wu Y, et al. Association of Intracranial Hemorrhage Risk With Non–Vitamin K Antagonist Oral Anticoagulant Use vs Aspirin Use: A Systematic Review and Meta-Analysis. JAMA Neurol. Published online August 13, 2018. doi:10.1001/jamaneurol.2018.2215
⁶ Connolly, S. J., Eikelboom, J., Joyner, C, et al; AVERROES Steering Committee and Investigators. Apixaban in patients with atrial fibrillation. N Engl J Med. 2011; 364(9), 806-817.

Seniors Bullying Seniors

Theresa Horton, MNSc, CNP, GNP-BC, CADDCT, CFRDT
Director of Education
South Central Center on Aging

Anti-Bullying Month is observed in October. Bullying is typically associated with a younger population. However, bullying among adults occurs in multiple settings and older adults are not immune from being victims. Bullying is defined as “unwanted aggressive behavior; observed or perceived power imbalance; and repetition of behaviors or high likelihood of repetition.”

It is estimated that 20% of older adults experience some form of bullying. Healthcare professionals, staff and families should be aware of what bullying behavior looks like and its potential effects. It can be subtle or aggressive. Bullying can include behaviors such as teasing, insulting, gossiping, criticizing, ignoring, whispering, name calling, laughing at or taunting someone, sarcasm, rude comments, use of threats, arguing, lying about the victim, destruction of property, stealing, pushing, hitting, barring from entering or exiting a room, physical or verbal sexual harassment, shunning, ostracizing, spreading rumors, enforcing non-existent seating assignments, using negative body language (offensive gestures or facial expressions, mimicking physical disability, turning away when victim speaks, etc.), and cyber bullying.

Traits that cause a person to bully someone vary and can include increased stress, the need for power or control, low self-esteem, passive-aggressive behavior, verbal or physical aggressiveness and a superiority complex. Some older adults have a history of bullying that has continued throughout life. An older adult may bully because of prejudices or because of a sense of loss of control in their life. They may be dealing with loneliness or boredom or suffer from health conditions, such as dementia, that may contribute to bullying behaviors.

Identifying factors that can increase the risk of an older adult being bullied is important for intervention and prevention. Some of these include being new to a community, having little or no support network, being heavily dependent on others for daily needs, or having a passive demeanor. Others may be at risk for bullying if they annoy or irritate others or are quick-tempered. Health conditions or physical disabilities can increase the risk as well.

Bullying can have cognitive, physical, psychological or emotional consequences and can affect not only the victim, but also those who witness it. Policies should be in place to develop clear rules and expectations, including appropriate assessments and interventions. It is important that any complaints be taken seriously and that staff be educated to recognize and report bullying immediately.

Sources:

Bullying Among Seniors (and Not the High School Kind). National Center for Assisted Living. 2017

http://www.mybetternursinghome.com/senior-bullying-guest-post-by-robin-bonifas-phd-msw-and-marsha-frankel-licsw/

Opioid Abuse Among Older Adults: A Growing Concern

By Stephanie Rose, MSW
Department of Health Sciences, University of Central Arkansas

With the increase among the aging Baby-Boomer population, there has been an overall increase of prescription drug use. Many older adults struggle with co-morbid diagnoses, contributing to multiple prescriptions being consumed at one time (Dowell, 2016). Older adults are also more likely to be victims of medication theft (Collins, 2018). With the rising amounts of opioid overdoses, the use of opioids for pain-management among older adults is a growing concern (Dowell, 2016). Historically, there has been more of a focus on younger adults and opioid misuse; however, the average age (50 or older) of treatment admissions for opioid abuse is rising. One in four older adults have used a prescription drug that has the potential for addiction (Carew, 2018). The U.S. Department of Health and Human Services found that while 500,000 older adults were prescribed higher than recommended amounts of opioids, 90,000 of these individuals were identified as high risk for abuse and/or overdose (Collins, 2018).

