AGEC

From the Director’s Desk

Winter 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)

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.

Beyond Diabetes: Use of Antidiabetic Agents in Heart Failure

Winter 2021 Newsletter

By Tyler R. Walsh, PharmD and Lisa C. Hutchison, PharmD, MPH
University of Arkansas for Medical Sciences (UAMS) College of Pharmacy

According to the Centers of Disease Control, diabetes is a risk factor for developing heart failure.¹ Many patients with diabetes will develop heart failure, so clinicians would be excited to have medications that could treat diabetes and also improve heart failure outcomes. The sodium-glucose cotransporter 2 (SGLT-2) inhibitors are possibly those medications.

SGLT-2 inhibitors work in diabetes by inhibiting the reabsorption of glucose in the kidney causing more glucose to be excreted in the urine .² Two of the SGLT-2 inhibitors have evidence of benefit in heart failure. The exact mechanism of action for the SGLT-2 inhibitors in heart failure remains unknown. Dapagliflozin (Farxiga) has FDA approval for treatment of heart failure in addition to diabetes mellitus type 2.³ This approval was based on results of the Dapagliflozin and Prevention of Adverse Outcomes in heart Failure (DAPA-HF) trial.⁵ Another SGLT-2 inhibitor, empagliflozin (Jardiance), showed benefit in the Cardiovascular and Renal Outcomes with Empagliflozin in Heart Failure (EMPEROR) trial but currently is not FDA approved for heart failure treatment.⁶The third SGLT-2 inhibitor, canagliflozin (Invokana), is not currently seeking FDA approval for heart failure treatment.

Table 1. Dapagliflozin and Empagliflozin in Heart Failure Trials

	Dapagliflozin⁵	Empagliflozin⁶
Patients	4,744 (2,373 treatment, 2,371 placebo)	3,730 (1,863 treatment, 1,876 placebo)
Percentage of patients with DM	41.7% in both treatment and placebo arms	49.8% in both treatment and placebo arms
Primary outcome was a composite of:	Worsening HF or death from CV causes	Adjudicated CV death or first hospitalization for HF
Efficacy results	Dapagliflozin 16.3% vs. Placebo 21.2% HR 0.75 (95% CI 0.65-0.85, p<0.001)	Empagliflozin 19.4% vs. Placebo 24.7% HR 0.75 (95% CI 0.65-0.85, p<0.001)
Safety results	No difference between groups	Uncomplicated UTIs 4.9% empagliflozin 4.5% placebo

DM = diabetes mellitus type 2; HF = heart failure; CV = cardiovascular; UTIs = urinary tract infections

Based on the data from each of these trials, both agents are effective in the treatment of heart failure independent of their effectiveness in diabetes.⁶ Of note, in both studies patients with a New York Heart Association (NYHA) classification of II had more benefit compared to patients with an NYHA classification of III or IV.^5,6 In a post-hoc analysis of the DAPA-HF trial researchers analyzed the efficacy and safety of dapagliflozin based on age. The benefit/risk profile of dapagliflozin was as favorable in older adults as in younger adults.⁷ However, some key exclusion criteria were patients with hypotension (systolic reading <95 mmHg at two readings), patients with current or recent decompensated heart failure, and patients with recent revascularization, so caution should be used if dapagliflozin is initiated in a patient with any of these characteristics.⁸

Lastly, it is important to consider the disadvantages of these medications. Both of these medications are contraindicated with a creatine clearance less than 30 mL/min.^2,4 Also, since these medications increase glucose in the urine, the risk of developing a urinary tract infection is about 6% in men and 18% in women.^2,4 Finally, we must consider the financial burden of these medications on our patient population. These medications cost about $21 per tablet ($630 per month).^2,4 These medications could be covered by a patient’s Medicare Part D plan, but they are currently only available as name brand and are not generic. While these medications are promising for clinical outcomes many patients may be unable to afford them.

The prevalence of diabetes and heart failure is high in the older adult. These medications should be considered as add on therapy to standard of care regimens for the treatment of diabetes and heart failure. The use of SGLT-2 inhibitors, dapagliflozin and empagliflozin, can help treat diabetes as well as improve outcomes directly related to heart failure.

