Chadley Uekman

Proton-Pump Inhibitors as Potentially Inappropriate Medications in Older Adults

Arkansas Geriatric Education Collaborative

By: Janna Hawthorne, PharmD, University of Arkansas for Medical Sciences

In October 2015 the American Geriatrics Society (AGS) released updates to the 2012 version of the Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. A. new class of drugs, proton-pump Inhibitors (PPIs), was added to the 2015 AGS Beers Criteria as potentially inappropriate in older adults.(1) PPIs are clinically indicated for use in acute ulcers, gastroesophageal reflux disease, erosive esophagitis, hypersecretory conditions, prevention of nonsteroidal anti-inflammatory drug (NSAID)-induced ulcers, and treatment of Helicobacter pylori infections.(2)

Commonly prescribed, and also available over-the counter, PPIs include omeprazole (Prilosec), esomeprazole (Nexium), and pantoprazole (Protonix). In 2015, it was reported that esomeprazole (Nexium) was the fourth highest prescribed medication in the United States, ranking with 15.2 million prescriptions annually.(3) The warning with PPIs in the 2015 AGS Beers Criteria is based upon studies which indicate that PPI use longer than eight weeks in the elderly population can put them at increased risk for developing Clostridium difficile infection (CDI) and can lead to bone loss and fractures.(1) In this update, the evidence suggesting potential for inappropriate use of PPIs in older adults is high with the strength of recommendation being strong. (1) A high quality of evidence implies that the studies were well-conducted, well-designed, and looked at the population in question. The strong recommendation informs us that the benefits of not using this class of medications outweighs the risk that is apparent with its use.(1)

The enhanced risk of Clostridium difficile infection is due to the potent acid suppressing nature of PPIs. Low acidity within the stomach provides ingested bacteria an environment in which they can flourish. If Clostridium difficile bacteria colonize the stomach, they can overpower the normal gut flora and produce toxins that lead to intestinal injury and inflammation.(2) The injury and inflammation that develop from this exposure will produce extensive diarrhea that could lead to dehydration, delirium, and other critical conditions within the elderly population. In a 2012 meta-analysis looking at the association of PPIs with development of Clostridium difficile infection, data showed that for every 3,925 patients taking a chronic PPI, one person will develop a Clostridium difficile infection, nearly twice the normal incidence of CDI.(4)

PPIs also have the added concern for increased bone loss and subsequent fracture. Theories suggest that calcium must have acid in order to be absorbed from the stomach. Therefore, the acid suppressing manner of PPIs may result in decreased calcium absorption and subsequent loss of bone mineral density (BMD).(5) Elderly women lose BMD at a rate of 10% per decade after menopause and elderly men decline at the same rate later in life. With the great decline in BMD simply due to aging alone, anything to exacerbate this decline could result in tremendous complications, such as hip fracture. In 2015 a meta-analysis was published that looked at the risk of fracture as associated with the use of PPIs. Data from this meta-analysis reported a 26% increase in hip fractures in patients who take PPIs chronically. The risk of spine and any-site fracture also increased by 58% and 33% respectively.(5)

High-risk patients who have erosive esophagitis, Barrett’s esophagitis, pathological hypersecretory conditions, are on oral corticosteroids or prolonged use with NSAIDs, or have demonstrated need for maintenance therapy may benefit from chronic PPI use.(1) If a patient does not have a medical indication for chronic use of PPIs, therapy should be tapered and discontinued. The first step in discontinuation of therapy would be to decrease the daily dose to the lowest dose possible. After a few weeks of the lowest possible dose, the PPI should be discontinued. After discontinuation, the patient should self-monitor for relapse of symptoms such as heartburn, indigestion, and chest pain. If symptoms recur, you may initiate a trail trial period of 4-8 weeks of the lowest possible dose of a preferred PPI or initiate therapy with a histamine2-receptor antagonist. The patient should then be followed closely and another trial of discontinuation should be tried.(6)

References:

