Winter 2023 Newsletter

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

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

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

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

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

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

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

References:

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

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

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

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

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

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

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

Fall 2022 Newsletter

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

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

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

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

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

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

References

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

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

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

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

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

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

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

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

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

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

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

Spring 2022 Newsletter

By Haylee Whitehurst, Occupational Therapy Doctorate Student
College of Nursing & Health Professions
Arkansas State University
Edited by Jessica Camp, DNP, APRN, AGCNS-BC, NE-BC, CDP

Did you know?

Unintentional weight loss occurs in 15%- 20% of older adults and is associated with increased morbidity and mortality.

Background/Significance of Unintentional Weight Loss in Older Adults

It can be difficult to notice gradual changes in a loved one when family members see them frequently. That’s why, as professionals, we must keep an eye out for weight changes over time. Weight loss can be due to inadequate food intake as well as other contributing factors that may indicate an underlying health, behavioral, or emotional issue. Some overweight aging adults  can benefit from healthy weight loss to relieve pressure on joints and heart function. In these cases, it is important that weight loss is controlled and on purpose so the individual is losing fat and not valuable muscle mass. However, when weight begins to drop off unintentionally, whether the aging adult could benefit from some weight loss or not, medically speaking the risks to their health can be very serious. Following unintentional weight loss, the immune system can deteriorate, leaving an older adult more vulnerable to infection and illness with a weakened ability to recover. An aging adult may experience fatigue as weight and overall health decline, which can prevent activity, exercise, and social participation. If they do lose weight in muscle mass, the aging adult will weaken and may be at greater risk of falls and injuries, which can be very dangerous for older adults (Gaddey & Holder, 2014).

Share These Tips with Families to Help Prevent Unintentional Weight Loss in Older Adult Patients

1. Add spices and color to food
   1. If your family member has lost the sense of taste, then they might not be excited about eating. Consider incorporating some hot pepper, mustard, sage or other spices and flavorings in your loved one’s next meal.
2. Consider supplements
   1. Supplements can nourish your loved one’s body and prevent malnutrition. Ask your family member’s doctor or registered dietitian what supplements would be the most appropriate.
3. Exercise with your loved one
   1. Physical activity can improve appetite, so encourage your family member to exercise a few times a week. For example, you can go on a walk or take an aerobics class. Regular exercise will also improve bone strength and boost the immune system.
4. Prepare snacks
   1. If your family member isn’t consuming enough calories during meal times then prepare some healthy snacks. For example, cauliflower, broccoli, and carrots, are packed with vitamins and minerals older adults need to thrive. Almonds, fresh fruit, and boiled eggs are other great snacks. For additional calories, peanut butter, cheese, puddings and other easy-to-eat foods may be suggested.
5. Check medications
   1. If your family member takes medication that causes swallowing difficulties, nausea, or dry mouth, it can negatively affect his or her appetite (Gaddey & Holder, 2014). Voice your concerns to your loved one’s doctor and have that doctor reevaluate these medications to see if adjustments can be made.

Treatment Options

Determining the specific cause of weight loss can lead to a clearer course of action for us as professionals, whether it be a medical, dental, psychological, financial, or lifestyle solution. Treatment often involves a multidisciplinary team, including dentists; dietitians; speech, occupational, or physical therapists; and social service workers (Gaddey & Holder, 2014). Do your part by recognizing unintentional weight loss and assessing the cause, bringing attention to the treatment team, or making appropriate referrals when needed.

Everyone’s metabolism naturally slows down as they age, so it makes sense that an older adult will eat less food than they used to. It’s important to give extra attention to the nutrient quality and caloric density of food to ensure that they get adequate vitamins and minerals, especially if they may have digestive difficulties. There are ways to make meals more appealing to older adults with declining appetites and ways to make meals more accessible even for those with dental problems. It can also be a significant advantage, if you can encourage friends and family to sit down for meals together with the older adult so they have companionship and encouragement to eat whenever possible. 

Common Strategies to Address Unintentional Weight Loss in Older Adults:

• Dietary changes
• Environmental modifications
• Nutritional supplements
• Flavor enhancers
• Appetite stimulants

Resources for Professionals to give to Family Members

• Areas Agencies on Aging (AAA)
  • Meals on Wheels
  • Senior Centers
  • Transportation options
• Division of Aging, Adult, & Behavioral Health Services (DAABHS)
• Program of All-Inclusive Care for the Elderly (PACE)
• Senior Community Service Employment Program

References

Gaddey, H. L., & Holder, K. (2014). Unintentional weight loss in older adults. American Family Physician, 89(9), 718–722. https://www.aafp.org/afp/2014/0501/p718.html

Programs for Adults & Seniors. (n.d.). Arkansas Department of Human Services. Retrieved November 3, 2021, from https://humanservices.arkansas.gov/learn-about-programs/programs-for-adults-seniors/