References:

Heart Failure (2020). Centers for Disease Control and Prevention. Retrieved from https://www.cdc.gov/heartdisease/heart_failure.htm.
Dapagliflozin (2021). Lexicomp. Retrieved on January 11, 2021.
FDA approves new treatment for a type of heart failure (2020). U.S. Food and Drug Administration. Retrieved from https://www.fda.gov/news-events/press-announcements/fda-approves-new-treatment-type-heart-failure.
Empagliflozin (2021). Lexicomp. Retrieved on January 11, 2021.
McMurray, J. J., Solomon, S. D., Inzucchi, S. E., Køber, L., Kosiborod, M. N., Martinez, F. A., … & Langkilde, A. M. (2019). Dapagliflozin in patients with heart failure and reduced ejection fraction. New England Journal of Medicine, 381(21), 1995-2008.
Packer, M., Anker, S. D., Butler, J., Filippatos, G., Pocock, S. J., Carson, P., … & Zannad, F. (2020). Cardiovascular and renal outcomes with empagliflozin in heart failure. New England Journal of Medicine, 383(15), 1413-1424.
Martinez, F. A., Serenelli, M., Nicolau, J. C., Petrie, M. C., Chiang, C. E., Tereshchenko, S., … & McMurray, J. J. (2020). Efficacy and safety of dapagliflozin in heart failure with reduced ejection fraction according to age: insights from DAPA-HF. Circulation, 141(2), 100-111.
McMurray, J. J., DeMets, D. L., Inzucchi, S. E., Køber, L., Kosiborod, M. N., Langkilde, A. M., … & Selvén, M. (2019). A trial to evaluate the effect of the sodium–glucose co‐transporter 2 inhibitor dapagliflozin on morbidity and mortality in patients with heart failure and reduced left ventricular ejection fraction (DAPA‐HF). European journal of heart failure, 21(5), 665-675.

The Importance of Vitamin D in the Wintertime

Winter 2021 Newsletter

By Dr. Audrey Folsom, DHSc, MSHS, MT(ASCP), Assistant Professor of Clinical Lab Sciences, and Mr. Eric West, MBA, DTR, Assistant Professor of Dietetics
Arkansas State University

Vitamin D deficiency and insufficiency affects individuals across all ethnicities and age groups, but older adults are especially vulnerable. Vitamin D deficiency is a widespread problem, which is attributed to many different factors, including lifestyle and environmental factors.

Vitamin D is an essential component for bone health, helping stave off the development of osteomalacia (bone softening), aiding in preventing muscle weakness, and minimizing bone fractures due to falls. The absorption of vitamin D through UVB-irradiation from sun exposure becomes less efficient in older adults, therefore vitamin D deficiency has become more prevalent in this population (Boucher, 2012). Other factors such as reduced appetite, taking multiple medications, and being under stress add to the prevalence of this deficiency. (Boucher, 2012; Kweder & Eidi, 2018)

Aside from the well-known association between vitamin D and bone health, there have been studies that indicate a correlation between low levels of the vitamin and an increased risk of developing oral, gastrointestinal, urinary, and even respiratory infections (Kweder & Eidi, 2018). Vitamin D has several critical roles in immunity and a deficiency can lead to a dysfunctional immune system. Additionally, if the deficiency is sustained, it can lead to the development of autoimmune conditions or cancers (AACC, 2020). Moreover, research indicates an association between low levels of vitamin D and diseases associated with aging such as cognitive decline, depression, osteoporosis, cardiovascular disease, hypertension, type 2 diabetes, and cancer (Meehan & Penckofer, 2014). With the high prevalence of vitamin D deficiency and its underestimation from many physicians, vitamin D deficiency has become a worldwide health issue (Kweder & Eidi, 2018).

A lack of vitamin D production by the skin during the winter months has been linked to Seasonal Affective Disorder (SAD), also known as the “winter blues”. Depression is linked to lower blood levels of vitamin D (Anglin, Samaan, Walter, & McDonlad, 2018). Normally, the body can manufacture enough vitamin D during the spring, summer and fall months to last through the winter. The body can store vitamin D in the liver and in fat cells (Harvard Health Publishing, 2007), and then use it to get through a winter season. However, because we now have desk jobs or work inside, and use sunscreen when we are outside during the summer, our body struggles to make and store enough to last through the winter months.

While the deficiency is commonly seen in the older adult, there are other contributing risk factors. They include dark skin pigmentation, impaired or poor skin integrity, reduced time spent outdoors and reduced exposure to sunlight, having a body mass index (BMI) greater than 30, and impaired renal function. It is also noted that females are at higher risk than males for vitamin D deficiency (Meehan & Penckofer, 2014). This higher risk comes from differences in body composition. Females (and overweight people) naturally have a higher body fat percentage than males. Vitamin D is a fat-soluble vitamin that gets trapped in fat cells, where it can no longer be used by the body (Donnelly Michos, n.d.). Therefore, a higher body fat percentage leads to lower vitamin D levels.