1. American Geriatric Society 2015 Beers Criteria Update Expert Panel (2015). American Geriatrics Society 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. Journal of American Geriatric Society, 63, 2227-2246. doi: 10.1111/jgs.13702
2. Kapadia, A., Wynn, D., & Salzman, B. (2010). Potential adverse effects of proton pump inhibitors in the elderly. Clinical Geriatrics. 18(7), 24-31.
3. Brown. T. (2015). 100 best-selling, most prescribed branded drugs through March. Medscape Medical News. Retrieved from http://www.medscape.com/viewarticle/844317
4. Tleyjeh, I., Bin Abdulhak, Aref., Riaz, M., Alasmari, F., Garbati, M., AlGhamdi, M., Rahman Khan, A., Al Tannir, M., Erwin, P., Ibrahim, T., AlLehibi, A., Baddour, L., & Sutton, A. (2012). Association between proton pump inhibitor therapy and Clostridium difficile infection: a contemporary systematic review and meta-analysis. Plos One. 7(12), 1-12.
5. Zhou, B., Huang, Y., Li, H., Sun, W., & Liu, J. (2015). Proton-pump inhibitors and risk of fractures: an update meta-analysis. Osteoporosis International, 26(10), 1-9. doi: 10.1007/s00198-015-3365-x
6. PPIs in older people—do you know the risks? (2014, January), Health News and Evidence. Retrieved from http://www.nps.org.au/publications/health-professional/health-news-evidence/2014/ppi-risks-in-older-peopleProin

The Importance of Nutrition Assistance in Older Adulthood

by Alicia S. Landry, PhD, RD, LDN, SNS, Assistant Professor/University of Central of Central (UCA)

After age fifty, there are many metabolic and physiologic changes impacting the nutritional needs of an individual. A slower metabolic rate with age is due to a decrease in muscle mass; this results in lower caloric needs. Many older people experience difficulty obtaining sufficient nutrients to support or achieve optimal health. These challenges may be related to inadequate dentition or swallowing issues, cognitive and psychosocial changes, as well as insufficient income. Inadequate energy intake can eventually lead to chronic fatigue, depression, and a weakened immune system.1

As health practitioners, it is critical that we encourage older adults to consume nutrient-dense diets. The significance of this was noted in 2006 when the inclusion of separate nutrition recommendations for individuals 70 and over2 was made. Meeting daily protein requirements is essential for the aging adult because protein provides essential nutrients for the maintenance of bone structure and muscle mass. The Recommended Dietary Allowance for protein is 0.66 grams/kilogram/day for adults over 70 years of age, however, recommendations for older adults suggest that 1.2 grams/kilograms/day will meet the needs of many older adults. Carbohydrate in the form of high quality fiber, more complex carbohydrates and few simple starches or sugar should equate to 130 grams/day. Fats are the most efficient source of energy but there is no determined recommendation so these should be chosen wisely and should include fats with omega 3 and omega 6 fatty acids.2 Adequate Calcium and vitamin D are also important in the diets of older adults.

Older adults may experience changes in taste and appetite. Physical ailments, prescription medications, and loss of a significant other may impact appetite; emotional factors such as loneliness and depression can affect diet and appetite. Limited budgets may make affording food needed to support a balanced, healthy diet difficult.

“While federally funded programs provide food to millions of older adults each year, there are still many older adults going hungry.3 Food assistance programs can improve nutritional well-being, functional independence, and quality of life.1 General assistance programs such as the Supplemental Security Income (SSI), is intended to increase a person’s income to the defined poverty threshold. However, if SSI benefits are paying for expenses like medications and doctor visits, there may not be enough left for nutrient-dense food. Federal nutrition assistance through the United States Department of Agriculture (; http://www.fns.usda.gov/programs-and-services) include the Supplemental Nutrition Assistance Program (SNAP) and Senior Farmers’ Market Nutrition Program. Unfortunately, only about eight percent of participants in SNAP are aged 60 or over. Many eligible older adults report a “stigma” associated with receiving food assistance and therefore never try to obtain the benefits. According to USDA guidelines, households may have $2,250 in countable resources, such as a bank account, or $3,250 in countable resources if at least one person is age 60 or older, or is disabled. Resources that are not considered include homes and land, resources of people who receive SSI, resources of people who receive Temporary Assistance to Needy Families (TANF), and most retirement (pension) plans. An income test is performed and deductions for medical and shelter costs are included.

