AGEC

Creating a Gerontology-focused Health Fair

New CNHP ASU Logo

by Jessica E. Camp, MSN, APRN, AGCNS; Addie N. Fleming, MNSc, RN, CCRN; Valerie Fielder, BS, CDP, and Samantha M. Hollis, BSN, RN, CDP
Edited by Dr. Susan Hanrahan and Dr. Linda Tate
Arkansas State University, UAMS Center on Aging Northeast & Schmieding Home Caregvier Training Program, St. Bernards Medical Center

The committee designed a health screening event for older adults, their caregivers, and professionals that provide care to older adults. Northeast Arkansas has a large number of elderly, care givers, and a large variety of professional services. The event was designed to bring everyone together. It was planned for November to increase attendance by avoiding other area events and in conjunction with National Family Caregiver Month. The Fair gathered more than 200 patients and 90 vendors from the community. This article shares the successes of the event and the opportunities for next year.

Advisory Panel
The Center on Aging had a vision for the event. The mission and vision were shared with the team during recruitment and revisited at the initial meeting. An advisory panel consisted of the many health professionals, community members, university faculty and leaders from services for older adults in the area was invited to participate.

Health Screenings
The local university, ASU, provided a great foundation for creating a health screening event.

The physical therapy department provided “timed up and go” (TUG) screenings aimed at identifying balance issues and risk for falling. Social work faculty provided anxiety and depression screenings. Communication Disorders students provided hearing screens in a private room. Nursing students provided blood pressure checks, height, and weight and body mass index screenings. Dietary Approaches to Stop Hypertension (DASH) diet education was given verbally and in writing to persons at risk for or currently experiencing hypertension. Exercise, weight loss and the DASH diet can help control chronic illnesses, such as heart disease and diabetes, making it important information to share with older adults and their caregivers (Cash & Glass, 2015, p. 1047).

The Arkansas Department of Health provided vaccinations based on the Center for Disease Control and Prevention (CDC) recommendations for adults and older adults (Cash & Glass, 2015, pp.18-21). Hilltop Eye Care and Southern Eye Associates provided vision screenings and education on cataracts and glaucoma. St. Bernard’s Imaging Center conducted bone density screenings as well as total cholesterol, anemia, and glucose laboratory screenings. Higginbotham Family Dental provided dental screenings. Additional professionals were invited and provided services or information about services.

Transportation
Transportation for the public was not available to the event. This was noted by some persons unable to attend as a barrier. Requests to public transportation and local churches to enlist transportation assistance were not met. For the 2018 event, negotiations are in process.

Communication
Some screening groups left before the event ended which participants complained about. Critical conversations with the voluntary service professional groups will need to take place early in the planning of the 2018 event to ensure the professionals stay for the whole event, which could include shortening the event.

A secondary communication issue was not being able to hear announcements made at the event stage. With exciting activities such as the mayor’s appearance and a physician’s panel, it was difficult for the audience to hear anywhere past the first row of vendors. This is an opportunity that can be corrected for the 2018 Senior Expo (Larsen, 2018).

Professionals
Health professionals, caregivers, and patients were targeted to receive education during the event. Several vendors voiced a desire to attend the planned educational sessions, but were unable because they were also manning a booth at the event. In post-event discussions, it was decided that a separate educational event targeting health professionals could be a solution.

Vendors
While the volume of local vendors involved in the first annual event surpassed the goal, there were still challenges. Discussions with leaders of another local annual health fair shared tactics that prevented vendors from leaving their event early, such as imposing fines or not inviting them to future events.

In summary, these services met the needs of many older adults. Senior Health Fairs bring value to the intended audience. Targeted health fairs, such as this one, provide more opportunities for older adults to interact with health professionals in the community. With the success of the first event, the 2^nd Annual UAMS Center on Aging Northeast’s Senior Expo is scheduled for November 9, 2018.

References:

Cash, J. C. & Glass, C. A. (2016). Adult-gerontology practice guidelines. New York: Springer Publishing Company.

Larsen, P. (2018). Lubkin’s chronic illness: Impact and illness. Burlington, MA: Jones & Bartlett Publishing.

Rhoads, J. & Peterson, P. S. (2018). Advanced health assessment and diagnostic reasoning (3^rd ed.). Burlington, MA: Jones & Bartlett Publishers.

From the Director’s Desk

by Robin McAtee, PhD, RN, FACHE, Director, Arkansas Geriatric Education Collaborative at UAMS

Hello from the Arkansas Geriatric Education Collaborative (AGEC), the Geriatric Workforce Enhancement Program for Arkansas. As we enter into the winter of 2018, there is snow on the ground and temps are single digits, but the sun is shining! It is exciting to start a new year as we enter the last six months of this grant. We are anxiously awaiting the release of a request for proposal from HRSA so we can apply for another grant, but delays are inevitable it seems as the US government struggles to approve a fiscal year budget!

