Whitney Thomasson

Continuous Glucose Monitoring: Potential Benefits in Type 2 Diabetes Mellitus

Summer 2021 Newsletter

By Madeline Malloy, Doctor of Pharmacy Candidate, and Lisa C. Hutchison, PharmD, MPH, BCPS, BCGP
University of Arkansas for Medical Sciences (UAMS) College of Pharmacy

Type 2 diabetes mellitus (T2DM) is a common condition that is caused by insulin resistance, resulting in an increase in blood glucose levels. Diabetes disproportionately affects adults aged 65 and older with 1 in 4 receiving a diagnosis.¹ Stabilizing glucose levels has shown to be increasingly more important in diabetes as there are on-going studies evaluating the association between glucose variability and the development of comorbidities that can have a serious impact on ones’ health including heart disease, kidney disease, and vision loss.^2,3

To keep their blood glucose levels in a healthy range, patients must monitor their blood glucose levels and adjust their insulin accordingly. Through the use of a glucometer and testing with finger sticks, patients can accurately measure their glucose themselves. However, there are several limitations to self-monitoring blood glucose (SMBG) such as: user error, multiple finger pricks causing decreased compliance, and the quality and stability of the enzymatic test strips.⁴An alternative method to measuring glucose levels is through continuous glucose monitoring (CGM), which periodically tracks blood sugar levels at different intervals throughout the day. Monitors used for CGM have the ability to sync up to smartphones and tablets, allowing patients to see their glucose level in real time, set alarms for instances of hypoglycemia or hyperglycemia, and track meals, activity, and medications aiding a more in-depth analysis of their glucose trends. Some monitors even connect to insulin pumps, administering insulin when needed. For CGM to work, a sensor is placed under the skin typically on the abdomen or on the upper arm. This sensor measures the glucose level within the interstitial fluid, which is found between cells.The patient replaces the sensor every 3 to 7 days depending on the monitor. In addition, they must calibrate it twice daily, as opposed to 4 – 6 finger sticks per day using SMBG methods.⁵

While the use of CGM in type 1 diabetes mellitus (T1DM) is well established, it has yet to become commonplace for T2DM patients who require insulin therapy. Recently, there have been many studies discussing the potential benefits T2DM patients could derive from CGM such as better glycemic control, A1C reduction, and life-style modifications.⁶

Hypoglycemia is a serious risk for older patients, as it is associated with an increased risk for falls, arrhythmias, cognitive impairment, and even death. A study by Polonsky et al. showed that patients using a CGM reported fewer moderate-to-severe hypoglycemic events over the course of 6 months and greater reductions in hypoglycemic events that necessitated assistance from a caretaker, paramedic, or the ER.⁷ Both older adults and their caretakers that are burdened with the responsibility of managing diabetes may benefit from the ability to monitor real-time levels and be alerted by hypoglycemic events.

The use of CGM has shown statistically significant differences in A1C reduction compared to SMBG in T2DM patients. Vigersky et al. performed a study on the effect of CGM in patients with T2DM that were not on prandial insulin. Those randomized to use a CGM intermittently for 12 weeks had an improved A1C at 12 weeks and continued that improvement during the 40-week follow-up compared to those that only used SMBG. The CGM decreased their A1Cs by 1.0, 1.2, 0.8, and 0.8% whereas the SMBG group decrease their A1cs by 0.5, 0.5, 0.5, and 0.2% at 12, 24, 38, and 52 weeks, respectively.⁸Ruedy et al. shifted the focus of their study to the effectiveness of CGM in older adults >60 with both T1DM and T2DM on multidose insulin injection therapy (MDI). The results of this study showed a greater A1C reduction (−0.9 ± 0.7% versus −0.5 ± 0.7%, P < .001) and decreased glycemic variability in the CGM group as opposed to the SMBG group. The results of this trial show that while we know CGM is beneficial for T1DM, CGM also aids older patients with T2DM get closer to their goal A1C.⁹

In addition, CMG can contribute to patient education and subsequently, behavioral change, helping patients commit to lifestyle modifications and improve blood glucose levels. A systematic review performed by Taylor et al. demonstrated that CGM use was associated with positive lifestyle modifications such as a decrease in body weight and caloric intake, adherence to diet, and increased physical activity compared to SMBG.These studies demonstrate that CGM can help control T2DM in the short term, and in the long term through an improvement in the patient’s lifestyle and adherence to their treatment.⁶

A literature review showed that in adults, ages 51.7 – 60 years old, CGM supported greater reductions in A1C, bodyweight, and caloric intake, and increased adherence to diet and physical activity. Not only that, but a >90% compliance to CGM wear-time and calibration was reported.¹⁰ Ruedy et al. states that satisfaction was high with the CGM, defined as perceived benefits, were high compared to perceived difficulties.⁹ Polonsky et al. found that regarding patients’ quality of life, those that used the CGM reported feeling as though they were in a better state of well-being, less fearful of a hypoglycemic event, and less distressed.⁷ The high praise of the CGM system from these studies could mean that CGM has the potential to reduce burnout in those that are overwhelmed by their disease state management.

Patients with T2DM have similar goals and face similar obstacles in managing their blood glucose as those with T1DM no matter their age, and therefore, could also benefit from continuous glucose monitoring.⁶ With improvements made in the CGM technology in the future, it seems that CGM may very well become the standard of care to reduce the burden of diabetes management and improve the health outcomes for patients with T2DM.