It is projected that the amount of older adults who abuse illicit substances will double by 2020 (Carew, 2018). Misuse and abuse of prescription opioids in older adults is associated with higher levels of pain, depression and low-level physical disabilities. In 2012, 2.9 million adults, age 50 or older reported using their prescription medications for reasons other than prescribed. Pain-medication accounted for almost half of drug-toxicity related visits to the emergency room for those ages 50 or older (Chang, 2018). This highlights the need for increased attention on older adults and opioid misuse/abuse.

There are a number of initiatives being developed and implemented in order to address these concerns. The CDC has developed guidelines regarding better management of chronic pain (Loreck, 2016). These guidelines address pain management strategies including the oversight of prescription and opioid use, appropriate opioid selection, patient education, when to cease opioid prescriptions, as well as appropriate follow-up (Dowell, 2016). Additional risks and concerns are associated with ceasing opioid prescription-management too quickly, particularly if the person is not provided adequate follow-up and resources for pain-management (Collins, 2018). This is especially concerning due to the rise of heroin use among older adults, as well as, an increase in those who are ages 50-70 receiving methadone treatment (Carew, 2018).

Interventions

Knowing the warning signs of substance abuse can assist with intervention that may save lives. It is important to increase awareness of what interventions are available and what to do should there be a concern. Some helpful tips include:

Knowing what resources exist to assist older adults is important. Proper treatment is essential, particularly since higher rates of depression and anxiety were reported among those ages 50 and older and who misused/abused their opioid prescriptions. Factors that can affect the rates of abuse may include use of opioids as an attempt to cope with the multiple changes that occur in this life-stage, as well as perceived greater pain (Chang, 2018).
Look for warning signs of substance abuse. Several warning signs include slurred speech, hostile and/or depressed mood, memory loss, confusion, and increased isolation. (Hazelden, 2018).
Increasing social engagement can be helpful, particularly since increased opioid use is associated with increased isolation (Chang, 2018).
Identifying supportive resources, including housing and food assistance, as well as addiction education that addresses issues of empowerment, decreasing stressors and enhancing coping skills. (Hazelden, 2018).

It is of further importance to select the right treatment. Due to the complex needs of an individual struggling with addiction, it is important for treatment to seek appropriate practitioners with expertise. Addiction is influenced by a variety of issues, including genetics, mental health, environmental and health factors. An array of practitioners with special skills and training who can appropriately address substance use disorders are available. Some examples of special certifications in Arkansas include Licensed Alcoholism and Drug Abuse Counselor (LADAC), Licensed Associate Alcoholism and Drug Abuse Counselor (LAADAC), Advanced Alcohol and Drug Counselor (AADC) and Certified Alcohol and Drug Counselor (ADC). These credentials require years of additional experience and education focused on addiction. Many times, these are additional credentials and education that general licensed mental health providers (LPC, LCSW, PsyD, PhD, etc.) acquire in order to provide adequate treatment to those struggling with addiction. Being well versed on the treatment options available can be especially beneficial.

The rise of opioid misuse and abuse among older adults continues to be a growing concern and challenge. There are a number of related dangers and outcomes on the rise, particularly since the population of older adults continues to increase. Many of the needs and risk factors of older adults using opioid prescriptions are unique and require well-informed interventions. The UCA Addiction Studies Program prepares students to work in the addiction field by providing comprehensive education in the field of addiction. Students obtain knowledge of addiction including mental health, counseling skills, prevention, as well as, epidemiology and etiology of addiction. The program also requires an internship experience within the field of addiction treatment. UCA Addiction Studies Program continues to prepare students with a special skill-set to address this ever-growing need.

References

Carew, A. M., & Comiskey, C. (2018). Treatment for opioid use and outcomes in older adults: A systematic literature review doi:https://doi-org.library.capella.edu/10.1016/j.drugalcdep.2017.10.007

Chang, Y. (2018). Factors associated with prescription opioid misuse in adults aged 50 or older doi:https://doi-org.library.capella.edu/10.1016/j.outlook.2017.10.007

Collins, S. (2018). Older Americans and opioid misuse: supporting an often overlooked populations in the opioid crisis. Retrieved August 29, 2018