Fall was a busy time as we continued our programming in education with our partners. We had two video-teleconferences/webinars with over 150 attendees at each program. Being able to broadcast our programs on-line/webinar is really helping us to reach more individuals, especially those in rural areas and those who can’t leave work to attend in person. Our academic partners, ASU and UCA, were also busy reaching thousands of students with geriatric content during the fall semester! We continue to seek new ways to reach and teach these audiences and if you have any suggestions, please let us know.

During November, National Family Caregiver Month, we partnered with the UAMS Schmieding Home Caregiving Training Program to host a panel discussion regarding family caregiving. Donna Terrell (a former caregiver for her daughter) from FOX 16 was the moderator, Les Warren (a legislator from Hot Springs), Beth Coulson (a former judge who serves on the board of several community organizations), and Dr. Sybil Hampton (a former educator and former President of the Winthrop Rockefeller Foundation) who all had extensive experience caring for elderly parents, served as panelists. It was a well-attended and engaging event that culminated in presenting awards to 6 deserving family caregivers from all across the state!

As spring approaches, our community programs will blossom! Tai Chi, diabetic empowerment education programs, healthy cooking, dementia experiences, and many others are all planned and scheduled. We also have exciting events scheduled for professionals and direct care workers such as certified dementia training and new webinars! Please keep close tabs on our website for upcoming events! See you in the spring!!!

Statins: When Do the Benefits Outweigh the Risks in the very Elderly?

by Taylor J Neeley and Lisa C Hutchison, PharmD, MPH, UAMS

High quality studies show that statins significantly reduce all-cause mortality in older patients with established cardiovascular disease (CVD). One meta-analysis included approximately 20,000 patients between ages 65 and 82 with coronary heart disease who received either placebo or statin. There was a 22% decrease in all-cause mortality over 5 years in the statin group vs. placebo. The meta-analysis also revealed significant risk reductions in cardiovascular mortality, nonfatal myocardial infarction, and strokes of around 30% each. ¹

However, the benefits for patients 75 years and older without CVD are less clear because major statin trials have excluded patients greater than 75. Very few trials have included patients over 70 years of age, and evidence for patients >80 is largely limited and conflicting.² For example, in the Antihypertensive and Lipid Lowering treatment to prevent Heart Attack Trial (ALLHAT-LLT), initiation of pravastatin 40 mg for primary prevention in patients 65 years and older showed no risk reduction in cardiovascular events.⁴ However, in the Prospective Study of Pravastatin in Elderly at Risk (PROSPER) trial, patients of ages 70-82 with at least one cardiovascular risk factor (hypertension, smoking, and/or diabetes) were randomized to either pravastatin 40 mg or placebo. There was a significant reduction in major vascular events (stroke, fatal or non-fatal MI) in pravastatin group vs. placebo. ⁵

So, guidelines provide no specific recommendations for statin therapy in the middle and oldest old without CVD. Despite the lack of information, approximately 39% of patients 79 and older are on statin therapy for primary prevention of cardiovascular events. ³

Because this population is known to be more vulnerable to adverse drug effects, we see hospitalizations due to statin-induced rhabdomyolysis is 5 times more likely in patients 65 and older versus younger patients.²Even moderate muscle pain, a common side effect of statins, could cause already frail patients to increase their fall risk and/or immobility. And in rare cases, statins cause confusion and memory loss, especially with atorvastatin, lovastatin, simvastatin. Fortunately, these effects are reversible upon discontinuation.^{6, 7}

More research of statin benefits vs. risks, specifically in patients 75 and older at risk for CVD, are needed. So for now, patient-centered decision-making is key when the evidence is unclear.

Current ACC/AHA guidelines recommend that in patients >75 with established CVD

Begin statin therapy, but at a moderate intensity. There is strong evidence of statin cardiovascular benefit in this population.
In patients already well established on a high intensity statin with no complications, this may be continued. ⁸

In patients > 75 without established cardiovascular disease:

The decision to initiate a statin should be individualized and should weigh in heavily on patient concerns and goals. ²
- Factors that may support initiation of a statin:
  - Few comorbidities,
  - > 1 cardiovascular risk present
  - Patient priority to minimize cardiovascular risk
- Factors that may support avoiding statin initiation:
  - High comorbidities
  - Only 1 cardiovascular risk present
  - History of myopathy
  - Severe dementia
  - Frailty
  - High risk of drug-drug interactions
  - Patient priority to avoid pill burden
  - Patient priority to avoid adverse drug effects
  - Life expectancy < 1 year
In patients already well established on a statin with no complications, this may be continued.

Finally, in all elderly patients initiated on a statin, monitoring for adverse side effects should be a priority due to increased risks. Reassessment of factors such as development of dementia, frailty, and life expectancy should be made after starting therapy as these may change overtime and affect the decision to continue.