The best way to know if a vitamin D deficiency is present is to get tested. A primary care provider can order a 25-hydroxyvitamin D, the most abundant and common form of vitamin D found in the blood. This blood test requires no specific preparation and can be done during a regular check up. Once the results come back, the reference ranges for normal levels are indicated on the report, but it is worth noting that the Endocrine Society defines vitamin D deficiency as a 25-hydroxyvitamin D blood level below 20 ng/mL (50 nmol/liter) and vitamin D insufficiency as a level between 21–29 ng/mL (52.5–72.5 nmol/liter) (AACC, 2020).

If the test levels come back below the normal reference range, it is possible that this is due to a lack of sun exposure or a lack of absorption from the intestines, which is common with many bowel disorders such as irritable bowel syndrome, Crohn’s disease, etc. (AACC, 2020) A primary care provider can make a recommendation for supplementing with vitamin D3, which can be easily purchased at most pharmacies and grocery stores. Blood levels can be checked again after several months of supplementation to see if the dosage is adequate, excessive, or inadequate. It is important to get tested before supplementation is started, as high levels of vitamin D in the blood can lead to an accumulation of calcium in the kidneys and blood vessels, which could cause damage (AACC, 2020).

Foods rich in vitamin D include egg yolks and oily fishes, but the amount required to get enough vitamin D is more than the average person would eat. There are fortified foods such as milk and cereals, but even those do not provide enough. The two remaining solutions are to get more sunshine or to supplement. Getting more sunshine can be tricky for those who live in the northern states due to the low angle of the sun’s rays during the winter months, which decreases UVB absorption by the skin. This doesn’t even factor the increased amount of time we spend indoors due to the winter weather. Therefore, most primary care providers will recommend a supplement to get blood levels up. (Harvard Health Publishing, 2007)

In conclusion, vitamin D is a crucial component of a healthy life, especially in older adults. Adequate levels can help keep the diseases of aging at bay. Vitamin D deficiency can be attributed to our modern lifestyle, which keeps us indoors year-round, as well as other risk factors such as being female, having a darker skin pigmentation, and being overweight. Testing is the only way to know if a deficiency is present, and supplementing with vitamin D should be undertaken under the direction of a primary care provider.

References

AACC. (2020, December 4). Vitamin D Tests. Retrieved from Lab Tests Online: https://labtestsonline.org/tests/vitamin-d-tests

Anglin, R., Samaan, Z., Walter, S., & McDonlad, S. (2018, January 2). Vitamin D Deficiency and Depression in Adults: Systematic Review and Meta-Analysis. Retrieved from Cambridge University Press: https://www.cambridge.org/core/journals/the-british-journal-of-psychiatry/article/vitamin-d-deficiency-and-depression-in-adults-systematic-review-and-metaanalysis/F4E7DFBE5A7B99C9E6430AF472286860

Boucher, B. J. (2012). The Problems of Vitamin D Insufficiency in Older People. Aging and Disease, 313–329. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3501367/

Donnelly Michos, E. (n.d.). How Does Vitamin D Affect Women’s Health? Retrieved January 7, 2020, from Johns Hopkins Medicine: https://www.hopkinsmedicine.org/health/wellness-and-prevention/how-does-vitamin-d-affect-womens-health

Harvard Health Publishing. (2007, February). Vitamin D and Your Health: Breaking Old Rules, Raising New Hopes. Retrieved from Harvard Health Publishing : https://www.health.harvard.edu/staying-healthy/vitamin-d-and-your-health-breaking-old-rules-raising-new-hopes

Kweder, H., & Eidi, H. (2018). Vitamin D Deficiency in Elderly: Risk Factors and Drugs Impact on Vitamin D Status. Avicenna Journal of Medicine, 139–146. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6178567/

Meehan, M., & Penckofer, S. (2014). The Role of Vitamin D in the Aging Adult. Journal of Aging and Gerontology, 60–71. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4399494/

Dementia Friendly Business Trainings from AGEC

Winter 2021 Newsletter

By Laura Spradley, MS
Outreach Coordinator
UAMS Arkansas Geriatric Education Collaborative (AGEC)

Local businesses owners are trying to differentiate themselves these days from the competition. Examples of how to “stand out” from the competition are providing extraordinary customer service, doing business differently than your competition, and creating a lasting impression and memorable reasons to return to your business. We at the Arkansas Geriatric Education Collaborative (AGEC) believe having front line employees and supervisors trained in “dementia friendly” business concepts and communications is another great way to “stand out!”

