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Arkansas Geriatric Education Collaborative

AGEC

From The Director’s Desk

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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)

Fall 2019

 

Hello everyone from the Arkansas Geriatric Education Collaborative (AGEC), the Geriatric Workforce Enhancement Program for Arkansas. Summer of 2019 is over and we are beginning one of the busiest times of the year. Summer was very eventful for us as we started our new grant and began working to bring new partners and collaborators on board with the AGEC!

We have been very busy this fall with community and health professional programming. We had our first fall professional continuing education program featuring our newest AGEC member Leah Tobey, PT, DPT and Morgan Storey, APRN who presented a two-hour webinar entitled Urological Issues in Older Adults & Pelvic Floor Physical Therapy Interventions. This event focused on improving the attendees’ awareness of urological and non-invasive pelvic floor PT services, and evidence-based treatment options for urinary urgency management. They also reviewed potential medication causes of urinary incontinence and best suited options for treatment. Stay tuned for our upcoming continuing education events on our website at agec.uams.edu. We have started new fall community programs with our partner Arkansas AARP. We are conducting lunch and learns in several rural locations across the state with topics ranging from pain management to family caregiving for loved ones with dementia.

Our academic partners are also busy this fall. UCA just completed their annual Inter Profession Education forum on October 15 with over 400 students in attendance from OT, PT, Nursing, Health Sciences, Exercise and Sport Sciences, Addiction Studies, Communication Sciences and Disorders, Family and Consumer Sciences and Psychology. Students were able to learn how each profession would contribute to the health and wellbeing of a real patient who served as a ‘live’ client. Nine clients and caregivers discussed their case with inter professional groups of students that then offered suggestions on how they would assist the client in their care. ASU faculty are updating curriculum and clinical experiences in areas that impact older adults and have many nurse practitioner students involved in projects such as screening for osteoporosis, colorectal cancer, and depression.

In other exciting news, we had 20 stellar applications for 5 Geriatric Student Scholar positions! After much hard decision making, we have named our 5 new scholars for this year and will be announcing them soon – stay tuned!

We continue to seek new ways to reach and teach all audiences and if you have any suggestions, please let us know.

Leakage – Is it a Normal Part of Aging?

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By Leah R. Tobey, PT, DPT
Clinical Coordinator
UAMS Arkansas Geriatric Education Collaborative

 

First and foremost, having a candid conversation with your healthcare provider is the very best way to manage leakage, whether it be urine or bowel. But, do keep reading this article for your personal and professional knowledge. According to the National Association for Continence (NAFC). bladder control problems affect about 25 million Americans, and 85% of them are women. But this is rarely talked about. Probably one of the hardest things for patients is to bring up the topic of urinary leakage to their healthcare providers due to the private nature of this topic. As a general statistic, women wait about 6.5 years to talk to their doctor about urinary leakage. Although the statistic is moving in the right direction, from about 10 years, that’s still too long to live with symptoms when there are proven, evidence-based treatments available. The Women’s Preventive Services Initiative (WPSI) disseminates evidence-based clinical recommendations for women’s preventative healthcare services in the United States. The WPSI estimates 55% of women with urinary incontinence did not report symptoms to their healthcare providers because of embarrassment, stigma, or acceptance as normal. Starting the conversation and using appropriate screens for urinary incontinence could help identify these patients who might be uncomfortable initiating the conversation.

The National Institute on Aging (NIA) defines urinary incontinence as leaking urine by accident. Earlier this month, the AGEC had the pleasure of hosting a webinar on “Urological Issues in Older Adults & Pelvic Floor Physical Therapy Interventions.” Let’s test your knowledge of pelvic health and aging. Is incontinence a natural part of aging? Is incontinence after childbirth normal? Is it normal to wake up to urinate every night? The answer to each of these questions is no. They are all myths for which we might have at one time believed to be a part of the aging process. According to the NIA and International Continence Society (ICS) weak bladder or pelvic floor muscles can cause leakage as can damage to the nerves that control the bladder from Parkinson’s disease or diabetes, for example. Associated with aging, diseases like arthritis can make it difficult to get to the bathroom in time or blockage from an enlarged prostate in men can cause urinary leakage. The NIA reports incontinence can happen to anyone and it is more common in older people, especially women; but this doesn’t have to be the case. For the dedicated patient, incontinence can be significantly reduced or cured with the help of behavioral, lifestyle, pharmacologic and nonpharmacological treatment, including physical therapy treatment. Pelvic floor muscle exercises (also known as Kegels) when performed correctly can effectively strengthen the core and pelvic floor, allowing the muscles to more strongly hold urine and prevent leakage. A physical therapist with certification in pelvic floor therapy can help educate and teach patients about Kegels, timed voiding, lifestyle changes and evaluate other related back or hip problems which could make urinary leakage worse. For more information visit the National Association for Continence www.nafc.org.

Leah R. Tobey is a doctor of physical therapy, and has been treating patients with incontinence for over 10 years.