References:

Ross SD, Allen IE, Connelly JE, Korenblat BM, Smith ME, Bishop D, Luo D. Clinical Outcomes in Statin Treatment TrialsA Meta-analysis. Arch Intern Med.1999;159(15):1793–1802. doi:10.1001/archinte.159.15.1793
Pletcher, M. J., Coxson, P. G., Thekkethala, D., Guzman, D., Heller, D., Goldman, L., & Bibbins-Domingo, K. Statins for Primary Prevention in Older Adults.
Stone NJ, Robinson JG, Lichtenstein AH, et al. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2014;129(25 Suppl 2):S1-45.
ALLHAT Officers and Coordinators for the ALLHAT Col- laborative Research Group. Major outcomes in moderately hypercholesterolemic, hypertensive patients randomized to pravastatin vs. usual care: the Antihypertensive and Lipid Lowering Treatment to Prevent Heart Attack Trial (ALL- HAT-LLT). JAMA 2002; 288: 2998–3007.
Shepherd J, Blauw GJ, Murphy MB, et al. Pravastatin in eld- erly individuals at risk of vascular disease (PROSPER): a randomised controlled trial. Lancet 2002; 360: 1623–1630.
Baigent C, Blackwell L, Emberson J, et al. Efficacy and safety of more intensive lowering of LDL cholesterol: a meta-analysis of data from 170,000 participants in 26 randomised trials. Lancet2010;376:1670-81.
Haag MD, Hofman A, Koudstaal PJ, et al. Statins are associated with a reduced risk of Alzheimer disease regardless of lipophilicity. The Rotterdam Study. J Neurol Neurosurg Psychiatry 2009;80:13-7.
Lambert, M. (2014). ACC/AHA Release Updated Guideline on the Treatment of Blood Cholesterol to Reduce ASCVD Risk. American family physician, 90(4), 260.

From the Director’s Desk

By Ronni Chenoff, PhD, FAND, FASPEN

UAMS Arkansas Geriatric Education Collaborative

The Arkansas Geriatric Education Collaborative (AGEC), a Geriatric Workforce Enhancement Program, is working on goals and objectives for the second year of this program to educate health professionals, students, caregivers, first responders and the general public about issues and topics that affect our older population. We are proud of our achievements during the first year and are coming up to midway through year 02.

We will continue to offer video teleconferences four times/year; the first conference, broadcast in September addressed strategies to prevent and manage falls in both in-patient and outpatient settings. An upcoming video teleconference, scheduled for October 26, will be on trauma in the geriatric patient and anti-coagulant reversal strategies. Previous programs that you may have missed will be available as DVDs or on-line (unedited). Coming programs may be seen at UAMS or a site near where you or work by the interactive television network, but programs are now available through Blackboard Collaborative, a web-streaming option; this means you can stay at your computer and receive the program in real time and ask questions through the chat option. This is always true for some live programming; on November 2, we are sponsoring a Geriatric Grand Rounds to be broadcast live and video streamed. The grand rounds speaker will be Dr. Richard Zraick, professor and chairman of Speech Pathology/Audiology at the University of Central Florida, formerly professor in the College of Health Professions at UAMS and UALR. He will be addressing “Communication Impairment in Persons with Alzheimer’s disease”. We are delighted to offer you the opportunity to access AGEC programming more conveniently.

Opportunities for more education in geriatrics include the Arkansas Geriatric Education Mentors and Scholars (ARGEMS) program, a self-study for health professionals that can be completed on line and the Summer Institute, a program for faculty in the health professions. ARGEMS can be started at the participants’ convenience; more information may be obtained at our website, www.agec.org, for interested readers. Invitations for Summer Institute for Faculty will be sent out after the New Year. If you are interested, read more about it on our website. Both programs are tuition-free.

As we plan ahead, we would love to hear from you about what you would like to know more about. We will be conducting a statewide needs assessment in the spring, 2017 and hope you will take the time to answer the questions on line or using a mailed survey. In the meantime, feel free to e-mail your suggestions for topics and programs to agec@uams.edu or post a note on our website page.

We all wish you a great fall and holiday season and hope to see you soon!

10 Interesting Facts about Senior Citizens

By Regina V. Gibson, MALS, RN, CHES

UAMS Arkansas Geriatric Education Collaborative

1. Senior Citizens are Still Active in the Workforce

There are currently over 5 million senior citizens who are active in the work force. That means that 5 million older people are still sharing their skills and expertise to help make the world and their industry a better place.

2. Senior Citizens Are More Likely to Vote

Senior citizens make up the majority of registered voters. That means that they are also good citizens with a strong sense of civic pride and commitment to their country.

3. Senior Citizens Have a Day of Recognition

May is the designated month for appreciating and recognizing senior citizens. August 21st, however, is official Senior Citizens Day. Its purpose is to bring awareness about social and economic issues regarding the well-being of seniors, as well as to honor them for their contributions.

4. Senior Citizens are More Likely to Commit Suicide

The media may lead us to believe that younger people are more inclined to take their own lives. However, the truth is that people 65 and older are more likely to commit suicide than any other age group.

Men are more likely to commit suicide than women. According to the CDC, the suicide probability for women levels off in the 60’s, but continues to climb for men. Contributing factors can include depression (which is often missed, ignored or misdiagnosed in the elderly), loneliness, isolation, physical limitations (feelings of low self-worth), poverty, illness, and being recently divorced or widowed.

Suicide goes up in individuals with access to hand guns. Lethal weapons, but especially guns, are the main method for suicide among the elderly.

