by Regina Gibson, MALS, CHES, CCRP,
Arkansas Geriatric Education Collaborative (AGEC)

Pictured above are Dr. Ronni Chernoff and Dr. Jeanne Wei

Recently at the College of Medicine Annual Faculty Dinner, Ronni Chernoff, Ph.D., professor in the Department of Geriatrics at the Donald W. Reynolds Institute on Aging and Director of the Arkansas Geriatric Education Collaborative, received an award of admiration and appreciation for her commitment to excellence in education programs. She was thanked for her vision, dedication, and inspiration.

Chernoff is a graduate of Cornell University. She earned two master’s degrees from Columbia University and a doctorate in health professions education from the University of Pennsylvania. The author or editor of numerous widely used textbooks including Geriatric Nutrition: The Health Professional’s Handbook (Jones & Bartlett), Chernoff has published dozens of research studies, book chapters and other publications on geriatric nutrition, nutrition support, and clinical nutrition. Chernoff has held leadership positions in the American Society for Parenteral and Enteral Nutrition; the Gerontological Society of America; the National Association of Geriatric Education Centers and the National Association for Geriatric Education. Her service at the national level includes the White House Conference on Aging; Medicare Coverage Advisory Committee; the Institute of Medicine’s Committee to Review Child and Adult Care Food Program Meal Requirements; and has served as a member of the Cornell University Board of Trustees. Dr. Chernoff is also the former president of the Academy of Nutrition and Dietetics.

by Cynthia C. Mercado, EMBA, M.A. and Stanley K. Ellis, Ed.D.

Evidence–based outcomes have become the by-word of research organizations, especially to document accountability for use of scarce resources in government-funded research. The Arkansas Geriatric Education Collaborative (AGEC), a Geriatric Workforce Enhancement Program funded by the Health Resources and Services Administration, is a case in point. Currently, in its second year of implementation, AGEC’s goal is to educate Arkansas’ health care professionals, students, caregivers, first responders and the general public about issues and topics that affect the older population. Advancing such goals requires AGEC to offer a whole host of initiatives such as video teleconferences, Alzheimer’s Dementia training, Geriatric Grand Rounds, Arkansas Geriatric Mentors and Scholars (AR-GEMS), evidence-based self-management programs for older adults, caregiver classes, first responder classes, and Summer Institute for Faculty, among others.

How does AGEC track the progress of these endeavors? How does AGEC know whether these initiatives reach their intended end-users? How can AGEC best respond to the current needs of Arkansas healthcare professionals? Answering such questions provides AGEC valuable feedback to guide planning and policy directives.

To answer these questions AGEC, in collaboration with the UAMS Office of Educational Development Evaluation (OED) Team, has designed a process to help assess and evaluate the outcomes of their numerous educational endeavors. Both quantitative and qualitative data are collected from participants using mailed and online survey questionnaires. To date, OED has created and administered Survey Monkey questionnaires to evaluate the program’s impact on the practice/job of the participants and knowledge shared with friends and co-workers (90-day evaluation); evaluated programs and speakers related to content delivery, and strengths of the educational activity; gathered participants’ feedback about the tour in the Alzheimer’s/Dementia Experience: Take a Walk in Their Shoes; and caregivers’ view of the Geriatric-focused program presentations. These questionnaires include demographic variables such as age, race or ethnicity, gender and professional affiliations. A comprehensive participant database is continuously updated through the use of the Participant Profile surveys. For some participants (e.g., MD, DO, RN, PT), the Program Sign-in Sheet for Contact Credit Hours documents their professional activities to fulfill their mandatory CE/CPE hours.

A program as dynamic as AGEC will continue to evaluate its offerings to help guide the future directions and address the educational needs of the participants. Plans are underway to conduct a statewide needs assessment in the spring of 2017.

We urge you, the participants in these activities, to complete these evaluations because policy makers and researchers rely on your feedback to make policy decisions and provide activities that will help you, your clients and loved ones receive quality services they deserve.

by Laura Smith-Olinde, Ph.D., CCC/A, and Steven E. Boone, Ph.D.

