From the Director’s Desk

Spring 2021 Newsletter

By Robin McAtee, PhD, RN, FACHE, Director, Arkansas Geriatric Education Collaborative (AGEC), a Geriatric Workforce Enhancement Program (GWEP) at the University of Arkansas for Medical Sciences (UAMS) Donald W. Reynolds Institute on Aging (DWR IOA)

Wow, it has been over a year since the pandemic began and although we can see light at the end of the tunnel, we are still in the tunnel, yet thriving! The AGEC may look a little different than it did 12-15 months ago, but we are persevering and growing. We are now more diverse in our program offerings while still meeting and exceeding our goals and objectives. Over the past year we have embraced new partnerships and expanded outreach while maintaining key programs and activities.

During the past quarter, we started a new partnership with the Central Arkansas Library System that has gone state wide entitled “Learn from Home” and first aired on January 19^th. The Learn from Home Series is held monthly and covers topics such as “Understanding Dementia and Alzheimer’s Disease” and “Disaster Planning for Seniors”. We have also started monthly healthy cooking classes called “Cooking Live with AGEC: From Our Kitchen to Yours”. Both programs are going very well with thousands of online views. Programs with other partners included “Fall Prevention” with UCA Outreach and a “Memory Café” with Hendrix College featuring water stories and trivia. Those are just a sampling of the many programs we are having with our partners. Thank you partners for your continued support and vital participation during these difficult times!

We have also continued with our healthcare professions programming. Beginning in January with Lee Kathryn Lackey talking about “Supporting Military Caregivers” followed by Dr. Leah Tobey and myself presenting at Geriatric Grand Rounds on the “4Ms of Age-Friendly Care.” In February, “Racial/Ethnic Disparities in COVID-19 Predictors and Outcomes” was presented by Drs. Clare Brown and George Pro, followed later in February by Dr. Paul Parcon presenting on “Neuroinflammation in Alzheimer’s Disease”. “Opioid Tapering” was presented by Dr. Corey Hayes on March 18^th which was in partnership with the UAMS OPAL grant. Our next webinar will be in June regarding oral hygiene in older adults.

Finally, something we are very excited about with the AGEC is our involvement in older adult mass vaccination clinics in central AR. This is one of the activities supported by the CARES portion of our GWEP grant this quarter, and it has been extremely rewarding! AGEC staff along with the UAMS College of Nursing and Pharmacy students have been active in providing thousands of COVID-19 vaccines to older adults in partnership with local pharmacies, emergency management organizations, and many other volunteer groups. What great events!

Thank you all for supporting AGEC in our clinical, educational, and outreach efforts!

Aspirin for Primary Prevention in Older Adults

Spring 2021 Newsletter

By Katharine Stockton, Pharm.D. and Lisa C. Hutchison, PharmD, MPH
University of Arkansas for Medical Sciences (UAMS) College of Pharmacy

Heart disease and stroke are leading causes of death in older adults.¹ For prevention of cardiovascular disease, aspirin works as an antiplatelet through inhibition of cyclooxygenase-1 and 2 enzymes. It irreversibly inhibits the formation of thromboxane A₂ via acetylation of platelet cyclooxygenase, which then inhibits platelet aggregation.⁷Aspirin is proven effective for secondary prevention of cardiovascular diseases including coronary artery disease (CAD), peripheral artery disease (PAD), and stroke/transient ischemic attack (TIA).^2-6 However, the benefit to risk ratio of aspirin for primary prevention of cardiovascular disease is not as favorable given aspirin’s potential to cause bleeding.

Prior to the 2019 guidelines update from American College of Cardiology (ACC) and American Heart Association (AHA), aspirin was recommended for primary prevention of cardiovascular disease by these groups and other revered organizations^8,9 However, the 2019 ACC and AHA give more cautious recommendations regarding aspirin for primary prevention¹⁰:

Low-dose aspirin (75-100mg daily) might be considered for the primary prevention of ASCVD among select adults 40-70 years of age who are at a higher ASCVD risk but not at an increased risk of bleeding.
Low-dose aspirin (75-100mg daily) should not be administered on a routine basis for the primary prevention of ASCVD among adults > 70 years of age.
Low-dose aspirin (75-100mg daily) should not be administered for the primary prevention of ASCVD among adults of any age who are at increased risk of bleeding.