Montana has the highest suicide rate among seniors.

5. Poverty Is Still a Serious Issue for Senior Citizens

Over 16% of seniors live in poverty.

“9.4 percent of seniors had incomes in 2006 below the poverty threshold of $9,669 for an individual, and $12,186 for a couple, nearly a quarter of older Americans (22.4 percent) had family incomes below 150 percent of the poverty line.” — Center for American Progress. This is not always due to mismanagement of funds. As the economy fluctuates, seniors often find that the value of their assets and savings may not match or exceed the rising cost of health care, medications, assisted living and other needs of aging.

6. Senior Citizens Still Have Sex

At least 73% of all senior citizens are still sexually active and not always with their spouses and partners. The elderly are also just as likely to engage in experimental sexual practices as any other age group.

The numbers don’t change much over the age groups either. Men and women in their 60’s, 70’s and beyond reported to be just as satisfied and sometimes more satisfied than when they were younger.

Elders who are single or widowed are highly likely to seek out one or more sexual partners. Rather than being appalled at the sexual preferences and practices of the aging population, more education and health screenings need to be available, since those over 60 are the least willing to implement safe-sex practices.

7. Senior Citizens are Tech Savvy

More than 40% of seniors have computer access and are active online. About 15 million Facebook users are 65 and older.

Along with social media sites where they can connect with friends and family, older computer users play online games, read news sites, sign up for dating sites, and contribute to sites related to their interests. They are bloggers, survey takers, shoppers, reviewers, photographers, and more.

8. Senior Citizens Still Drive, Even When They Shouldn’t

About 80% of seniors own a car and drive frequently. Whereas only 1% of senior deaths are due to a motor vehicle accident, they are more likely to have crashes at intersections than other age groups. Elderly men have three times higher death rate from car accidents than women. Although there are many jokes about the elderly driving too slowly, they are just as likely to get pulled over for speeding.

9. Senior Citizens Enjoy Hobbies that are Creative or Useful

The majority of senior citizens, whether working or retired, enjoy hobbies and social activities. Crafting, woodworking, dancing, exercise, pets, travel, charity work and church are some of the preferred activities.

10. Senior Citizens are Individuals

You can group them together, you can study them statistically and you can stare at infographics for days. But it still comes down to individuality.

Seniors come from all classes, all ethnicities and all educational backgrounds. They run marathons, go to college, work at jobs, take dance classes, use online dating sites, and play games on Facebook. Until you reach out and get to know a senior, you will never know for sure what makes them tick.

Reference:

http://eldercareissues.blogspot.com/2014/01/10-interesting-facts-about-senior.html

Use of Technology and Home Exercise Compliance in Older Adults

By Chad Lairamore, PhD, PT, GCS, NCS and Sarah Walker, DPT

University of Central Arkansas

Patient compliance has been a consistent challenge to ensuring appropriate treatment within all fields of healthcare.^1-3 Not only is compliance crucial to decreasing healthcare costs by minimizing wasted healthcare dollars on repeated services where benefits are not fully realized; compliance by patients may become a factor in provider viability, with reimbursement impacted by the outcomes that clients achieve.^1,4,5 As healthcare continues to move toward value and outcome-based models of reimbursement, this old problem takes on a new perspective as reimbursements may soon be incentivized by, or even directly linked with, patient outcomes.^6-8 Additionally, for patients to receive appropriate medical treatment they must have a partnership with the care provider and be engaged in managing their own health care. The choices they make every day have the greatest impact on their wellbeing.^1,5 In fact the World Health Organization states that “Increasing the effectiveness of adherence interventions may have a far greater impact on the health of the population than any improvement in specific medical treatments.”⁵ Non-compliance is of particular importance in the older adult population, as data indicate that those over the age of 65 are less likely to perform their prescribed home exercise program.^9,10

Emerging evidence suggests that providing patients with a more engaging form of home exercise program beyond either the standard written or verbal instructions can result in an increase in patient compliance. In this time of rapidly advancing personal technology, one solution to improving compliance may lie in the palm of our hand through the appropriate utilization of smart devices. Smartphone and tablet applications are a readily available, familiar, and ubiquitous tool at the fingertips of most clinicians and patients.

This technology is currently grossly underutilized and unstudied, but could potentially serve to revolutionize patient outcomes by dramatically increasing rates of patient compliance. However, Individuals over the age of 65 represent the lowest demographic for smart phone usage with only 27% reporting having a smartphone.¹¹

To bridge this gap, we partnered students from the University of Central Arkansas Physical Therapy Department with older adults participating in a pro bono clinic associated with the course Adult Neurological Rehabilitation. Clients were loaned an iPad mini if they did not already own a smart device, and students instructed the clients on use of the smart device. The goals of this learning experience were to 1) facilitate improved engagement and home exercise program compliance, and 2) educate students on the potential use of technology for increasing patient engagement and compliance compared to standard printed home exercise programs.