Roughly 15%, ~37.5 million people, of the entire adult U.S. population has hearing loss, but the percentages increase with age. In adults aged 55 to 64, 17% have significant hearing loss; that number goes up to 25% for adults aged 65 to 74 and is over 50% in adults older than 75 years.¹

When we talk with someone who has hearing loss, we usually know it, even though we cannot see the loss directly. Studies have linked untreated hearing loss to dementia, cognitive decline, and increases in social isolation, and depression.^2-6 Recent studies show that older adults using hearing aids or cochlear implants have better communication. They also have slower cognitive decline, and fewer social isolation and depression symptoms.^7-10 With such positive results, urging older adults to seek healthcare for diagnosis and treatment of hearing loss makes sense.

The best hearing healthcare starts with seeing an audiologist for hearing and communication needs assessments. Assessments include listening needs for face-to-face, media (TV, radio, movies), telecommunications (phone, computer), and alerting signals (alarm clock, smoke alarm) situations.¹¹ Audiologists should also help their clients figure out if they need any hearing assistive technologies to meet these needs and what kinds of devices may work best for them and their families. Right now, no medicine or surgery can cure age-related hearing loss. The best treatments remain aural rehabilitation and sound amplifying devices, the most well known being hearing aids. Digital hearing aids provide great sound quality, but digital technology keeps hearing aids costly ($400-$3000 per aid) and many people cannot afford them.¹² Medicare does not cover hearing aids, but some Medicare Advantage plans and other insurers offer partial coverage.

It happens that there are other, lower-cost amplification choices than hearing aids: handheld devices and personal sound amplifying products (PSAPs). Handheld devices have a microphone to place near the sound source and send the sound directly to earphones either wirelessly or through a wire. Sending the sound straight to the listener bypasses other sounds in the area and makes speech easier to comprehend. One example of a handheld device is “TVEars” ($60.00 -$160.00).¹³ Housemates without hearing loss often complain the TV is too loud; using TVEars the person with normal hearing can set the TV volume, while the person with hearing loss adjusts the TVEars volume. Another example is the “Pocketalker Ultra 2.0” (~$175.00).¹³  Unlike the wireless TV Ears, the Pocketalker has a wire that plugs into the microphone and carries sound directly to the earphones. The 2.0 version also has a “telecoil” that can pick up sounds in any setting that is “looped”, for example churches and theaters. The Pocketalker microphone/amplifier is about the size of a TV remote and can be used anywhere, for example in a pharmacy, a doctor’s office, or a nursing home. A sound amplifier could help ensure that patrons with hearing loss can hear and comprehend what is said and not just nodding and smiling.

The second choice, Personal Sound Amplification Products (PSAPs), costs $10 – $400 each, making them more attractive than hearing aids. The Food and Drug Administration (FDA) classifies hearing aids as Class 1 medical devices but does not regulate PSAPs. The FDA issued guidance in 2013 on PSAPs: (1) PSAPs should not be used to treat hearing loss;⁽²⁾ PSAPs should be used by those with normal hearing who need a boost in some settings; and ⁽³⁾ no professional fitting is needed.¹⁴  PSAPs look like hearing aids and amplify sound, but they are not designed to fit a specific hearing loss. In terms of function, a recent study ¹⁵ showed that two low-cost PSAPs (Woodland Whisper; CyberScience Amplifier) and one low-end hearing aid (MD Hearing Aid Pro) did not give enough amplification at the high pitches needed by most people with age-related hearing loss, and generated a lot of internal noise, which may interfere with listening. For all PSAPs, as hearing loss increased, none gave enough amplification for listeners. Even so, some PSAPs may be a good choice for someone with a mild hearing loss who needs “just a little help sometimes.”

In summary, there are less costly options to hearing aids available over the counter, are less expensive than hearing aids, and do not require a visit to a professional. Devices such as TVEars and Pocketalker have been available for many years and work well. PSAPs are newer, may not give enough amplification if a hearing loss is greater than “mild” and, unlike hearing aids, are not programmable. The best course of action, if possible, is to start with a hearing test and consider hearing aids. Medicare will pay for a hearing evaluation. Test results can help people understand how much hearing loss they have, and will serve as a baseline for future hearing tests.