To Sleep or Not to Sleep? Management of Insomnia and the Elderly

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By Sarah Albanese, PharmD and Lisa Hutchison, PharmD, MPH, BCPS, BCGP
University of Arkansas for Medical Sciences (UAMS) College of Pharmacy

Approximately, 50% of older adults report trouble falling and staying asleep.1 As people age, sleep cycle changes, chronic medical conditions, and medications decrease total sleep time, increase awakenings, and decrease time in deep sleep.1 Insomnia increases the risk of depression, cognitive impairment, hypertension, heart disease, chronic fatigue, diabetes, and falls.  Non-pharmacological treatments are recommended first including cognitive behavioral therapy for insomnia (CBT-I) with sleep hygiene and controlling stimuli that make sleeping difficult.  CBT-I has shown long-term improvements in insomnia over pharmacological options.1,3,4

Information on the most common medications used for insomnia in elderly patients is listed in Table 1.  Although low cost, benzodiazepines, non-benzodiazepines sedatives, and diphenhydramine are not recommended for treatment of insomnia in the elderly due to their minimal effectiveness and numerous side effects.1,4-7 Preferred agents based upon efficacy and safety include doxepin at doses of 6 mg or less, ramelteon and suvorexant.  However, these agents are higher cost, making affordability an issue. Suvorexant, like benzodiazepines and non-benzodiazepines, is a schedule IV controlled substance, which indicates a potential for abuse and affects accessibility to the drug when prescriptions expire or need refills. The higher doses of doxepin, while low cost, are not recommended as side effects increase significantly. Trazodone has pronounced side effects and benefits are short term. Mirtazapine showed significant benefit with insomnia treatment, but data is limited to patients with depression.1,3-7 Melatonin has shown minor benefits for insomnia treatment, decreasing sleep onset by 5-7 minutes. However, melatonin has become a favorite option for insomnia treatment in elderly individuals due to its benign side effect profile, accessibility, and low cost.

Insomnia is a major problem in the elderly population, with many negative effects if left untreated. Pharmacological options provide some benefit for insomnia, but a majority of products have major side effects. Non-pharmacological treatments like CBT-I are recommended for insomnia treatment in elderly people over pharmacologic options due to the long-term efficacy and lack of negative effects.1-7

 

Table 1: Medications for Insomnia Treatment 1,3-8

Medication Class and Examples Advantages Disadvantages Cost
Benzodiazepines

Temazepam

Triazolam

 

  

 

 Side effects: Drowsiness, falls, fractures, cognitive impairment, delirium, increased accidents, tolerance, rebound insomnia

 

Minimal effectiveness

Not for long-term use

Schedule IV controlled substance – potential for abuse

 $ – $$
Non – Benzodiazepine Sedatives

Zolpidem

Zaleplon

Eszopiclone

 Short half-life-less hangover

 

Fewer side effects at low doses

 Side effects: same as benzodiazepines, plus sleep -walking, -eating, -driving, rebound insomnia

 

Not for long-term use

Schedule IV controlled substance – potential for abuse

 $
Antidepressants Doxepin

Trazodone

Mirtazapine

 

 Improvement significant

 

Doxepin: Minimal side effects at doses ≤ 6 mg

 

 Side effects: drowsiness, dizziness, constipation

 

Doxepin: Pronounced side effects at doses >6 mg including dry mouth, rebound insomnia, orthostatic hypotension, cognitive impairment

 

Trazodone: Beneficial effects subside after 1 week; Other side effects: arrhythmias, orthostatic hypotension, falls

 

Mirtazapine: Indicated for insomnia if also treating depression; Other side effects: hyponatremia, weight gain, dry mouth

 $

 

Except:

Doxepin

3-6 mg $$$

 
Antihistamines

Diphenhydramine

 Available over-the-counter Side effects: drowsiness, dizziness, cognitive impairment, falls, constipation, tolerance $
Melatonin Receptor Agonists
Ramelteon, Melatonin		 Minimal side effects

 

No rebound insomnia

 

Ramelteon:

Significant improvement

 

Melatonin:

Available over-the-counter

 Side effects: Headache, nausea, vomiting, upper respiratory infection, runny nose, dizziness

 

Melatonin: Dietary supplement with lack of standardization

 

 Ramelteon $$$

 

Melatonin $
Orexin Receptor Antagonist

Suvorexant

 Well-tolerated Side effects: drowsiness

Schedule IV controlled substance – potential for abuse

 $$$

$ = cost <$1/day; $$ = Cost $1-2/day; $$$ = cost $3-10/day

References:

  1. Patel D, Steinberg J, Patel P. Insomnia in the elderly: a review. J Clin Sleep Med 2018;14:1017-24.
  2. Vaz Fragoso C, Gill TM. Sleep complaints in the community – living older adults: a multifactorial geriatric syndrome. J Am Geriatr Soc 2007;55:1853-66.
  3. Kamel NS, Gammack JK. Insomnia in the elderly: cause, approach, and treatment. Am J Med 2006;119:463-69.
  4. McCall WV. Sleep in the elderly: burden, diagnosis and treatment. Prim Care Companion J Clin Psychiatry 2004;6:9 – 20.
  5. Reynolds AC, Adams RJ. Treatment of sleep disturbance in older adults. J Pharm Pract Res 2019;49:296-304.
  6. Sateia MJ, Buysse DJ, Krystal AD, Neubauer DN, Heald JL. Clinical practice guidelines for pharmacological treatment of chronic insomnia in adults: an American academy of sleep medicine clinical practice guidelines. J Clin Sleep Med 2017l;13:307-49.
  7. 2019 American geriatrics society beers criteria update expert panel. American geriatric society 2019 updated AGS beers criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc 2019;67:674-94.
  8. Good Rx Inc. Available at: https://www.goodrx.com/ .

