AGEC

Meet AGEC’s New Junior Faculty Development Awardees

Robin McAtee, PhD, RN, FACHE, Arkansas Geriatric Education Collaborative (AGEC) Director, and Ronni Chernoff, PhD, FAND, FASPEN, Associate Director, are pleased to announce the newest awardees of the AGEC Junior Faculty Development Fellowship in geriatrics at the Donald W. Reynolds Institute on Aging at UAMS.

Caitlin Price, Au.D., Ph.D., CCC-A and Lee Isaac, Psy.D. were notified of the decision in June 2022. Dr. Price will begin her year-long program in July 2022, and Dr. Isaac will begin in January 2023. The AGEC Junior Faculty Development program objective is to support the career development of professionals who want to specialize in academic and clinical geriatrics. The award includes $25,000 in salary support and supported attendance at one national geriatric conference.

About Dr. Caitlin Price

Caitlin Price, Au.D., Ph.D., CCC-A, is an assistant professor in the UAMS Department of Audiology and Speech Pathology and is a licensed clinical audiologist with expertise in adult diagnostics, rehabilitation, and auditory electrophysiology. She has extensive clinical experience with geriatric populations and has initiated patient-driven inquiries on best practices and other clinically applicable research topics related to cognitive aging, auditory perception, and speech-in-noise processing. In her postdoctoral fellowship, she worked with interdisciplinary teams to evaluate the impact of cognitive impairment on the auditory processing of speech in older adults. Her research aims to assess individual differences that contribute to speech-in-noise deficits and develop effective clinical interventions to foster successful communication across the lifespan.

About Dr. Lee Isaac

Lee Isaac, Psy.D., is a postdoctoral fellow in Clinical Neuropsychology at UAMS and will be joining the faculty as an assistant professor in August 2022. He graduated from La Salle University in Philadelphia, PA, with a doctoral degree in Clinical Psychology, and completed his clinical internship at UAMS. He specializes in geriatric neuropsychology, and his clinical work includes neurocognitive assessment for patients with suspected neurodegenerative conditions and movement disorders. His research presently focuses on updated assessments for dementia populations and diagnostic specificity in types of dementia, particularly with the integration of technology.

From the Director’s Desk

Spring 2022 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)

Thank you to all of our AGEC health professional friends and peers for continuing to support AGEC programs and activities. We started off this year with more depressing COVID-19 Omicron news and a huge uptick in positive cases. However, we marched on and now as spring is emerging, we are once again having face-to-face programs and attending in-person events. Hooray! Our community participants have been very excited about getting back together face-to-face for evidence-based programs and activities and attendance has been great. The social isolation over the past two years has certainly taken its toll, but we are doing what we can to limit or even reverse its effect.

Over the past 3 months we have worked diligently to maintain programming and activities and our outcomes are great. For the clinical activities in March, we were excited to partner with Opioid Prevention for Aging and Longevity (OPAL) and UAMS’s Academic Detailing program at the Psychiatric Research Institute to provide 2 hours of continuing education on Naloxone to AGEC’s clinical partners at ARcare in England, Augusta, Cabot West, Bald Knob, Wynne and Benton. OPAL is also securing Naloxone kits which will be distributed to these clinics when available.

We continued to also provide many programs virtually. Highlights included several events via Zoom such as: Eat Well Live Well at the Benton Senior Center; Mental Health, Food, & Exercise with partners AARP & AR-Connect; Internet Safety via Zoom in partnership with the Central Arkansas Library System; Caregiver Resources with partner AARP; Kidney Health at the Bryant Senior Center; and Preventing Isolation in partnership with UCA students. The AGEC Age Wise podcast continues to be popular along with AGEC’s Facebook page where we now have over 2,400 followers. The program “Understanding Dementia & Alzheimer’s Disease” was presented for 28 UCA Consumer Science students in February, and a video caregiver story entitled “Dealing with Hardships While Caring for Parents” was released online for National Caregivers Day on 2/18/22, with over 2,800 views.

Health Professional trainings have also been active with over 200 attendees this past quarter. Webinars included: Immunization 2022: Communication & Science Update (1/12/22); and The Importance of Hearing in Healthy Cognitive Aging (2/16/22). On 2/8/22, The Challenges and Opportunities: Working with Rural CBOs, was presented to a national audience during a GWEP-CC Peer Sharing Webinar, and the AGEC webinar for March was in partnership with OPAL with Kirk Lane, AR Drug Director, titled Arkansas Naloxone Project.

AGEC has also been excited to get back out in the community presenting evidence-based programs and activities face-to-face at local communities of faith and senior centers. Older adults are attending these programs and enjoying meeting again with their peers! We at the AGEC thank all of you for your loyalty and partnerships; we could not reach all the healthcare professionals, students, or older adults without all of you! Thank you!!!

Weight Loss in Older Adults: Can We Stop the Losing Battle?

Spring 2022 Newsletter

By Haylee Whitehurst, Occupational Therapy Doctorate Student
College of Nursing & Health Professions
Arkansas State University
Edited by Jessica Camp, DNP, APRN, AGCNS-BC, NE-BC, CDP

Did you know?

Unintentional weight loss occurs in 15%- 20% of older adults and is associated with increased morbidity and mortality.