This update to guidelines and change from previous recommendations stems from recently published studies on the use of aspirin in the elderly.¹⁰ A series of articles from the Aspirin in Reducing Events in the Elderly (ASPREE) study were published in 2018.^11-13 The ASPREE study enrolled people 70 years of age or older who did not have cardiovascular disease, dementia, or any physical disability. Subjects were randomized to receive either aspirin or placebo. Aspirin use did not prolong disability-free survival over a period of 5 years in the intervention group as compared to placebo (P=0.79).¹¹ However, aspirin increased all-cause mortality in the elderly compared to placebo (1.14, CI 1.01 – 1.29).¹² This was attributed to cancer-related death and was an unexpected result of the study that should be interpreted cautiously given the confidence interval.

The ASPREE study also evaluated the effect of aspirin on cardiovascular events and bleeding. Cardiovascular disease was defined as a composite of fatal coronary heart disease, nonfatal myocardial infarction, fatal or nonfatal stroke, or hospitalization for heart failure. The study found no significant difference in the rate of cardiovascular disease with 10.7 events per 1000 person-years in the aspirin group and 11.3 events per 1000 person-years in the placebo group (0.95, CI 0.83 – 1.08). However, there was a significant difference noted in the composite rate of major hemorrhage for those in the aspirin group (1.38, CI 1.18-1.62; P < 0.001).¹³ Specifically, a significant difference was identified in subdural or extradural hemorrhage (1.79, CI 1.06-3.02) and upper gastrointestinal bleeding (1.87, CI 1.32-2.66). It is important to note that the ASPREE trial evaluated use of aspirin in the “healthy elderly” and did not meet the expected rate of cardiovascular events; therefore the potential cardiovascular advantages may be underestimated.¹³ However, the results of the ASPREE trial are similar to a recent meta-analysis evaluating use of aspirin for primary prevention in adults, which also concluded aspirin use did not significantly reduce cardiovascular endpoints, but was associated with an increased risk of bleeding.¹⁴

Given these study results and recent guideline updates, use of aspirin for primary prevention in the geriatric population should be carefully considered. Clinicians should evaluate patient history, cardiovascular risk factors, bleeding risk in discussion with older adults before recommending, starting, or continuing aspirin in patients greater than 70 years old.

References:

FastStats – Deaths and Mortality. Centers for Disease Control and Prevention. Published 2019. https://www.cdc.gov/nchs/fastats/deaths.htm
Winstein CJ, Stein J, Arena R, et al. Guidelines for Adult Stroke Rehabilitation and Recovery: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association . Stroke. 2016;47(6):e98-e169. doi:10.1161/STR.0000000000000098
Kulik A, Ruel M, Jneid H, et al. Secondary prevention after coronary artery bypass graft surgery: a scientific statement from the American Heart Association. Circulation. 2015;131(10):927-964. doi:10.1161/CIR.0000000000000182
Piepoli MF, Hoes AW, Agewall S, et al. 2016 European Guidelines on cardiovascular disease prevention in clinical practice: The Sixth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of 10 societies and by invited experts)Developed with the special contribution of the European Association for Cardiovascular Prevention & Rehabilitation (EACPR). Eur Heart J. 2016;37(29):2315-2381. doi:10.1093/eurheartj/ehw106
Levine GN, Bates ER, Bittl JA, et al. 2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2016;68(10):1082-1115. doi:10.1016/j.jacc.2016.03.513
Conte MS, Bradbury AW, Kolh P, et al. Global vascular guidelines on the management of chronic limb-threatening ischemia . J Vasc Surg. 2019;69(6S):3S-125S.e40. doi:10.1016/j.jvs.2019.02.016
Aspirin. Lexi-Drugs. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL. Available at: https://online.lexi.com/ . Accessed November 19, 2020.
Vandvik PO, Lincoff AM, Gore JM, et al. Primary and Secondary Prevention of Cardiovascular Disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(4):e637-e668. doi:10.1378/chest.141.4.1129c.
Kernan WN, Ovbiagele B, Black HR, et al. ). Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2017;45(7):2160-2236.
Arnett DK, Blumenthal RS, Albert MA, et al. 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease. Journal of the American College of Cardiology. 2019;74(10):e177-e232. doi:10.1016/j.jacc.2019.03.015.
McNeil JJ, Woods RL, Nelson MR, et al. Effect of Aspirin on Disability-free Survival in the Healthy Elderly . The New England Journal of Medicine . 2018;379(16):1499-1508.
McNeil JJ, Nelson MR, Woods RL, et al. Effect of Aspirin on All-Cause Mortality in the Healthy Elderly . The New England Journal of Medicine . 2018;379(16):1519-1528.
McNeil JJ, Wolfe R, Woods RL, et al. Effect of Aspirin on Cardiovascular Events and Bleeding in the Healthy Elderly . The New England Journal of Medicine . 2018;379(16):1509-1518.
Guirguis-Blake JM, Evans CV, Senger CA, O’Connor EA, Whitlock EP. Aspirin for the primary prevention of Cardiovascular events: a systematic evidence review for the U.S. Preventive Services Task Force. Ann Intern Med 2016; 164: 804-13.

