AGEC

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.

From the Director’s Desk

Arkansas Geriatric Education Collaborative

by Ronni Chernoff, PhD, FAND, FASPEN, AGEC Director and Professor, Reynolds Institute on Aging

As we transition from an old year to a new one, it is always good to reflect on what we accomplished during 2015 and what our goals are for the new year. Our Geriatric Education Center had an awesome 18 years of developing, producing, and evaluating programs on issues related to aging, and we are so 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 hope to continue our connection and friendships with many of you while we forge ahead with the Geriatric Workforce Education Program (GWEP), the Arkansas Geriatric Education Collaborative, and meet new people interested in geriatric topics and issues. We all hope that our contribution to improving the health care for our senior citizens continues to be successful.

The Arkansas Geriatric Education Collaborative (AGEC) is moving along right on schedule! We have some new staff members who are part of our group, Sajni Kumpuris and Kerry Krell, MPH, CHES. Sajni has been with the Arkansas Geriatric Education Center working on the Alzheimer’s Disease supplements but has now increased her time and contribution to manage, not only the Alzheimer’s education projects but also, our web-based activities. Kerry is new to the AGEC and is our Outreach Coordinator. She will be working with the new providers and audiences for whom we are developing educational programs and materials. We are excited to have them and look forward to you having the opportunity to meet them.

The new www.agec.org website is being revamped and will offer easier navigation and more features. Watch for the launch in March, 2016. We are in the process of confirming dates for future programs and will get them up on the website calendar as soon as they are set.

Our next program will be a live, interactive 2-hour video teleconference on May 05, 2016 on “Common Dental Issues of Older Adults & Nutritional Implications”. This video teleconference will be live on the UAMS campus and broadcast to interative receiver sites across Arkansas.

Arkansas Geriatric Education Mentors and Scholars (AR-GEMS), our online self-study program in geriatrics for health practitioners, has been updated and will soon be uploaded onto the UAMS Blackboard so that it is more user-friendly.

The AGEC faculty Summer Institute is scheduled for May 16-20, 2016. Letters of invitation were sent to deans of colleges and universities in Arkansas that have health professional programs; the purpose is to update faculty with information about aging and issues that elderly Arkansans have to face and increase the geriatric content in the courses they teach or develop new courses for students who will be the future health care providers.

Watch our video on Alzheimer’s help in Arkansas