Physical Activity for Older Adults

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By Stacy Harris, DNP, APRN
School of Nursing
University of Central Arkansas

Being physically active is one of the most important lifestyle habits people of all ages can take to improve their health. Recently, the United States Department of Health and Human Services (2018), released new physical activity guidelines. The new guideline recommends adults try to achieve a minimum of 150 minutes (2 hours and 30 minutes) of moderate activity or 75 minutes (1 hour and 5 minutes) of intensive activity each week. The new guideline highlights special populations, including recommendations for the older adult. Older adults should try to achieve the adult recommendations along with balance training and muscle strengthening activities. In addition, the guideline states that older adults with chronic conditions or disabilities should engage in physical activity according to their abilities, explaining that any activity level is better than being sedentary.

As adults age and chronic conditions become common, patients may feel becoming physical fit and more active is unrealistic and not beneficial. However, numerous studies have shown older adults benefit from physical activity. Lövdén, Xu and Wangy (2013) published a critique of a meta analysis that linked increased aerobic physical activities with enhance cognition in sedentary adults.  In a randomized control trial of Tai Chi training in adults (mean age 77) with mild cognition issues 30 minutes of Tai Chi three times a week over 12 months resulted in a 4% lower conversion to dementia compared to 17% for the control group (Lövdén, Xu and Wangy, 2013).  Tai Chi is a low impact activity practiced as a graceful form of exercise involving a series of movements performed in a slow, focused manner accompanied by deep breathing.

Older adults may be overwhelmed or intimidated when a health care provider uses the word “exercise.” The word exercise suggests a level of activity that may be unattainable for older adults. Patients may be more likely to relate to leisure activities such as gardening, dancing or walking. Evidence suggests that leisure activities are beneficial to cardiovascular health. Mensink, Ziese and Kok (2009) found older adults who participated in leisure activities at 1-2 hours per week, had lower systolic blood pressure, heart rate and body mass than sedentary adults.

Besides improving cardiovascular health, physical activity is also proven to improve orthopedic issues. Half of all older adults have knee and hip pain and may worry that increasing physical activity will worsen already achy joints (Peterson, Osterloh and Graff, 2019). The good news is that this idea has been disproven by multiple scientific trials. The American College of Rheumatology and the Osteoarthritis Research Society International recommends activity as first line treatment for knee and hip pain. Activities such as water aerobics, land-based (i.e. walking) and Tai Chi are appropriate activities.

At the University of Central Arkansas (UCA), the Department of Exercise and Sport Science, developed an exercise program for older adults who reside at College Square Apartments, a retirement community on the UCA campus. A faculty member and students meet with participating residents who have been cleared by their primary care provider. Before exercise begins, the students conduct a motivational interview with the participant and create mutual agreed upon goals. The students administer the Senior Fit Test, interpret the results, then prepare and lead the participants through 6-8 weeks of exercise. At the end of the program students administer the Senior Fit Test again, and then review and debrief with the participant.

Older adults may think participating in a fitness program or purchasing expensive equipment is needed to improve fitness. Home-based items such as lifting full milk gallon jugs or carrying laundry baskets up steps are ways to increase strength. Stretch bands are low-cost items that can be used to help with flexibility and strength, too. Any physical activity is worthwhile and helps cardiovascular, joint and mental health. Just move!

 

 

References

Lövdén, M., Xu, W. & Wangy, H. X. (2013). Lifestyle change and the prevention of cognitive decline and dementia. Current Opinions in Psychiatry 26 (3): 239-243.

Mesink, B. M., Ziese, T. & Kok, F.J. (2009). Benefits of leisure-time physical activity on the cardiovascular risk profile at older age. International Journal of Epidemiology (28): 659-666.

Peterson, N. E., Osterloh, K. D., & Graff, M. N. (2019). Exercises for older adults with knee and hip pain. The Journal for Nurse Practitioners, (15) 263-267.

S. Department of Health and Human Services (2018). Physical activity guidelines advisory committee scientific report, 2nd Ed. Retrieved from https://health.gov/paguidelines/second-edition/report/

 

Special Focus Facility Programs for the Aging Population

Arkansas State University

Dr. Angela Stone Schmidt, Professor Emeritus
College of Nursing & Health Professions
Arkansas State University

 

The “Special Focus Facility” (SFF) program, is implemented by Centers for Medicare and Medicaid Services (CMS) for the aging and others requiring the need for long term nursing care. The purpose of this initiative is to keep the public, healthcare providers and consumers, informed when discussing long term care options.  The SFF report is a result of state agency inspections resulting in what that agency is doing to improve quality of care for the aging after deficiencies have been cited.  There are specific areas reviewed to determine quality and these reports are available online.  Those long term care facilities, identified as a “Special Focus Facility”, are identified and include measures of quality, or lack of, with available evidence, identifying high and low performing nursing homes.

In June 2019, the release of a list of 400 nursing homes across the country by the Senate Committee on Aging was deemed to have persistently poor survey inspection results. Policy makers took note and responded, directing attention to the quality issues of long term care. CMS gave the list to Senator Robert P. Casey (D-Pa.), a member of the special committee on aging, which included 6 from Arkansas. A subsequent announcement was made by CMS of how the list is being sorted for possible inclusion in its SFF Program. David Gifford, Senior Vice President of Quality and Regulatory Affairs, American Health Care Association (AHCA), supported making relevant, transparent information available to families and consumers so they could make informed care decisions for selecting a quality facility.