In order to gauge patient compliance, we used the application Wellpepper during the pro bono clinic and for 1 month following the clinic. Wellpepper is an application that is used to create custom care plans, share and update exercises remotely, and track results.¹² The application was administered by student physical therapists using an iPad. With supervision from a licensed physical therapist, students created customized home exercise programs that were then available to clients via the application on their own personal device or the device that was lent to them. Within the app, therapists and students were able to change and update their client’s home exercises, and check in to see if they were being performed. This innovative system attempts to capitalize on the assumption that greater patient engagement and support, coupled with a more dynamic interface, can increase patient compliance.

Anecdotally, we found that clients fell into one of three categories. Those who already had a “relationship” with their smartphone or tablet were likely to engage with the application Wellpepper and perform their home exercise program on a regular basis. The clients who did not own a smartphone or tablet, but who demonstrated an interest in using the application, were also likely to engage with the home exercise program and have good compliance. In fact, several clients who fell in this category bought tablets to be able to continue their exercise routine. Finally, the clients who did not show an early interest in the technology were generally non-compliant with their home exercise program. These results are not surprising as previous research investigating elderly participants use of a home program found that compliance was influenced by the individual’s preference for the program structure and how that program was delivered.¹³

In conclusion, we found the use of smart devices may increase patient engagement and improve compliance for some older adults. However, smart device usage is not for everyone. Clinicians need to match instructional techniques with their client’s preference. Additionally, as instructors, we need to not only teach our students to use technology for increasing patient engagement, but also to use traditional instructional strategies as well as other alternative strategies to better match home programs to the patient’s preference.

References:

Martin LR, Williams SL, Haskard KB, DiMatteo MR. The challenge of patient adherence. Therapeutics and Clinical Risk Management. 2005;1(3):189-199.
Vermeire E, Hearnshaw H, Van Royen P, Denekens J. Patient adherence to treatment: three decades of research. A comprehensive review. Journal of C`linical Pharmacy and Therapeutics. 2001;26(5):331-342.
Campbell R, Evans M, Tucker M, Quilty B, Dieppe P, Donovan J. Why don’t patients do their exercises? Understanding non-compliance with physiotherapy in patients with osteoarthritis of the knee. Journal of Epidemiology and Community Health. 2001;55(2):132-138.
Jack K, McLean SM, Moffett JK, Gardiner E. Barriers to treatment adherence in physiotherapy outpatient clinics: A systematic review. Manual Therapy.15(3):220-228.
Adherence to Long Term Therapies – Evidence for Action. Wolrd Health Organization 2003: http://www.who.int/chp/knowledge/publications/adherence_report/en/.
VanLare JM, Conway PH. Value-based purchasing—national programs to move from volume to value. New England Journal of Medicine. 2012;367(4):292-295.
Miller HD. From volume to value: better ways to pay for health care. Health Affairs. 2009;28(5):1418-1428.
Roadmap for Implementing Value Driven Healthcare in the Traditional Medicare Fee-for-Service Program In: Services TUSDoHaHSaTCfMM, ed. CMS website 2009:31. ????
Henry KD, Rosemond C, Eckert LB. Effect of number of home exercises on compliance and performance in adults over 65 years of age. Physical Therapy. 1999;79(3):270-277.
Riel H, Matthews M, Vicenzino B, Bandholm T, Thorborg K, Rathleff MS. Efficacy of live feedback to improve objectively monitored compliance to prescribed, home-based, exercise therapy-dosage in 15 to 19 year old adolescents with patellofemoral pain- a study protocol of a randomized controlled superiority trial (The XRCISE-AS-INSTRUcted-1 trial). BMC Musculoskeletal Disorders. 2016;17:1-12.
Smith A. U.S. Smartphone Use in 2015. 2015; http://www.pewinternet.org/2015/04/01/us-smartphone-use-in-2015/.
Weiler A. mHealth and big data will bring meaning and value to patient-reported outcomes. mHealth. 2016;2(1).
Simek EM, McPhate L, Hill KD, Finch CF, Day L, Haines TP. What are the characteristics of home exercise programs that older adults prefer?: A cross-sectional study. American Journal of Physical Medicine & Rehabilitation. 2015;94(7):508-521.

From the Director’s Desk

by Ronni Chernoff, PhD, AGEC Director and Professor, Department of Geriatrics

We are getting started on year 2 of the Arkansas Geriatric Education Collaborative (AGEC), a Geriatric Workforce Enhancement Program. We just completed a progress report for the year that ended June 30, 2016. During 2015-2016, the partners in the AGEC offered 37 academic courses, our 5-day summer institute for faculty, 60 hours for the Arkansas Geriatric Education Mentors and Scholars (ARGEMS) program, 2 Geriatric Grand Rounds, an APRN geriatric pharmacology course, co-sponsored a 5-day geriatric long term care conference, and co-sponsored several diabetes, healthy aging, and falls prevention workshops. In collaboration with the Centers on Aging, AARP, AHECs, and our academic partners, Arkansas State University and the University of Central Arkansas, we supported 30 other educational offerings, including 4 video teleconferences (VTC) that were broadcast via the interactive television network and live-streamed via Blackboard. The VTCs were digitally recorded, edited and burned as DVDs which are available for viewing. We also started working with our first responders (firefighters, police, and EMS) to teach them how to effectively manage elderly individuals who have dementia. We had almost 1800 encounters in education with Arkansans seeking to learn more about aging. We are so proud of what we achieved in year 1 of this project!

