AGEC

From the Director’s Desk

Winter 2023 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! Can you all believe it is 2023 and we have been enduring COVID and all that has entailed for almost three years? However, we are all learning to live with it better and getting out and enjoying things again. The AGEC programs are thriving and our community partners are busy once again. It is wonderful to see older adults congregating and enjoying each other’s company again! We are also having full classes where programs based on evidence are being taught and activities being enjoyed. In addition, as we begin this new year, our academic partners are working with health professions students to ensure many complete their degrees this spring. We can all look forward to having more healthcare professionals begin their careers knowing more about how to appropriately care for older adults.

This quarter, I want to talk to you a little more about what we started discussing last quarter, the 4M’s of Age-Friendly Care. I introduced that concept last quarter and this time I want to delve into one of those 4M’s a little more and subsequently discuss one more in-depth in each quarter this year. The first one we will review here is “What Matters”. This is what all the other “M’s” focus around. As I mentioned in the last Directors Desk, this is where the conversation with the patient, family, and caregiver(s) begins. The healthcare team should discuss the older adult’s health outcome goals and care preferences, including end-of-life care, across all settings. Their goals and preferences then direct the overall plan of care. Ideally, this should be asked at almost every visit, just to ensure priorities haven’t changed. What matters most to someone certainly changes with time, age, and of course life events. This month it might be caring for a disabled spouse, but if that spouse passes away, then what matters also changes, so as healthcare professionals, we need ask.

What matters should be inclusive, individualized, holistic, person-centered, patient-centered, respectful, prognosis-centered, collaborative, responsive, integrative, and of course, achievable. It also helps clinicians to build trust, treat older adults with humility and respect, maintain a patient-centered approach, create effective and actionable healthcare conversations, and frequently decreases unwanted care and treatments. Knowing what matters drives patient care goals. So just ask: what matters, what is most important to you in this stage of your life, and how can I, as a healthcare professional, help you achieve your goals?

This was just a quick overview of “What Matters”, but I hope helps to inform and remind us all of why we are healthcare professionals and why we should always ask and listen to our patients first. If you want to learn more, additional information can be found here.

If you would like more information or training regarding the 4M’s of Age-Friendly Care, please contact the AGEC.

Polypharmacy: Mitigation Strategies for Primary and Long-Term Care

Winter 2023 Newsletter

Mark Foster, DNP, APRN, FNC-BC, & Randi Davis, DNP, APRN, FNP-BC
College of Nursing and Health Professions
Arkansas State University

Polypharmacy in the older population continues to be prevalent across the state of Arkansas and nationally as well. The definition of polypharmacy varies depending on the source; however, on average, polypharmacy is defined as the use of five or more prescription drugs. According to the Centers for Disease Control and Prevention (CDC), “nearly 7 in 10 adults aged 40–79 used at least 1 prescription drug in the past 30 days in the United States (69.0%) and Canada (65.5%), and around 1 in 5 used at least 5 prescription drugs (22.4% in the United States and 18.8% in Canada)”, (CDC, 2019). Additionally, “The prevalence of polypharmacy has been reported to be approximately 40% with a third of residents in long-term facilities using 9 or more medications,” (Hawthorne et al., 2017). The Arkansas Department of Health Office of Long-term Care reports more than 23,000 Arkansans receive services in long-term care facilities each year, (Arkansas Department of Health, n.d.). Therefore, this underscores the significance of the potential impact on elderly Arkansans.

Polypharmacy increases the risk of adverse drug reactions, drug interactions, cognitive impairment, increased fall risk, and duplicate therapy. Coleman (2022) indicated the likelihood of hospitalization is 34% in patients taking 5-9 medications, and the likelihood of hospitalization increases to 98% in patients taking 10 or more medications. A recent study indicated the most commonly consumed prescription medications among our elderly were those prescribed for cardiovascular health and mental health (Hawthorne et al., 2017). These findings are not surprising considering that heart disease is the leading cause of death in the United States. Therefore, careful consideration of prescribing patterns is essential, particularly for antihypertensives, anticholinergics, and antidepressant medications.

Furthermore, frailty has also been associated with polypharmacy. Frailty is defined as, “a complex geriatric syndrome resulting in decreased physiological reserves,” (Gutiérrez-Valencia et al., 2018, p. 1433). A systematic review of 25 quantitative studies analyzed the relationship between polypharmacy and frailty among the elderly population and found a significant association. Therefore, strategies to decrease polypharmacy could also be utilized in an effort to prevent and manage frailty (Gutiérrez-Valencia et al., 2018).

Strategies for mitigation of polypharmacy in primary and long-term care include the utilization of evidenced-based instruments and adherence to recommended criteria. Instruments may include the STOPP (Screening Tool of Older Person’s Prescriptions) and START (Screening Tool to Alert doctors to Right Treatment) tools. The Beers Criteria has been widely accepted as a useful resource, listing medications that should be avoided in the elderly population. In addition, the Medication Appropriateness Index (MAI) may be applied to assess the appropriateness of medications prescribed for elderly patients.

Healthcare providers in are in a strategic position to initiate and monitor deprescribing practices, particularly regarding the geriatric population with multiple medication regimens, (Diggins, 2019). It is vital for all members of the healthcare team including primary care providers, mental health providers, pharmacists, social workers, and nurses to work collaboratively to optimize the plan of care for elderly patients. Accurate medication reconciliation and maximization of the capabilities of electronic medical record systems to include interfacing between primary, acute, and long-term care settings is paramount to the success of this collaborative effort.