“Meals and snacks are provided by Adult Day Care Centers. Commodity foods can be obtained through the USDA’s Commodity Supplemental Food Program. Adult Day Cares are funded through the Child and Adult Care Food Program (CACFP) which provides aid to adult care institutions to provide nutritious foods for the health and wellness of older adults and disabled persons. The Commodity Supplemental Food Program supplements older adults’ diets with foods like low-fat dry milk, juice, rice, oats, peanut butter, dry beans, as well as canned meats, fruits, and vegetables.

“The US Department of Health and Human Services (US DHHS) administers the Older Americans Act Nutrition Program which includes Congregate Nutrition Services, Home-Delivered Nutrition Services, and the Nutrition Services Incentive Program. All people 60 and over as well as their spouses are eligible to receive meals through US DHHS programs regardless of income. The Home-Delivered Nutrition program aims to serve frail, homebound, or isolated individuals who are age 60 or over. The Nutrition Services Incentive Program provides grants to states, territories, and eligible tribal organizations that provide congregate and home-delivered meal programs, like senior centers and Meals on Wheels programs. A sample meal pattern that would be served daily at a congregate feeding site or home-delivered may be seen in Table 1. A very helpful resource may be found with the Older Americans Act Nutrition Programs Toolkit provided online by the National Resource Center on Nutrition, Physical Activity & Aging. Privately funded nutrition resources for aging adults include the National Foundation to End Senior Hunger, Feeding America, local food banks, as well as Meals on Wheels Association of America and others. Meals on Wheels provides a nutritious meal, visit, and safety check with each delivery. Depending on the funds available and the sponsor organization, days/times of delivery and meal composition varies. Regardless, older adults receiving Meals on Wheels food often are able to live at home, independently for a longer time.
Not only is the number of older adults continuing to grow, many older adults are experiencing inadequate savings and retirement. Adequate nutrition can save healthcare dollars and significantly improve quality of life for our aging adults. All health professionals can promote healthy nutrition practices in older adults and identify signs of malnourishment, feeding difficulties, or psychosocial changes impacting nutrient intake.

Table 1. Sample Meal Pattern


Food Type	Recommended Portion Size
Protein foods	3 oz., cooked portion
Vegetables and fruits	Two ½ cup portions
Enriched white or whole grain bread or alternative	1 serving (one slice bread or equivalent)
Butter or margarine	1 tsp
Dairy	8 oz. fat-free or low-fat milk or calcium equivalent
Dessert	One ½ cup serving (fruit, pudding, gelatin, ice cream, sherbet, etc.)
Source: US Department of Health and Human Services

References:
1. Drewnowski A, Shultz JM. Impact of aging on eating behaviors, food choices, nutrition, and health status. J Nutr Health Aging. 2001;5:75–79
2. Otten JJ, Hellwig JP, Meyers LD, editors. IOM. Dietary Reference Intakes: The essential guide to nutrient requirements. Washington, DC: The National Academies Press; 2006.
3. Coleman-Jensen, A., Rabbitt, M., Gregory, C., & Singh, A. (2015). Household Food Security in the United States in 2014, Table 2. USDA ERS.

Alzheimer’s Disease and Dementia

by Kathryn A. Packard, M.Ed., MS, LPC, CDP, CADDCT UAMS Oaklawn Center on Aging / Arkansas Aging Initiative

In 2013, five million Americans were living with Alzheimer’s disease and by 2050 this number is projected to rise to 14 million according to the Centers for Disease Control and Prevention. Alzheimer’s is the sixth leading cause of death for all ages and fifth leading cause of death for people 65 years of age and older. Alzheimer’s Disease does not discriminate; it affects, women, men, and all ethnic groups, and begins at various ages. Someone will develop Alzheimer’s every 65 seconds with an annual cost of more than $203 billion.