(https://www.aging.senate.gov/imo/media/doc/SFF%20List%20with%20Cover%20Letter%20051419%20-%20Casey.pdf )

CMS and state agencies have inspected nursing homes on a regular basis to determine if they are providing the quality of care that Medicare and Medicaid require to protect and improve residents’ health and safety. When nursing homes do not meet CMS’ health care or fire safety standards, these instances are cited as deficiencies, and CMS requires that the problems be corrected. Most nursing homes have some deficiencies identified, as reported by CMS, with the average being 6-7 deficiencies per inspection.

“Skilled nursing facilities (SNFs) and nursing facilities (NFs) are required to be in compliance with the requirements in 42 CFR Part 483, Subpart B, to receive payment under the Medicare or Medicaid programs.  To certify a SNF or NF, a state surveyor completes at least a Life Safety Code (LSC) survey, and a Standard Survey. The State has the responsibility for certifying a SNF’s or NF’s compliance or noncompliance, except in the case of State-operated facilities.  However, the State’s certification for a skilled nursing facility is subject to CMS’ approval.  “Certification of compliance” means that a facility’s compliance with Federal participation requirements is ascertained.  In addition to certifying a facility’s compliance or noncompliance, the State recommends appropriate enforcement actions to the State Medicaid agency for Medicaid and to the regional office for Medicare.” (https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/NHs.html )

Some nursing homes make unsustainable improvements to correct an identified problem on inspection but as a result, have repeated cycles of serious deficiencies because of not addressing the underlying systemic problems that contributed to the needed improvement to improve quality of care. These facilities identified as a SFF had a compliance history which posed risks to residents’ health and safety. The methodology for identifying facilities for the SFF program is based on the same methodology used in the health inspection domain of The Five-Star Quality Rating System. CMS calculates a total weighted health inspection score for each facility.  Results from over three cycles (approximately three years) of inspections are converted into points based on the number of deficiencies cited and the scope and severity level of those citations, including any repeat visits. The more deficiencies that are cited, and the more cited at higher levels of scope and severity, the more points are assigned. Note that a lower survey score corresponds to fewer deficiencies and revisits, and thus better performance on the health inspection domain. (Five Star Rating System for Special Focused Facility, updated 9/25/19, https://www.cms.gov/Medicare/ProviderEnrollment-and-Certification/CertificationandComplianc/downloads/usersguide.pdf)

The Nursing Home Compare Five Star Quality Rating System design was developed by CMS with leading researchers in the long-term care field and contributions by consumers and provider groups.  The rating system features an Overall Quality Rating of one to five stars based on nursing home performance on three domains, each of which has its own ratings. The three domains include:

1) Health Inspection measures derived from outcomes from state health inspections that are based on the number, scope, and severity of deficiencies identified during the three most recent annual inspection surveys, as well as substantiated findings from the most recent 36 months of complaint investigations.

2) Staffing measures that are based on nursing home staffing levels with ratings on the staffing domain including at least two measures: Registered nurse (RN) hours per resident day; and total nurse staffing (the sum of RN, licensed practical nurse (LPN), and nurse aide) hours per resident per day.

3) Quality Measures based on MDS and claims-based quality measures (QMs), reflect performance on 17 of the QMs that are currently posted on the Nursing Home Compare website. These include ten long-stay measures and seven short-stay measures. Quality Domain information for all measures are available at: https://www.cms.gov/medicare/quality-initiatives-patient-assessmentinstruments/nursinghomequalityinits/nhqiqualitymeasures.html.

 

Therefore, the facilities with the most points in a State become candidates for the SFF program. The number of nursing homes on the candidate list is based on five candidates for each SFF slot, with a minimum candidate pool of five nursing homes and a maximum of 30 per State. State agencies use this list to select nursing homes to fill the SFF slot(s) in their state. Once a State selects a facility as an SFF, the State Survey Agency, conducts a full, onsite inspection of all Medicare health and safety requirements every six months and makes recommendations. These may include fines, denial of Medicare payment, or other measures, until the nursing home either (1) graduates from the SFF program; or (2) is terminated from the Medicare and/or Medicaid program(s). Once an SFF graduates or is terminated, each State then selects a new SFF from a monthly list of candidates. CMS also informs candidate nursing homes of their inclusion on the SFF candidate list in the monthly preview of the Five-Star Quality Rating System.

The Center for Medicare Advocacy looked at information on Nursing Home Compare for each of the 21 SFF graduates on CMS’s May 16, 2019 list. Four facilities had new names on Nursing Home Compare: https://www.medicare.gov/nursinghomecompare/search.html . According to their study, standards for graduation from SFF were vague. CMS describes graduates as SFFs that have “made significant improvements in quality of care – and those improvements are continued over time.”  CMS does not reflect the many recent graduates that continue to have serious deficiencies, multiple complaint surveys, and inadequate nurse staffing. Some facilities even change their name to avoid recognition and avoid scrutiny. This Center’s analysis is consistent with The New York Times report in July 2017, which found that 52% of 528 SFFs that graduated before 2014 were cited with serious harm or jeopardy in the years after they graduated. More than one-third of the facilities received the lowest federal rating for health and safety.( https://www.medicareadvocacy.org/cma-alert-june-20-2019/ )