Background/Significance of Unintentional Weight Loss in Older Adults

It can be difficult to notice gradual changes in a loved one when family members see them frequently. That’s why, as professionals, we must keep an eye out for weight changes over time. Weight loss can be due to inadequate food intake as well as other contributing factors that may indicate an underlying health, behavioral, or emotional issue. Some overweight aging adults can benefit from healthy weight loss to relieve pressure on joints and heart function. In these cases, it is important that weight loss is controlled and on purpose so the individual is losing fat and not valuable muscle mass. However, when weight begins to drop off unintentionally, whether the aging adult could benefit from some weight loss or not, medically speaking the risks to their health can be very serious. Following unintentional weight loss, the immune system can deteriorate, leaving an older adult more vulnerable to infection and illness with a weakened ability to recover. An aging adult may experience fatigue as weight and overall health decline, which can prevent activity, exercise, and social participation. If they do lose weight in muscle mass, the aging adult will weaken and may be at greater risk of falls and injuries, which can be very dangerous for older adults (Gaddey & Holder, 2014).

Share These Tips with Families to Help Prevent Unintentional Weight Loss in Older Adult Patients

Add spices and color to food
1. If your family member has lost the sense of taste, then they might not be excited about eating. Consider incorporating some hot pepper, mustard, sage or other spices and flavorings in your loved one’s next meal.
Consider supplements
1. Supplements can nourish your loved one’s body and prevent malnutrition. Ask your family member’s doctor or registered dietitian what supplements would be the most appropriate.
Exercise with your loved one
1. Physical activity can improve appetite, so encourage your family member to exercise a few times a week. For example, you can go on a walk or take an aerobics class. Regular exercise will also improve bone strength and boost the immune system.
Prepare snacks
1. If your family member isn’t consuming enough calories during meal times then prepare some healthy snacks. For example, cauliflower, broccoli, and carrots, are packed with vitamins and minerals older adults need to thrive. Almonds, fresh fruit, and boiled eggs are other great snacks. For additional calories, peanut butter, cheese, puddings and other easy-to-eat foods may be suggested.
Check medications
1. If your family member takes medication that causes swallowing difficulties, nausea, or dry mouth, it can negatively affect his or her appetite (Gaddey & Holder, 2014). Voice your concerns to your loved one’s doctor and have that doctor reevaluate these medications to see if adjustments can be made.

Treatment Options

Determining the specific cause of weight loss can lead to a clearer course of action for us as professionals, whether it be a medical, dental, psychological, financial, or lifestyle solution. Treatment often involves a multidisciplinary team, including dentists; dietitians; speech, occupational, or physical therapists; and social service workers (Gaddey & Holder, 2014). Do your part by recognizing unintentional weight loss and assessing the cause, bringing attention to the treatment team, or making appropriate referrals when needed.

Everyone’s metabolism naturally slows down as they age, so it makes sense that an older adult will eat less food than they used to. It’s important to give extra attention to the nutrient quality and caloric density of food to ensure that they get adequate vitamins and minerals, especially if they may have digestive difficulties. There are ways to make meals more appealing to older adults with declining appetites and ways to make meals more accessible even for those with dental problems. It can also be a significant advantage, if you can encourage friends and family to sit down for meals together with the older adult so they have companionship and encouragement to eat whenever possible.

Common Strategies to Address Unintentional Weight Loss in Older Adults:

Dietary changes
Environmental modifications
Nutritional supplements
Flavor enhancers
Appetite stimulants

Resources for Professionals to give to Family Members

Areas Agencies on Aging (AAA)
- Meals on Wheels
- Senior Centers
- Transportation options
Division of Aging, Adult, & Behavioral Health Services (DAABHS)
Program of All-Inclusive Care for the Elderly (PACE)
Senior Community Service Employment Program

References

Gaddey, H. L., & Holder, K. (2014). Unintentional weight loss in older adults. American Family Physician, 89(9), 718–722. https://www.aafp.org/afp/2014/0501/p718.html

Programs for Adults & Seniors. (n.d.). Arkansas Department of Human Services. Retrieved November 3, 2021, from https://humanservices.arkansas.gov/learn-about-programs/programs-for-adults-seniors/

Home Medication Management

Spring 2022 Newsletter

By Sarah Emison, Pharm.D. and Lisa C. Hutchison, PharmD, MPH, BCPS, BCGP
University of Arkansas for Medical Sciences (UAMS) College of Pharmacy

Many older adults have difficulty taking their medications every day at home. With chronic health conditions, daily medications are an important part of staying healthy just like eating a balanced diet and exercising regularly. Forgetting to take medications that are needed increases the risk of disease flare-up, hospitalization, and nursing home admission. Clinicians need to stay current on the options to help older adults stay independent in their homes or reduce the burden on caregivers.

A key factor in managing medications at home is to maintain a current list. This list should include all prescription medications as well as any medications a patient is taking without a prescription including over-the-counter medications, dietary supplements, vitamins, and herbal remedies. The medication name, dose, and directions should be included. The patient or caregiver should be educated on what each medication is for as well as how to take it and what should be expected, both therapeutic and adverse effects. It may be helpful to write this information on the medication list as a reminder or a reference. The patient/caregiver should keep this list in a convenient location such as a wallet or purse for when they have a doctor’s visit or an emergency. (Zonsius 2022)

The second factor in managing medications at home is to have a way to keep track of administration. Simple options include a calendar to mark off when medications are taken, or a daily administration record. They are available from some pharmacies, doctors’ offices, and the Internet, or a person can create their own. These charts can be posted on the refrigerator or other convenient location. Another option is a talking alarm which can be set to provide a reminder of when it is time to take your medication. See Figure 1 for examples of charts and alarms. People with smart phones can download an app which will provide reminders and allow tracking of when medications are taken. Some examples include MediSafe and DoseCast. (Treichler 2022)