We will continue to offer video teleconferences four times/year, twice in the Fall and twice in the Spring. Upcoming video teleconferences are scheduled for September 14 and October 26. Programs can be seen at UAMS or a site near where you live or work or by the interactive television network, but programs are now available through Blackboard Collaborative, a web-streaming option; this means you can stay at your computer and receive the program in real time and ask questions through the chat option. We are delighted to offer you the opportunity of accessing AGEC programming more conveniently.

The new www.agec.org website was launched and now offers easier navigation and more features. Please visit the website and read all about our new features. There are two portals, one for health professionals and one for community members who are not health professionals. We are working on a curriculum for direct care workers that will be available for continuing education credit.

As we plan ahead, we would love to hear from you about what you would like to know more about. We will be conducting a statewide needs assessment in the Spring, 2017 and hope you will take the time to do it on line or use a mailed survey to give us some feedback. In the meantime, feel free to e-mail your suggestions for topics and programs to agec@uams.edu or post a note on our website page. Look for “Save the Date” cards and announcements for the geriatrics and long term care 17th annual conference September 22-24. A Geriatric Grand Rounds on communication issues in dementia patients is scheduled for November 2 and we will be web-streaming, video teleconferencing, and having face to face video teleconferences in the Fall. Hope you are having a great summer and we look forward to seeing you soon!!

From the Director’s Desk

Ronni Chernoff, PhD, FAND, FASPEN, Director

We are coming to the end of the first year of the Arkansas Geriatric Education Collaborative, a Geriatric Workforce Enhancement Program. It is an appropriate time to look back on our first year and recap some of the continuing and new achievements. We continue to be proud of what we contributed to the education and training of health professionals, faculty and students who are

looking forward to careers in one of the many health care disciplines in Arkansas. We are proud of the new, updated Arkansas Geriatric Education Mentors and Scholars (AR-GEMS) self-study, and our successful Summer Institute for Faculty training programs.

We continue to offer video teleconferences four times/year but now, not only can you attend in person at a receiver site near where you live and work or by the interactive television network, but programs are now available through Blackboard Collaborative, a web-streaming option; this means you can stay at your computer and receive the program in real time and ask questions through the chat option. We are delighted to offer you the opportunity of accessing AGEC programming more conveniently.

The AGEC is partnering with first responder organizations to help our police, firefighters, and EMTs recognize and manage people with dementia. We are providing training and support materials to make them better able to help those in need. We are also collaborating with our partners to provide useful and relevant information on aging to seniors who attend AARP programs and local Arkansas Aging Initiative sites for lifestyle and educational workshops.

The new www.agec.org website has been launched and offers easier navigation and more features. Please visit the website and read all about our new features. There are two portals, one for health professionals and one for community members who are not health professionals.

As we plan for our second year, we would love to hear from you about what you would like to know more about. Feel free to e-mail your suggestions for topics and programs to agec@uams.edu or post a note on our website page. Our next program will be in the Fall because summertime is for leisure and vacation; our usual audiences, students, faculty and community groups are at a lake, at a beach, or at a campsite, enjoying family time and will participate in educational programs when school starts again in late Summer. Look for “Save the Date” cards and announcements for the Geriatrics and Long Term Care 17th Annual Conference September 22-24. A Geriatric Grand Rounds on Communication Impairment in Persons with Alzheimer’s Disease is scheduled for November 2. We will be web-streaming, video teleconferencing, and having face-to-face video teleconferences in the Fall. Have a great summer and we look forward to seeing you again in late Summer!

Proton-Pump Inhibitors as Potentially Inappropriate Medications in Older Adults

Arkansas Geriatric Education Collaborative

By: Janna Hawthorne, PharmD, University of Arkansas for Medical Sciences

In October 2015 the American Geriatrics Society (AGS) released updates to the 2012 version of the Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. A. new class of drugs, proton-pump Inhibitors (PPIs), was added to the 2015 AGS Beers Criteria as potentially inappropriate in older adults.(1) PPIs are clinically indicated for use in acute ulcers, gastroesophageal reflux disease, erosive esophagitis, hypersecretory conditions, prevention of nonsteroidal anti-inflammatory drug (NSAID)-induced ulcers, and treatment of Helicobacter pylori infections.(2)

Commonly prescribed, and also available over-the counter, PPIs include omeprazole (Prilosec), esomeprazole (Nexium), and pantoprazole (Protonix). In 2015, it was reported that esomeprazole (Nexium) was the fourth highest prescribed medication in the United States, ranking with 15.2 million prescriptions annually.(3) The warning with PPIs in the 2015 AGS Beers Criteria is based upon studies which indicate that PPI use longer than eight weeks in the elderly population can put them at increased risk for developing Clostridium difficile infection (CDI) and can lead to bone loss and fractures.(1) In this update, the evidence suggesting potential for inappropriate use of PPIs in older adults is high with the strength of recommendation being strong. (1) A high quality of evidence implies that the studies were well-conducted, well-designed, and looked at the population in question. The strong recommendation informs us that the benefits of not using this class of medications outweighs the risk that is apparent with its use.(1)