The average life expectancy for Arkansans as of 2020 is 73.8 years (CDC, 2022). As the aging population continues to increase, incidence of health conditions requiring medical management among elderly Arkansans will continue to rise. Therefore, healthcare providers in Arkansas must be committed to employing the above mentioned strategies in order to decrease the prevalence of polypharmacy and its associated detrimental effects.

References:

Arkansas Department of Health. (n.d.). Office of long term care. Retrieved January 12, 2023, from https://humanservices.arkansas.gov/divisions-shared-services/provider-services-quality-assurance/office-of-long-term-care/

Centers for Disease Control and Prevention. (2022). Life expectancy at birth by state. Retrieved January 17, 2023, from https://www.cdc.gov/nchs/pressroom/sosmap/life_expectancy/life_expectancy.htm

Centers for Disease Control and Prevention. (2019). Prescription drug use among adults aged 40-79 in the United States and Canada. Retrieved January 12, 2023, from https://www.cdc.gov/nchs/products/databriefs/db347.htm#ref1

Coleman, B. (2022). Polypharmacy: Is It the new normal for the elderly patient? CEUfast. Retrieved January 12, 2023, from https://ceufast.com/course/is-polypharmacy-the-new-normal-for-the-elderly-patient

Diggins, K. (2019). Deprescribing: Polypharmacy management in older adults with comorbidities. The Nurse Practitioner, 44(7), 50-55. https://doi.org/10.1097/01.NPR.0000554677.33988.af

Gutiérrez-Valencia, M., Izquierdo, M., Cesari, M., Casas-Herrero, A., Inzitari, M., & Martínez-Velilla, N. (2018). The relationship between frailty and polypharmacy in older people: A systematic review. British Journal of Clinical Pharmacology, 84(7), 1432-1444. https://doi.org/10.1111/bcp.13590

Hawthorne, J., Warford, L., Hutchison, L., Pangle, A., Price, E., Wei, J., & Azhar, G. (2017). Prescription medication use in the oldest old of south-central United States. American Research Journal of Geriatrics and Aging, 1(1), 1-10.

UCA faculty and students provide accessible services for Arkansans at risk for and diagnosed with Alzheimer’s Disease and Related Dementias (ADRD)

Winter 2023 Newsletter

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By Darshon Reed, Ph.D. & Kalista Pettus
College of Health and Behavioral Sciences
University of Central Arkansas

The students in the College of Health & Behavioral Sciences at UCA are making a difference in the lives of Central Arkansans at risk for or diagnosed with Alzheimer’s Disease and Related Dementias (ADRD), as well as their caregivers through the Interprofessional Therapeutic Activity Program (I-TAP). The I-TAP consists of four sub-programs including the Student-Led Therapeutic Activity Program (S-TAP), Student-Led Dementia Caregiver Coaching Program (S-DCCP), Resilient Care Support Group, and the Student-Led Wellness Screening Clinic (S-WSC). With these four sub-programs, I-TAP meets the needs of older Central Arkansans that are at risk or already diagnosed with dementia or related diseases and their caregivers. These programs aim to improve quality of life for the participants as well as provide support and resources to the caregivers, which has been identified as a critical need in Central Arkansas. The I-TAP program is unique and innovative as all of its sub-programs utilize interprofessional collaboration of undergraduate and graduate students who are under the supervision of licensed clinicians. It is meant to increase access and quality of care as well as to provide educational resources to both those affected with such diseases and the public.

The Student-Led Therapeutic Activity Program (S-TAP) will run during the spring 2023 semester. During this time, over 75 students from Exercise Science, Physical Therapy, and Occupational Therapy will provide wellness education, physical activity, cognitive engagement, and risk assessment to improve quality of life, while providing respite and support for caregivers. Sessions for this program will be held one to two times a month. Each session will be approximately an hour to an hour and a half with part being individual activities and the other part being group focused activities.

The Alzheimer’s Disease and Dementia Arkansas State Plan 2021-2025 prioritizes the need for accessible services for ADRD including: 1) public awareness and education, 2) access and quality of care, 3) family caregiver support, & 4) dementia training and workforce development. The I-TAP addresses all four of these priority issues by engaging health professions students to perform interventions that provide education, physical activity, cognitive engagement, caregiver respite and support, and risk assessment. Involvement of students bolsters workforce development by increasing healthcare professionals’ knowledge regarding the complex needs of those with ADRD and their caregivers. Further, I-TAP programs are free of charge to all participants, which allows access despite financial resources. Financial support for the program has been generously provided through a recent grant from the Blue and You Foundation for a Healthier Arkansas in the amount of $51,801.00 which will fund the program for the entirety of 2023. Dr. Kerry Jordan and Dr. Melissa Allen received this grant from the Blue and You Foundation to continue to meet the needs of Central Arkansas while simultaneously providing training opportunities for students.