References:

National Diabetes Statistics Report. 2020. Centers for Disease Control and Prevention. Retrieved from https://www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statistics-report.pdf.
Ohara, M., Fukui, T., Ouchi, M., Hayashi, T., Oba, K., & Hirano, T. 2016. Relationship between daily and day-to-day glycemic variability and increased oxidative stress in type 2 diabetes. Diabetes Research and Clinical Practice 122: 62 – 70.
What is diabetes? 2020. Centers for Disease Control and Prevention. Retrieved from https://www.cdc.gov/diabetes/basics/diabetes.html.
Jasha van Enter, B. & von Hauff, E. 2018. Challenges and perspectives in continuous glucose monitoring. Chemical Communications 54: 5032 – 5045.
Continuous Glucose Monitoring. 2017. National Institute of Diabetes and Digestive and Kidney Diseases. Retrieved from https://www.niddk.nih.gov/health-information/diabetes/overview/managing-diabetes/continuous-glucose-monitoring.
Jackson, M.A., Ahmann, A., & Shah, V.N. 2021. Type 2 Diabetes and the Use of Real-Time Continuous Glucose Monitoring. Diabetes Technology & Therapeutics 23: 27 – 34.
Polonsky W.H., Peters A.L., & Hessler D. 2016. The impact of real-time continuous glucose monitoring in patients 65 years and older. Journal of Diabetes Science and Technology 10: 892 – 897.
Vigersky, R.A., Fonda, S.J., Chellappa, M., Walker, M.S., & Ehrhardt, N.M. 2012. Short-and Long-Term Effects of Real-Time Continuous Glucose Monitoring in Patients With Type 2 Diabetes. Diabetes Care 35: 32 – 38.
Ruedy, K.J., Parkin, C.G., Riddlesworth, T.D., & Graham, C. 2017. Continuous Glucose Monitoring in Older Adults With Type 1 and Type 2 Diabetes Using Multiple Daily Injections of Insulin: Results from the DIAMOND Trial. Journal of Diabetes Science and Technology 11(6): 1138 – 1146.
Taylor, P.J., Thompson, C.H., & Brinkworth, G.D. 2018. Effectiveness and acceptability of continuous glucose monitoring for type 2 diabetes management: A narrative review. Journal of Diabetes Investigation 9: 713 – 725.

Oral Health Inclusion in Nursing Curriculum

Summer 2021 Newsletter

By Mark Foster, DNP, APRN, FNP-BC
Assistant Professor, School of Nursing
Arkansas State University

Importance of Oral Health

Adequate oral health is considered a crucial part of overall health and well-being (Llyas, Zahid, Rafiq, Bilal, & Ishaq, 2018). Oral health can be defined as having, “non-bleeding gums, free of infection, pain, xerostomia, halitosis, and sensitivity.” Oral health also encompasses the ability to smile, chew, taste, speak, swallow, and touch. This generally means that the person does not have any kind of oral disease. Poor oral health can also affect a person socially, physically, and psychologically (Llyas et al., 2018).

Despite what some may think, oral health is a crucial factor to overall general health. It has been proven that early oral hygiene practices lead to better overall oral health and general health (Llyas et al., 2018).

Llyas et al. (2018) conducted a study that examined the attitudes and beliefs regarding oral health. The researchers aimed to retrieve data from educated people as well as uneducated people. The results indicated that 55% of the educated participants knew what oral health was, but almost all of the uneducated participants were unaware of what oral health was. Seventy-three percent of the educated participants reported that bleeding gums are a sign of oral disease, while most of the uneducated participants said it is not. This study proved that uneducated individuals do not receive adequate information on oral health (Llyas et al., 2018).

The integration of medical care and oral health is important for people of all ages (Lee et al., 2018). Dental caries is the most chronic disease in the pediatric population, and it is found in 91% of the adult population. Medical professionals can take simple precautionary steps to examine the oral health of patients. The medical professional only needs gauze, tongue depressor, and light to conduct the quick, oral examination. This will help identify signs and symptoms of systemic disease and improve their quality of life (Lee et al., 2018).

It has been shown that there is a relationship between oral health and cardiovascular disease (Sanchez et al., 2017). Patients with periodontal disease are four times more likely to develop cardiovascular disease.

Sanchez et al. (2017) conducted a study in which they evaluated patients with cardiovascular disease, and the researchers asked questions about their perceptions toward oral health. The patients were asked questions regarding information given on oral health during their cardiac care, maintaining their oral health, and when oral health was important. The results showed that six (50%) of the patients reported they experienced bad breath, toothache, swollen gums, and painful teeth. Seven (58%) of the patients did not know that there was a connection between oral health and cardiovascular disease (Sanchez et al., 2017). This study validates that cardiac care professionals need to address oral health with all of their patients. This would allow the patients to receive adequate oral health education, care, and referrals (Sanchez et al., 2017).

Natural dentition in older adults is important for oral health despite the misconceptions (Muller, Shimazaki, Kahabuka, & Schimmel, 2017). Often, geriatric patients get assistance for activities of daily living and oral hygiene gets neglected. This can lead to caries which can result in tooth loss and reduced quality of life. One functional indicator is to examine the plaque and denture plaque indices. This buildup is linked to the patient’s ability to maintain oral hygiene (Muller et al., 2017).

Oral Health in Nursing Curriculum

As previously noted, the practice of oral health is critical to maintaining one’s overall health and hygiene (Opacich, 2014). Contrary to belief, the responsibility of oral health practice and education does not solely rely upon dentists and dental students. Nurses are very involved in an individual’s oral health. It’s important for nurse practitioner programs to educate students on the early signs of caries, how to educate patient caregivers, and providing preventative oral health care services (Kent & Clark, 2018).

When adding curriculum it is important to ensure that the teaching methodologies are efficient and effective (Kent & Clark, 2018). One university in Indiana found that the STAR Legacy Cycle was practical. The STAR Legacy cycle include basic principles that consist of five steps: a challenge, initial thoughts, perspectives and resources, wrap-up, and assessment. Therefore, before a lecture, the students were given a ten-question pretest. Students were also given out-of-class assignments concerning children’s oral health and a posttest. In the class, students practiced screenings and fluoride varnish application (Kent & Clark, 2018).

Furthermore, there is a growing amount of evidence that supports interprofessional education (Nash et al., 2018). A university in Colorado has implemented an interprofessional approach to expand the HEENT (head, eyes, ears, nose, and throat) assessment to HEENOT (head, ears, eyes, nose, oral, and throat) (Estes et al., 2018). Nurse practitioner students were taught how to conduct oral exams, apply fluoride varnish, and recognize oral health pathology by dental faculty. The nursing students then completed a survey concerning their comfort towards oral health and their opinions about the activities completed (Estes et al., 2018).