Winter 2022 Newsletter

By S. Mark Foster, DNP, APRN, FNP-BC and Jessica Erin Camp, DNP, APRN, AGCNS-BC, NE-BC, CDP
College of Nursing & Health Professions
Arkansas State University

Suicide is a significant issue in the aging population. Rates of suicide are acutely high among men ages 85 and older, who have the highest rate of any group in the country (CDC, 2014). In addition, older persons’ suicide attempts are much more likely to result in death when compared to younger people (SPRC, 2020). Some significant reasons include careful planning, lethal methods chosen, reduced likelihood of being rescued, and frailty which decreases recovery likelihood (SPRC, 2020). Therefore, as healthcare providers we need to be aware of this risk and take action to help our patients.

Arkansas’s suicide death rate increased by an alarming 41% between 2000 and 2018, according to a new analysis of vital statistics data. The increase is especially concerning because the ongoing COVID-19 pandemic is further exacerbating risk factors for suicide. Not surprisingly, given concerns about exposure to COVID-19 in emergency departments, a decline in ED visits for psychiatric complaints was reported, particularly during the early phase of the pandemic (Yard et al. 2021). Survey data also point to higher levels of suicidal ideation and attempts among adults, particularly those experiencing more COVID-19-related adversities such as social distancing policies, distress, and fear of physical harm (Ammerman, et al. 2021).  Additional risk factors that may be impactful include: economic downturn, barriers to accessing healthcare, access to suicidal ideation and inappropriate media reporting. 

Providers need to be mindful of additional factors that may impact the care of this population, such as care delivery model changes, legislation, and an uptick in the media attention surrounding mental health. Increased legislative efforts and access to healthcare through telemedicine efforts may prove to have a positive impact on suicide rates in Arkansas.  During the ongoing pandemic, mental health care faces significant challenges related to staff shortages and decreased resources.  However, telemedicine is one of the best tools to tackle these challenges and simultaneously address the expected increase in demand for mental health (Wasserman et al, 2020).

Through legislative efforts Arkansas has established its own suicide hotline that is operated by the Arkansas Department of Health.  Websites such as The American Foundation for Suicide Prevention, Arkansas Suicide Prevention, Arkansas Suicide Prevention Network, or the National Action Alliance for Suicide Prevention may also serve as additional resources for patients and healthcare professionals alike. Additionally, the integration of more suicide prevention education within academia at all levels can raise awareness of this issue.

Awareness is essential, and providers are thus well-positioned to identify high-risk patients and initiate interventions to mitigate suicide-related morbidity and mortality (Rutz, 2001). Providers should talk with their older adult patients about prevention efforts, risk factors for suicide, and protective factors to prevent patients from suicide (SPRC, 2020). Providers should be aware of common risk factors, such as depression and other mental health problems, substance use problems including prescriptions, illness, disability, pain, and social isolation, particularly since the onset of the pandemic (SPRC, 2020) (USDHHS, 2016). Providers should also know what protective factors are, such as those that seek care for their mental and physical health problems, those with social connections, and having coping and adaptation skills (SPRC, 2020).

References

Ammerman, B. A., Burke, T. A., Jacobucci, R., & McClure, K. (2021). Preliminary investigation of the association between COVID-19 and suicidal thoughts and behaviors in the U.S. Journal of psychiatric research, 134, 32–38. https://doi.org/10.1016/j.jpsychires.2020.12.037

Centers for Disease Control and Prevention. (2014). Fatal injury reports, national and regional, 1999–2014. Retrieved from http://webappa.cdc.gov/sasweb/ncipc/mortrate10_us.html

Rutz W. Preventing suicide and premature death by education and treatment. J Affect Disord. 2001 Jan;62(1-2):123-9. doi: 10.1016/s0165-0327(00)00356-6. PMID: 11172879.

Suicide Prevention Resource Center (SPRC). (2020). Older adults. Retrieved from https://www.sprc.org/populations/older-adults

United States Department of Health and Human Services (USDHHS). (2016). Facing addiction in America: The Surgeon General’s report on alcohol, drugs, and health.