Rhinitis and the Older Adult

Spring 2021 Newsletter

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By Stacy E Harris, DNP, APRN, ANP-BC
School of Nursing
University of Central Arkansas

Rhinitis, commonly known as inflammation of the nasal mucous membranes, affects adults of all ages. There are two major categories of rhinitis: Allergic rhinitis (AR) and Non-allergic rhinitis (NAR). Most people are familiar with the symptoms of AR: sneezing; itching, watery eyes; conjunctival redness; and rhinorrhea, a watery nasal discharge. The most typical course of AR is exposure to a seasonal (spring or fall) allergen, such as tree, grass, or weed pollen. This type of rhinitis begins to emerge in adults around in the late teens and peaks in the 5^th decade of life. Non-allergic rhinitis presents with similar symptoms: rhinorrhea and nasal congestion, but without the sneezing or eye symptoms. This type of rhinitis affects more adults and older adults (Yilmaz & Corey, 2006). Non-allergic rhinitis has many subtypes: vasomotor, atropic or geriatric non-allergic, rhinitis medicamentosa, drug induced, hormonal, gustatory and infectious (Kennedy-Malone, Martin-Plank and Duffy, 2019). This article will focus on NAR, specifically “geriatric “ sometimes known as physiologic rhinitis, the most common type effecting older adults.

Physiologic age-related changes to the nose are well known. It is common for an older adult patient to verbalize a decrease in the ability to smell. Besides olfactory changes, several other physiologic changes occur in the nose. The tough structures of the nose atrophy. This causes the nose to lengthen and the nasal tip to begin to droop. When the supporting upper and lower cartilages weaken, the nasal passages begin to narrow and produce a feeling of or an actual obstruction. Previous nasal injuries of youth or septal deviation confound the narrowing. These changes explain why many older adults complain of nasal obstruction. The vascular bed of the nose undergoes microvascular changes. The turbinates receive a decrease in blood flow which reduces the size of the turbinates and predisposes the nose to dryness and crusting. The changes in the nasal mucosa are impactful too. The nasal mucosa goblet cells increase, and the function of the submucosal serous glands decrease. The submucosal glands are responsible for watery, clear, thin mucous. The goblet cells produce a thick, tenacious mucus. Both types of secretions are responsible for humidifying the air we inhale and mostly importantly, trapping and removing potential organisms from entering the respiratory tree. These mucosal changes explain why many adults complain of daily thick, mucus production and have frequent throat clearing (Jordan and Mabry, 1998; Yilmaz & Corey, 2006).

Older adults may present to their healthcare provider with complaints of “sinus trouble” characterized by thick post-nasal drainage, nasal congestion, and frequent throat clearing. However, differentiating these symptoms from the typical symptoms of sinusitis (post-nasal drainage, nasal congestion, face pain and pressure, fever, headache) is not always clear to the provider. This can lead to misdiagnosis and unneeded treatment. The older adult may be treated inappropriately with antibiotics or first-generation histamine blockers when more supportive treatments are indicated.

There are numerous pharmacologic and nonpharmacologic ways to improve the older adults’ nasal complaints. First, the provider must rule out any allergic or infectious causes for the rhinitis. Once an accurate diagnosis of geriatric rhinitis has been made, a through explanation of the age-related nasal changes must be shared with the patient. This may not be the answer the patient is expecting but it is needed for long term management. Humidification is the key to improving geriatric rhinitis. Increasing moisture inside the nose is the main goal. This can be done by increasing moisture in the home, specifically the bedroom, and using over the counter (OTC) saline nasal spray as much as 4-6 times per day. There are many types of delivery methods, such as nasal douching, water-picks or Neti pots to inject saline into the nasal mucosa. Pure sesame oil has been shown to aid in nasal dryness (Jordan and Mabry, 1998)