Business owners (including clinical venues) and their employees can receive our FREE dementia friendly business training via Zoom by trained AGEC staff. The business staff will learn many facts about dementia and Alzheimer’s disease. They will learn how to recognize possible signs of dementia in a customer, communication and interaction tips, and hints on how best to create a dementia-friendly physical environment, and they will learn about the availability of local resources to help those dealing with dementia or Alzheimer’s disease. The goal of this dementia-friendly business training is to provide increased awareness of dementia and Alzheimer’s disease, and to provide training on how to respond warmly and effectively when serving individuals who are living with dementia and their families.

The trainings are scheduled on days and times convenient for the business and their employees. The entire training takes approximately 45 minutes to complete. The necessary handouts and certificates of attendance provided by AGEC are free of charge.

The AGEC recognizes participating businesses who have completed the training with a banner announcing that they are now a dementia friendly business. AGEC can also provide customized, free, social media posts. The AGEC is available to participate with other media recognitions as needed or requested.

If your office, facility, or clinic staff could benefit from this training, or if you know a business or clinic who may be interested in becoming dementia friendly, please have them contact AGEC at agec@uams.edu or Laura Spradley at lspradley@uams.edu to request a dementia friendly business training.

National Caregivers Month: Early onset dementia

By Vanessa Lee

When two people get married, vows often include through sickness and health, for better or worse. Like most things, these words are often easier when simply spoken.

Rodney Smith never expected he’d become his wife’s caregiver, especially not so soon in their lives.

He met Danielle when he was 19 while stopping to fill his car with gas.

Caring for someone with early onset dementia

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“I’m facing one way and she’s facing the other way on the other side of the pump, and I just remembered her from high school and we started talking.”

Little did he know, that stop would change his life forever. A year-and-a-half later the pair tied the knot.

The Smith’s started their lives together in Germany after Danielle joined the Army. After serving a year in the Army, Danielle became pregnant with their first child and the couple decided to put down roots in Little Rock, Arkansas. They raised three children, two girls and a boy, along the way.

Rodney worked full-time while also leading the congregation at an area church. As Danielle watched her babies grow into children she developed a passion for teaching. She earned a bachelor’s degree and master’s degree while teaching high school English.

She was one semester away from earning her Ph.D. at the age of 41 when things began to change.

Danielle’s Diagnosis

In June 2015 Rodney began to notice subtle differences in his wife’s behavior.

“Forgetting conversations, just a little bit. It was nothing that really stood out. Looking back now knowing what we know you could tell, ‘ok those were early signs.’”

Forgetting her keys and forgetting to lock the door slowly progressed into several car accidents. Rodney felt that something wasn’t right and began looking for medical help.

After numerous doctors’ appointments with limited outcomes, he took Danielle to see Mark Pippenger, M.D., the director of the Walker Memory Center at the University of Arkansas for Medical Sciences (UAMS).

“He gave her a PET scan. That’s when he confirmed, he said ‘looks like she has early onset dementia.’”

This diagnosis in 2016 came as a shock as Danielle was only 41, however it is more common than many people realize. The Alzheimer’s Association estimates that 200,000 people in the United States have early onset dementia. Many of these people are in their 40s or 50s and have careers and families.

Caregiving

In 2016, Rodney stepped into the caregiving role when Danielle’s safety became a huge concern.

“We had gone downtown and renewed her teaching license and that was the last time she drove because on the way home she drove right through a four-way stop sign.”

It wasn’t long before Danielle had to stop working and needed round-the-clock care. Rodney managed Danielle’s medications, made sure someone was home to watch her, and he looked after their children who were 12, 19, and 20 at the time.

“I had to take the medicine and put it up then giving it to her myself in the morning or in the evening.”

By 2018, Danielle had lost the ability to care for herself or to communicate and life for Rodney became even more stressful. He was now a full-time caregiver.

“It begins to take a toll on you mentally watching someone you love just erode away in front of you.”

He knew it was very important for caregivers to take care of themselves, even on the hard days.

Rodney received some help from friends and family members who would bring food or sit with Danielle.

“It’s a heavy load because when you get off work you’re not off work. It’s like I was starting the second shift.”

After applying for disability for Danielle, the family received financial support seven months later and Rodney hired two caregivers who helped care for Danielle.

“They were almost like extended parts of the family so, that at least takes the mental pressure off of you knowing at home is covered.”

By September of 2019 Danielle’s health had drastically declined and she needed hospice care. Danielle passed away in April of 2020.