This interprofessional activity was completed during four different semesters (Estes et al., 2018). All of the nursing students reported that they felt more comfortable administering oral health exams after the activity in each of the four semesters. The senior-level students agreed with an interprofessional approach more than any other semester’s students. Also, senior students had a better report for organization and timing as well. This highlights an improvement in teaching methods and an increase in nursing students concerning oral health (Estes et al., 2018).

During a dissertation study by Opacich (2014), students participated in a pre-and post-test concerning oral health. The students had a pretest average of 59% and a posttest average of 82%. In the pretest, 21 students reported that they have not performed a comprehensive oral examination during a child’s welfare visit.

During the posttest, only five students reported they did not perform comprehensive oral examinations. Twenty-eight students (97%) also reported that they had not performed fluoride varnish on the pretest. During the posttest, only eight students reported not having performed fluoride varnish (Opacich, 2014).

During the pretest, 21% of the students felt as if they did not have enough knowledge to perform a comprehensive oral examination (Opacich, 2014). In the posttest, however all of the students felt as if they had the needed knowledge. When asked about fluoride varnishing in the pretest, 17 students did not feel like they had the proper knowledge, whereas only one student did not feel as if they had the proper knowledge on the posttest. This study emphasizes the positive effect that an oral health education program has on students (Opacich, 2014).

Therefore understanding the deficits to dental health in Arkansans and across the delta, Arkansas State University began integrating heavy content areas of dental health within their existing family nurse practitioner curriculum and having students complete the Smiles for Life oral health curriculum. Educating future providers in the first step addressing growing dental health concerns across the delta region and curtailing future health issues that arise from poor dental health.

References

Estes, K. R., Callanan, D., Rai, N., Plunkett, K., Brunson, D., & Tiwari, T. (2018). Evaluation of an interprofessional oral health assessment activity in advanced practice nursing education. Journal of Dental Education, 82(10), 1084.

Kent, K., & Clark, C. A. (2018). Open wide and say A-Ha: Adding oral health content to the nurse practitioner curriculum. Nursing Education Perspectives (Wolters Kluwer Health), 39(4), 253–254.

Lee, J. S., & Somerman, M. J. (2018). The importance of oral health in comprehensive health care. JAMA, 320(4), 339–340.

Müller, F., Shimazaki, Y., Kahabuka, F., Schimmel, M., & Müller, F. (2017). Oral health for an ageing population: the importance of a natural dentition in older adults. International Dental Journal, 67, 7–13.

Nash, W. A., Hall, L. A., Lee Ridner, S., Hayden, D., Mayfield, T., Firriolo, J., … Crawford, T. N. (2018). Evaluation of an interprofessional education program for advanced practice nursing and dental students: The oral-systemic health connection. Nurse Education Today, 66, 25–32.

Opacich, E. (2014). Improving oral health for underserved populations: Graduate nursing student education. Dissertation Abstracts International: Section B: The Sciences and Engineering. ProQuest Information & Learning.

Riley, E. (2018). The importance of oral health in palliative care patients. Journal of Community Nursing, 32(3), 57-61.

Ageless Grace as an Exercise Modality

Summer 2021 Newsletter

By Laura Stilwell, MEd
Education Coordinator
UAMS Arkansas Geriatric Education Collaborative (AGEC)

The mission of Arkansas Geriatric Education Collaborative (AGEC) is to provide high quality programs that support healthy aging in Arkansas. Two physical fitness programs used by AGEC are Tai Chi for Arthritis and Fall Prevention and Ageless Grace (AG). AG is an exercise program that, through muscle group targeting, meets the criteria of a fitness and fall prevention program for older adults. (Grabinar, et al., 2014) The activities in AG are fun, intentional, and accessible to persons of any age and physical ability. (Medved, 2013) For those reasons, AGEC chose AG as one of the fitness programs offered for community outreach. The focus of this article is to learn about AG, its development and its practice.

     The Ageless Grace program was developed by Denise Medved with the intention of meeting the criteria for physical fitness as well as brain fitness. Medved, a marketing executive and fitness instructor for over 30 years, and her development team compiled the series of exercises in the AG program based on studies in neuroplasticity. (Medved, 2013)   Neuroplasticity is defined as the capacity of neurons and neural networks in the brain to change their connections and behavior in response to new information. (Rugnetta, 2020) Each of the twenty-one exercises, or tools, emphasizes different anti-aging techniques that reinforce the theory of neuroplasticity. The exercises use a combination of flexibility, joint mobility, right-left brain coordination, cognitive function, and many other techniques to reinforce fall prevention, confidence and playfulness. (Medved, 2013) Medved asserts that with just ten minutes of practice every day using two or three of the “tools”, one will be aware of the positive differences in quality of life within 21 days. (Medved, 2013)

     Following the lesson plan of AG, each exercise session lasts 10 minutes and uses a minimum of three tools. The exercises are performed seated in a chair, using upbeat music and can be practiced in a group setting or alone. Each of the tools targets specific muscle groups to use during the session. The combination of muscle groups has a specific cognitive function as well as physical function during the exercise session. (Medved, 2013) The curriculum of Ageless Grace meets the recommendations of the Physical Activity Guidelines for Americans, 2^nd
Edition in an intentional and accessible manner. (PAGA, 2018)

     Activity for the older adult is crucial for maintaining quality of life. The recently updated Physical Activity Guidelines, 2nd Edition includes brain health benefits as part of the updated evidenced based benefits of physical activity.   The Guidelines state that physical activity can lead to improvement in cognitive function and sleep, as well as reductions in anxiety and depression risks. The combination of physical fitness with emotional fitness and brain health combine to contribute to an improved quality of life and healthy aging. (PAGA, 2018) According to the Guidelines, adults age sixty-five and older benefit from regular physical activity, even if that activity is below the key guidelines for exercise prescription. (PAGA, 2018)

    The success of an exercise program for the body and the brain can only be realized if participation occurs. (Cooper, 2020) Many adults are resistant to exercise due to cost, time constraints, and fear of injury. (PAGA, 2018) AG addresses these concerns by being cost effective, time effective, and practiced in the safety of a seated position. It is our job as practitioners and educators to encourage participants to commit to consistent exercise habits that incorporate a balance of participant preferences with evidence based practices. (Cooper, 2020) As educators for the older adult population, AGEC believes AG meets the criteria for physical fitness and cognitive health for older adults as outlined in the Physical Fitness Guidelines for Americans, 2^nd Edition.