References

1Anonymous. (2016). Quick statistics about hearing. National Institute on Deafness and Other
Communication Disorders. Accessed from https://www.nidcd.nih.gov/health/statistics/quick-statistics-hearing

2Uhlmann, R. F., Larson, E. B., Rees, T. S., Koepsell, T. D., & Duckert, L. G. (1989). Relationship of hearing impairment to dementia and cognitive dysfunction in older adults. JAMA, 261(13), 1916-1919.

3Lin, F. R., Metter, E .J., O’Brien, R. J., Resnick, S. M., Zonderman, A. B., & Ferrucci, L. (2011). Hearing loss and incident dementia. Archives of Neurology, 68(2), 214-220. doi:10.1001/archneurol.2010.362

4Lin, F. R., Yaffe, K., Xia, J., Xue, Q. L., Harris, T. B., PurchaseHelzner, E. L., … & Simonsick, E. (2013). Hearing loss and cognitive decline among older adults. JAMA Internal Medicine, 173(4), 293-299.

5Sung, Y. K., Li, L., Blake C., Betz, J., & Lin, F. R. (2016). Association of hearing loss and loneliness in older adults. J Aging Health, 28(6):979-94. doi: 10.1177/0898264315614570

6Paul, M., Kawachi, I., & Lin, F. R. (2014). The association between hearing loss and social isolation in older adults. Otolaryngology– Head and Neck Surgery, 150(3) 378–384.

7Mulrow, C. D., Aguilar, C., Endicott, J. E., Tuley, M. R., Velez, R., Charlip, W. S., … & DeNino, L. A. (1990). Quality-of-life changes and hearing impairment: a randomized trial. Annals of Internal Medicine, 113(3), 188-194.

8Choi, J. S., Betz, J., Li, L., Blake, C. R., Sung, Y.K., Contrera, K. J., & Lin, F. R. (2016). Association of using hearing aids or cochlear implants with changes in depressive symptoms in older adults. JAMA Otolaryngol Head Neck Surg, 142(7):652-7. doi: 10.1001/jamaoto.2016.0700

9Dawes, P., Emsley, R., Cruickshanks, K. J., Moore, D. R., Fortnum, H., Edmondson-Jones, M., … & Munro, K. J. (2015). Hearing loss and cognition: the role of hearing aids, social isolation, and depression. PloS one, 10(3), e0119616.

10Li, C. M., Zhang, X., Hoffman, H. J., Cotch, M. F., Themann, C. L., & Wilson, M. R. (2014). Hearing impairment associated with depression in US adults, National Health and Nutrition Examination Survey 2005-2010. JAMA Otolaryngology–Head & Neck Surgery, 140(4), 293-302.
11Compton-Conley, C. (2015). Best practices in hearing enhancement. Hearing Loss Magazine,
July/August, 9-13.

12Bainbridge, K. E. & Ramachandran, V. (2014). Hearing aid use among older U.S. adults: The National Health and Nutrition Examination Survey, 2005-2006 and 2009-2010. Ear and Hearing, 35(3), 289-294.

13Atcherson, S. R., Franklin, C. F., & Smith-Olinde, L. (2015). Hearing assistive and access technology. Plural Publishing, San Diego, CA.

14U.S. Food and Drug Administration (FDA). Regulatory requirements for hearing aid devices and personal sound amplification products—Draft guidance for industry and Food and Drug
Administration Staff. Washington, D.C.: FDA. Nov. 7, 2013. Accessed from
http://www.fda.gov/MedicalDevices/DeviceRegulationandGuidance/GuidanceDocuments/ucm373461.htm

15Smith, C., Wilber, L. A., & Cavitt, K. (2016). PSAPs vs hearing aids: An electroacoustic analysis of performance and fitting capabilities. Hearing Review, 23(7), 18.