One of the last phrases she was able to say to Rodney was ‘I love you.’

Finding help for caregivers

Finding help and support for caregivers can be a chore. Family friend Carolyn Torrence, also the executive director of Alzheimer’s Arkansas, helps connect people to resources and was an advocate for Danielle.

“Caregivers across Arkansas need support and education. The reality is caregivers include all genders, races, ages and incomes. Most of us are not equipped to fulfill the vigorous role of caregiving. Caregiving can impact families financially, emotionally and physically,” said Torrence.

Alzheimer’s Arkansas offers support groups and workshops for caregivers.

The Arkansas Geriatric Education Collaborative at UAMS also provides resources for caregivers.

“The purpose of the Arkansas Geriatric Education Collaborative is to provide dementia-focused caregiver training and education to family members who are caregivers and paid caregivers to improve the care for older Arkansans, said Laura Spradley, outreach coordinator for the Arkansas Geriatric Education Collaborative at UAMS.

Sharing caregiver stories highlights the challenges they face in hopes of finding solutions.

“It is imperative that we tell the stories of these amazing caregivers in Arkansas and to work with organization such as Alzheimer’s Arkansas to provide assistance and resources,” she said.

Rodney said the journey of a caregiver isn’t one many people can relate to without hearing what it entails or experiencing it.

“To the caregivers who are helping a spouse, a child, or a parent, it’s a load that I never could have identified with if I hadn’t gone through it myself.”

If you are a caregiver and need assistance you can find resources at agec.uams.edu or by visiting the UAMS AGEC Facebook page.

The AGEC is funded by the Health Resources and Services Administration’s Geriatric Workforce Enhancement Program under grant #U1QHP28723.

From the Director’s Desk

Fall 2020 Newsletter

Happy fall everyone! I just want to take a brief moment of your time to wish you a great and safe fall and winter. I know 2020 has been extremely challenging for most of us, but we are persevering. We at the AGEC have actually learned and grown a LOT. We have converted most of our programs so that they are available via virtual platforms and have actually increased our reach in many ways. We now understand (somewhat anyway) and utilize new and diverse technologies to present our programs, improve our communications, and extend our reach.

We have tried to concentrate on how we can help older adults learn about and adapt to e-visits and telemedicine and how we can use virtual platforms to keep educating older adults and healthcare professionals. We have developed “how-to” videos on such things as hand washing, using gloves, How to Join a Zoom call, and Learning the Zoom Screen. We have also developed new tools to help older adults stay active and social by providing virtual physical activity classes and informational topics on Facebook, Instagram and Twitter. We are also making an effort to reach those older adults in their homes, maybe isolated at home, by continually working with our partners who provide local services to older adults such as churches and senior centers.

I am not sure what the fall/winter of 2020/2021 will bring, but we are continually working, changing and trying to keep ready for the upcoming challenges. We are and want to continue to be part of positive change. If you have ideas for us, please let us know!

Stayed tuned to the AGEC website, Facebook page, Instagram, and Twitter accounts for upcoming exciting programs and please share the embedded links regarding the Zoom videos to your patients and family members who might benefit! Stay safe everyone, and remember to get your flu shot and to remind your patients to get theirs too!!!

Over the Counter Topical Agents for Arthritis Pain

Fall 2020 Newsletter

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

Osteoarthritis is the most common form of arthritis and is the leading cause of disability in adults.¹ Roughly 40% of adults in the United States will develop this disease in at least one hand by 85 years of age². Non-pharmacological therapies recommended for osteoarthritis include weight loss and resistance exercises, but these treatments are seldom enough. According to the American College of Rheumatology (ACR) osteoarthritis guidelines, topical NSAIDs like diclofenac should be considered before other topical agents and oral NSAIDs. This is due to the lower risk of systemic exposure and superior efficacy noted through clinical trials^3,4.

Ingredients of topical arthritis pain medications with example products are listed in Table 1. Topical lidocaine is also available for neuropathic or burn pain, but is not recommended for arthritis pain.