References

Cooper, S. (2020) Promoting Physical Activity for Mental Well-Being, American College of Sports Medicine’s Health and Fitness Journal, 24(3), 12-14.
doi:10.1249/fit0000000000000569

Grabiner, M.D., Crenshaw, J. R., Hurt, C. P., Rosenblatt, N. J., & Troy, K. L. (2014). Exercise-based fall prevention: can you be a bit more specific? Exercise and Sport Sciences Reviews, 42(4), 161–168.
https://doi.org/10.1249/JES.0000000000000023

Medved, D. (2013). Introduction to Ageless Grace, The Ageless Grace Brain Health Program Playbook, 5-7. Essay, Purple Iris Press, LLC.

Rugnetta, M. (2020, September 3). Neuroplasticity. Encyclopedia Britannica. https://www.britannica.com/science/neuroplasticity

US Department of Health and Human Services. (2018) Physical Activity Guidelines for Americans, 2^nd edition. SNAP Education Connection. 27-46, 66-87.
https://snaped.fns.usda.gov/library/materials/physica-activity-guidelines-americans-2nd-edition

From the Director’s Desk

Spring 2021 Newsletter

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)

Wow, it has been over a year since the pandemic began and although we can see light at the end of the tunnel, we are still in the tunnel, yet thriving! The AGEC may look a little different than it did 12-15 months ago, but we are persevering and growing. We are now more diverse in our program offerings while still meeting and exceeding our goals and objectives. Over the past year we have embraced new partnerships and expanded outreach while maintaining key programs and activities.

During the past quarter, we started a new partnership with the Central Arkansas Library System that has gone state wide entitled “Learn from Home” and first aired on January 19^th. The Learn from Home Series is held monthly and covers topics such as “Understanding Dementia and Alzheimer’s Disease” and “Disaster Planning for Seniors”. We have also started monthly healthy cooking classes called “Cooking Live with AGEC: From Our Kitchen to Yours”. Both programs are going very well with thousands of online views. Programs with other partners included “Fall Prevention” with UCA Outreach and a “Memory Café” with Hendrix College featuring water stories and trivia. Those are just a sampling of the many programs we are having with our partners. Thank you partners for your continued support and vital participation during these difficult times!

We have also continued with our healthcare professions programming. Beginning in January with Lee Kathryn Lackey talking about “Supporting Military Caregivers” followed by Dr. Leah Tobey and myself presenting at Geriatric Grand Rounds on the “4Ms of Age-Friendly Care.” In February, “Racial/Ethnic Disparities in COVID-19 Predictors and Outcomes” was presented by Drs. Clare Brown and George Pro, followed later in February by Dr. Paul Parcon presenting on “Neuroinflammation in Alzheimer’s Disease”. “Opioid Tapering” was presented by Dr. Corey Hayes on March 18^th which was in partnership with the UAMS OPAL grant. Our next webinar will be in June regarding oral hygiene in older adults.

Finally, something we are very excited about with the AGEC is our involvement in older adult mass vaccination clinics in central AR. This is one of the activities supported by the CARES portion of our GWEP grant this quarter, and it has been extremely rewarding! AGEC staff along with the UAMS College of Nursing and Pharmacy students have been active in providing thousands of COVID-19 vaccines to older adults in partnership with local pharmacies, emergency management organizations, and many other volunteer groups. What great events!

Thank you all for supporting AGEC in our clinical, educational, and outreach efforts!

Aspirin for Primary Prevention in Older Adults

Spring 2021 Newsletter

By Katharine Stockton, Pharm.D. and Lisa C. Hutchison, PharmD, MPH
University of Arkansas for Medical Sciences (UAMS) College of Pharmacy

Heart disease and stroke are leading causes of death in older adults.¹ For prevention of cardiovascular disease, aspirin works as an antiplatelet through inhibition of cyclooxygenase-1 and 2 enzymes. It irreversibly inhibits the formation of thromboxane A₂ via acetylation of platelet cyclooxygenase, which then inhibits platelet aggregation.⁷Aspirin is proven effective for secondary prevention of cardiovascular diseases including coronary artery disease (CAD), peripheral artery disease (PAD), and stroke/transient ischemic attack (TIA).^2-6 However, the benefit to risk ratio of aspirin for primary prevention of cardiovascular disease is not as favorable given aspirin’s potential to cause bleeding.

Prior to the 2019 guidelines update from American College of Cardiology (ACC) and American Heart Association (AHA), aspirin was recommended for primary prevention of cardiovascular disease by these groups and other revered organizations^8,9 However, the 2019 ACC and AHA give more cautious recommendations regarding aspirin for primary prevention¹⁰:

Low-dose aspirin (75-100mg daily) might be considered for the primary prevention of ASCVD among select adults 40-70 years of age who are at a higher ASCVD risk but not at an increased risk of bleeding.
Low-dose aspirin (75-100mg daily) should not be administered on a routine basis for the primary prevention of ASCVD among adults > 70 years of age.
Low-dose aspirin (75-100mg daily) should not be administered for the primary prevention of ASCVD among adults of any age who are at increased risk of bleeding.

This update to guidelines and change from previous recommendations stems from recently published studies on the use of aspirin in the elderly.¹⁰ A series of articles from the Aspirin in Reducing Events in the Elderly (ASPREE) study were published in 2018.^11-13 The ASPREE study enrolled people 70 years of age or older who did not have cardiovascular disease, dementia, or any physical disability. Subjects were randomized to receive either aspirin or placebo. Aspirin use did not prolong disability-free survival over a period of 5 years in the intervention group as compared to placebo (P=0.79).¹¹ However, aspirin increased all-cause mortality in the elderly compared to placebo (1.14, CI 1.01 – 1.29).¹² This was attributed to cancer-related death and was an unexpected result of the study that should be interpreted cautiously given the confidence interval.