Pharmacologic treatment including using mucous-thinning agents such as OTC guaifenesin has been shown to improve symptoms in patient with complaints of thick secretions. Topical and systemic decongestants can improve congestion but should be avoided due to the exacerbation of nasal mucosa dryness. Also, using first generation antihistamine (diphenhydramine, hydroxyzine) to treat nasal congestion should be avoided in older adults due to the sedating and anticholinergic activity. Newer second-generation antihistamines (loratadine, cetirizine, fexofenadine) are safe to use in older adults particularly if patients suffer from some allergic rhinitis too. Inhaled nasal steroids (Flonase, beclomethasone) are appropriate and safe in older adults suffering from allergic rhinitis, but long term can increase nasal dryness (Yilmaz & Corey, 2006).

Little research has been published regarding geriatric rhinitis. However, providers can improve the quality of life in the older patient by thoughtful education on age-related nasal changes. Also informing the older patient about OTC medications to avoid while providing them with simple treatments to increase humidification will ultimately improve rhinitis in the geriatric population.

Yilmaz, A. A. S. & Corey, J. P. (2006). Rhinitis in the elderly. Current Allergy and Asthma Reports, 6:125-131.

Jordan, J. A., & Mabry, R. L. (1998) Geriatric rhinitis: what it is and how to treat it. Geriatrics. 53(6) 76-80. Kennedy-Malone, L., Martin-Plank, l., & Duffy, E. (2019) Advanced practice nursing in the care of older adults, 2^nd Ed. FA Davis.

Healthy Ager Program Transforms During the Pandemic

Spring 2021 Newsletter

By Shawn Drake, PT, PhD, JoAnna Cupp, MS, RDN, LD, Brinda McKinney, PhD, MSN, RN, Lori Gatling, MSN, RN, CHSE
Arkansas State University

The College of Nursing and Health Professions (CNHP) at Arkansas State University and Center on Aging-Northeast partnered in 2004 and started the Healthy Ager Program (HAP). The objective of the HAP is to promote interprofessional educational and collaboration (IPEC) opportunities for health professions students’ while working with community-dwelling, older adults (Healthy Ager). The service-learning program provided students the opportunity to practice clinical skills learned in the classroom and apply their knowledge to improve the health and wellness in the older adult. COVID-19 heavily impacted the continuation of the HAP in Spring 2020. The program was suddenly halted, leaving the faculty with the question of how or if this program could continue.

COVID-19 forced the HAP faculty to think “outside the box” to develop a meaningful, service-learning experience for healthcare students and the Healthy Ager, while maintaining COVID-19 restrictions. In Spring 2021, the HAP moved to an online platform using Zoom. Student learning modules included exposure, immersion and mastery activities related to IPEC competencies focused on the older adult. Interprofessional teams comprised of students from nursing, physical therapy and nutritional science programs.

Exposure activities included introducing students to:

1) IPEC competencies¹ (communication, roles and responsibilities, values/ethics and team-based practice),

2) Quadruple Aims² (improved clinician experience, better outcomes, lower costs and improved patient experience),

3) Multidisciplinary Competencies for Older Adults³,

4) 4 M’s in the Care of Older Adults⁴ (what matters, medication, mentation, mobility), and

5) Team Strategies & Tools to Enhance Performance and Patient Safety⁵ (TeamSTEPPS)

The exposure activities were reinforced during Zoom activities, which included online simulation events (SBAR communication, dementia simulation) and collaborative sessions on home assessment, cultural competency and telemedicine.

Students participated in immersion activities through the use of Standardized Participants (SP) using Zoom as the telehealth platform. Each team was assigned an SP, who was over the age of 60 and was instructed to “act as themselves”. Each team completed an assessment using the 4M’s and provided interventions that focused on improving the 4Ms and Quadruple Aims for their SP. At the completion of each activity, small and large group debriefing occurred with the SP and faculty facilitator. The simulation activity allowed students time to practice telehealth presentation skills in a non-threatening environment, receive feedback on their team’s performance and implement changes before the real-life scenario.

Each team will participate in collaborative practice with their Healthy Ager in April. Team will provide an educational video and educational patient-specific pamphlet for their Healthy Ager which will allow for each team member to meet mastery level of IPEC competencies. In addition, the service-learning project allows for the Healthy Ager to improve his/her health and wellness with the expertise of each team.

The HAP has transformed itself in light of COVID-19 for the better. Despite the challenges of COVID-19, the HAP positively transformed. The new format allows the learner to meet the IPEC competencies, geriatric competencies, and practice telehealth.