Table 1: Over The Counter Topical Medications for Arthritis Pain^1,5,6,9
Ingredients	Brand Name Examples	Advantages	Disadvantages	Usual Area of Use
Menthol, camphor	Icy Hot Gel, Biofreeze, Tigerbalm	Cooling sensation with immediate effect	Does not treat inflammation or pain	Hand, knee, back
Salicylates	Bengay, Aspercreme, Myoflex	Cooling sensationSlight anti-inflammatory effectScented/unscented	Avoid with aspirin allergy	Knee, hand, foot
Capsaicin	Capzasin-HP creamZostrix, Capsiderm	Treatment of pain Potential adjunct agent when other therapies not tolerated	Skin irritation Poorly absorbed, Difficult adherence	Knee, hands
Diclofenac (NSAID) 1% gel	Voltaren Gel	Treatment of painGI & renal effects of oral NSAIDs unlikely	Skin irritation, Delayed pain relief, Difficult adherence	Knee, hand, foot

Until recently, diclofenac 1% gel (Voltaren) was only available by prescription⁵. This product provides both analgesic and anti-inflammatory actions to the affected joints. Safety and efficacy of diclofenac 1% gel on knee osteoarthritis was proven in three randomized double-blind multicenter trials³. The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) assessed pain (scale 0-20) and physical function (0-68) after 12 weeks. Patients 65 years and older showed significant improvement in pain (-5.3 vs. -4.1 p=0.02) and physical function (-15.5 vs -11, p=0.004) from baseline compared to placebo. There was also a significant decrease in pain on movement in the diclofenac group (-33.7 vs. -26.4, p=0.02).³ Study participants had over 90% adherence despite using a medication that requires application four times daily. Patients should be counseled on the importance of adherence and to not expect immediate relief.

Capsaicin is derived from chili peppers and acts as a counterirritant to pain. The agent is also useful for neuropathic pain. Capsaicin causes a depletion of substance P from sensory neurons, resulting in a numbing effect⁶. Capsaicin also requires application 3-4 times a day however, it requires a longer time to absorb into the skin before washing^6,7. A meta-analysis of 28 randomized-controlled trials explored the efficacy of capsaicin in osteoarthritis pain. Capsaicin trials were evaluated as low quality, but did show superiority to placebo when used at recommended doses (0.41, CI 0.17-0.64)⁷. Use of capsaicin on the hands is difficult, given the need to avoid touching the face or eyes after application to avoid burning. There is also concern for long-lasting nerve desensitization with chronic capsaicin use^6,8. The low quality evidence and adverse effects limit the use of capsaicin topical products for osteoarthritis to second line therapy after topical diclofenac. This meta-analysis also evaluated topical NSAIDs and found them overall superior to placebo based on effect size (0.30, CI 0.19-0.41).

Ingredients like camphor, menthol, and salicylates provide a distraction from pain through a cooling or warming sensation on the skin. These agents may provide an immediate feeling of relief but overall studies have shown mixed efficacy^4,9. Despite having been available for many years, there is limited data on their use.⁴ Menthol, camphor, and salicylate products are not currently recommended by the ACR guidelines for osteoarthritis pain management⁴. However, side effects with menthol and camphor products are few when used topically except to note that salicylates as a derivative of salicylic acid should not be used in patients with an aspirin allergy.⁹

Use of topical agents must be carefully guided in a geriatric population due increased absorption potential with the thinning of the skin in older adults and if heat is applied to the affected joint before or after topical application. Increased permeability may increase the risk of systemic side effects like that seen in oral NSAID medications. Topical agents are an important option because of easy application for patients suffering from mild to moderate osteoarthritis pain. The introduction of topical diclofenac to store shelves increases the availability of a therapy with evidence of providing significant pain reduction and improved physical function in patients with osteoarthritis.

References:

Osteoarthritis (2020). Centers for Disease Control and Prevention. Retrieved from https://www.cdc.gov/arthritis/basics/osteoarthritis.htm
Arthritis By The Numbers: Book of Trusted Facts & Figures (2019). Arthritis Foundation. Section Two: OA Facts (p17-27). Retrieved from https://www.arthritis.org/getmedia/e1256607-fa87-4593-aa8a-8db4f291072a/2019-abtn-final-march-2019.pdf
Baraf, H. S., Gloth, F. M., Barthel, H. R., Gold, M. S., & Altman, R. D. (2011). Safety and efficacy of topical diclofenac sodium gel for knee osteoarthritis in elderly and younger patients: pooled data from three randomized, double-blind, parallel-group, placebo-controlled, multicentre trials. Drugs & aging, 28(1), 27–40. https://doi.org/10.2165/11584880-000000000-00000
Kolasinski S., Neogi T., Hochberg M.,et. al. (2020). 2019 American College of Rheumatology/Arthritis Foundation Guideline for the Management of Osteoarthritis of the Hand, Hip, and Knee. American College of Rheumatology. Vol. 72, No. 2, February 2020, pp 149–162 DOI 10.1002/acr.24131
FDA Approves Three Drugs for Nonprescription Use Through Rx-to-OTC Switch Process (2020). S. Drug & Food Administration. Retrieved from https://www.fda.gov/news-events/press-announcements/fda-approves-three-drugs-nonprescription-use-through-rx-otc-switch-process.
Altman, R. D., Barthel, H. R. (2011). Topical therapies for osteoarthritis. Drugs, 71(10), 1259-1279.
Persson, M., Stocks, J., Walsh, D. A., Doherty, M., & Zhang, W. (2018). The relative efficacy of topical non-steroidal anti-inflammatory drugs and capsaicin in osteoarthritis: a network meta-analysis of randomised controlled trials. Osteoarthritis and cartilage, 26(12), 1575–1582. https://doi.org/10.1016/j.joca.2018.08.008
van Laar, M., Pergolizzi, J. V., Jr, Mellinghoff, H. U., et al. (2012). Pain treatment in arthritis-related pain: beyond NSAIDs. The open rheumatology journal, 6, 320–330. https://doi.org/10.2174/1874312901206010320
Rubbing It In (2019). Harvard Health Publishing. Retrieved from https://www.health.harvard.edu/pain/rubbing_it_in