The ASPREE study also evaluated the effect of aspirin on cardiovascular events and bleeding. Cardiovascular disease was defined as a composite of fatal coronary heart disease, nonfatal myocardial infarction, fatal or nonfatal stroke, or hospitalization for heart failure. The study found no significant difference in the rate of cardiovascular disease with 10.7 events per 1000 person-years in the aspirin group and 11.3 events per 1000 person-years in the placebo group (0.95, CI 0.83 – 1.08). However, there was a significant difference noted in the composite rate of major hemorrhage for those in the aspirin group (1.38, CI 1.18-1.62; P < 0.001).¹³ Specifically, a significant difference was identified in subdural or extradural hemorrhage (1.79, CI 1.06-3.02) and upper gastrointestinal bleeding (1.87, CI 1.32-2.66). It is important to note that the ASPREE trial evaluated use of aspirin in the “healthy elderly” and did not meet the expected rate of cardiovascular events; therefore the potential cardiovascular advantages may be underestimated.¹³ However, the results of the ASPREE trial are similar to a recent meta-analysis evaluating use of aspirin for primary prevention in adults, which also concluded aspirin use did not significantly reduce cardiovascular endpoints, but was associated with an increased risk of bleeding.¹⁴

Given these study results and recent guideline updates, use of aspirin for primary prevention in the geriatric population should be carefully considered. Clinicians should evaluate patient history, cardiovascular risk factors, bleeding risk in discussion with older adults before recommending, starting, or continuing aspirin in patients greater than 70 years old.

References:

FastStats – Deaths and Mortality. Centers for Disease Control and Prevention. Published 2019. https://www.cdc.gov/nchs/fastats/deaths.htm
Winstein CJ, Stein J, Arena R, et al. Guidelines for Adult Stroke Rehabilitation and Recovery: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association . Stroke. 2016;47(6):e98-e169. doi:10.1161/STR.0000000000000098
Kulik A, Ruel M, Jneid H, et al. Secondary prevention after coronary artery bypass graft surgery: a scientific statement from the American Heart Association. Circulation. 2015;131(10):927-964. doi:10.1161/CIR.0000000000000182
Piepoli MF, Hoes AW, Agewall S, et al. 2016 European Guidelines on cardiovascular disease prevention in clinical practice: The Sixth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of 10 societies and by invited experts)Developed with the special contribution of the European Association for Cardiovascular Prevention & Rehabilitation (EACPR). Eur Heart J. 2016;37(29):2315-2381. doi:10.1093/eurheartj/ehw106
Levine GN, Bates ER, Bittl JA, et al. 2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2016;68(10):1082-1115. doi:10.1016/j.jacc.2016.03.513
Conte MS, Bradbury AW, Kolh P, et al. Global vascular guidelines on the management of chronic limb-threatening ischemia . J Vasc Surg. 2019;69(6S):3S-125S.e40. doi:10.1016/j.jvs.2019.02.016
Aspirin. Lexi-Drugs. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL. Available at: https://online.lexi.com/ . Accessed November 19, 2020.
Vandvik PO, Lincoff AM, Gore JM, et al. Primary and Secondary Prevention of Cardiovascular Disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(4):e637-e668. doi:10.1378/chest.141.4.1129c.
Kernan WN, Ovbiagele B, Black HR, et al. ). Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2017;45(7):2160-2236.
Arnett DK, Blumenthal RS, Albert MA, et al. 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease. Journal of the American College of Cardiology. 2019;74(10):e177-e232. doi:10.1016/j.jacc.2019.03.015.
McNeil JJ, Woods RL, Nelson MR, et al. Effect of Aspirin on Disability-free Survival in the Healthy Elderly . The New England Journal of Medicine . 2018;379(16):1499-1508.
McNeil JJ, Nelson MR, Woods RL, et al. Effect of Aspirin on All-Cause Mortality in the Healthy Elderly . The New England Journal of Medicine . 2018;379(16):1519-1528.
McNeil JJ, Wolfe R, Woods RL, et al. Effect of Aspirin on Cardiovascular Events and Bleeding in the Healthy Elderly . The New England Journal of Medicine . 2018;379(16):1509-1518.
Guirguis-Blake JM, Evans CV, Senger CA, O’Connor EA, Whitlock EP. Aspirin for the primary prevention of Cardiovascular events: a systematic evidence review for the U.S. Preventive Services Task Force. Ann Intern Med 2016; 164: 804-13.

Rhinitis and the Older Adult

Spring 2021 Newsletter

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By Stacy E Harris, DNP, APRN, ANP-BC
School of Nursing
University of Central Arkansas

Rhinitis, commonly known as inflammation of the nasal mucous membranes, affects adults of all ages. There are two major categories of rhinitis: Allergic rhinitis (AR) and Non-allergic rhinitis (NAR). Most people are familiar with the symptoms of AR: sneezing; itching, watery eyes; conjunctival redness; and rhinorrhea, a watery nasal discharge. The most typical course of AR is exposure to a seasonal (spring or fall) allergen, such as tree, grass, or weed pollen. This type of rhinitis begins to emerge in adults around in the late teens and peaks in the 5^th decade of life. Non-allergic rhinitis presents with similar symptoms: rhinorrhea and nasal congestion, but without the sneezing or eye symptoms. This type of rhinitis affects more adults and older adults (Yilmaz & Corey, 2006). Non-allergic rhinitis has many subtypes: vasomotor, atropic or geriatric non-allergic, rhinitis medicamentosa, drug induced, hormonal, gustatory and infectious (Kennedy-Malone, Martin-Plank and Duffy, 2019). This article will focus on NAR, specifically “geriatric “ sometimes known as physiologic rhinitis, the most common type effecting older adults.