The enhanced risk of Clostridium difficile infection is due to the potent acid suppressing nature of PPIs. Low acidity within the stomach provides ingested bacteria an environment in which they can flourish. If Clostridium difficile bacteria colonize the stomach, they can overpower the normal gut flora and produce toxins that lead to intestinal injury and inflammation.(2) The injury and inflammation that develop from this exposure will produce extensive diarrhea that could lead to dehydration, delirium, and other critical conditions within the elderly population. In a 2012 meta-analysis looking at the association of PPIs with development of Clostridium difficile infection, data showed that for every 3,925 patients taking a chronic PPI, one person will develop a Clostridium difficile infection, nearly twice the normal incidence of CDI.(4)

PPIs also have the added concern for increased bone loss and subsequent fracture. Theories suggest that calcium must have acid in order to be absorbed from the stomach. Therefore, the acid suppressing manner of PPIs may result in decreased calcium absorption and subsequent loss of bone mineral density (BMD).(5) Elderly women lose BMD at a rate of 10% per decade after menopause and elderly men decline at the same rate later in life. With the great decline in BMD simply due to aging alone, anything to exacerbate this decline could result in tremendous complications, such as hip fracture. In 2015 a meta-analysis was published that looked at the risk of fracture as associated with the use of PPIs. Data from this meta-analysis reported a 26% increase in hip fractures in patients who take PPIs chronically. The risk of spine and any-site fracture also increased by 58% and 33% respectively.(5)

High-risk patients who have erosive esophagitis, Barrett’s esophagitis, pathological hypersecretory conditions, are on oral corticosteroids or prolonged use with NSAIDs, or have demonstrated need for maintenance therapy may benefit from chronic PPI use.(1) If a patient does not have a medical indication for chronic use of PPIs, therapy should be tapered and discontinued. The first step in discontinuation of therapy would be to decrease the daily dose to the lowest dose possible. After a few weeks of the lowest possible dose, the PPI should be discontinued. After discontinuation, the patient should self-monitor for relapse of symptoms such as heartburn, indigestion, and chest pain. If symptoms recur, you may initiate a trail trial period of 4-8 weeks of the lowest possible dose of a preferred PPI or initiate therapy with a histamine2-receptor antagonist. The patient should then be followed closely and another trial of discontinuation should be tried.(6)

References:

1. American Geriatric Society 2015 Beers Criteria Update Expert Panel (2015). American Geriatrics Society 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. Journal of American Geriatric Society, 63, 2227-2246. doi: 10.1111/jgs.13702
2. Kapadia, A., Wynn, D., & Salzman, B. (2010). Potential adverse effects of proton pump inhibitors in the elderly. Clinical Geriatrics. 18(7), 24-31.
3. Brown. T. (2015). 100 best-selling, most prescribed branded drugs through March. Medscape Medical News. Retrieved from http://www.medscape.com/viewarticle/844317
4. Tleyjeh, I., Bin Abdulhak, Aref., Riaz, M., Alasmari, F., Garbati, M., AlGhamdi, M., Rahman Khan, A., Al Tannir, M., Erwin, P., Ibrahim, T., AlLehibi, A., Baddour, L., & Sutton, A. (2012). Association between proton pump inhibitor therapy and Clostridium difficile infection: a contemporary systematic review and meta-analysis. Plos One. 7(12), 1-12.
5. Zhou, B., Huang, Y., Li, H., Sun, W., & Liu, J. (2015). Proton-pump inhibitors and risk of fractures: an update meta-analysis. Osteoporosis International, 26(10), 1-9. doi: 10.1007/s00198-015-3365-x
6. PPIs in older people—do you know the risks? (2014, January), Health News and Evidence. Retrieved from http://www.nps.org.au/publications/health-professional/health-news-evidence/2014/ppi-risks-in-older-peopleProin

The Importance of Nutrition Assistance in Older Adulthood

by Alicia S. Landry, PhD, RD, LDN, SNS, Assistant Professor/University of Central of Central (UCA)

After age fifty, there are many metabolic and physiologic changes impacting the nutritional needs of an individual. A slower metabolic rate with age is due to a decrease in muscle mass; this results in lower caloric needs. Many older people experience difficulty obtaining sufficient nutrients to support or achieve optimal health. These challenges may be related to inadequate dentition or swallowing issues, cognitive and psychosocial changes, as well as insufficient income. Inadequate energy intake can eventually lead to chronic fatigue, depression, and a weakened immune system.1

As health practitioners, it is critical that we encourage older adults to consume nutrient-dense diets. The significance of this was noted in 2006 when the inclusion of separate nutrition recommendations for individuals 70 and over2 was made. Meeting daily protein requirements is essential for the aging adult because protein provides essential nutrients for the maintenance of bone structure and muscle mass. The Recommended Dietary Allowance for protein is 0.66 grams/kilogram/day for adults over 70 years of age, however, recommendations for older adults suggest that 1.2 grams/kilograms/day will meet the needs of many older adults. Carbohydrate in the form of high quality fiber, more complex carbohydrates and few simple starches or sugar should equate to 130 grams/day. Fats are the most efficient source of energy but there is no determined recommendation so these should be chosen wisely and should include fats with omega 3 and omega 6 fatty acids.2 Adequate Calcium and vitamin D are also important in the diets of older adults.