Telehealth: Increasing Opportunities for Student Training and Expansion of Care to Senior Adults

Fall 2020 Newsletter

By Alicia S. Landry, PhD, RD, SDN, SNS
Family and Consumer Sciences
University of Central Arkansas

Telehealth is an umbrella term that often refers to healthcare services that are delivered virtually. Examples of telehealth are telemedicine, mHealth (mobile health), and store and forward. In order to lay some groundwork, we will start with brief definitions.

Telemedicine is two-way, synchronous discussion between a patient and a healthcare provider, or between multiple providers.
Mobile health is when a patient uses an application or software to manage health. An example would be tracking dietary intake using a food log app on a smartphone and syncing it with the platform a registered dietitian monitors to give the patient feedback on diet choices.
Store and forward includes gathering patient data (like photos of a rash or an x-ray) and using the information for diagnostic decisions made by a provider at a later time.

Using accurate terminology to describe telehealth interventions becomes important when multiple providers are providing care for a single patient as well as other situations. Having a healthcare team in sync with one another is critical to positive patient outcomes.

While telehealth could potentially result in healthcare savings as well as increased safety and convenience for aging adults as well as their providers (Snoswell, Taylor, and Caffrey, 2019), concerns remain about the feasibility of telehealth use in a geriatric population. Specialties such as psychiatry and counseling, physical and occupational therapy, and medical nutrition therapy have been positively impacted by the use of telehealth and should continue to grow as demands for specialists increase and the safety of going to practitioner offices remains in question. For most Medicare patients, virtual doctor visits are covered when a doctor is not available to see the patient in person and Medicare has expanded coverage for virtual visits in the wake of COVID-19 (Medicare, 2020).

Patient acceptance, insurance reimbursement, regulatory or licensure barriers, access to high-speed broadband or wireless networks, and privacy concerns are legitimate obstacles to implementing telehealth. In Arkansas, broadband access is very poor (41st in the US), making network infrastructure in rural areas somewhat prohibitive of the use of telehealth. The Arkansas Rural Connect program is expected to use $25 million to cover underserved and rural communities, and more recently, there have been expanded efforts to make wireless and broadband coverage available in rural areas. While 26% of adults over 60 years of age reported no access to the internet, only half of 45-59-year-olds reported no access (Arkansas Broadband Report, 2019) which means age gaps do occur in the access to high-speed internet as well as in the utilization of telehealth. As always, healthcare providers communicating with senior adults must recognize challenges in hearing, sight, technology access, as well as others to ensure the best care possible.

Patients with chronic conditions like diabetes, cardiovascular disease, and obesity show favorable responses to home management via telehealth when led by an interprofessional team of healthcare providers. If it is possible that telehealth can allow seniors to remain safely at home for a longer time, ensure older adults are compliant with medication use, and reinforce support of caregivers, it may be time to take a deeper look into the possibilities for allied health professionals to grow the telehealth outlet.

During this time of physical distancing, older adults are more likely to feel socially isolated, experience food insecurity, and delay routine healthcare. In the National Poll on Healthy Aging, 45% of respondents said the pandemic made them more interested in telehealth and only 25% reported being concerned they would have difficulty seeing or hearing the provider during a video visit (Buis et al., 2020). Reduced risk of falls or decreased exposure to disease benefits the frail elderly, and telehealth can allow resource providers to maintain closer contact with older adults. In-home caregivers who may have their own families or other jobs can connect with healthcare providers which may reduce stress and improve the quality of care. Mobility (address movement and physical activity), mentation (assess cognition level), medication (identify the type, dose, supply), and what matters (determine goals, preferences, priorities) are the four M’s of age-friendly health and remembering these for telehealth visits can make these visits even more successful for the aged (Institute for Healthcare Improvement, 2019).