The Arkansas Geriatric Education Collaborative (AGEC), a Geriatric Workforce Enhancement Program, has reached the halfway point in our funding. We continue to achieve our goals for this program, along with our long-time partners (ASU and UCA) and our more recent partners (CareLink, Mainline Clinic in Lincoln County, McAuley Senior Center, and AARP), to educate health professionals, students, caregivers, first responders and the general public about issues and topics that affect our older population.  We are also proud of our innovative projects to improve patient care and disseminate best practices information using a variety of delivery systems.

In preparation for a new grand cycle that starts at the end of 2017, we are developing a statewide needs assessment.  We really want, need and appreciate your input and ideas.  Please think about what information or experiences you would like to have to provide better care to our older adult patients.  Then watch and listen for our notification that the needs assessment survey is available and respond to it!  The more input we have, the more valuable our future events will be for you. In the meantime, feel free to e-mail your suggestions for topics and programs to agec@uams.edu or post a note on our website page.

The AGEC funded two junior faculty fellowships during 2016 and had outstanding fellows, Drs. Jennifer Vincenzo and Elvin Price.  Dr. Vincenzo is faculty in physical therapy at UAMS Northwest and Dr. Price is faculty in pharmacy at UAMS.  We are excited to have two new fellows for 2017.  Dr. Lisa VanHoose is physical therapy faculty at UCA and Dr. Upendra Kar is research faculty in the UAMS College of Pharmacy.  We anticipate great things from both of them and are delighted to be able to offer them this opportunity.

We continue to offer video teleconferences four times/year; to sponsor Alzheimer’s disease-focused geriatric grand rounds twice yearly; offer Arkansas Geriatric Education Mentors and Scholars (AR-GEMS) for health care professionals; host the Summer Institute for faculty members who want an update on geriatric content; sponsor training for first responders, community members and others. For those interested in more education and programs in geriatrics, more information can be obtained at our website, www.agec.org.

As we plan ahead, we would love to hear from you about what you would like to know more about. Remember, we will be conducting a statewide needs assessment in the spring, 2017 and hope you will take the time to answer the questions on-line or by using a mailed survey.

We all wish you a very happy and successful new year and look forward to your participation in one or more of our programs.  Hope to see you soon!

Ronni Chernoff, Ph.D., FAND, FASPEN, Director, AGEC and Professor, Reynold’s Department of Geriatrics

By Kerry Krell, MPH

UAMS Arkansas Geriatric Education Collaborative (AGEC)

Fall is here and that means cooler weather, the holidays, and flu season are around the corner. People over the age of 65 are considered high risk for serious complications from the flu, such as pneumonia, bronchitis, sinus infections and ear infections that can quickly lead to hospitalization and sometimes death. Certain medical conditions, such as diabetes, heart disease, chronic lung disease, and people who have a weakened immune system due to chemotherapy or other immune-suppressing medications, put seniors at an even greater risk for flu and flu-related complications.

Fortunately, the flu vaccine is widely available and is the number one tool that health care providers can use to help keep their senior patients healthy. However, the best protection against flu requires a multi-faceted approach. The CDC offers some tips below to maximize older adults’ protection against the flu.

• Strongly encourage patients over the age of 65 to get a flu vaccine. There are two vaccines designed specifically for people 65 and older:
  • The high dose vaccine contains 4 times the amount of antigen as the regular flu shot.
  • The adjuvanted flu vaccine is designed to help create a stronger immune response to vaccination. This vaccine is available for the first time in the United States during the 2016-17 flu season.
• Encourage your older patient’s family and caregivers to also get vaccinated against the flu. By vaccinating the family and caregivers of your patient, you’re helping develop another layer of protection for your older patient. This is particularly important for patients in long-term care facilities. Unfortunately, long-term care personnel continue to have the lowest flu vaccination rates (69.2% compared to 91.2% in hospitals) among all health care personnel.
• Encourage older patients and their caregivers to practice good health habits. This means covering coughs, washing hands often, and avoiding those who are sick.
• Encourage older patients to seek medical advice quickly if they develop flu-like symptoms. This includes fever, cough, sore throat, runny or stuffy nose, body aches, headache, chills and fatigue.
• Advise older patients to get the pneumococcal (pneumonia) vaccine. Flu commonly causes pneumonia and pneumonia is one of the most serious flu-related complications in older adults. This vaccine can protect against pneumonia, meningitis, and bloodstream infections.