Improving Well-Being in the Garden with AGEC and Hendrix College

Winter 2023 Newsletter

By Dr. Jennifer Peszka, Professor, Psychology
Dr. Anne Goldberg, Professor, Sociology/Anthropology
and Dr. Pete Gess, Professor, Psychology
Hendrix College

During the past 5 years, Hendrix faculty and students have collected data with the goal of understanding variables associated with healthy aging by studying older adults in areas where people live extra-long/healthy lives (Blue Zones). Through this work, it has been identified that many healthy ageing adults participate in gardening. In collaboration with AGEC, we sought to implement a gardening intervention that would increase time spent gardening as well as socializing with a Hendrix student garden partner for eleven low-income older adults. During Spring 2022, through collaborations with two living facilities in Conway, and AGEC funding, nine Hendrix students partnered with eleven older Arkansans to provide raised bed wheelchair accessible garden bed kits. Students met with their garden partner one-on-one twice weekly for a month. They spent this time gardening and socializing with their garden partner.

Assessment

Pre and post whole program assessments were designed. While the sample is very small, for this project we had nearly 100% participation in the assessment component. The goal of this assessment was to understand enjoyment of garden activity, as well as feelings of belongingness, satisfaction with life, and perceived stress before and after the month-long program.

At the start of this program, no more than 1/3 of the participants identified plants or social activities as a relaxing activity, a hobby, or an activity that aided in their feelings of productivity. Following the program, we asked participants whether they found their garden stressful (1) or relaxing (7), whether working in the garden felt more like work (a chore) (1) or a hobby (play) (7), and whether working in their garden made them feel productive (1=never to 5=always). As can be seen in Figure 1, after the program, working in the garden was perceived by the participants as relaxing, a hobby, and producing feelings of productivity that most of the participants were not experiencing before the project began.

Before the program, all participants strongly agreed that they enjoyed spending time outside. Therefore, the program could not have increased this enjoyment. However, it is likely that the program increased the time that they were able to spend outside. We found that when the program started at one facility participants were not allowed easy access to the out-of-doors and that access was made easier once the program began and they had reason to go into the backyard of the facility.

Our pre-program assessments of enjoyment of life, belongingness, and satisfaction with life for these eleven participants were nearly at the top of the scales and their stress levels were very low. Therefore, it would have been unlikely that these measures would show improvements in these variables as there was a ceiling effect. We do have anecdotal reports from students that their garden partners did enjoy the activity and some students even reported they continued to visit their garden partner and tend the gardens after the month-long program completed.

Summary: There is a good deal of psychological research suggesting that engaging in nature can improve well-being and gardening provides an accessible outdoor activity for many older Arkansans. This project increased outdoor activity in these older adults. Hendrix students are currently planning for the next iteration of this program which will involve indoor gardening through the winter when access to the out-of-doors can be limiting for many older adults.

Figure 1. Experience of gardening time in program as a relaxing, hobby, that produced feelings of productivity.

Geriatric Student Scholars 2022-2023 Selected

It is with great pleasure that the UAMS Arkansas Geriatric Education Collaborative (AGEC) announces its 2022-2023 selection for the Geriatric Student Scholars program – Dhielan Bustos (College of Health Professions), Ranique Daniel (College of Nursing), Stephanie Graves (College of Health Professions), Szarria Thomas (College of Pharmacy), and Julia Townsley (College of Medicine).

The purpose of the Student Scholars program (sponsored by AGEC) is to increase health professions students’ interest and exposure to older adults, to improve knowledge of older adults and the specialized care they need and to promote interprofessional collaboration among health professions students.

We are so excited to announce the Geriatric Student Scholars for FY 2023 to support emerging health professionals education and participation surrounding specialized needs for older adults, and to foster interprofessional collaboration in academic and clinical geriatrics. The goal of the Geriatric Workforce Enhancement Program (GWEP) is to enhance the quality of health care for elderly Arkansans through research, education and training. The Geriatric Student Scholars program is an excellent way to achieve this goal and mentor future healthcare team members.
AGEC Director, Robin McAtee, Ph.D., RN., FACHE

The Arkansas Geriatric Education Collaborative is a program of the University Of Arkansas for Medical Sciences – Donald W. Reynolds Institute on Aging. The collaborative is funded by a Health Resources and Services Administration grant of $3.7 million for a Geriatrics Workforce Enhancement Program.

Geriatric Student Scholars – Congrats!

Dhielan Bustos (Third-year Doctor of Physical Therapy student, NWA campus)
Ranique Daniel (Fourth-year BSN student)
Stephanie Graves (Second-year Physician Assistant student)
Szarria Thomas (Second-year Pharmacy student)
Julia Townsley (Second-year Medicine student)

Dhielan Bustos is a third-year Doctor of Physical Therapy student at the UAMS-NWA campus. He is originally from California but was raised in New Jersey and attended Rutgers University where he received his Bachelor of Science degree in Neurobiology. Dill, a nickname he goes by, has worked in many settings that led to his acceptance to PT school that included a skilled nursing facility, an outpatient sports clinic, and an outpatient geriatric clinic. Besides studying, Dill likes coffee, going to the gym, playing tennis, and spending time with friends and family. His interests in geriatrics began at his first PT tech job in a skilled nursing facility where he got to work with many geriatric patients with complex medical conditions. He recognized just how powerful the rehabilitation can be for older adults by assisting with exercises, providing care, and witnessing their incredible progression. In his career as a physical therapy student, he looks to figure out ways at which he can incorporate higher intensity interval training in the older adult population as part of their treatment plan. Dill is very thankful for being chosen to be a Geriatric Student Scholar and is excited to gain insight on how he can improve the lives of older adults.