References:

1. McKearney, Shelley. “IPEC Core Competencies.” Interprofessional Education Collaborative, www.ipecollaborative.org/ipec-core-competencies.

2. “ACTS Supports the Quadruple Aim.” ACTS Supports the Quadruple Aim | AHRQ Digital Healthcare Research: Informing Improvement in Care Quality, Safety, and Efficiency, digital.ahrq.gov/acts/quadruple-aim.

3. Author(s): Todd P. Semla, John O. Barr, Judith L. Beizer, Sue Berger, Ronni Chernoff, JoAnn Damron‐Rodriguez, Charlotte Eliopoulos, Carol S. Goodwin, Catherine L. Grus, Kathy Kemle, Ethel L. Mitty, Kenneth Shay, Gregg A. Warshaw. “Multidisciplinary Competencies in the Care of Older Adults at the Completion of the Entry-Level Health Professional Degree.” National Center for Interprofessional Practice and Education, 2 June 2020, nexusipe.org/informing/resource-center/multidisciplinary-competencies-care-older-adults-completion-entry-level.

4. “What is an Age-Friendly Health System?:IHI”. Institute for Healthcare Improvement. www.ihi.org/Engage/Initiatives/Age-Friendly-Health-Systems/Pages/default.aspx

5. “TeamSTEPPS®.” AHRQ, www.ahrq.gov/teamstepps/index.html

Arkansas Geriatric Education Collaborative Programs for Older Adults

Spring 2021 Newsletter

By Laura Stilwell, MEd
Education Coordinator
UAMS Arkansas Geriatric Education Collaborative (AGEC)

The Arkansas Geriatric Education Collaborative (AGEC) at the University of Arkansas for Medical Sciences has the mission to provide high quality programs that support healthy aging in Arkansas. Currently the population of adults age 65 and older is 54 million, or about sixteen percent of the nation’s population (US Census Report, 2019). In Arkansas, the number of adults age 65 and older is 524,000 and represents 17.4 percent of the state population (US Census Report, 2019). By the year 2030, the population of adults age 65 and older is expected to rise to 20 percent nationally and to 26 percent statewide (US Census Report, 2020).

The aging population, becoming the largest population sector in the future, has specific needs that must be addressed by the medical community. This age group presents with a host of chronic health problems; cardiovascular disease, hypertension, type II diabetes, osteoarthritis, muscular atrophy and dementia related illnesses. Through regular exercise and nutritional monitoring many of the chronic debilitating diseases can be improved, alleviated or prevented (Lee et al., 2017) (USDA, 2021). Of all Medicare beneficiaries, 68% suffer from 2 or more chronic diseases (Lochner et al., 2013).

Two modalities that have a positive effect on the quality of life of older adults are exercise prescription and nutritional monitoring (Minett et al., 2019). The medical community, recommends exercise prescription as the first choice in prevention and reversal of some of the chronic diseases of the older population (Tyndall, et al., 2018). For maximum efficacy, dietary education along with the exercise prescription provide the cornerstone of creating and sustaining enhanced quality of life for the older adult (Minett et al., 2019).

At AGEC, three programs have been implemented to address the need for regular exercise and for dietary education. Ageless Grace, a non-weight bearing aerobic activity, and Tai Chi for Arthritis and Fall Prevention are programs that provide modalities for improving muscle mass, balance and improved cardiac output (Grabiner et al., 2014). Using the USDA’s Dietary Guidelines for 2020-2025, AGEC has developed a cooking class entitled From Our Kitchen to Yours. The recipes and content are based specifically on chapter 6 of the guidelines which is dedicated to the dietary needs of the older adult population (USDA, 2021). The nutritional guidelines found in the Dietary Guidelines for 2020-2025 provide years of research for the nutritional needs of the older adult (USDA, 2021).Information about all three programs can be found on the AGEC website (agec.uams.edu) and on our Facebook page.

The literature cited gives a rationale for the holistic care of the older adult. By providing education and programs that target the health issues faced by the older adult, overall wellness and quality of life can be achieved. Students, clinicians, and physicians in tandem with the programs provided by AGEC and its partners shape this pro-active version of health care for older adult education in Arkansas.