Older adults may experience changes in taste and appetite. Physical ailments, prescription medications, and loss of a significant other may impact appetite; emotional factors such as loneliness and depression can affect diet and appetite. Limited budgets may make affording food needed to support a balanced, healthy diet difficult.

“While federally funded programs provide food to millions of older adults each year, there are still many older adults going hungry.3 Food assistance programs can improve nutritional well-being, functional independence, and quality of life.1 General assistance programs such as the Supplemental Security Income (SSI), is intended to increase a person’s income to the defined poverty threshold. However, if SSI benefits are paying for expenses like medications and doctor visits, there may not be enough left for nutrient-dense food. Federal nutrition assistance through the United States Department of Agriculture (; http://www.fns.usda.gov/programs-and-services) include the Supplemental Nutrition Assistance Program (SNAP) and Senior Farmers’ Market Nutrition Program. Unfortunately, only about eight percent of participants in SNAP are aged 60 or over. Many eligible older adults report a “stigma” associated with receiving food assistance and therefore never try to obtain the benefits. According to USDA guidelines, households may have $2,250 in countable resources, such as a bank account, or $3,250 in countable resources if at least one person is age 60 or older, or is disabled. Resources that are not considered include homes and land, resources of people who receive SSI, resources of people who receive Temporary Assistance to Needy Families (TANF), and most retirement (pension) plans. An income test is performed and deductions for medical and shelter costs are included.

“Meals and snacks are provided by Adult Day Care Centers. Commodity foods can be obtained through the USDA’s Commodity Supplemental Food Program. Adult Day Cares are funded through the Child and Adult Care Food Program (CACFP) which provides aid to adult care institutions to provide nutritious foods for the health and wellness of older adults and disabled persons. The Commodity Supplemental Food Program supplements older adults’ diets with foods like low-fat dry milk, juice, rice, oats, peanut butter, dry beans, as well as canned meats, fruits, and vegetables.

“The US Department of Health and Human Services (US DHHS) administers the Older Americans Act Nutrition Program which includes Congregate Nutrition Services, Home-Delivered Nutrition Services, and the Nutrition Services Incentive Program. All people 60 and over as well as their spouses are eligible to receive meals through US DHHS programs regardless of income. The Home-Delivered Nutrition program aims to serve frail, homebound, or isolated individuals who are age 60 or over. The Nutrition Services Incentive Program provides grants to states, territories, and eligible tribal organizations that provide congregate and home-delivered meal programs, like senior centers and Meals on Wheels programs. A sample meal pattern that would be served daily at a congregate feeding site or home-delivered may be seen in Table 1. A very helpful resource may be found with the Older Americans Act Nutrition Programs Toolkit provided online by the National Resource Center on Nutrition, Physical Activity & Aging. Privately funded nutrition resources for aging adults include the National Foundation to End Senior Hunger, Feeding America, local food banks, as well as Meals on Wheels Association of America and others. Meals on Wheels provides a nutritious meal, visit, and safety check with each delivery. Depending on the funds available and the sponsor organization, days/times of delivery and meal composition varies. Regardless, older adults receiving Meals on Wheels food often are able to live at home, independently for a longer time.
Not only is the number of older adults continuing to grow, many older adults are experiencing inadequate savings and retirement. Adequate nutrition can save healthcare dollars and significantly improve quality of life for our aging adults. All health professionals can promote healthy nutrition practices in older adults and identify signs of malnourishment, feeding difficulties, or psychosocial changes impacting nutrient intake.

Table 1. Sample Meal Pattern


Food Type	Recommended Portion Size
Protein foods	3 oz., cooked portion
Vegetables and fruits	Two ½ cup portions
Enriched white or whole grain bread or alternative	1 serving (one slice bread or equivalent)
Butter or margarine	1 tsp
Dairy	8 oz. fat-free or low-fat milk or calcium equivalent
Dessert	One ½ cup serving (fruit, pudding, gelatin, ice cream, sherbet, etc.)
Source: US Department of Health and Human Services

References:
1. Drewnowski A, Shultz JM. Impact of aging on eating behaviors, food choices, nutrition, and health status. J Nutr Health Aging. 2001;5:75–79
2. Otten JJ, Hellwig JP, Meyers LD, editors. IOM. Dietary Reference Intakes: The essential guide to nutrient requirements. Washington, DC: The National Academies Press; 2006.
3. Coleman-Jensen, A., Rabbitt, M., Gregory, C., & Singh, A. (2015). Household Food Security in the United States in 2014, Table 2. USDA ERS.