Ranique Daniel is a Senior BSN Student from Marked Tree, Arkansas. She is a recent University of Arkansas Alumna (Woo Pig!) and first-generation college graduate with a B.S. in Public Health and minor in Medical Humanities. She is honored to have been selected as a Geriatric Student Scholar, and looks forward to expanding her knowledge on serving this special population. She had the opportunity of working with this population this past summer with a student nurse internship at Wellth, Inc., and has always had the desire to learn more about their standard of care after taking care of her own great grandmother for many years. She witnessed a deficit in the care for older adults during this time in the Delta region of Arkansas, and this made her realize the importance of how much further it is we have to go, and it starts with us! This is a wonderful opportunity to work with this interdisciplinary team and the UAMS Geriatric Education Collaborative to further advance her education, and she looks forward to what this year brings!

Szarria Thomas is a second-year pharmacy student at University of Arkansas Medical Sciences. She has a received a Bachelor of Science in Biology with a chemistry minor. Her past and current experience working in retail pharmacy with geriatric patients, exposed to her the importance of the need of more exploration of the care of geriatric population. The opportunity to immerse into the study of how medications effect geriatric patients is intriguing and imperative to the future. Her goal as an AGEC scholar is to gain knowledge through research that will propel her passion to clinically provide exceptional care as well as knowledge to the geriatric community.

Julia Townsley

Julia Townsley is a second-year MD student in the College of Medicine at UAMS. She is from Fayetteville, AR, where she grew up and would later attend college. She received a B.S. Degree in Biomedical Engineering at the University of Arkansas. Julia is the President of the UAMS Geriatric Interest Group and is completing the Honors in Underserved Primary Care Program. With experience being a caregiver for her grandmothers, Julia was drawn to geriatric medicine from a young age and is excited to work with the aging population. She is grateful for the opportunity to be an AGEC Geriatric Student Scholar and is looking forward to the experiences she will have within the program. Her future goals include working as a geriatrician to be an advocate for elder patients and to provide a supportive community for her patients. In her free time, Julia is a singer for a local church and enjoys spending time with her friends.

From the Director’s Desk

Fall 2022 Newsletter

Happy fall to everyone! I know most of us are very happy to see the trees turning and the temperatures dropping. The AGEC and partners have started fall programs and classes and are very busy. This quarter I want to talk a little more in-depth about the AGEC’s clinical focus on the 4M’s framework of Age-Friendly Care.

In 2017, The John A. Hartford Foundation and the Institute for Healthcare Improvement (IHI), in partnership with the American Hospital Association and the Catholic Health Association of the United States, had a vision and plan to infuse healthcare with a new concept called age-friendly care. The IHI defined age-friendly care as care that “Follows an essential set of evidence-based practices; Causes no harm; and Aligns with What Matters to the older adult and their family or other caregivers”. Therefore, if a healthcare system wants to become certified as an Age-Friendly Health System, they must provide care that meets evidence-based elements of high-quality care, known as the “4Ms,” to all older adults in their system.

The 4Ms are: What Matters, Medication, Mentation, and Mobility. The first M regarding What Matters is regarded as essential and if done properly, all of the M’s revolve around it. All care should center around what Matters most to the older adult. This is where the conversation with the patient, family, and caregiver(s) begins. The healthcare team should discuss the older adult’s health outcome goals and care preferences, including end-of-life care, across all settings. Their goals and preferences then dictate the overall plan of care. Medication, should be age-friendly and not compromise mentation, mobility or What Matters. Mentation is the next M where providers should work to prevent, identify, treat and manage dementia, delirium, depression, and other conditions that affect the mind. Finally, Mobility is considered. The team should ensure safe movement and function that supports what matters to the older adult and what promotes meaningful activities. This was a simplified and quick summary of the age-friendly framework and I would encourage you all to learn more. More information can be found at https://www.ihi.org/Engage/Initiatives/Age-Friendly-Health-Systems/Documents/IHIAgeFriendlyHealthSystems_GuidetoUsing4MsCare.pdf.

The AGEC has a wonderful rural clinical partner that is essential to our success with implementing age-friendly care, ARcare. ARcare is a federally qualified healthcare clinic (FQHC) network that works tirelessly in rural communities to ensure patients are able to benefit from accessible, affordable, quality, routine medical care. Services from ARcare include primary care, behavioral health, pharmacies, community outreach programs, and more. When approached in late 2018 about being part of the AGEC, ARcare staff were enthusiastic and embraced the concepts inherent in the 4M’s framework of Age-Friendly Care. Since beginning the partnership in 2019, Dr. Leah Tobey, our AGEC Clinical Coordinator, has taught this framework in six ARcare rural clinics. She continues to update new staff, work on quality improvement projects, and helps with rural community projects. To date, the ARcare network has five clinics that are certified level I or II as Age-Friendly by the Institute for Healthcare Improvement. We are proud of ARcare and their work with making their care age-friendly and we would encourage all who provide care to older adults to consider these 4Ms.

If you would like more information or training regarding the 4M’s of Age-Friendly care, please contact the AGEC.