Reference:

http://www.cdc.gov/flu/about/disease/65over.htm.

By  Jill S. Detty Oswaks, DNSc, CRNA, and Lorena Thompson, DNP, CRNA

Over the years, anesthesia care and safety has improved, expanding anesthesia delivery to all age groups with a wide range of health needs. Parallel to the increased safety using newer anesthetic agents and technology, scientific knowledge is emerging on the effects of stress and anesthesia on long term health.  The baby boom generation will enter retirement with a greater projected lifespan than their parents and with greater health issues.⁴ Anesthesia providers and patients, aged 60 and older, must be aware of the potential effects of anesthesia on long term health.

Age, which affects almost every organ system, is strongly correlated with diseases, need for hospitalization and length of stay, injuries, and adverse reactions to medications¹. The associated risks for increased morbidity and mortality parallel an increase in surgeries in the aging population.

A major public health concern is post-operative cognitive decline (POCD) in the elderly. The study of POCD is to determine if a link between perioperative care and POCD exists and strategies to prevent its development.  Postoperative cognitive decline is defined as a drop in cognitive performance on neuropsychological tests postoperatively as compared to preoperative performance². Unfortunately, diagnosis can only occur in individuals who have undergone preoperative neuropsychological testing.   The implications of POCD are greater than just cognitive decline and include increased morbidity and mortality, decreased quality of life, and earlier exit from the workforce².

Like any public health concern there are modifiable and non-modifiable risk factors for POCD.   The non-modifiable risk factors include increased age, fewer years of previous education, type of surgery, genetic risk, preoperative renal insufficiency, previous stroke, and lower performance on preoperative neuropsychological tests². Patients’ and anesthesia’s focus is on the modifiable risk factors.

Individuals can contribute to improved postoperative outcomes through smoking cessation, controlling diabetes, and physical exercise^2,3. While aging is associated with decreased physiologic reserve, this is worsened by sedentary lifestyles³. Physical exercise is associated with increasing physiologic reserve and adaptation to stress. Improved physical reserve is associated with decreased psychological stress, better healing, faster return to preoperative physiologic baseline and decreased postoperative pain³.

Anesthesia providers have an ever increasing awareness of monitoring anesthetic depth, medications and adverse effects in the elderly and anesthetic management strategies to improve outcomes. Concerted efforts between the aging patient and anesthesia can decrease modifiable risks and decrease the risk of POCD.

References:

1. Alvis, B.D., & Hughes, C.G. (2015). Physiology considerations in geriatric patients.  Anesthesiology Clinics, 33, 447–456. doi: 10.1016/j.anclin.2015.05.003.
2. Berger, M., Nadler, J., Browndyke, J., Terrando, N., Ponnusamy, V., Cohen, H.J., Whitson, H.E., & Mathew, J.P. (2015). Postoperative cognitive dysfunction: Minding the gaps in our knowledge of a common postoperative complication in the elderly. Anesthesiology Clinics, 33, 517–550. doi: 10.1016/j.anclin.2015.05.008
3. Carli, F. & Scheede-Bergdahl (2015). Prehabilitation to enhance perioperative care.  Anesthesiology Clinics 33, 17–33. doi:10.1016/j.anclin.2014.11.002
4. King, D. E., Matheson, E., Chirina, S., & Shankar, A. (2013). The status of baby boomer’s health in the United States: The healthiest generation? JAMA Internal Medicine, 173(5), 385-386. Jill S. Detty Oswaks, DNSc, CRNA, Lorena Thompson, DNP, CRNA

By Nick Grunewald, PharmD candidate and Lisa Hutchison, PharmD, MPH

Dabigatran is a twice a day oral anticoagulant indicated for stroke prevention in patients having atrial fibrillation and deep vein thrombosis/pulmonary embolism treatment and prevention. These conditions are more prevalent in older and frail adults. Dosage ranges from 110mg twice a day to 150mg twice a day, with 150mg doses noted as having a higher incidence of bleeding.1 Dabigatran becomes therapeutic within 24 hours of administration with continuation of therapy. Studies show that dabigatran is an acceptable alternative to warfarin and has a similar adverse effect profile.2 Dabigatran acts as a direct thrombin inhibitor, and in comparison to warfarin, it does not require frequent monitoring, has a more rapid effect, and fewer drug-drug interactions.