Physiologic age-related changes to the nose are well known. It is common for an older adult patient to verbalize a decrease in the ability to smell. Besides olfactory changes, several other physiologic changes occur in the nose. The tough structures of the nose atrophy. This causes the nose to lengthen and the nasal tip to begin to droop. When the supporting upper and lower cartilages weaken, the nasal passages begin to narrow and produce a feeling of or an actual obstruction. Previous nasal injuries of youth or septal deviation confound the narrowing. These changes explain why many older adults complain of nasal obstruction. The vascular bed of the nose undergoes microvascular changes. The turbinates receive a decrease in blood flow which reduces the size of the turbinates and predisposes the nose to dryness and crusting. The changes in the nasal mucosa are impactful too. The nasal mucosa goblet cells increase, and the function of the submucosal serous glands decrease. The submucosal glands are responsible for watery, clear, thin mucous. The goblet cells produce a thick, tenacious mucus. Both types of secretions are responsible for humidifying the air we inhale and mostly importantly, trapping and removing potential organisms from entering the respiratory tree. These mucosal changes explain why many adults complain of daily thick, mucus production and have frequent throat clearing (Jordan and Mabry, 1998; Yilmaz & Corey, 2006).

Older adults may present to their healthcare provider with complaints of “sinus trouble” characterized by thick post-nasal drainage, nasal congestion, and frequent throat clearing. However, differentiating these symptoms from the typical symptoms of sinusitis (post-nasal drainage, nasal congestion, face pain and pressure, fever, headache) is not always clear to the provider. This can lead to misdiagnosis and unneeded treatment. The older adult may be treated inappropriately with antibiotics or first-generation histamine blockers when more supportive treatments are indicated.

There are numerous pharmacologic and nonpharmacologic ways to improve the older adults’ nasal complaints. First, the provider must rule out any allergic or infectious causes for the rhinitis. Once an accurate diagnosis of geriatric rhinitis has been made, a through explanation of the age-related nasal changes must be shared with the patient. This may not be the answer the patient is expecting but it is needed for long term management. Humidification is the key to improving geriatric rhinitis. Increasing moisture inside the nose is the main goal. This can be done by increasing moisture in the home, specifically the bedroom, and using over the counter (OTC) saline nasal spray as much as 4-6 times per day. There are many types of delivery methods, such as nasal douching, water-picks or Neti pots to inject saline into the nasal mucosa. Pure sesame oil has been shown to aid in nasal dryness (Jordan and Mabry, 1998)

Pharmacologic treatment including using mucous-thinning agents such as OTC guaifenesin has been shown to improve symptoms in patient with complaints of thick secretions. Topical and systemic decongestants can improve congestion but should be avoided due to the exacerbation of nasal mucosa dryness. Also, using first generation antihistamine (diphenhydramine, hydroxyzine) to treat nasal congestion should be avoided in older adults due to the sedating and anticholinergic activity. Newer second-generation antihistamines (loratadine, cetirizine, fexofenadine) are safe to use in older adults particularly if patients suffer from some allergic rhinitis too. Inhaled nasal steroids (Flonase, beclomethasone) are appropriate and safe in older adults suffering from allergic rhinitis, but long term can increase nasal dryness (Yilmaz & Corey, 2006).

Little research has been published regarding geriatric rhinitis. However, providers can improve the quality of life in the older patient by thoughtful education on age-related nasal changes. Also informing the older patient about OTC medications to avoid while providing them with simple treatments to increase humidification will ultimately improve rhinitis in the geriatric population.

Yilmaz, A. A. S. & Corey, J. P. (2006). Rhinitis in the elderly. Current Allergy and Asthma Reports, 6:125-131.

Jordan, J. A., & Mabry, R. L. (1998) Geriatric rhinitis: what it is and how to treat it. Geriatrics. 53(6) 76-80. Kennedy-Malone, L., Martin-Plank, l., & Duffy, E. (2019) Advanced practice nursing in the care of older adults, 2^nd Ed. FA Davis.

Healthy Ager Program Transforms During the Pandemic

Spring 2021 Newsletter

By Shawn Drake, PT, PhD, JoAnna Cupp, MS, RDN, LD, Brinda McKinney, PhD, MSN, RN, Lori Gatling, MSN, RN, CHSE
Arkansas State University

The College of Nursing and Health Professions (CNHP) at Arkansas State University and Center on Aging-Northeast partnered in 2004 and started the Healthy Ager Program (HAP). The objective of the HAP is to promote interprofessional educational and collaboration (IPEC) opportunities for health professions students’ while working with community-dwelling, older adults (Healthy Ager). The service-learning program provided students the opportunity to practice clinical skills learned in the classroom and apply their knowledge to improve the health and wellness in the older adult. COVID-19 heavily impacted the continuation of the HAP in Spring 2020. The program was suddenly halted, leaving the faculty with the question of how or if this program could continue.

COVID-19 forced the HAP faculty to think “outside the box” to develop a meaningful, service-learning experience for healthcare students and the Healthy Ager, while maintaining COVID-19 restrictions. In Spring 2021, the HAP moved to an online platform using Zoom. Student learning modules included exposure, immersion and mastery activities related to IPEC competencies focused on the older adult. Interprofessional teams comprised of students from nursing, physical therapy and nutritional science programs.

Exposure activities included introducing students to:

1) IPEC competencies¹ (communication, roles and responsibilities, values/ethics and team-based practice),

2) Quadruple Aims² (improved clinician experience, better outcomes, lower costs and improved patient experience),

3) Multidisciplinary Competencies for Older Adults³,

4) 4 M’s in the Care of Older Adults⁴ (what matters, medication, mentation, mobility), and

5) Team Strategies & Tools to Enhance Performance and Patient Safety⁵ (TeamSTEPPS)

The exposure activities were reinforced during Zoom activities, which included online simulation events (SBAR communication, dementia simulation) and collaborative sessions on home assessment, cultural competency and telemedicine.

Students participated in immersion activities through the use of Standardized Participants (SP) using Zoom as the telehealth platform. Each team was assigned an SP, who was over the age of 60 and was instructed to “act as themselves”. Each team completed an assessment using the 4M’s and provided interventions that focused on improving the 4Ms and Quadruple Aims for their SP. At the completion of each activity, small and large group debriefing occurred with the SP and faculty facilitator. The simulation activity allowed students time to practice telehealth presentation skills in a non-threatening environment, receive feedback on their team’s performance and implement changes before the real-life scenario.