This information of the SFF Program is necessary for discharge planners seeking nursing home placement and other healthcare providers, as well as consumers in response to advocacy for our aging population. When admission to a nursing home is considered, use the comparison website to determine results of the survey process for quality and performance. Compare website information about the nursing home’s star ratings, staffing, quality measures, and inspection results at: https://www.medicare.gov/nursinghomecompare/search.html .  Even as a healthcare provider making recommendations for placement, visit the nursing home and talk to staff, residents, physicians, and other families, to assist families to make informed decisions. Call the state survey agency (agency contact information is posted on Nursing Home Compare) to find out more about the nursing home.  If the nursing home is an SFF, look at the length of time that the nursing home has been on the SFF list. This has importance if the nursing home has been an SFF nursing home for more than 18 to 24 months, since such nursing homes are closer to either graduating (due to improvements) or ending their participation in Medicare and Medicaid.  CMS reports that most of the nursing homes in the SFF program significantly improve their quality of care within 18-24 months after being selected, while about 10% tend to be terminated from Medicare and Medicaid.  Lists are provided by state at: https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/downloads/sfflist.pdf

From The Director’s Desk

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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)

Summer 2019

 

I begin this letter with some exciting news. It was announced on June 10 that we were successful in our quest for renewing our grant!  We were fully funded from Health Resources and Services Administration (HRSA) with a five year $3.74M grant to continue and expand the work of the Arkansas Geriatric Education Collaborative.   Therefore as we wind-up the activities of fiscal year 2019, we are excited to get started on all of our new and continued activities for the new grant period!

First, to recap the last three months of fiscal year 2019, we were very busy. In April, we had two major events.  April 2, UAMS AGEC in collaboration with Hendrix College, sponsored an “Aging in Arkansas Symposium” in Conway where the results of an older adult needs assessment were discussed by a panel of experts.  April 12 we has a forum, Combating the Opioid Crisis and Chronic Pain, in partnership with the Clinton School of Public Service. This forum was focused on older adults in Arkansas managing chronic pain issues. Panelist included UAMS experts Michael Mancino, M.D.; Teresa Hudson, Pharm.D., Ph.D.; Masil George, M.D.; Heejung Choi, M.D.; Kristin Garner, M.D., Leah Tobey, D.P.T., and Kirk Lane, Arkansas drug director. To supplement this presentation and program, the AGEC and the UAMS Center for Health Literacy developed a Chronic Pain Book for patients. The book has been reviewed by the UAMS IMPACT group and many others. It was unveiled at the forum and has been extraordinarily well received. A link can be found on our website for more information on the books: https://agec.uams.edu/chronic-pain-book-and-addiction-resources/
Books can be ordered by emailing agec@uams.edu. The forum was followed by the posting of the AGEC produced video of an opioid addiction story on the UAMS Facebook page and it has received over 18,000 views!

On April 22, we had our second spring CE Webinar entitled Beers Criteria Update and Evidenced Based Alternatives featuring Lisa C. Hutchison, Pharm.D., MPH, BCPS, FCCP and Janna Hawthorne, Pharm.D., MA, Ed. This was followed on May 8 by a live Facebook event with Alzheimer’s Arkansas entitled: Understanding Respite Care in partnership with Alzheimer’s Arkansas where we had over 750 views on Facebook.

Starting in June, the AGEC crew started production for our First Responder Dementia Training Distance Learning Program. This program should be ready for viewing soon! Stay tuned!

At the end of May, we were privileged to have a presentation from our first cohort of Geriatric Scholars. They presented to the AGEC leadership on the activities from this semester including their interdisciplinary project and helped us discuss ways to improve the program. This program will be continued in the new grant!

We were also active with our community based partners with several programs and activities. In addition, we also partnered with the Oaklawn Center on Aging in response to a request from Mental Health America of Middle Tennessee who had heard about the AGEC’s First Responder Training. Kathy Packard MS, M.Ed., LPC, CDP, and I trained first responders to be Certified Dementia Practitioners and in Elder Abuse and Neglect identification and reporting. The program was extremely well received.

 

Thank you for all you do for older adults in Arkansas and we look forward to continuing to partner with many of you to expand and improve services and programs.

Helping Your Patients with the Medicare Maze

Oaklawn Center on Aging

By Kathy Packard, MS, M.Ed., LPC
Oaklawn Center on Aging

 

As a healthcare professional, you may be asked questions regarding Medicare. If your patients are approaching their 65th birthday or currently enrolled Medicare, they may be receiving daily mail with Medicare information, supplemental insurance and prescription drug plans (Part D).   With open enrollment in October you may want to keep Medicare information available for your patients. The information being mailed out to your patients can be overwhelming and very confusing for someone who does not know how to navigate the Medicare system.  This is the reason it is called the Medicare maze.  As their provider, patients may feel comfortable asking you questions regarding their Medicare coverage.  Therefore, you need to be prepared to help them navigate this maze.

There may be special programs for some patients.  Older individuals who have difficulty affording medications, may qualify for a federal program, extra help, a state program, or a Medicare Savings Program.  These programs are based on financial need and can assist paying Medicare and prescription drugs costs, premiums, deductibles, coinsurance and copayments for Part A, B and D.  Arkansas uses the baseline federal income and resource limits.  If you think your patient may qualify, have them call the Senior Health Insurance Information Program (SHIIP) office (1-800-224-6330) and they will direct the caller to a counselor who is trained to make application for them.