References

Dietary Guidelines Advisory Committee (2021). Dietary Guidelines for Americans 2020-2025. https://www.dietaryguidelines.gov/sites/default/files/2021-03/Dietary_Guidelines_for_Americans-2020-2025.pdf

Grabiner, M.D., Crenshaw, J. R., Hurt, C. P., Rosenblatt, N. J., & Troy, K. L. (2014). Exercise-based fall prevention: can you be a bit more specific? Exercise and Sport Sciences Reviews, 42(4), 161–168. https://doi.org/10.1249/JES.0000000000000023

Lee, P. G., Jackson, E.A., Richardson, C. R., (2017). Exercise Prescriptions in Older Adults. American Family Physician, 95(7), 425–432.

Lochner, K. A., Goodman, R. A., Posner, S., & Parekh, A. (2013). Multiple Chronic Conditions Among Medicare Beneficiaries: State-level Variations in Prevalence, Utilization, and Cost, 2011. Medicare & Medicaid Research Review, 3(3), mmrr.003.03.b02.
https://doi.org/10.5600/mmrr.003.03.b02.

Minett, M. M., Binkley, T.L., Holm, R. P., Runge, M., & Specker, B. L. (2019). Feasibility and Effects on Muscle Function of an Exercise Program for Older Adults. Medicine and Science in Sports and Exercise, 52(2), 441–448.

Tyndall, A. V., Clark, C. M., Anderson, T. J., Hogan, D. B., Hill, M. D., Longman, R.S., & Poulin, M. J., (2018) Protective Effects of Exercise on Cognition and Brain Health in Older Adults, Exercise and Sport Sciences Reviews, 46(4), 215-223
https://doi.org/10.1249/JES.0000000000000161

United States Census Bureau, (2019). American Community Survey TableID S0103.
https://data.census.gov/cedsci/table?q=S0103&tid=ACSST1Y2019.S0103&hidePreview=false

United States Census Bureau, (2019). Population Estimates for Arkansas. https://www.census.gov/quickfacts/table/AR/AGE775219

Vespa, J., Armstrong, D. M., & Medina, L., (2020). Demographic Turning Points for the United States: Population Projections for 2020 to 2060. https://www.census.gov/library/publications/2020/demo/p25-1144pdf.html

From the Director’s Desk

Winter 2021 Newsletter

Happy New Year from the Arkansas Geriatric Education Collaborative (AGEC), the Geriatric Workforce Enhancement Program for Arkansas. As we say goodbye to the holidays of 2020, we say goodbye (and in many instances, good riddance!) to 2020. I think 2021 is dawning brighter as we see hope for containment of COVID-19 and push forward into embracing positive healthy habits for the new year.

We were busy this past fall with community and health professional programming and working with our clinical partners. We hosted several AGECaring Friends Facebook live events, posted AGEC Caregiver and PT Corner tips, and posted many Zoom programs. We also had several webinars including Dr. Jennifer Dillaha, on November 12 presenting “COVID-19: Examining 2020 and Looking into 2021” with over 160 attendees. Programs continued as we have learned to adjust to more virtual formats

We are also very proud to announce that The Arkansas Geriatric Education Collaborative (AGEC) has created a new podcast called UAMS Age Wise! This podcast was created to dive deep into the challenges facing the older population and those healthcare professionals caring for this aging population. Experts from the AGEC and our community and academic partners along with experts from the Donald W. Reynolds Institute on Aging and all across the UAMS Campus will talk about a variety of topics relevant to aging. These include managing caregiver stress, creating New Year resolutions, having successful telemedicine visits, virtual education for older adults, and the importance of medical wellness visits. The podcast is available on several popular platforms including Apple Podcasts, Spotify, Anchor, and Overcast. Two episodes are posted every month! Please subscribe and join us!!

We are very excited about the possibility of face-to-face encounters again sometime in 2021! We want to see and experience everyone again. If you have ideas for us, (virtual or in-person) please let us know!

Stayed tuned to the AGEC website, Facebook page, Instagram, and Twitter accounts – and now our new podcast – for upcoming exciting programs. Stay safe everyone and remember to get your flu and COVID-19 vaccines as soon as you can – and remind your patients to get theirs too!!!