Pill containers are another option that help a patient that just needs to see if they have taken their medications (or not) each day to help keep track. Also, they can be filled ahead of time by caregivers so a person can maintain independence with taking medications each day. These containers come in a wide variety. Most recognized are weekly containers with openings for 7, 14, or 30 days. These can be filled with medications that are needed for each day. Other pill containers are arranged with 4 administration times for each day of the week. (Figure 2)

Some high-tech products provide automatic dispensing of the medications when it is administration time. Alarms sound when it is time to take the medication so the patient can press a button for the tablet(s) to be dispensed. In this way, they prevent a person from opening up the containers when it isn’t time to take their medication. In addition, some can be connected to the Internet to allow monitoring of medication dispensed remotely by caregivers who can’t be present for each administration time. (Figure 3)

Individuals with low vision may benefit from larger print prescription labels. These can be request from most pharmacies. Pill containers as discussed above are often labeled in Braille for the days of the week or administration times. Other options are gadgets have been developed which are attached to prescription bottles or use a reading device programmed to provide talking prescription instructions.

Many pharmacies provide services that can be helpful in managing medications at home. Pill packing services involve preparing a blister pack for each administration time for medications. Often these are provided without additional charge. Pill packing services can be arranged by some local community pharmacies, particularly stores that are independently owned. Some mail order pharmacies also provide this service.

Another important service that community pharmacies provide is medication reconciliation and comprehensive medication review. As the number of prescriptions and over-the-counter medications a patient takes increases, it becomes more likely that a medication is continued that is no longer needed, a drug-drug interaction is occurring, or administration instructions get confused between different medications. Pharmacists are trained to review each medication to determine if any of these concerns are occurring and can work with providers to assure a patient is on an optimal medication regimen. Having fewer medications to take is another way to help with managing medications at home. A medication reconciliation and review is recommended for all older adults each time a medication is prescribed. (LeBlanc 2015)

In conclusion, health care professionals need to be aware of the many options for helping patients manage medications at home. Medication education and reconciliation go hand-in-hand with tools and devices designed to keep medication administration safe and convenient for our older patients.

Figure 1: Examples of Alarms and Charts

Figure 2: Pill Container Examples

Figure 2: Automatic Pill Dispenser Examples

References:

LeBlanc RG, Choi J. Optimizing medication safety in the home. Home Healthcare Now, 2015; 33:313-9

Treichler C. The 10 best medication reminder apps for 2022. Onlinedoctor January 16. 2022. https://www.onlinedoctor.com/best-medicine-reminder-apps/ . Accessed April 12, 2022.

Zonsius MC, Myftari K, Newman M, Emery-Tiburcio EE. Optimizing older adults’ medication use. AJN, 2022; 122:38-43.

Collegiate Interprofessional Experiences for Improved Dementia Care Management

Spring 2022 Newsletter

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By Michael Gallagher, PhD., Emily McIndoe, Robert Hogue, and Kerry Jordan, PhD, RN, CNS, CNL-BC
Department of Exercise and Sport Science and the School of Nursing
University of Central Arkansas

In the last 40+ years, the focus on patient health care has changed from a one-size-fits-all to a holistic and person-centered approach to therapy. This person-centered approach is now recognized as desirable as society moves away from reductionism and treating individuals simplistically to understanding and addressing the whole-person with regards to chronic diseases such as dementia (Greene et al., 201). The benefit of a holistic approach is care that not only applies to the person with chronic disease but also to their caretakers. Benefits also apply to the professional community through interprofessional education and collaboration.

There are six dementia care management programs used around the world that incorporate person-centered care and each of these programs includes some level of interprofessional education and collaboration ranging from care management teams of four to eight different professions. Nurses led many of these interprofessional teams. The professions for collaborative care in dementia may include nurses, physicians, counselors, psychologists, exercise specialists and therapists, occupational and speech therapists, and pharmacists (Dreier-Wolfgramm et al., 2017). However, depending on the program’s goals, care management programs do not need to include every profession for the program to be successful. For example, a person-centered approach may include collaboration among nurses, occupational or speech therapists, or just exercise specialists and speech therapists. The goals of the program dictate the number of professions involved. Care management programs for people with dementia not only help persons with dementia in the program but also may provide respite for the caretaker, further education on dementia, or both. Education for both persons with dementia and their caretakers may include signs of disease progression, approaches to slow disease progression, management of activities of daily living, management of episodes of forgetfulness and agitation, and how to stay connected and engaged with their loved one or client.

One of the most impactful pieces of information to provide those affected with dementia is that a person with dementia can live a high-quality life. The appreciation for providing a means to have a high-quality life is present in care management programs that focus on the person instead of the dementia diagnosis. Interprofessional collaboration achieves this united appreciation by providing a community that allows each profession to contribute to the benefit of an individual and/or caretaker. One such care management program, DementiaNet, highlights the role of interprofessional education to “increase collaboration, knowledge and skills acquisition” towards effective interprofessional collaboration (Oostra et al., 2021). Additionally, teams should provide access to varying levels of generalized and tailored care to promote physical, psychological, and social well-being improvements among persons with dementia (Kuipers et al., 2019). Collegiate interprofessional education can lead towards effective interprofessional collaboration as these soon-to-be professionals are able to apply the educational concepts from the classroom or online resources through the UAMS Arkansas Geriatric Education Collaborative to supervised real world situations. As a result, these students can further promote awareness of dementia and advocate to destigmatize the dementia diagnosis among persons with dementia, the caretaker, and the public. It is not every day that students get to experience and reflect on the impact they may have on persons with a chronic disease such as dementia. Those student experiences and subsequent reflections may be rewarding and open them up for a greater appreciation of the role of other professions, the benefits of collaborating in a person-centered approach to care, and potentially create new professional goals never considered before.