Changes in Social Interactions in Older Arkansans across the COVID-19 Pandemic

Fall 2022 Newsletter

By Dr. Jennifer Peszka, Professor, Psychology
Dr. Anne Goldberg, Professor, Sociology/Anthropology
and Dr. Pete Gess, Professor, Psychology
Hendrix College

Previous research shows that loneliness is detrimental to healthy aging. When the COVID-19 pandemic struck, it led to early calls for strict limitations to in-person social interactions (lockdowns and social distancing). During Spring 2021, Hendrix College and AGEC conducted a telephone survey of nearly 867 older Arkansans to examine social connection and isolation during the COVID-19 pandemic. Those data indicated that during the early part of the pandemic, in person social interactions and satisfaction with social interactions declined. While not a completely satisfying replacement, supplementing lost in-person social interactions with technology facilitated communication did help buffer some of the negative impact on satisfaction for some participants. During Spring of 2022, we conducted a follow-up survey to replicate previous findings, look for changes as social interactions began to shift back to normal, and to add additional questions to probe further into findings seen in the original survey data.

About the participants

603 older Arkansans completed the automated telephone survey. 68.3% of the participants were between 65 and 74 years old, and 31.7% were 75 years old or older. 86.5% identified as White, non-Hispanic; 8.0% as Black; .2% as Hispanic; and 5.3% as other, preferred not to answer, or mixed. 65.9% identified as women, 33.2% as men, and 0.8% as preferred not to answer. To examine economic status, we asked them to indicate how often they worry about paying their monthly bills. 8.1% said always, 15.0% said frequently, 34.9% said seldom, and 42.0% said they never worry about paying their bills.

What they told us

Frequency of interactions: In the 2021 survey, 76% of participants reported curtailing their in-person social interactions since the pandemic began at least some, 41% were curtailing a lot. Now, when the virus is waning and vaccines are widely available, curtailment was not as widely spread with about one half reporting they were curtailing their in-person social activities at least some (50.4%) and substantially fewer were curtailing it by a lot or completely (27.6%) (See Figure 1). For in person activities, in 2021, only about one-third (31%) of the sample was engaging in in-person social activities multiple times a week, but in 2022, we saw that double (63%).

Social satisfaction: 93% of the participants rated themselves as satisfied with their social connection before the pandemic, that number reduced to 67% during the pandemic in 2021, and this has started to recover now in 2022 with 78% of the participants rating themselves as satisfied with their social connections now.

Social technology use: In 2022, we investigated a specific kind of social technology: the video chat. Video chatting was prevalent in this sample even before the pandemic, with about 40% of the sample engaging in video chatting multiple times a week before the pandemic began. About one-quarter of the participants (22.8%) reported using video chat even more during the pandemic.

In 2021, during the pandemic, 60% of the participants said they felt socially connected when engaging in online social interactions. In 2022, after an additional year of these sorts of interactions, it seems there has been a slight increase in satisfaction, with about 10% of participants being less likely to disagree with this and 10% being more likely to agree, with 70% of participants reporting feeling socially connected when engaging in these online interactions (See Figure 2).

Summary: In person social interactions and satisfaction with social interactions are still lower than during pre-pandemic times, but they are starting to recover. Nonetheless, some older Arkansans find themselves experiencing loneliness and isolation even when there is no pandemic. These findings suggest that with practice and motivation older Arkansans can increase their technological interactions and that these can serve as a reasonably satisfactory replacement to in person social interactions when necessary. We should work to develop programs to increase fluency and availability of social technology for older Arkansans.

Management of Weight Loss in Hospitalized Older Adults

Fall 2022 Newsletter

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

Weight loss is often identified during hospitalization when older adults are assessed. Up to 60% of hospitalized older adults are malnourished or at risk for malnutrition, and this is associated with threefold increased costs and co-morbidities such as pressure injuries, infections, and falls.1 Length of stay and mortality increase as a result. Appetite often diminishes when illness develops and patients are admitted to the hospital. Families and caregivers become more vigilant as their loved one has an acute illness, requesting interventions that would improve appetite and nutritional status.

Non-pharmacological methods often implemented during hospitalization to combat nutritional deficits usually include addition of protein/calorie supplements. An approach used less often is to liberalize the diet. For example, a low sodium diet is a standard order for individuals with cardiac disease. A low sodium diet can significantly decrease blood pressure in individuals with hypertension by 4.5mmHg/2.4mmHg on average,2 but a recent randomized controlled trial, SODIUM-HF, did not verify dietary sodium restriction to 1500mg/day was associated with a reduction in mortality or cardiovascular hospitalization/emergency department visits in ambulatory care patients over a year.3 Removing a dietary sodium restriction and encouraging family members and caregivers to select food items the patient likes should be considered. Mealtime is often a social event, and having family or friends eat along with the older adult can improve the amount of food ingested.

Careful review of a patient’s medication list may reveal drug therapy that is contributing to anorexia. Drugs well-known to cause anorexia include amiodarone, SSRI’s, SNRi’s, phenothiazines, opioids, acetylcholinesterase inhibitors, and digoxin.4 Drug-induced nausea may present with anorexia. Stopping these medications, or reducing them to their lowest effective dose, may aid in restoring a patient’s appetite. Another contributor may be drug-induced constipation which can present as anorexia. Finally, some medication regimens include a large number of oral tablets or capsules with a volume that equates to a small meal. A focused attempt to reduce pill burden or to spread out their administration may help to improve appetite.

Medications are sometimes used off-label to stimulate appetite and induce weight gain in older adults. Most commonly used are mirtazapine, megestrol, and dronabinol.4,5 Dronabinol works as a cannabinoid to increase appetite, but as would be expected, causes significant central nervous system side effects. Megestrol is approved by the US Food and Drug Administration for anorexia or cachexia associated with AIDS or cancer. As a synthetic progestin, it can increase appetite, however, small studies and retrospective data show mixed results with increasing weight or strength in older adults. So while it may cause increased dietary intake, any gain of weight is likely increased body fat. Megestrol can increase blood pressure, blood glucose, and risk for thromboembolism.