The need to increase knowledge and to assist families and those affected by Alzheimer’s disease is growing. In the United States, there are over 15 million unpaid caregivers. Although in recent years much attention has been given to Alzheimer’s Disease, and there is more awareness of the devastation of the disease, more education and information is needed on how to best care for those who have been diagnosed.

The Arkansas Geriatric Education Collaborative is funded to train first responders in the State of Arkansas. Certified First Responder/Alzheimer’s Disease and Dementia Care Trainers will be presenting the training. The curriculum they will be offering was developed by the National Council of Certified Dementia Practitioners. The mission of the training program is “to promote, encourage and enhance the knowledge, skills and practice of all persons who provide care and or services to dementia clients by means of requiring excellent standards of education, dementia specific training and incentives for professional development of those who are dedicated to the ever growing field of dementia care”.

When first responders are called to a scene it is because the caregiver believes there are no other options available to him/her, has reached caregiver burnout, or the dementia person’s behavior has become dangerous to self or others. Knowledge about how to diffuse the situation can be priceless to someone who is afraid, doesn’t know how to handle the situation, and needs assistance. How to approach a dementia client using appropriate tone of voice and facial expressions may seem like a small thing, but to someone who is afraid and confused, knowing what to do can be extremely reassuring and comforting.

For first responders, knowing the difference between normal aging and dementia is also important. Asking appropriate questions of the caregiver to diffuse the situation can be valuable to the entire community. First responders may be the link that assists the caregiver to keep the dementia client at home or in their residential environment.

Alzheimer’s and Dementia Care Training will teach first responders about dementia diagnosis, prognosis, and treatment; how to communicate with the patient and the caregiver; what to look for and how to react with disruptive behaviors, catastrophic reactions, care concerns such as abuse and neglect, and driving issues. Included will be information on diversity, cultural competence, the importance of spiritual care and end of life issues. These are important tools for all first responders as well as for caregivers.

In addition to these special classes offered to first responders, the UAMS Centers on Aging, the Arkansas Aging Initiative, along with the Schmieding Home Caregiver Training programs offer family caregiver workshops with a focus on Alzheimer’s disease. Teaching about dementia can relieve stress for caregivers and enhance a dementia client’s chances of remaining at home. Knowing how to care for dementia patients is the first step toward improving care of our older adults who suffer from this disease. For more information, please visit www.arcargiving.org or www.agec.org.

References:
Budson, Andrew E. and Kowall, Neil W. 2014 John Wiley and Sons ltd.

From the Director’s Desk

Arkansas Geriatric Education Collaborative

by Ronni Chernoff, PhD, FAND, FASPEN, AGEC Director and Professor, Reynolds Institute on Aging

As we transition from an old year to a new one, it is always good to reflect on what we accomplished during 2015 and what our goals are for the new year. Our Geriatric Education Center had an awesome 18 years of developing, producing, and evaluating programs on issues related to aging, and we are so proud of what we contributed to the education and training of health professionals, faculty and students who are looking forward to careers in one of the many health care disciplines in Arkansas. We hope to continue our connection and friendships with many of you while we forge ahead with the Geriatric Workforce Education Program (GWEP), the Arkansas Geriatric Education Collaborative, and meet new people interested in geriatric topics and issues. We all hope that our contribution to improving the health care for our senior citizens continues to be successful.

The Arkansas Geriatric Education Collaborative (AGEC) is moving along right on schedule! We have some new staff members who are part of our group, Sajni Kumpuris and Kerry Krell, MPH, CHES. Sajni has been with the Arkansas Geriatric Education Center working on the Alzheimer’s Disease supplements but has now increased her time and contribution to manage, not only the Alzheimer’s education projects but also, our web-based activities. Kerry is new to the AGEC and is our Outreach Coordinator. She will be working with the new providers and audiences for whom we are developing educational programs and materials. We are excited to have them and look forward to you having the opportunity to meet them.