Remember: October 15, 2019-December 7, 2019, is open enrollment for all parts of Medicare.  To research the Medicare part D plans in your patients’ area of the state, they can go online to www.medicare.gov to view and compare available plans. To research parts A, B & C (Medicare Advantage plans) they can go online to www.insurance.arkansas.gov or call SHIIP counselors at 1-800-224-6330.

In addition to the maze of decisions, Medicare recently changed the format of their card to protect against identity theft. Most new Medicare beneficiaries turning 65 will apply for Medicare by going online to www.ssa.gov or by calling their local Social Security office. After the application is complete, Medicare cards will be received prior to or the month of their 65th birthday.   The new Medicare card has a unique number for each recipient, they no longer use Social Security numbers as the identifying number.  All Medicare beneficiaries have until December 31, 2019 to obtain the new card and will be required to use the new Medicare card no later than January 2020. Most medical practices and healthcare facilities began taking the new Medicare card this year.   Current Medicare beneficiaries should have received their new Medicare card by now, but if they haven’t, they should call 1-800-Medicare to order one.

Assisting Medicare beneficiaries has a positive health benefit. By taking away the stress of making these confusing decisions by themselves, you may well decrease their blood pressure and improve their health and health services!

 

 

Drug-Induced Parkinsonism in Older Adults

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by Rachel Briggler, PharmD candidate and Lisa Hutchison, PharmD, FCCP, MPH, BCPS, BCGP
University of Arkansas for Medical Sciences (UAMS) College of Pharmacy

 

Drug-induced parkinsonism (DIP) is one of the most common non-vascular neurological disorders in older adults but tends to go undiagnosed due to the similarities with Parkinson’s Disease (PD).2-3 DIP is an acute movement disorder that is generally characterized by bilateral and symmetric movements with more bradykinesia (slowness of movement) and rigidity than those with PD. However, asymmetric movements are shown to occur in about 30% of cases.1,4

The presence of other movement disorders such as akathisia (feeling of restlessness and urgent need to move), orofacial dyskinesia (involuntary, repetitive movements of mouth, tongue, and face), or tardive dyskinesia (involuntary, repetitive movements of trunk and limbs) suggest that parkinsonism is more likely to be caused by a medication and not PD.2 Since there is significant overlap in their presentation, symptoms alone are not enough to distinguish DIP from PD 3

DIP is caused by the use of drugs or toxins that deplete the dopaminergic system. These drugs are often referred to as dopamine-blocking agents.4-5 Dopamine-blocking agents that block ³80% of central dopamine receptors will produce parkinsonism symptoms in almost all patients.4 The clinical diagnosis of parkinsonism requires that patients meet certain criteria in order to rule out other causes of the movement disorder. The criteria includes the presence of parkinsonism, no history of parkinsonism before use of the offending drug, onset of parkinsonism symptoms during the use of the offending drug, and no significant dopamine transporter (DAT) uptake in the striatum (DAT imaging is used for the differential diagnosis between DIP and PD).1

As patients age, dopamine cells and dopamine transporters decrease which in turn requires less dopamine receptor blockade to reach the threshold for parkinsonism. 2 This puts the patient at a higher risk of developing symptoms. Some other risk factors include female sex, genetic variants, preexisting movement disorders, and cigarette smoking which can increase the likelihood of developing drug-induced parkinsonism when taking certain medications.1,4-5 DIP usually develops between two weeks and one month following the introduction of a new medication or an increase in the dose1,3. Knowing some of the medications that have an increased likelihood of causing DIP can potentially decrease the amount of cases seen. Some of the medications known to cause DIP are:

  1. Typical Antipsychotics (the most common)
    1. Haloperidol
    2. Prochlorperazine
    3. Thioridazine
    4. Trifluoperazine
  2. Atypical Antipsychotics
    1. Aripiprazole
    2. Lurasidone
    3. Olanzapine
    4. Risperidone
    5. Ziprasidone
  3. Antiemetics/ Motility Agents
    1. Metoclopramide
    2. Prochlorperazine
  4. Antidepressants
    1. Citalopram
    2. Fluoxetine
    3. Fluvoxamine
    4. Paroxetine
    5. Sertraline

Drug-induced parkinsonism can have a major impact on daily living so treatment can be life changing. The best way to treat this condition is to discontinue the use of the offending drug. Most cases have complete resolution of symptoms after the drug is stopped, but there are cases when symptoms may persist for months.4 Generally, the symptoms subside within four months but there are instances when it takes longer.6 It is important to give an adequate amount of time between the discontinuation of the drug and determining if there is a potential for underlying PD or Lewy body Dementia.3,6 If symptoms persist for 36 months, then another diagnosis such as tardive dyskinesia or idiopathic PD should be considered.4

                Since older adults are at an increased risk of developing DIP, it is important that practitioners and pharmacists take the time to look at a patient’s medications in order to identify potential causative agents. Discontinuation, dose decrease, or a change in medication may be needed to reverse the symptoms.