At the University of Central Arkansas, we recently conducted an 11-week interprofessional student-led clinic for people with dementia living in the community (S-TAP). We used three different professions in our program: exercise science, communication science, and nursing. Not only did this program demonstrate significant improvement in functional status for those who participated, but it also demonstrated significant impact on student attitudes toward people with dementia. As one student wrote after participating: “I feel I gained a greater understanding of older adults with dementia and learned how to connect with them better. My feelings toward them changed in the sense that I realized they are not completely helpless.”

References

Dreier-Wolfgramm, A., Michalowsky, B., Austrom, M.G., van der Marck, M.A., Iliffe, S., Alder, C., Vollmar, H.C., Thyrian, J.R., Wucherer, D., Zwingmann, I., Hoffmann, W. (2017). Dementia care management in primary care: Current collaborative care models and the case for interprofessional education. Zeitschrift für Gerontologie und Geriatrie, 50(Supplement 2), S67-S77

Greene, S.M., Tuzzio, L., Cherkin, D. (2012). A framework for making patient-centered care front and center. The Permanente Journal, 16(3), 49-53

Kuipers, S.J., Cramm, J.M., Nieboer, A.P. (2019). The importance of patient-centered care and co-creation of care for satisfaction with care and physical and social well-being of patients with multi-morbidity in the primary care setting. BMC Health Services Research, 19: 13

Oostra., D.L., Harmsen, A., Nieuwboer, M.S., Rikkert, M.G.M.O., Perry, M. (2021). Care integration in primary dementia care networks: A longitudinal mixed-methods study. International Journal of Integrated Care, 21(4): 29, 1-12

UAMS PatientsLearn: Free Educational Programs for Older Adults and Caregivers

Spring 2022 Newsletter

By Whitney Thomasson, MAP, CRS
Research Assistant
UAMS Arkansas Geriatric Education Collaborative (AGEC)

The Arkansas Geriatric Education Collaborative (AGEC) has worked in partnership with the UAMS Institute for Digital Health & Innovation (IDHI) via PatientsLearn to provide free, on-demand, virtual educational programs for older adults on a variety of topics such as disaster preparedness and social isolation. UAMS PatientsLearn is an online medical education hub, with a patient-centered approach for health and wellness resources. In total, 7 AGEC programs are available, ranging from about 25 minutes to 1 hour in length. These programs can be valuable educational tools for older adults, caregivers, and healthcare professionals for referral resources. Registration is free, simple, and available nationwide. Click here for our available programs via UAMS PatientsLearn.

Recognizing & Preventing Social Isolation: This program educates participants on both the warning signs and the effects of isolation and loneliness. Tips for prevention are shared, along with resources for both older adults and caregivers facing these issues.
Heart Health & Brain Health: This program helps viewers better understand the connection between heart and brain health. Risk factors and prevention measures for stroke, dementia, and heart disease are also discussed.
Eat Well Live Well: Through utilization of the Dietary Guidelines for Americans, this program defines terms about diet and nutrition, and highlights reliable dietary resources. Eat Well Live Well aims to guide older adults in developing healthy dietary patterns.
Understanding Dementia & Alzheimer’s Disease: This program was created for family caregivers and community members alike to gain awareness and knowledge about dementia and Alzheimer’s disease. Normal aging vs dementia is discussed, along with risk factors, the stages of Alzheimer’s disease, and dementia-friendly communication skills.
Understanding Opioids: The definition and examples of opioids are covered in this program, along with a background of the opioid epidemic and its effect on prescriptions. Best practices after receiving a prescription opioid are addressed, along with a variety of non-opioid pain management alternatives. Free chronic pain booklets are available for viewers.
Fall Prevention & Home Safety: In this program, viewers learn about how to identify and prevent the risk of falls, the physical and mental consequences of falling, resources for safety checks, and exercises for fall prevention. Tips for improving an older adult’s balance, as well as for improving home safety, are discussed.
Disaster Preparedness for Seniors: In collaboration with the American Red Cross, preparedness tips for many types of disasters (weather, climate, home fire/flood, etc.) are covered. Emergency kits, evacuation plans, as well as best practices for caring for a loved one with dementia in a disaster are covered in this program.

All of the above programs are available 24/7, at no cost, via UAMS PatientsLearn. Be sure to check back later in 2022 for additional programming. Please share these programs with older adults and caregivers in your circles who may benefit from this education!

From the Director’s Desk

Winter 2022 Newsletter

Happy New Year to all of you from the Arkansas Geriatric Education Collaborative staff! As we have attempted to settle back into routines after the holidays, I suspect many of you may be struggling a bit, just as we are here at the AGEC. We had just begun to get back out into the communities with robust programming when Omicron decided to visit. Here we go again!

On the positive side, after almost two years, we have all learned new skill sets! We can effectively work remotely: we can teach and learn, we can conduct community education and exercise activities, we can “meet”, we can still deliver great outcomes, and most of all – we have learned that no one cares what we look like on Zoom!

Fall of 2021 was very busy for AGEC. We met with our HRSA project officer in October and reviewed our quarterly report where we were congratulated on all of our accomplishments, including our MIPS and age-friendly training with our clinical partner, ARcare. A special thanks and shout out to our lead partner at ARcare, John Beard, and Dr. Leah Tobey, here at the AGEC, for their tireless training and reporting which is required to meet objectives of this grant!