Mirtazapine is a popular choice for improving appetite due to its safety profile. This antidepressant is relatively well-tolerated with significant side effects of marked sedation, xerostomia, increased cholesterol, and constipation. Increased appetite as a side effect is reported in 17% of patients, therefore, clinicians began trying it in older adults for anorexia.6 Most studies have been in older adults with depression, and results were mixed. A retrospective study of hospitalized patients evaluating use of mirtazapine, megestrol and dronabinol showed improvement in percentage meal intake but no differences between these agents. A control group was not included so authors were unable to assess the effect of other changes, particularly the effect of improvement in admission disease/symptoms.7

So what is best practice? The Choosing Wisely campaign suggests we optimize social supports, provide feeding assistance, and clarify patient goals and expectations instead of prescribing appetite stimulants or high-calorie supplements for treatment of anorexia in older adults.8 Furthermore, we should first assess if this symptom is an adverse drug event of an already prescribed medication. Finally, as with all medications, if pharmacological interventions are subsequently tried, periodic assessment of benefit and risk is important to consider if the appetite stimulant should be continued.

References:

Shrader E, Baumgartel C, Gueldenzoph, et al. Nutritional status according to Mini Nutritional Assessment is related to functional status in geriatric patients—independent of health status. J Nutri Health Aging, 2014; 18:257-63.
Lai JS, Aung YN, Khalid Y, Cheah SC. Impact of different dietary sodium reduction strategies on blood pressure: a systematic review. Hypertens Res, 2022; doi: 10.1038/s41440-022-00990-5. Online ahead of print.
Ezekowitz JA, Colin-Ramirez E, Ross H, et al. Reduction of dietary sodium to less than 100 mmol in heart failure (SODIUM-HF):an international, open-label, randomized, controlled trial. Lancet, 2022; 399:1391-1400.
Cheung NC, Noviasky JA, Ulen KR, Brangman SA. Efficacy and safety of megestrol in the hospitalized older person. Sr Care Pharm, 2022; 37:284-92.
Fox CB, Treadway AK, Blaszczyk AT, Sleeper RB. Megestrol acetate and mirtazapine for the treatment of unplanned weight loss in the elderly. Pharmacotherapy, 2009; 29:383-97.
Howard ML, Hossaini R, Tolar C, Gaviola ML. Efficacy and safety of appetite-stimulating medications in the inpatient setting. Ann Pharmacother, 2019; 53:261-7.
American Geriatrics Society/American Board of Internal Medicine Foundation. Choosing Wisely. www.ChoosingWisely.org.

Caregiver Strain: Strategies for Prevention

Fall 2022 Newsletter

Sarah Davidson, DNP, RN, CNE
Associate Dean, College of Nursing and Health Professions
Arkansas State University

Caring for an elderly family member comes with great rewards and equally great complications. The complexities of caregiving may become difficult to manage and caregivers are especially susceptible to caregiver role strain. Caregiver role strain occurs when caregivers experience stress because of the increased responsibility, change in lifestyle, and financial obligations associated with taking care of another person (Caregiver Role Strain, 2020; Kimura, et al., 2019). The demands of caring for someone with a chronic illness or condition that prevents them from taking care of their basic needs may lead to exhaustion and stress (Caregiver, 2009). Caregivers may also experience feelings of frustration, sadness, guilt, and isolation (Caregiver Stress: Tips for Taking Care of Yourself, 2022; Franzen et al., 2021). Almost 60% of caregivers also work outside the home. Juggling work, family and caregiving responsibilities often becomes overwhelming and leads to diminished productivity, unanticipated financial strain, and missed opportunities for professional growth (10 Tips to Manage Caregiver Role Strain, 2020; Andersson et al., 2019; Dickson et al., 2022)). Responsibilities are often magnified by the large number of co-morbid medical conditions generally experienced by elders and difficulties navigating through the healthcare system increase along with the complexity of care (Dickson et al., 2022). The uncertainty of life expectancy and associated emotional strain add to the already complicated situation (Hovland & Kramer, 2019).

Meeting the challenges associated with caregiving starts with recognition of the normal symptoms experienced by many caregivers. Withdrawal from usual activities; losing interest in things normally enjoyed; feeling irritated, angry, and moody; or having thoughts of suicide and death are often common in caregivers. Those caring for others may have trouble concentrating; feel overwhelmed; and suffer from increased health and sleep problems along with appetite changes. The high levels of stress associated with caregiving often have negative health effects. Although these symptoms are frequently experienced by caregivers, achieving a balanced, stable life can be reached with knowledge of and access to helpful resources (Caregiver Stress: Tips for Taking Care of Yourself, 2022; Kimura et al., 2019).