The new www.agec.org website is being revamped and will offer easier navigation and more features. Watch for the launch in March, 2016. We are in the process of confirming dates for future programs and will get them up on the website calendar as soon as they are set.

Our next program will be a live, interactive 2-hour video teleconference on May 05, 2016 on “Common Dental Issues of Older Adults & Nutritional Implications”. This video teleconference will be live on the UAMS campus and broadcast to interative receiver sites across Arkansas.

Arkansas Geriatric Education Mentors and Scholars (AR-GEMS), our online self-study program in geriatrics for health practitioners, has been updated and will soon be uploaded onto the UAMS Blackboard so that it is more user-friendly.

The AGEC faculty Summer Institute is scheduled for May 16-20, 2016. Letters of invitation were sent to deans of colleges and universities in Arkansas that have health professional programs; the purpose is to update faculty with information about aging and issues that elderly Arkansans have to face and increase the geriatric content in the courses they teach or develop new courses for students who will be the future health care providers.

Watch our video on Alzheimer’s help in Arkansas

Does the use of hearing aids improve balance — fact or fiction?

by D. Mike McDaniel, Professor of Communication Disorders / Arkansas State University

Recently, a team of researchers from a prestigious medical school published the results of a study in which they reported that hearing aid use apparently resulted in improved balance within an elderly sample of hearing impaired individuals (Rumalla, Karim, and Hullar, 2015). These findings were subsequently summarized in a second tier publication favored by, and directed at those, who dispense hearing aids. A recent internet search using “hearing aids” and “improved balance” as key words resulted in an alarming number of sites across the country that dispense hearing aids citing the article and its claims as a marketing tool. Given the fact that the elderly have the greatest risks for falls, which are the leading cause of injury and death in the elderly, and the elderly exhibit the largest incidence for hearing impairment, if the use of hearing aids do improve balance then certainly this information should be disseminated from within the scientific community following extensive clinical trials.

The method by which the medical school chose to assess and report balance was primitive and did not represent current state-of-the-art technology. Fortunately, the Arkansas State University Physical Therapy Department does have computerized posturography which is assessed via a sensory organization testing device. The device is a NeuroCom Balance Master. Through the combined effort of the Communication Disorders and Physical Therapy Departments, researchers were able to replicate the original study. Researchers used a similar population of adult experienced hearing aid users, the same research design, and the more sophisticated NeuroCom Balance Master.

The recent abstract of the AState replication project is as follows:
“The purpose of this study was to evaluate the balance of experienced adult hearing aid users with and without their hearing aids via Computerized Posturography (CP). CP was accomplished by employing the Sensory Organization Test (SOT) on the NeuroCom Balance Master. The SOT assessed each participant’s balance and the strategy used to maintain balance in six progressively challenging conditions. Twenty two adults using bilateral at-the-ear hearing aids participated in the study. All participants completed all SOT protocols with and without their hearing aids. No statistically significant differences in participants’ balance were identified regardless of the presence or absence of their hearing aids during SOT. These results failed to support previous research, which indicated that amplification of auditory input could benefit balance in individuals with hearing and balance disorders. Further research utilizing randomized controlled trials is needed to resolve the disparity between the current results and those of previous studies.”

Clearly, the results of this replication study did not support those from the original research report. In short, researchers were unable to demonstrate any statistical relationship between balance and the use of hearing aids from this group of participants. Findings do support the need for a comprehensive clinical trial before claims of improved balance from hearing aid use can be made.

References:

Rumalla, K., Karim, A. M., & Hullar, T. E. (2015). The effect of hearing aids on postural stability.
The Laryngoscope, 125, 720-723. doi: 10.1002/lary.24974