Each team will participate in collaborative practice with their Healthy Ager in April. Team will provide an educational video and educational patient-specific pamphlet for their Healthy Ager which will allow for each team member to meet mastery level of IPEC competencies. In addition, the service-learning project allows for the Healthy Ager to improve his/her health and wellness with the expertise of each team.

The HAP has transformed itself in light of COVID-19 for the better. Despite the challenges of COVID-19, the HAP positively transformed. The new format allows the learner to meet the IPEC competencies, geriatric competencies, and practice telehealth.

References:

1. McKearney, Shelley. “IPEC Core Competencies.” Interprofessional Education Collaborative, www.ipecollaborative.org/ipec-core-competencies.

2. “ACTS Supports the Quadruple Aim.” ACTS Supports the Quadruple Aim | AHRQ Digital Healthcare Research: Informing Improvement in Care Quality, Safety, and Efficiency, digital.ahrq.gov/acts/quadruple-aim.

3. Author(s): Todd P. Semla, John O. Barr, Judith L. Beizer, Sue Berger, Ronni Chernoff, JoAnn Damron‐Rodriguez, Charlotte Eliopoulos, Carol S. Goodwin, Catherine L. Grus, Kathy Kemle, Ethel L. Mitty, Kenneth Shay, Gregg A. Warshaw. “Multidisciplinary Competencies in the Care of Older Adults at the Completion of the Entry-Level Health Professional Degree.” National Center for Interprofessional Practice and Education, 2 June 2020, nexusipe.org/informing/resource-center/multidisciplinary-competencies-care-older-adults-completion-entry-level.

4. “What is an Age-Friendly Health System?:IHI”. Institute for Healthcare Improvement. www.ihi.org/Engage/Initiatives/Age-Friendly-Health-Systems/Pages/default.aspx

5. “TeamSTEPPS®.” AHRQ, www.ahrq.gov/teamstepps/index.html

Arkansas Geriatric Education Collaborative Programs for Older Adults

Spring 2021 Newsletter

By Laura Stilwell, MEd
Education Coordinator
UAMS Arkansas Geriatric Education Collaborative (AGEC)

The Arkansas Geriatric Education Collaborative (AGEC) at the University of Arkansas for Medical Sciences has the mission to provide high quality programs that support healthy aging in Arkansas. Currently the population of adults age 65 and older is 54 million, or about sixteen percent of the nation’s population (US Census Report, 2019). In Arkansas, the number of adults age 65 and older is 524,000 and represents 17.4 percent of the state population (US Census Report, 2019). By the year 2030, the population of adults age 65 and older is expected to rise to 20 percent nationally and to 26 percent statewide (US Census Report, 2020).

The aging population, becoming the largest population sector in the future, has specific needs that must be addressed by the medical community. This age group presents with a host of chronic health problems; cardiovascular disease, hypertension, type II diabetes, osteoarthritis, muscular atrophy and dementia related illnesses. Through regular exercise and nutritional monitoring many of the chronic debilitating diseases can be improved, alleviated or prevented (Lee et al., 2017) (USDA, 2021). Of all Medicare beneficiaries, 68% suffer from 2 or more chronic diseases (Lochner et al., 2013).

Two modalities that have a positive effect on the quality of life of older adults are exercise prescription and nutritional monitoring (Minett et al., 2019). The medical community, recommends exercise prescription as the first choice in prevention and reversal of some of the chronic diseases of the older population (Tyndall, et al., 2018). For maximum efficacy, dietary education along with the exercise prescription provide the cornerstone of creating and sustaining enhanced quality of life for the older adult (Minett et al., 2019).

At AGEC, three programs have been implemented to address the need for regular exercise and for dietary education. Ageless Grace, a non-weight bearing aerobic activity, and Tai Chi for Arthritis and Fall Prevention are programs that provide modalities for improving muscle mass, balance and improved cardiac output (Grabiner et al., 2014). Using the USDA’s Dietary Guidelines for 2020-2025, AGEC has developed a cooking class entitled From Our Kitchen to Yours. The recipes and content are based specifically on chapter 6 of the guidelines which is dedicated to the dietary needs of the older adult population (USDA, 2021). The nutritional guidelines found in the Dietary Guidelines for 2020-2025 provide years of research for the nutritional needs of the older adult (USDA, 2021).Information about all three programs can be found on the AGEC website (agec.uams.edu) and on our Facebook page.

The literature cited gives a rationale for the holistic care of the older adult. By providing education and programs that target the health issues faced by the older adult, overall wellness and quality of life can be achieved. Students, clinicians, and physicians in tandem with the programs provided by AGEC and its partners shape this pro-active version of health care for older adult education in Arkansas.

References

Dietary Guidelines Advisory Committee (2021). Dietary Guidelines for Americans 2020-2025. https://www.dietaryguidelines.gov/sites/default/files/2021-03/Dietary_Guidelines_for_Americans-2020-2025.pdf

Lee, P. G., Jackson, E.A., Richardson, C. R., (2017). Exercise Prescriptions in Older Adults. American Family Physician, 95(7), 425–432.

Lochner, K. A., Goodman, R. A., Posner, S., & Parekh, A. (2013). Multiple Chronic Conditions Among Medicare Beneficiaries: State-level Variations in Prevalence, Utilization, and Cost, 2011. Medicare & Medicaid Research Review, 3(3), mmrr.003.03.b02.
https://doi.org/10.5600/mmrr.003.03.b02.

Minett, M. M., Binkley, T.L., Holm, R. P., Runge, M., & Specker, B. L. (2019). Feasibility and Effects on Muscle Function of an Exercise Program for Older Adults. Medicine and Science in Sports and Exercise, 52(2), 441–448.