Kimura et al. (2019) found that caregiver burden can be reduced through emotional and practical support. Asking for and accepting help may be difficult but is one of the most valuable ways to deal with stress. A strong support team of family and friends along with health care resource personnel can provide a break from daily caregiving tasks. The caregiving load can be alleviated through the establishment of a routine of self-care to maintain health. Setting realistic goals that focus on what can be accomplished without outside assistance and using social and professional resources to fill in the gaps may relieve anxiety. Support groups for a variety of disorders are available in most areas and provide a healthy outlet to talk with others facing the same situation. Caregivers may take personal time by using respite care options such as short-term nursing homes, adult day care, or in-home respite. (Caregiver Stress: Tips for Taking Care of Yourself, 2022). The eventuality of death remains at the forefront of caregiver worries and hospice care professionals can alleviate much of this with information about expectations along with psychosocial and spiritual support (Hovland & Kramer, 2019).

Health care providers play an essential role to connect caregivers with resources. Caregivers are often hesitant to ask for assistance, therefore, during each health care encounter assessments should include questions regarding the mental and physical status of the caregiver (Onega, 2013). The Caregiver Strain Index (CSI) (1983) is a useful tool that addresses many symptoms commonly identified in caregivers. The Modified Caregiver Strain Index (MCSI) (Thornton & Travis, 2003) is a shorter, quicker assessment tool that addresses financial, physical, psychological, social, and personal areas of identified stress to help health care providers recognize caregivers in need of more in-depth assessment and/or follow-up. The MCSI is easy to administer and has higher reliability than the original CSI although the CSI is more useful to measure caregiver strain in outcomes research (Thornton & Travis, 2003).

Caring for an elderly family member provides immense rewards and affords time for families to adjust to the inevitability of loss. Recognizing the stressors associated with caregiving and developing healthy strategies to deal with them can be accomplished by creating a strong support system, taking time to maintain personal health, and utilizing personal and professional resources. Healthcare professionals are at the forefront of identifying caregivers in need of resources with regular, thorough assessments that may include the CSI or MCSI.

References

10 Tips to Manage Caregiver Role Strain (2020). CaringBridge. https://www.caringbridge.org/resources/caregiver-role-strain/

Andersson, M.A., Walker, M.H., & Kaskie, B.P. (2019). Strapped for time or stressed out? Predictors of work interruption and unmet need for workplace support for among informal elder caregivers. Journal of Aging and Health, 3(4), 631-651. DOI: 10.1177/0898264317744920.

Caregiver (2009). Family Caregiver Alliance. https://www.caregiver.org/resource/caregiving/?via=caregiver-resources,all-resources

Caregiver Role Strain (2020). University of Wisconsin School of Medicine and Public Health. https://patient.uwhealth.org/healthfacts/6921

Caregiver Stress: Tips for Taking Care of Yourself (2022). Mayo Clinic. https://www.mayoclinic.org/healthy-lifestyle/stress-management/in-depth/caregiver-stress/art-20044784

Dickson, V.V., Melnyk, H., Ferris, R., Leon, A., Arcila-Mesa, M., Rapozo, C., Chodosh, J., & Blaum, C.S. (2022). Perceptions of treatment burden among caregivers of elders with diabetes and co-morbid Alzheimer’s Disease and related dementias: A qualitative study. Clinical Nursing Research, 0(0). doi.org/10.1177/10547738211067880

Franzen, S., Eikelboom, W.S., vanden Berg, E., Jiskoot, L. C., van Hemmen, J., & Papma, J.M. (2021). Caregiver burden in a culturally diverse memory clinic population: The caregiver strain index-expanded. Dementia and Geriatric Cognitive Disorders, 50, 333-340. DOI: 10.1159/000519617

Hovland, C.A. & Kramer, B.J. (2019). Barriers and facilitators to preparedness for death: Experiences of family caregivers of elders with dementia. Journal of Social Work in End-of-Life & Palliative Care, 15(1), 55-74. DOI: 10.1080/15524256.2019.1595811

Kimura, H., Nishio, M., Kukihara, H., Koga, K., & Inoue, Y. (2019). The role of caregiver burden in the familiar functioning, social support, and quality of family life of family caregivers of elders with dementia. Journal of Rural Medicine, 14(2), 156-164.

Onega, L.L. (2013). The Modified Caregiver Strain Index (MCSI). Try This: Best Practices in Nursing Care to Older Adults, The Hartford Institute for Geriatric Nursing, New York University, College of Nursing, 14. https://hign.org/consultgeri/try-this-series/modified-caregiver-strain-index-mcsi

Thornton, M. & Travis, S.S. (2003). Analysis of the reliability of the Modified Caregiver Strain Index. Journal of Gerontology, 58(2), S127-132. doi: 10.1093/geronb/58.2.s127

Occupational Therapy Doctoral Capstone Students Create Interprofessional “Conway Brain Injury Community” to Meet Documented Community Need

Fall 2022 Newsletter

By Emily Wish, OTD, OTR/L, PCBIS, Lorrie George Paschal, PhD, OTR, ATP, and Duston Morris, PhD, MS, CHES, ACE-HWC
Department of Occupational Therapy
University of Central Arkansas

According to the Arkansas State Plan for Traumatic Brain Injuries (UAMS, 2020), there were approximately 2,300 individuals living with a brain injury in Arkansas between 2013-2019. In the River Valley and Central Arkansas areas (including Conway, Cleburn, Johnson, Logan, Perry, Pope, Pulaski, Van Buren, White, and Yell counties) there are 685 individuals registered with the TBI registry (UAMS, 2020). As of March 2022, it is estimated that there are approximately 611 individuals hospitalized due to a TBI in the US (CDC, 2022). Stroke, which is an acquired non-traumatic brain injury, is one of the leading causes of disability in the US (Virani et al., 2020). With the risk factors for stroke increasing since 1995, it is no surprise that the prevalence of this disease has also increased in the US (Virani et al., 2020). Arkansas is one of the top 14 states in the US in rates of stroke hospitalization (CDC, 2021). According to the Brain Injury Association of America, 95% of individuals living with a brain injury do not receive the long-term treatment and support they need to be successful in their occupations (Ashley et al., 2019). Acquired brain injuries impact individuals for a lifetime, but there is a lack of local resources that address occupational and healthcare needs for this population following discharge from rehabilitation.