Older Adults and COVID-19: A Call for Physical Activity Intervention

Winter 2021 Newsletter

By Sarah Walker, PT, DPT
Department of Physical Therapy
University of Central Arkansas

As healthcare professionals are faced with the numerous challenges of the COVID-19 pandemic, clinicians who serve geriatric clients are being met with stark statistical findings from epidemiology studies. Age in advance of 65 years is the single most important predictor of mortality from COVID-19, with elderly individuals representing a significantly higher proportion of those who perish from the disease. ^1-3 This increased risk is multifactorial, but is heavily influenced by declines in immune system function that reduce responses to viral infection.³ These findings support recommendations by community health leaders for elders to self-isolate in order to avoid infection.²

One consequence for older adults under self-isolation or quarantine is psychological trauma, including increased feelings of anxiety, stress, and anger. ^{2, 4} Anxiety and depression can also cause maladaptive changes to immune function, potentially further increasing an already vulnerable population. ⁵ In addition, geriatric individuals have an increased psychosocial burden associated with isolation as compared to other age groups.² Because self-isolation is not benign, clinicians must provide other evidence-based strategies to clients in order to decrease morbidity and increase immune system protection from this virus. ^{3, 6}

Physical activity is widely prescribed to seniors because movement has been shown to boost immune system function, reduce inflammation, improve emotional well-being, and reduce all-cause mortality.⁶ Encouraging elderly clients to engage in a more active and movement rich lifestyle can take the form of both physical activity and physical exercise. Physical activity suggestions may include dancing in their living rooms, walking outdoors, gardening, or playing with a beloved pet. Whereas physical exercise represents a planned and structured movement with a clear and purposeful intervention such as lifting weights, aerobics, or yoga.

Physical exercise of moderate intensity (64-76% of maximum heart rate) lasting 15-40 minutes in duration for 3 days per week over 6 months has demonstrated a significant increase in the number of T cells in the blood of elderly adults. Regular long-term exercise has also demonstrated enhanced immune response against both viruses and bacteria and appears to slow immunological ageing.⁶ Acute bouts of exercise, like walking for 30 minutes at a moderate intensity, likewise demonstrated enhanced immune function by a variety of mechanisms. The findings of previous research also suggest that acute moderate intensity resistance training for 45 minutes can result in increased activity.

Evidence is compelling that physical activity can be beneficial for older adults, especially during the COVID-19 pandemic. Physical activity and exercise can increase immune system function and psychological well-being in this exceptionally vulnerable population. Clinicians should encourage and promote physical activity in older adults in order to decrease the risk of COVID-19 complications.

References

1. Daoust JF. Elderly people and responses to COVID-19 in 27 Countries. PLoS One. 2020 Jul 2;15(7):e0235590.

2. Javadi SMH, Nateghi N. COVID-19 and its psychological effects on the elderly population. Disaster Med Public Health Prep. 2020 Jun;14(3):e40-e41.

3. Abdelbasset WK. Stay Home: Role of Physical Exercise Training in Elderly Individuals’ Ability to Face the COVID-19 Infection. J Immunol Res. 2020;Nov 28;8375096.

4. Torales J, O’Higgins M, Castaldelli-Maia JM, Ventriglio A. The outbreak of COVID-19 coronavirus and its impact on global mental health. Int J Soc Psychiatry. 2020 Jun;66(4):317-320.

5. Kiecolt-Glaser JK, Glaser R. Depression and immune function: central pathways to morbidity and mortality. J Psychosom Res. 2002 Oct;53(4):873-6.

6. Amatriain-Fernández S, Gronwald T, Murillo-Rodríguez E, Imperatori C, Solano AF, Latini A, Budde H. Physical Exercise Potentials Against Viral Diseases Like COVID-19 in the Elderly. Front Med (Lausanne). 2020 Jul 3;7:379.

Beyond Diabetes: Use of Antidiabetic Agents in Heart Failure

Winter 2021 Newsletter

By Tyler R. Walsh, PharmD and Lisa C. Hutchison, PharmD, MPH
University of Arkansas for Medical Sciences (UAMS) College of Pharmacy

According to the Centers of Disease Control, diabetes is a risk factor for developing heart failure.¹ Many patients with diabetes will develop heart failure, so clinicians would be excited to have medications that could treat diabetes and also improve heart failure outcomes. The sodium-glucose cotransporter 2 (SGLT-2) inhibitors are possibly those medications.