AGEC also continued with webinars with Dr. Lee Isaac in October where he presented Diversity in Dementia, and Dr. Jonathan Laryea who spoke in December regarding Older Adults and Constipation. Dr. Tobey and Ms. Spradley from the AGEC also spoke at the Reynolds Institute on Aging 5^th Annual Dementia Update to caregivers, and I presented at the Dementia Update to the healthcare professionals regarding: What Matters Most: A critical part of the dementia care equation.

We had a plethora of special events during November that aligned with National Family Caregiver Month, and they were all very well received. AGEC Podcasts are doing well and Vanessa Lee & Laura Spradley spent time being guests on The Vine, a KTHV Channel 11 morning program, where they spoke about AGEC caregiver-related programs in November and appeared again in December.

As we buckle down for what are usually the worst winter months in Arkansas, January and February, let’s keep working and helping our older adults. Let’s keep learning and improving our knowledge and skills for them!

Stay warm and safe!

Taking a Deeper Look at Aducanumab

Winter 2022 Newsletter

By Jasmine (Sea) An, PharmD, PGY2 Geriatric Pharmacy Resident, and Lisa C Hutchison, PharmD, MPH
University of Arkansas for Medical Sciences (UAMS) College of Pharmacy

In June 2021, the U.S. Food and Drug Administration (FDA) approved the first-of-its-kind monoclonal antibody indicated for treatment of Alzheimer’s disease in patients with mild cognitive impairment or mild stage of disease. Despite this groundbreaking approval, controversy surrounds the drug.

Aducanumab (Aduhelm) is an anti-amyloid monoclonal antibody directed against aggregated amyloid beta (AAB) plaques, which is a defining pathophysiological feature of Alzheimer’s disease.¹ Administration requires infusion over a 1-hour period every 4 weeks. The dose is slowly titrated to meet the goal dose (10 mg/kg) by the seventh infusion. According to the FDA label, no diagnostic tests are required to confirm the presence of AAB plaques prior to initiating this therapy. However, patients are required to obtain magnetic resonance imaging (MRI) at baseline and prior to their seventh and twelfth dose to screen for potential adverse events. The FDA label does not specify any contraindications.

Part of the controversy with aducanumab is the limited data available to evaluate the efficacy of aducanumab. Approval was based on two phase-3 trials. Phase-3 trials help confirm effectiveness and safety of investigational drugs. Both trials were terminated early due to clinical futility. However, Biogen, the manufacturer of aducanumab, subsequently conducted post hoc analysis of the data from the terminated trials to present to the FDA.

The two trials are called ENGAGE² and EMERGE³. Both trials were 18-month, double-blind, randomized, placebo-controlled, parallel group studies. Patients received placebo, low-dose aducanumab (3 or 6 mg/kg), or high dose aducanumab (6 or 10 mg/kg). Some of the major exclusion criteria were:

age over 85,
transient ischemic attack or stroke within one year prior to screening,
contraindications to having a brain MRI or PET scan, and
use of medications with platelet antiaggregant or anticoagulant properties.^2,3

The primary endpoint was changes from baseline in Clinical Dementia Rating Scale Sum of Boxes (CDR-SB), and secondary endpoints were changes from baseline in Mini-Mental State Exam (MMSE), Alzheimer’s Disease Assessment Scale-Cognitive Subscale (ADAS-Cog), and Alzheimer’s Disease Cooperative Study Activities of Daily Living MCI (ADCS-ADL-MCI). Both trials showed statistical reduction in AAB plaque compared to baseline. However, neither trial showed statistically significant difference in clinically useful endpoints for low-dose aducanumab.⁴ As for high-dose aducanumab, there were mixed results with the EMERGE trial showing statistical significance in the primary endpoint while the ENGAGE trial not showing any statistically significant difference.⁴

In addition to the question of efficacy, safety is another concern. Specifically, amyloid-related imaging abnormalities edema (ARIA-E) occurred in 35% of patients who received aducanumab compared to 3% from the placebo group.⁴ Even though ARIA-E was found to be reversible and non-significant, symptoms such as changes in mental state, confusion, and gait disturbances may be present. Other serious adverse reactions shown on imaging were microhemorrhage and amyloid-related imaging abnormalities-hemosiderin deposition (ARIA-H) which both had ≥10% higher risk compared to placebo. Other safety concerns were headaches, falls, and diarrhea.⁴

Aducanumab was FDA approved through accelerated approval and Biogen must conduct a fourth randomized clinical trial to prove that aducanumab actually slows the progression of Alzheimer’s disease measured in clinical results, not just in changes in AAB plaque. Other barriers to utilizing this medication include cost. Initially Biogen indicated the estimated cost was $56,000 per year (excluding cost of administration and imaging), but that figure was lowered to $28,200 per year as of January 2022.⁵ Because of the lack of clear clinical improvement and safety concerns, the Department of Veterans Affairs did not include aducanumab on its national formulary⁶, and other major health systems such as the Cleveland Clinic and Mount Sinai have affirmed their opposition to the drug as well.⁷ As of January 2022, the Centers for Medicare and Medicaid Services (CMS) made a draft decision to cover aducanumab only in studies approved by CMS or supported by the National Institutes of Health. This proposal is open to public comment for 30 days and final decision will be made by April 11.⁸

Despite finally having the first agent for treatment of Alzheimer’s disease, we cannot celebrate just yet. There is ambiguity in data, major safety concerns, and high potential to increase disparity in care. These issues must be considered prior to initiating aducanumab therapy.