Wasserman, D., Iosue, M., Wuestefeld, A., & Carli, V. (2020). Adaptation of evidence-based suicide prevention strategies during and after the COVID-19 pandemic. World psychiatry : official journal of the World Psychiatric Association (WPA), 19(3), 294–306. https://doi.org/10.1002/wps.20801

Yard, E., Radhakrishnan, L., Ballesteros, M. F., Sheppard, M., Gates, A., Stein, Z., Hartnett, K., Kite-Powell, A., Rodgers, L., Adjemian, J., Ehlman, D. C., Holland, K., Idaikkadar, N., Ivey-Stephenson, A., Martinez, P., Law, R., & Stone, D. M. (2021). Emergency Department Visits for Suspected Suicide Attempts Among Persons Aged 12-25 Years Before and During the COVID-19 Pandemic – United States, January 2019-May 2021. MMWR. Morbidity and mortality weekly report, 70(24), 888–894. https://doi.org/10.15585/mmwr.mm7024e1

Fall 2021 Newsletter

By Kylie Murphy, OTS, BS
Occupational Therapy Student, College of Nursing & Health Professions
Arkansas State University
Edited by Jessica Camp, DNP, APRN, AGCNS-BC, NE-BC, CDP

SIGNIFICANCE OF FALLING FOR OLDER ADULTS & POSSIBLE INTERVENTIONS

According to the Centers for Disease Control and Prevention (CDC) (2020, p. 1), “around 36 million older adults fall each year, resulting in more than 32,000 deaths.” Falls in the older adult population can result in broken bones and head injuries. Falling is not a normal part of aging. Falls are a result of physical changes or poor home environmental setup. There are multiple sources available which can aid providers in having conversations with their patients to help prevent home falls.

According to the CDC (2018) and Mayo Clinic (2019), some fall prevention options for providers to discuss with patients include suggesting patients:

• schedule yearly eye and foot examinations
• add grab bars near bathtub and toilet
• have plenty of light throughout the home
• get plenty of exercise
• store items within easy reach
• use assistive devices when needed
• remove throw rugs
• keep an updated list of medications
• maintain a clutter-free home

Additional things to consider when talking with patients about preventing falls at home, should include adding their vitamins, supplements and over the counter medications to their list of home medications. Patients need to know that all their daily medications are important to include.

Patients also need to know that vision changes are a normal part of aging and that these changes can influence a person’s fall risk. Eye examinations from an optometrist are critical in identifying eye problems early on. Explain to patients that some common eye problems they will be screened for may include glaucoma, cataracts, macular degeneration, diabetic retinopathy, and conjunctivitis. All of these eye conditions can influence a person’s fall risk.
Foot examinations should be performed during a yearly check-up like a Medicare Annual Wellness Visit. Providers should check sensation, blood flow, and changes to the shape of the feet. Instruct the patient remove their shoes and socks when seating them in your exam rooms or other treatment areas.

Another intervention is the reduction of clutter and good lighting in your clinical areas, just like we would the home environment to be. Reducing clutter and having good lighting reduces tripping hazards that may cause falls when patients come to visit you. Modeling a safe environment can provide visual examples for you to use when discussing a patient’s home environment modifications.

Another critical aspect in reducing fall risk for your patients is to promote a healthy lifestyle. Exercises that promotes balance, strength, and coordination such as, Tai Chi, will help prevent falls for an aging individual in your care. Devices such as a plastic seat in the shower or a raised toilet seat can be helpful to patients who have fallen in the bathroom. These items can provide a stable surface when doing daily activities and may have some coverage by insurances.
Resources to share with your patients and families can sometimes be challenging to locate when you are busy working. Below are some online resources for family members and caregivers that provide more information on home fall prevention in older adults. Please share them with your patients and their families:

• Fall prevention resources for older adults and caregivers
https://acl.gov/FallsPrevention
• Debunking the Myths of Older Adult Falls
https://www.ncoa.org/article/debunking-the-myths-of-older-adult-falls
• Video on 6 steps to prevent falls from the National Council on Aging (NCO)
https://www.ncoa.org/article/preventing-falls-tips-for-older-adults-and-caregivers
• 18 Steps to Fall Proofing Your Home from the NCO
https://www.ncoa.org/article/18-steps-to-fall-proofing-your-home
• Evidence-Based Falls Prevention Programs from the NCO
https://www.ncoa.org/article/evidence-based-falls-prevention-programs
• Eldercare Locator
https://eldercare.acl.gov/Public/Index.aspx
• National Assistive Technology (AT) Program search
https://www.at3center.net/stateprogram#
• CDC- Adult fall prevention resources
https://www.cdc.gov/falls/resources.html

References
Centers for Disease Control and Prevention . (2018). Family caregivers: Protect your loved ones from falling . https://www.cdc.gov/steadi/pdf/STEADI-CaregiverBrochure.pdf
Centers for Disease Control and Prevention . (2020). Injury prevention & control: Keep on your feet. CDC. https://www.cdc.gov/injury/features/older-adult-falls/index.html#:~:text=About%2036%20million%20older%20adults,bones%20or%20a%20head%20injury
Mayo Clinic Staff. (2019). Fall prevention: Simple tips to prevent falls. Mayo Clinic. https://www.mayoclinic.org/healthy-lifestyle/healthy-aging/in-depth/fall-prevention/art-20047358

Winter 2021 Newsletter

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

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

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

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

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

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

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

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

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

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

References

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

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

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

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

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

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

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