To address this need, recent occupational therapy doctoral students Dr. Emily Wish and Dr. Mckenzie Svebek created the Conway Brain Injury Community (CBIC) in the University of Central Arkansas’ Department of Occupational Therapy in the College of Health and Behavioral Sciences (CHBS). This community allows members, post-acquired brain injury, to come together to work on increasing their occupational performance and overall health and well-being.

The vision of the CBIC program combines Dr. Wish’s desire to facilitate occupational performance of members and Dr. Svebek’s aim to establish a supportive interprofessional approach. Together, a community-based network of community dwelling individuals post-acquired brain injury and faculty supervised occupational therapy students was established to holistically address the needs of this community. Partnership with faculty and students from a variety of CHBS disciplines enhances the program by providing a unique approach of involving professors, students, and clinicians to meet the needs of CBIC members. At this time, primary team members include occupational therapy and health coaching. Other disciplines participate based on members’ interests. For example, this semester, dietetics students provided a presentation on heart healthy food choices.

This interprofessional program was an outcome of capstone projects but has become sustainable through partnership and supervision of occupational therapy faculty member, Dr. Lorrie George-Paschal, and health sciences faculty member Dr. Duston Morris. Through an interprofessional collaborative approach, the CBIC team leads theory-based and client-centered sessions tailored to address goals the members have set for themselves.

Operating within the UCA semester schedule, the group meets weekly, with the exception of school breaks. The program is based on the theory of Occupational Adaptation which strives to improve occupational functioning by creating a change in the internal adaptation process of members through engagement in desired occupations. At the beginning of the 14-week semester-long program, participants complete Occupational-Adaptation based Instruments, developed by Dr. George-Paschal with Dr. Krusen (2019). These instruments provide structure for the program. Because the program is research-based, participants first review and sign informed consent approved by Research Compliance at UCA. If they give consent, participants complete the Occupational Adaptation Practice Guide to set meaningful goals. When goals have been set, participants evaluate their current sense of mastery on their established goal(s) using the six-item Relative Mastery Scale (George-Paschal, Krusen, & Fan, 2021). This valid and reliable instrument is used to measure individual and group outcomes. The RMS is completed again in the middle and at the end of the semester.

Example goals of current CBIC members include improvement in upper extremity tone management and range of motion, cooking with one hand, sewing with one hand, improved handwriting with the non-dominant hand, improving awareness of the left visual field, and improving community mobility. CBIC members are partnered with one to two occupational therapy students and a health coaching student to work on their goals. Occupational therapy sessions are held for two hours each week with activities focused on each member’s specific goal(s). Activities are scaffolded to increase success. For the CBIC member who wants to sew, students and faculty created opportunities that have progressed from operating functions on the sewing machine with one-hand, to sewing straight seams, to making a drawstring bag, and most recently making their own pillow case. The next step is to meet at a local fabric store to choose Christmas fabric for the member to make a quilt top. Signs of adaptation for this member have been noted through signs of initiation and generalization as the member shared that they have visited a local sewing center to try out and consider the purchase of a sewing machine for home.

Weekly health coaching sessions are held on a separate day and last one hour. Students from occupational therapy and health coaching work together and often attend the sessions led by the other discipline. Participants feel an accountability to their health coaching goals as evidenced by one member pushing to finish a project during an occupational therapy session because they had set a goal to complete it with their health coaching student.

In addition to the individual activities, the program includes informational and support group activities. This semester, activities have included a presentation on nutrition for heart health (provided by UCA nutrition students) and various activities to promote self-worth and group connection. This supportive community provides a safe space for CBIC members to identify, establish and achieve personal and/or health-related goals throughout their rehabilitation journey. While this is not therapy, it does provide CBIC members an opportunity to reflect on their strengths through recovery and to maintain and improve their long-term occupational performance.

Starting with four members in June 2022, the program has expanded to seven members this fall and will continue to reach more individuals in the Central Arkansas area.
The goal is to provide a sustainable interprofessional program that can serve the needs of the members post-acquired brain injury while simultaneously providing opportunities for CHBS students to learn and engage in meaningful healthcare community services. UCA OT Doctoral Capstone student Kassidy Sawyer will provide program management and direction in 2023. For more information about the CBIC, please contact Dr. Emily Wish, CBIC program director at ewishotd@gmail.com.

George-Paschal, L. & Krusen, N. (2019). Occupational Adaptation Practice Guide. Copyrighted
2019.
George-Paschal, L. & Krusen, N. (2019). Relative Mastery Scale. Copyrighted 2019.
George-Paschal., L, Krusen, N.E., Fan, C.W. (2021). Psychometric evaluation of the Relative
Mastery Scale: An Occupational Adaptation instrument. OTJR: Occupation, Participation and Health. [online first 12.31.2021 Sage Journals. https://doi.org/10.1177%2F15394492211060877