References

ADUHELM (aducanumab-avwa) . Biogen. Cambridge, MA. 2021.
221AD301 Phase 3 Study of Aducanumab (BIIB037) in Early Alzheimer’s Disease (ENGAGE). ClinicalTrials.gov identifier: NCT02477800. Updated September 2, 2021. Accessed September 17, 2021. https://clinicaltrials.gov/ct2/show/NCT02477800
221AD302 Phase 3 Study of Aducanumab (BIIB037) in Early Alzheimer’s Disease (EMERGE). ClinicalTrials.gov identifier: NCT02484547. Updated September 2, 2021. Accessed September 17, 2021. https://clinicaltrials.gov/ct2/show/NCT02484547
Haeberlein SB, Hehn C, Tian Y et al. EMERGE and ENGAGE Topline Results: Two Phase 3 Studies to Evaluate Aducanumab in Patients With Early Alzheimer’s Disease: Biogen Presentation. 2020.
Terry M. Biogen Cuts Price of Much-Debated Alzheimer’s Drug in Half. BioSpace. December 20, 2021. Accessed January 3, 2022. https://www.biospace.com/article/biogen-cuts-price-of-alzheimer-s-drug-aduhelm-in-half/
Kansteiner F. Biogen’s controversial Alzheimer’s med Aduhelm turned away by VA on efficacy and safety worries. FIERCE Pharma. August 11, 2021. Accessed September 3, 2021. https://www.fiercepharma.com/pharma/biogen-s-alzheimer-s-med-aduhelm-absent-from-veterans-association-formulary-efficacy-and
Belluck P. Cleveland Clinic and Mount Sinai Won’t Administer Aduhelm to Patients. The New York Times. July 14, 2021. Accessed September 3, 2021. https://www.nytimes.com/2021/07/14/health/cleveland-clinic-aduhelm.html
Mcginley L, Goldstein A. Medicare proposes covering expensive drug for early-stage Alzheimer’s, but with restrictions that will sharply limit use. The Washington Post. January 11, 2022. Accessed January 13, 2022. https://www.washingtonpost.com/health/2022/01/11/alzheimers-drug-aduhelm-medicare-coverage/

New Year. New Goals. New Supplements? The Use of Probiotics in Senior Adults

Winter 2022 Newsletter

By Alicia S. Landry, PhD, RD, LDN, SNS
Department of Nutrition and Family Sciences
University of Central Arkansas

Dietary supplements can be casually grouped into a broad category of vitamins and minerals – multivitamins – that can be taken once daily to help meet the dietary recommendations of certain age groups. However, the dietary supplement industry has grown to include much more than traditional vitamin and mineral supplements and has expanded to include antioxidants, fiber, amino acids, probiotics, prebiotics, synbiotics, herbals, and protein or amino acids, among others. Dietary supplements are available in pills, capsules, liquids, gummies and can be found in energy drinks, snack bars, cookies, and other commonly available foods.

The Food and Drug Administration (FDA) regulates dietary supplement products and dietary ingredients, but under a different set of regulations than those standards for food and drug products (Nutrition, 2020). Dietary supplements are not pre-approved by the FDA for safety or effectiveness before marketing. Claims that supplement companies make and word-of-mouth may over-promise and under-deliver results for memory health, bowel movements, joint relief, and other ailments. Some dietary supplements can be very dangerous when paired with prescription drugs (i.e. St. John’s Wort and warfarin) while others may reduce efficacy (i.e. Black Cohosh and statins) and still, others may have no effect on pharmacokinetics whatsoever. There are few evidence-based research studies that ‘prove’ the effectiveness of dietary supplements. Conducting research on these items proves difficult, especially in senior adults, because the dose of active ingredients can vary across brands, ratios of fat and lean mass affect absorption, disease states and other medications interact with absorption, and as humans age the predictability and efficiency of gut functions are altered. Controlling these extraneous variables in conducting randomized-controlled research trials can seem impossible when gathering evidence to make general evidence-based recommendations about consuming dietary supplements.

While health professionals can advocate that no pill will replace nutrients in a balanced and moderate diet, sometimes supplementation is warranted (i.e. B12 deficiency). One such example of using dietary supplements to increase absorption and help positively influence gut function is probiotics. Probiotics are “live microorganisms that, when administered in adequate amounts, confer a health benefit on the host” (Hill et al., 2014). Probiotics are usually bacterial components of the normal human intestinal flora that produce as end products of metabolism, lactate and short-chain fatty acids. Lactobacilli and bifidobacteria are examples and have well-defined benefits in human health (Ouwehand et al., 2002). Other similar terms that may be mentioned in probiotic literature are prebiotics and synbiotics. Prebiotics are defined as “a substrate that is selectively utilized by host microorganisms conferring a health benefit” (Gibson et al., 2017). Synbiotics are defined as “a mixture comprising live microorganisms and substrate(s) selectively utilized by host microorganisms that confers a health benefit on the host” (Swanson et al., 2020).

Common issues seen in aging adults that can affect nutritional status and dietary intake are inflammation-related and include constipation, undernutrition, neurodegenerative diseases, metabolic disorders, and reduced immune function (Ale & Binetti, 2021). While one’s overall health depends largely on the healthy functioning of the digestive system, the advantage of probiotic use among older adults is the prevention of antibiotic-associated diarrhea and Clostridium difficile colitis infection. Depending on the strain of probiotic taken, constipation and diarrhea (Björklund et al., 2012) as well as diverticulitis, mental conditions (Inoue et al., 2018; Kim et al., 2020), the immune system (Ibrahim et al., 2010), vitamin absorption, and metabolic disorders (Cicero et al., 2021) can all be positively affected.