Until now, if a patient on dabigatran had a major bleed, there was no way to quickly reverse its effects. Clinicians (and patients) had to wait until the drug was eliminated from the body for its effect on bleeding to dissipate or sometimes in extreme bleeding situations clinicians might try prothrombin complex concentrate to reverse dabigatran effects. Not having a reversal agent was considered a disadvantage for use of the dabigatran, and clinicians worried about its overall safety in older adults.

Idarucizumab (Praxbind®) has been recently marketed as a reversal agent for dabigatran. It is a humanized monoclonal antibody fragment (Fab) that binds to dabigatran and its metabolites with higher affinity than that of dabigatran’s binding to thrombin, neutralizing its anticoagulant effect. The recommended dose of idarucizumab is 5 g, provided as two doses separated by 15 minutes. Idarucizumab is supplied in vials containing 2.5 g/50 mL.3

In studies of normal volunteers taking dabigatran, after infusion of idarucizumab, immediate and complete reversal of the dabigatran-induced increase in dilute thrombin time (dTT) was reported for all idarucizumab dose groups . Reversal was sustained (i.e., mean dTT values remained at <ULN for 72 h) with the 2 g, 4 g, and 5 g plus 2·5 g doses. In addition to complete reversal of dabigatran, study data showed that 24 hours after administration of idarucizumb, anticoagulation with dabigatran can be restarted with full therapeutic effect.⁴ ⁵ In summation, study data show that complete reversal of dabigatran is obtained in minutes after administering 2 doses of 2.5mg of idarucizumab.

At present, idarucizumab’s place in therapy as a reversal agent for dabigatran is limited to emergent situations. This may decrease the occurrence of major bleeds due to trauma or surgical intervention. However, careful consideration for its use should be made. The average wholesale price (AWP) cost of idarucizumab is $42/mL, equaling $4200 per administration. Casual use of this agent could cause undue expense to patients and institutions. Therefore, risk benefit should be evaluated in every patient that would be considered for administration of idarucizumab.

References:

1. Boehringer Ingelheim. Pradaxa Full Prescribing Information. Last Accessed on 6/25/16. Available at http://docs.boehringer-ingelheim.com/Prescribing%20Information/PIs/Pradaxa/Pradaxa.pdf
2. Dabigatran Versus Warfarin In Patients With Atrial Fibrillation, Connolly SJ, N Engl J Med, 2009, 361(12):1139-51

3. Boehringer Ingelheim. FDA Approves Praxbind® (idarucizumab), Specific Reversal Agent for Pradaxa® (dabigatran etexilate mesylate). PRAXBIND Full Prescribing Information. Last Accessed on 10/27/15. Available at: http://us.boehringer-ingelheim.com/content/dam/internet/opu/us_EN/documents/Media_Press_Releases/2015/Praxbind.pdf

4. S Glund, J Stangier, M Schmohl, et al. Safety, tolerability, and efficacy of idarucizumab for the reversal of the anticoagulant effect of dabigatran in healthy male volunteers: a randomised, placebo-controlled, double-blind phase 1 trial Lancet (2015) published online June 16. Last Accessed on 10/27/15. Available at: http://dx.doi.org/10.1016/S0140-6736(15)60732-2

5. Pollack CV, Reilly PA, Eikelboom J, Glund S, Verhamme P, Bernstein RA, Dubiel R, Huisman MV, Hylek EM, Kapmhusien PW, Kreuzer J, Levy JH, Sellke FW, Stangier J, Steiner T, Wang B, Kam CW, Weitz JI 2015) Idarucizumab for dabigatran reversal. N Engl J Med 373:511–520