For registered dietitians, the expanding telehealth world has been a phenomenal way to provide integrated and patient-centered care, even with guidelines about physical distancing and preventing the spread of infectious disease. For example, a registered dietitian observing mealtimes with speech pathologists and occupational therapists allows the interprofessional team to make decisions about food consistency, swallowing risk, socialization, and other issues impacting nutrition status. For patients with at-home parenteral nutrition, registered dietitian observation along with pharmacy and medical providers reduces the risk of bloodstream infections and hospital readmission (Raphael et al., 2019). In diabetes self-management education (DSME), registered dietitians are able to teach blood glucose monitoring and follow patients in real-time as they report their blood glucose levels. Telehealth DSME has had great success and shown significant reductions in hemoglobin A1c and blood pressure in patients with diabetes (Nicoll et al., 2014). Group therapy or support groups with counselors, registered dietitians, and social workers may help alleviate distress and loneliness of isolation. The use of multidisciplinary clinics has been shown to improve outcomes in aging adults (Erskine, Griffith, & Degroat, 2013; Kozak et al., 2017) and implementing telehealth in these clinics makes scheduling less burdensome. Dietitians across the State are utilizing telehealth for DSME and dietetic interns are learning multiple telehealth platforms in order to be better equipped as they enter the dietetics profession.

During the spring of 2020, multiple hospitals and primary care provider clinics closed and only allowed medically necessary procedures. These restrictions affected dietetics education because students were no longer allowed in hospitals like during traditional internships. Turning to telehealth and working alongside registered dietitians – even at a distance – to monitor and educate patients allowed students to continue their education and graduate on time. Likewise, these opportunities often included exposure to interprofessional teams of pharmacists, physicians, and other therapists which may not have been accessible during typical rotations. Taking advantage of these technologies gave students an opportunity to participate in ground-breaking healthcare as well as provided them with the confidence to interact in a healthcare team. While we must still train healthcare professionals to have bedside manner and we need to ensure students are competent in clinical skills, considering telehealth as a significant portion of their educational experience is worthwhile.

Arkansas Department of Commerce. (2019). Arkansas State Broadband Manager’s Report. Available at: https://www.arkleg.state.ar.us/Calendars/Attachment?committee=685&agenda=3195&file=Exhibit%20F%20Arkansas%20State%20Broadband%20Manager%20Report.pdf
Buis, L., Singer, D., Solway, E., Kirch, M., Kullgren, J., & Malani, P. (2020). Telehealth use among older adults before and during COVID-19. University of Michigan National Poll on Healthy Aging. August 2020. Available at: http://hdl.handle.net/2027.42/15625
Erskine, K. E., Griffith, E., & Degroat, N. (2013). An interdisciplinary approach to personalized medicine: Case studies from a cardiogenetics clinic. Personalized Medicine, 10(1), 73–80.
Institute for Healthcare Improvement. (2019). “What Matters” to older adults? A toolkit for health systems to design better care with older adults. Retrieved from: http://www.ihi.org/Engage/Initiatives/Age-Friendly-Health-Systems/Documents/IHI_Age_Friendly_What_Matters_to_Older_Adults_Toolkit.pdf
Kozak, V. N., Khorana, A. A., Amarnath, S., Glass, K. E., & Kalady, M. F. (2017). Multidisciplinary clinics for colorectal cancer care reduces treatment time. Clinical Colorectal Cancer, 16(4), 366–371.
Medicare. (2020). Available at: https://www.medicare.gov/coverage/telehealth
Nicoll, K. G., Ramser, K. L., Campbell, J. D., et al. (2014). Sustainability of improved glycemic control after diabetes self-management education. Diabetes Spectrum, 27(3), 207-211.
Raphael, B.P., Schumann, C., & Garrity-Gentille, S. (2019). Virtual telemedicine visits in pediatric home parenteral nutrition patients: A quality improvement initiative. Telemedicine Journal and E-health, 25(1), 60–65.
Snoswell, C. L., Taylor, M. L., & Caffery, L. J. (2019). The breakeven point for implementing telehealth. Journal of Telemedicine and Telecare, 25(9), 530-536. doi: 10.1177/1357633X19871403.