In one study with elderly subjects, improved mental status and reduction of depression and anxiety were noted (Inoue et al., 2018). The probiotic treatment was paired with 12-weeks of physical activity classes including resistance training. The effect solely of the probiotics cannot be determined, but it is encouraging to consider the potential benefits of a combined program such as this one. In another study, probiotics were evaluated for their role in reducing inflammation, especially neuroinflammation seen in the early stages of Alzheimer’s disease (Leblhuber et al., 2018). All in all, there may be significant and promising results from the use of probiotics. However, probiotic effects can be attributed only to the strain or strains tested and not to the species or the whole group of lactic acid bacteria. Probiotics are defined by genus, species, and strain designation. The names sound complicated, but they are important for connecting the specific probiotic strain to the strain’s published scientific literature. Furthermore, products should contain the specific strain(s) of bacteria at the same levels used in published research. Common microorganisms are Lactobacillus and Bifidobacteria as well as Saccharomyces, Streptococcus, Enterococcus, Escherichia, and Bacillus.Probiotics must have live microorganisms in the product when they are placed on the shelf and throughout their shelf life, checking the brand reputation and evidence-based literature behind the brand and strains is very important in selecting quality supplements.

Probiotics, contained in “functional foods” (foods that provide physiological benefits or reduce the risk of chronic diseases, over and above their basic nutritional value), are available in several forms with the most common being yogurt. Some brands of yogurt specifically market patented live organisms while others contain microorganisms already present in the human gut microbiota. Fermented drinks, like buttermilk, kefir, or kombucha, and dehydrated bacteria in the form of powders are also available. As with all supplements, a healthcare provider should be consulted before use, and especially with probiotics, if the patient is immuno-compromised, probiotics should be used only under the supervision of a healthcare professional. Most probiotics are sold as dietary supplements or ingredients in foods and cannot legally claim to cure, treat, or prevent disease. Claims made on a product should be truthful and substantiated, but this may not always be the case.

Consider the following tips to help your patients or loved-ones as they explore dietary supplements: (1) recommend they visit with a registered dietitian nutritionist about their diet and lifestyle, (2) be wary of claims about curing multiple diseases, (3) fact check overly impressive-sounding terms, ancient secrets, miracle cures, and statements that suggest the product can treat or cure diseases or that it is quick and effective, (4) the term “natural” does not always mean safe, and (5) items that are extremely costly may not be warranted. As a reminder, healthy daily activities like consuming a balanced diet and being physically active remain incredibly important, our combined lifestyle factors affect our gut bacteria and gut health. The registered dietitian nutritionist is the expert on the healthcare team to ask about balanced diets and dietary supplements. Maintaining a healthy gut is about more than taking a probiotic supplement; keeping our guts functioning properly is essential to overall health and well-being.

References

Ale, E. C., & Binetti, A. G. (2021). Role of probiotics, prebiotics, and synbiotics in the elderly: Insights into their applications. Frontiers in Microbiology, 12, 631254. https://doi.org/10.3389/fmicb.2021.631254

Björklund, M., Ouwehand, A. C., Forssten, S. D., Nikkilä, J., Tiihonen, K., Rautonen, N., & Lahtinen, S. J. (2012). Gut microbiota of healthy elderly NSAID users is selectively modified with the administration of Lactobacillus acidophilus NCFM and lactitol. Age, 34(4), 987–999. https://doi.org/10.1007/s11357-011-9294-5

Cicero, A. F. G., Fogacci, F., Bove, M., Giovannini, M., & Borghi, C. (2021). Impact of a short-term synbiotic supplementation on metabolic syndrome and systemic inflammation in elderly patients: A randomized placebo-controlled clinical trial. European Journal of Nutrition, 60(2), 655–663. https://doi.org/10.1007/s00394-020-02271-8

Ibrahim, F., Ruvio, S., Granlund, L., Salminen, S., Viitanen, M., & Ouwehand, A. C. (2010). Probiotics and immunosenescence: Cheese as a carrier. FEMS Immunology and Medical Microbiology, 59(1), 53–59. https://doi.org/10.1111/j.1574-695X.2010.00658.x

Inoue, T., Kobayashi, Y., Mori, N., Sakagawa, M., Xiao, J.-Z., Moritani, T., Sakane, N., & Nagai, N. (2018). Effect of combined bifidobacteria supplementation and resistance training on cognitive function, body composition and bowel habits of healthy elderly subjects. Beneficial Microbes, 9(6), 843–853. https://doi.org/10.3920/BM2017.0193

Kim, C.-S., Cha, L., Sim, M., Jung, S., Chun, W. Y., Baik, H. W., & Shin, D.-M. (2020). Probiotic supplementation improves cognitive function and mood with changes in gut microbiota in community-dwelling older adults: A randomized, double-blind, placebo-controlled, multicenter trial. The Journals of Gerontology Series A: Biological Sciences and Medical Sciences, 76(1), 32–40. https://doi.org/10.1093/gerona/glaa090

Leblhuber, F., Steiner, K., Schuetz, B., Fuchs, D., & Gostner, J. M. (2018). Probiotic supplementation in patients with Alzheimer’s Dementia—An explorative intervention study. Current Alzheimer Research, 15(12), 1106–1113. https://doi.org/10.2174/1389200219666180813144834

Nutrition, C. for F. S. and A. (2020, February 4). Dietary Supplements. FDA; FDA. https://www.fda.gov/food/dietary-supplements

Ouwehand, A. C., Salminen, S., & Isolauri, E. (2002). Probiotics: An overview of beneficial effects. Antonie Van Leeuwenhoek, 82(1–4), 279–289.