Dowell, D., Haegerich, T., & Roger, C. (2016). CDC guidelines for prescribing opioids for chronic pain-United States. Retrieved August 27, 2018 from: https://www.collins.senate.gov/newsroom/older-americans-and-opioid-misuse-supporting-often-overlooked-population-opioid-crisishttps://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fmmwr%2Fvolumes%2F65%2Frr%2Frr6501e1er.htm

Loreck, D., Brandt, N. J., & DiPaula, B. (2016). Managing opioid abuse in older adults: Clinical considerations and challenges. Journal of Gerontological Nursing, 42(4), 10-15. doi:http://dx.doi.org.library.capella.edu/10.3928/00989134-20160314-04

Hazelden Betty Ford Foundation. (2018). Older adults deserve recovery from alcoholism, addiction to prescription drugs. Retrieved August 29^th, 2018 from: http://www.hazelden.org/web/public/ade60306.page

Substance Abuse and Mental Health Services Administration. (2017). Opioid use in the older adult population. Retrieved August 27, 2018 from: https://www.samhsa.gov/capt/sites/default/files/resources/resources-opiod-use-older-adult-pop.pdf

Flu Vaccination Toolkit Aimed at Increasing Flu Vaccination Rates in Communities

ImmunizeAR

by Heather Mercer
Executive Director, ImmunizeAR

Last flu season was brutal. In Arkansas, 227 people died from influenza, including 171 adults who were 65 and older, and we had a record number of flu-related hospitalizations. Arkansans aren’t doing a great job getting flu vaccines. According to the CDC, only 46 percent of the general population got a flu vaccine during the 2016-17 season.¹ One reason for the low vaccination rate in Arkansas may be a lack of patient understanding of the efficacy of the flu vaccine. The media didn’t help this last year when they wrongly reported the U.S. flu vaccine was only 10 percent effective based on Australia’s flu season. Vaccinations for other diseases work so well that people may have unrealistic expectations for the flu vaccine. Some individuals choose not to get the flu shot because of the evidence that the flu vaccine isn’t 100% effective in preventing the flu. However, if someone receives the flu shot and still gets the flu, the flu shot can reduce the severity of their symptoms and help them stay out of the hospital. A better understanding of this information could help increase people’s willingness to accept the vaccine.

To improve the numbers of Arkansan’s getting the flu vaccine, The Arkansas Immunization Action Coalition (ImmunizeAR) has available for distribution, by downloading and printing from their website, a Flu Prevention Workshop toolkit, “Let’s Talk About the Flu.” The toolkit provides all the materials needed for a church or a community-based organization to host a one-hour long interactive workshop in plain language. It is designed to help increase flu vaccinations among adults, including older adults. The purpose of the workshop is to help community members learn about the flu in an easy to understand manner, provide information about the flu vaccine, address questions and concerns about the flu vaccine in a supportive environment, and if possible provide the flu vaccine at the end of the workshop with the assistance of a pharmacist. The toolkit is available on the ImmunizeAR website in English and Spanish https://www.immunizear.org/let-s-talk-about-the-flu .

It is important for everyone over the age of six months to get a flu vaccine every year. For older adults and others who are at high-risk of complications, a flu vaccine can reduce hospitalizations by as much as 70 percent and deaths by 85 percent.² It is the best way to protect you and your family.

The CDC recommends getting a flu vaccine before flu begins spreading in the community. It takes about two weeks after vaccination for antibodies that protect against flu to develop in the body. It is recommended people get a flu vaccine by the end of October. The flu vaccine is available at most pharmacies and physician offices and the Arkansas Department of Health that started their mass flu clinics at the end of September. You can go to this link to find a mass flu clinic in your area: https://www.immunizear.org/news-and-events-1

ImmunizeAR is a non-profit organization dedicated to improving vaccination rates for all Arkansans through education, advocacy, and statewide partnerships. If you would like more information about the flu prevention toolkit or ImmunizeAR, please email heather@immunizear.org.

FluVaxView 2016-2017 Flu vaccination rates for persons aged 6 months and older. https://www.cdc.gov/flu/fluvaxview/reportshtml/trends/index.html
https://www.cdc.gov/flu/about/disease/65over.htm