Tyndall, A. V., Clark, C. M., Anderson, T. J., Hogan, D. B., Hill, M. D., Longman, R.S., & Poulin, M. J., (2018) Protective Effects of Exercise on Cognition and Brain Health in Older Adults, Exercise and Sport Sciences Reviews, 46(4), 215-223
https://doi.org/10.1249/JES.0000000000000161

United States Census Bureau, (2019). American Community Survey TableID S0103.
https://data.census.gov/cedsci/table?q=S0103&tid=ACSST1Y2019.S0103&hidePreview=false

United States Census Bureau, (2019). Population Estimates for Arkansas. https://www.census.gov/quickfacts/table/AR/AGE775219

Vespa, J., Armstrong, D. M., & Medina, L., (2020). Demographic Turning Points for the United States: Population Projections for 2020 to 2060. https://www.census.gov/library/publications/2020/demo/p25-1144pdf.html

From the Director’s Desk

Winter 2021 Newsletter

Happy New Year from the Arkansas Geriatric Education Collaborative (AGEC), the Geriatric Workforce Enhancement Program for Arkansas. As we say goodbye to the holidays of 2020, we say goodbye (and in many instances, good riddance!) to 2020. I think 2021 is dawning brighter as we see hope for containment of COVID-19 and push forward into embracing positive healthy habits for the new year.

We were busy this past fall with community and health professional programming and working with our clinical partners. We hosted several AGECaring Friends Facebook live events, posted AGEC Caregiver and PT Corner tips, and posted many Zoom programs. We also had several webinars including Dr. Jennifer Dillaha, on November 12 presenting “COVID-19: Examining 2020 and Looking into 2021” with over 160 attendees. Programs continued as we have learned to adjust to more virtual formats

We are also very proud to announce that The Arkansas Geriatric Education Collaborative (AGEC) has created a new podcast called UAMS Age Wise! This podcast was created to dive deep into the challenges facing the older population and those healthcare professionals caring for this aging population. Experts from the AGEC and our community and academic partners along with experts from the Donald W. Reynolds Institute on Aging and all across the UAMS Campus will talk about a variety of topics relevant to aging. These include managing caregiver stress, creating New Year resolutions, having successful telemedicine visits, virtual education for older adults, and the importance of medical wellness visits. The podcast is available on several popular platforms including Apple Podcasts, Spotify, Anchor, and Overcast. Two episodes are posted every month! Please subscribe and join us!!

We are very excited about the possibility of face-to-face encounters again sometime in 2021! We want to see and experience everyone again. If you have ideas for us, (virtual or in-person) please let us know!

Stayed tuned to the AGEC website, Facebook page, Instagram, and Twitter accounts – and now our new podcast – for upcoming exciting programs. Stay safe everyone and remember to get your flu and COVID-19 vaccines as soon as you can – and remind your patients to get theirs too!!!

Older Adults and COVID-19: A Call for Physical Activity Intervention

Winter 2021 Newsletter

By Sarah Walker, PT, DPT
Department of Physical Therapy
University of Central Arkansas

As healthcare professionals are faced with the numerous challenges of the COVID-19 pandemic, clinicians who serve geriatric clients are being met with stark statistical findings from epidemiology studies. Age in advance of 65 years is the single most important predictor of mortality from COVID-19, with elderly individuals representing a significantly higher proportion of those who perish from the disease. ^1-3 This increased risk is multifactorial, but is heavily influenced by declines in immune system function that reduce responses to viral infection.³ These findings support recommendations by community health leaders for elders to self-isolate in order to avoid infection.²

One consequence for older adults under self-isolation or quarantine is psychological trauma, including increased feelings of anxiety, stress, and anger. ^{2, 4} Anxiety and depression can also cause maladaptive changes to immune function, potentially further increasing an already vulnerable population. ⁵ In addition, geriatric individuals have an increased psychosocial burden associated with isolation as compared to other age groups.² Because self-isolation is not benign, clinicians must provide other evidence-based strategies to clients in order to decrease morbidity and increase immune system protection from this virus. ^{3, 6}

Physical activity is widely prescribed to seniors because movement has been shown to boost immune system function, reduce inflammation, improve emotional well-being, and reduce all-cause mortality.⁶ Encouraging elderly clients to engage in a more active and movement rich lifestyle can take the form of both physical activity and physical exercise. Physical activity suggestions may include dancing in their living rooms, walking outdoors, gardening, or playing with a beloved pet. Whereas physical exercise represents a planned and structured movement with a clear and purposeful intervention such as lifting weights, aerobics, or yoga.

Physical exercise of moderate intensity (64-76% of maximum heart rate) lasting 15-40 minutes in duration for 3 days per week over 6 months has demonstrated a significant increase in the number of T cells in the blood of elderly adults. Regular long-term exercise has also demonstrated enhanced immune response against both viruses and bacteria and appears to slow immunological ageing.⁶ Acute bouts of exercise, like walking for 30 minutes at a moderate intensity, likewise demonstrated enhanced immune function by a variety of mechanisms. The findings of previous research also suggest that acute moderate intensity resistance training for 45 minutes can result in increased activity.

Evidence is compelling that physical activity can be beneficial for older adults, especially during the COVID-19 pandemic. Physical activity and exercise can increase immune system function and psychological well-being in this exceptionally vulnerable population. Clinicians should encourage and promote physical activity in older adults in order to decrease the risk of COVID-19 complications.

References

1. Daoust JF. Elderly people and responses to COVID-19 in 27 Countries. PLoS One. 2020 Jul 2;15(7):e0235590.

2. Javadi SMH, Nateghi N. COVID-19 and its psychological effects on the elderly population. Disaster Med Public Health Prep. 2020 Jun;14(3):e40-e41.

3. Abdelbasset WK. Stay Home: Role of Physical Exercise Training in Elderly Individuals’ Ability to Face the COVID-19 Infection. J Immunol Res. 2020;Nov 28;8375096.

4. Torales J, O’Higgins M, Castaldelli-Maia JM, Ventriglio A. The outbreak of COVID-19 coronavirus and its impact on global mental health. Int J Soc Psychiatry. 2020 Jun;66(4):317-320.

5. Kiecolt-Glaser JK, Glaser R. Depression and immune function: central pathways to morbidity and mortality. J Psychosom Res. 2002 Oct;53(4):873-6.

6. Amatriain-Fernández S, Gronwald T, Murillo-Rodríguez E, Imperatori C, Solano AF, Latini A, Budde H. Physical Exercise Potentials Against Viral Diseases Like COVID-19 in the Elderly. Front Med (Lausanne). 2020 Jul 3;7:379.