Preventing Suicide in the Aging Population

Winter 2022 Newsletter

By S. Mark Foster, DNP, APRN, FNP-BC and Jessica Erin Camp, DNP, APRN, AGCNS-BC, NE-BC, CDP
College of Nursing & Health Professions
Arkansas State University

Suicide is a significant issue in the aging population. Rates of suicide are acutely high among men ages 85 and older, who have the highest rate of any group in the country (CDC, 2014). In addition, older persons’ suicide attempts are much more likely to result in death when compared to younger people (SPRC, 2020). Some significant reasons include careful planning, lethal methods chosen, reduced likelihood of being rescued, and frailty which decreases recovery likelihood (SPRC, 2020). Therefore, as healthcare providers we need to be aware of this risk and take action to help our patients.

Arkansas’s suicide death rate increased by an alarming 41% between 2000 and 2018, according to a new analysis of vital statistics data. The increase is especially concerning because the ongoing COVID-19 pandemic is further exacerbating risk factors for suicide. Not surprisingly, given concerns about exposure to COVID-19 in emergency departments, a decline in ED visits for psychiatric complaints was reported, particularly during the early phase of the pandemic (Yard et al. 2021). Survey data also point to higher levels of suicidal ideation and attempts among adults, particularly those experiencing more COVID-19-related adversities such as social distancing policies, distress, and fear of physical harm (Ammerman, et al. 2021). Additional risk factors that may be impactful include: economic downturn, barriers to accessing healthcare, access to suicidal ideation and inappropriate media reporting.

Providers need to be mindful of additional factors that may impact the care of this population, such as care delivery model changes, legislation, and an uptick in the media attention surrounding mental health. Increased legislative efforts and access to healthcare through telemedicine efforts may prove to have a positive impact on suicide rates in Arkansas. During the ongoing pandemic, mental health care faces significant challenges related to staff shortages and decreased resources. However, telemedicine is one of the best tools to tackle these challenges and simultaneously address the expected increase in demand for mental health (Wasserman et al, 2020).

Through legislative efforts Arkansas has established its own suicide hotline that is operated by the Arkansas Department of Health. Websites such as The American Foundation for Suicide Prevention, Arkansas Suicide Prevention, Arkansas Suicide Prevention Network, or the National Action Alliance for Suicide Prevention may also serve as additional resources for patients and healthcare professionals alike. Additionally, the integration of more suicide prevention education within academia at all levels can raise awareness of this issue.

Awareness is essential, and providers are thus well-positioned to identify high-risk patients and initiate interventions to mitigate suicide-related morbidity and mortality (Rutz, 2001). Providers should talk with their older adult patients about prevention efforts, risk factors for suicide, and protective factors to prevent patients from suicide (SPRC, 2020). Providers should be aware of common risk factors, such as depression and other mental health problems, substance use problems including prescriptions, illness, disability, pain, and social isolation, particularly since the onset of the pandemic (SPRC, 2020) (USDHHS, 2016). Providers should also know what protective factors are, such as those that seek care for their mental and physical health problems, those with social connections, and having coping and adaptation skills (SPRC, 2020).

References

Ammerman, B. A., Burke, T. A., Jacobucci, R., & McClure, K. (2021). Preliminary investigation of the association between COVID-19 and suicidal thoughts and behaviors in the U.S. Journal of psychiatric research, 134, 32–38. https://doi.org/10.1016/j.jpsychires.2020.12.037

Centers for Disease Control and Prevention. (2014). Fatal injury reports, national and regional, 1999–2014. Retrieved from http://webappa.cdc.gov/sasweb/ncipc/mortrate10_us.html

Rutz W. Preventing suicide and premature death by education and treatment. J Affect Disord. 2001 Jan;62(1-2):123-9. doi: 10.1016/s0165-0327(00)00356-6. PMID: 11172879.

Suicide Prevention Resource Center (SPRC). (2020). Older adults. Retrieved from https://www.sprc.org/populations/older-adults

United States Department of Health and Human Services (USDHHS). (2016). Facing addiction in America: The Surgeon General’s report on alcohol, drugs, and health.

Wasserman, D., Iosue, M., Wuestefeld, A., & Carli, V. (2020). Adaptation of evidence-based suicide prevention strategies during and after the COVID-19 pandemic. World psychiatry : official journal of the World Psychiatric Association (WPA), 19(3), 294–306. https://doi.org/10.1002/wps.20801

Yard, E., Radhakrishnan, L., Ballesteros, M. F., Sheppard, M., Gates, A., Stein, Z., Hartnett, K., Kite-Powell, A., Rodgers, L., Adjemian, J., Ehlman, D. C., Holland, K., Idaikkadar, N., Ivey-Stephenson, A., Martinez, P., Law, R., & Stone, D. M. (2021). Emergency Department Visits for Suspected Suicide Attempts Among Persons Aged 12-25 Years Before and During the COVID-19 Pandemic – United States, January 2019-May 2021. MMWR. Morbidity and mortality weekly report, 70(24), 888–894. https://doi.org/10.15585/mmwr.mm7024e1