 

 

References

  1. Shin HW, Chung SJ. Drug-induced parkinsonism. J Clin Neurol. 2012;8(1):15–21. doi:10.3988/jcn.2012.8.1.15
  2. Wyant J, Kara and Chou L, Kelvin. Drug-induced parkinsonism. In: Hurtig I, Howard, ed. UpToDate. Waltham, MA: UpToDate; 2019. www.uptodate.com. Accessed June 20, 2019.
  3. Pamela J and Stephen J., Williamson. Drug-Induced Parkinsonism In The Elderly. The Lancet. 2019;324:8411. Published 1984 Nov 10. Doi: 10.1016/S0140-6736(84)91516-2
  4. Mehta, S., Morgan, J. and Sethi, K. (2015). Drug-induced Movement Disorders. Elsevier, 33(1), pp.153-174. Available at: https://www.sciencedirect.com/science/article/pii/S0733861914000796 .
  5. Savica R, Grossardt BR, Bower JH, Ahlskog JE, Mielke MM, Rocca WA. Incidence and time trends of drug-induced parkinsonism: A 30-year population-based study. Mov Disord. 2017;32(2):227–234. doi:10.1002/mds.26839
  6. Brandt J., Nicole. Detecting Drug-Induced Parkinsonism. Aging Well. 2010; 3(3): 24. http://www.todaysgeriatricmedicine.com/archive/082510p24.shtml. Accessed June 20, 2019.

Involving Students in Holistic Wellness for Seniors

UCA logo

By Alicia S. Landry, PhD, RDN, LDN, SNS
Lydia Sartain, MS, RD, LD, CDE
Nina Roofe, PhD, RDN, LDN, FAND, CNWE

College of Health and Behavioral Sciences, University of Central Arkansas

 

Making the aging process fulfilling and enjoyable should be the goal of healthcare providers working with older adults. While indicators of wellness have been assessed to see how they may interrelate in aging, there is still some work to be done to get the message out that holistic wellness in older adults can positively impact quality of life. For example, in patients diagnosed with Parkinson’s and Alzheimer’s disease, declines in functional status have been related to declines in cognition1. In frail and cognitively impaired elderly people, strength and balance training showed improvements in functional and cognitive abilities2. Finally, older adults who report social isolation, also show delayed recovery of systolic blood pressure in response to stress3. A focus on holistic health and wellness in the senior population is a complex, yet much-needed objective.

In order to approach aging holistically, there are a few key recommendations healthcare providers can encourage older adults to do:

  1. Stay active and engaged in social relationships
  2. Spend time mentoring others
  3. Eat a healthy diet
  4. Exercise body and mind
  5. Find healthcare providers they trust

With these in mind, faculty at the University of Central Arkansas (UCA) developed an interprofessional learning opportunity for students and local older adults. Through our ongoing partnership with Faulkner County Center on Aging, we were able to enhance our theme meal by involving students from nutrition and dietetics, interior design, and family and consumer sciences (FACS) education. The goal was to provide a service to the elderly participants  while encouraging interprofessional interactions outside of the classroom environment. The theme meal encouraged all the students to assess quickly and think critically during the event, a valuable skill for their future careers.

FACS majors who needed to assess growth and development milestones asked participants to bring in grandchildren. Interior design students observed the building and activities to work with mobility and design issues, then make recommendations. Nutrition students developed and produced a healthy, safe meal with any leftovers going to homebound seniors. The student-produced menu was based on the theme, A Night at the Drive-In, and included grilled hamburgers, oven roasted potatoes, tossed salad, ambrosia salad, and chocolate chip cookies.

The theme meal was successful, and students learned valuable lessons, including planning, organizing, budgeting, and ensuring customer satisfaction. Students also had the opportunity to develop higher level skills, including effective management and decision making. The interprofessional aspect provided students the opportunity to learn textbook concepts while interacting with others to meet numerous objectives for their classes.

Student reflections included quotes like:

“During the theme meal project I learned how to better work with others and share ideas to come up with one main idea. This helped me learn how to come up with the main idea collaboratively and emphasized the importance of communication. This can be applied to learning because it is important to listen to other ideas and consider what is the best one and maybe even putting more than one idea together to find the best outcome. Part of learning is collaborating with others and being willing to put your idea aside if someone has a better one.”

“Accountability is an interesting subject we covered this semester. I honestly thought we would have a problem with someone not doing their part for the theme meal. I was so wrong! I was so proud of how responsible every single person was the day of the theme meal. Everyone arrived on time and did the part they were assigned. There was no withdrawal, aggression, regression, or projection. The reason why I thought back to this topic is that I experience problems with accountability from my staff at work. I guess I assumed that more college students act like this than I thought, and is why I was worried about it from our class. I am so pleased with the maturity of our class’s theme meal. Everyone was accountable for a task and completed it with no complaints”.

“I would have liked to spend more time talking to those who  frequent the center in order to get a better understanding of what a normal day looks like to them.”

“My favorite thing was seeing all of the seniors enjoy the theme of the meal and the meal itself. I think that this theme was great because it was something everyone, despite many differences, could enjoy!”

After evaluating student reflections and surveys from the meal participants, we began to consider other ways in which holistic senior wellness could be addressed. Our search led us to consider a fascinating study done to assess seniors’ wellness using e-health applications4. These researchers used technology to ask seniors questions, look at physical and functional health, as well as spend time with them in an assisted living facility. The takeaway message was that this method provided immediate feedback and education opportunities to promote holistic well-being in seniors. In future collaborations, we would like to integrate technology applications to assess cognitive performance, physiological and functional variables, as well as other components of wellness like social and financial aspects. With these added components, healthcare providers in communication and speech, psychology and counseling, health education, physical and occupational therapy, as well as kinesiology could be seamlessly integrated into a community preventative health model that is beneficial and scalable. Using something like a theme meal to get students serving in our community has been a fantastic way to introduce them to interprofessional care as well as teach critical components in our disciplines. Getting students involved in interprofessional discussions and regularly assessing the domains of wellness alongside senior adults could redefine holistic wellness in aging.

 

 

 

  1. Stella F, Banzato CEM, Quagliato EMAB, Viana MA, Christofoletti G. Dementia and functional decline in patients with Parkinson’s disease. Dement Neuropsychol. 2008;2(2):96–101. doi:10.1590/S1980-57642009DN20200004
  2. Dorner T, Kranz A, Zettl-Wiedner K, Ludwig C, Rieder A, Gisinger C. The effect of structured strength and balance training on cognitive function in frail, cognitive impaired elderly long-term care residents. Aging Clin Exp Res. 2007 Oct;19(5):400-5.PMID: 18007119
  3. Xia N, Li H. Loneliness, Social Isolation, and Cardiovascular Health. Antioxid Redox Signal. 2018;28(9):837–851. doi:10.1089/ars.2017.7312
  4. Thompson HJ, Demiris G, Rue T, et al. A Holistic approach to assess older adults’ wellness using e-health technologies. Telemed J E Health. 2011;17(10):794–800. doi:10.1089/tmj.2011.0059

 

Ways to improve health in your geriatric patients

Arkansas State University

By Dalton Smith, ATC, 1st Year SPT
College of Nursing and Health Professions 
Arkansas State University

 

In 2015 the world population of adults over the age of 60 was at 900 million but by 2050 that number is projected to be at 2 billion1! With this we should expect our patient population demographics to shift towards these older adults, and with it our treatment strategies. The World Health Organization defines health as “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity”2.  Older adults are plagued with added stressors that accompany aging such as losing mental capacities and a decrease in functional ability. This leads to isolation, loneliness or even psychological distress and then add chronic illness or acute injuries and you’ve got the formula for a health disaster.

Healthy people 2020 objectives identify multiple areas to improve older adult health as a priority. But are we doing the best we can to help? Over the next few decades we will see these cases more and more. According to the CDC, Arkansans 50 years and over are among the leaders in the nation who report they rarely or never receive the social support they need3. So, the question is how can our healthcare professionals have a positive impact on health in our older patient population?

The first thing that can be done to help is to listen to our patients. Many of us know already that our patients want to talk about their lives, but did you know that adequate emotional and social support is associated with a reduced risk of mental illness, physical illness and mortality4? So talk to your patients, actually listen and support them. This is a very easy, yet effective, way to have a positive influence on your patients.

Another way to help is to offer encouragement! Encourage them to eat healthy diets, get involved in their community and get at least 30 minutes of physical activity a day. Studies have shown that having better physical health has a large effect on mental health and having better mental health has a stronger effect on current physical health5. Therefore encouraging older adults and providing resources about the importance of physical health will have a positive effect on their overall health.

Sometimes a little education is all that is needed. Many patients aren’t aware of the resources they have access to. Here are some things you can educate them about:

  • For patients interested in becoming more physically active, there are many locations that offer Silver Sneaker6 programs throughout the state.
  • Maybe they want to become more involved in the community but don’t know how. There are many opportunities to be found on volunteerar.org7 that they could explore or you could recommend based on their interests.
  • If transportation is an issue, there are services throughout the state that could help get them to and from healthcare visits.
  • Using ChooseMyPlate.org9 or referring to a registered dietitian, you would be able to give them the information they need to start them on a path toward a healthy diet. And AGEC offers a diabetes empowerment education program10 that is extremely beneficial to older patients living with diabetes.
  • There is an abundant amount of resources available to older adults in Arkansas ranging from abuse hotlines to foster grandparent programs. They can be found on humanservices.arkansas.gov11 or even on the AGEC website under free community programs10.

At the end of the day it’s about finding ways to help people. Sure, we can inform them that eating well, participating in regular physical activity and not using tobacco will increase their well-being, but through listening we offer the support our patients need and can direct them to additional resources.

 

  1. WHO (2019). Mental health of older adults. Available at: https://www.who.int/news-room/fact-sheets/detail/mental-health-of-older-adults .
  2. World Health Organization (1948). Constitution of the World Health Organization. Available at: http://www.who.int/governance/eb/who_constitution_en.pdf (Accessed 17 Jul. 2019).
  3. Centers for Disease Control and Prevention and National Association of Chronic Disease Directors. The State of Mental Health and Aging in America Issue Brief 1: What Do the Data Tell Us? Atlanta, GA: National Association of Chronic Disease Directors; 2008.
  4. Strine TW, Chapman DP, Balluz L, Mokdad AH (2008). Health-related quality of life and health behaviors by social and emotional support: Their relevance to psychiatry and medicine. Soc Psychiatry Psychiatr Epidemiol 43:151-159.
  5. Ohrnberger J, Fichera E, Sutton M. The dynamics of physical and mental health in the older population. J Econ Ageing. 2017;9:52–62. doi:10.1016/j.jeoa.2016.07.002
  6. https://tools.silversneakers.com/LocationSearch
  7. https://www.volunteerar.org/organization
  8. https://www.care.com/c/stories/5841/arkansas-transportation-resources/
  9. https://www.choosemyplate.gov/older-adults
  10. https://agec.uams.edu/communityprograms/
  11. https://humanservices.arkansas.gov/programs-services/services-by-group/senior