SGLT-2 inhibitors work in diabetes by inhibiting the reabsorption of glucose in the kidney causing more glucose to be excreted in the urine .² Two of the SGLT-2 inhibitors have evidence of benefit in heart failure. The exact mechanism of action for the SGLT-2 inhibitors in heart failure remains unknown. Dapagliflozin (Farxiga) has FDA approval for treatment of heart failure in addition to diabetes mellitus type 2.³ This approval was based on results of the Dapagliflozin and Prevention of Adverse Outcomes in heart Failure (DAPA-HF) trial.⁵ Another SGLT-2 inhibitor, empagliflozin (Jardiance), showed benefit in the Cardiovascular and Renal Outcomes with Empagliflozin in Heart Failure (EMPEROR) trial but currently is not FDA approved for heart failure treatment.⁶The third SGLT-2 inhibitor, canagliflozin (Invokana), is not currently seeking FDA approval for heart failure treatment.

Table 1. Dapagliflozin and Empagliflozin in Heart Failure Trials

	Dapagliflozin⁵	Empagliflozin⁶
Patients	4,744 (2,373 treatment, 2,371 placebo)	3,730 (1,863 treatment, 1,876 placebo)
Percentage of patients with DM	41.7% in both treatment and placebo arms	49.8% in both treatment and placebo arms
Primary outcome was a composite of:	Worsening HF or death from CV causes	Adjudicated CV death or first hospitalization for HF
Efficacy results	Dapagliflozin 16.3% vs. Placebo 21.2% HR 0.75 (95% CI 0.65-0.85, p<0.001)	Empagliflozin 19.4% vs. Placebo 24.7% HR 0.75 (95% CI 0.65-0.85, p<0.001)
Safety results	No difference between groups	Uncomplicated UTIs 4.9% empagliflozin 4.5% placebo

DM = diabetes mellitus type 2; HF = heart failure; CV = cardiovascular; UTIs = urinary tract infections

Based on the data from each of these trials, both agents are effective in the treatment of heart failure independent of their effectiveness in diabetes.⁶ Of note, in both studies patients with a New York Heart Association (NYHA) classification of II had more benefit compared to patients with an NYHA classification of III or IV.^5,6 In a post-hoc analysis of the DAPA-HF trial researchers analyzed the efficacy and safety of dapagliflozin based on age. The benefit/risk profile of dapagliflozin was as favorable in older adults as in younger adults.⁷ However, some key exclusion criteria were patients with hypotension (systolic reading <95 mmHg at two readings), patients with current or recent decompensated heart failure, and patients with recent revascularization, so caution should be used if dapagliflozin is initiated in a patient with any of these characteristics.⁸

Lastly, it is important to consider the disadvantages of these medications. Both of these medications are contraindicated with a creatine clearance less than 30 mL/min.^2,4 Also, since these medications increase glucose in the urine, the risk of developing a urinary tract infection is about 6% in men and 18% in women.^2,4 Finally, we must consider the financial burden of these medications on our patient population. These medications cost about $21 per tablet ($630 per month).^2,4 These medications could be covered by a patient’s Medicare Part D plan, but they are currently only available as name brand and are not generic. While these medications are promising for clinical outcomes many patients may be unable to afford them.

The prevalence of diabetes and heart failure is high in the older adult. These medications should be considered as add on therapy to standard of care regimens for the treatment of diabetes and heart failure. The use of SGLT-2 inhibitors, dapagliflozin and empagliflozin, can help treat diabetes as well as improve outcomes directly related to heart failure.

References:

Heart Failure (2020). Centers for Disease Control and Prevention. Retrieved from https://www.cdc.gov/heartdisease/heart_failure.htm.
Dapagliflozin (2021). Lexicomp. Retrieved on January 11, 2021.
FDA approves new treatment for a type of heart failure (2020). U.S. Food and Drug Administration. Retrieved from https://www.fda.gov/news-events/press-announcements/fda-approves-new-treatment-type-heart-failure.
Empagliflozin (2021). Lexicomp. Retrieved on January 11, 2021.
McMurray, J. J., Solomon, S. D., Inzucchi, S. E., Køber, L., Kosiborod, M. N., Martinez, F. A., … & Langkilde, A. M. (2019). Dapagliflozin in patients with heart failure and reduced ejection fraction. New England Journal of Medicine, 381(21), 1995-2008.
Packer, M., Anker, S. D., Butler, J., Filippatos, G., Pocock, S. J., Carson, P., … & Zannad, F. (2020). Cardiovascular and renal outcomes with empagliflozin in heart failure. New England Journal of Medicine, 383(15), 1413-1424.
Martinez, F. A., Serenelli, M., Nicolau, J. C., Petrie, M. C., Chiang, C. E., Tereshchenko, S., … & McMurray, J. J. (2020). Efficacy and safety of dapagliflozin in heart failure with reduced ejection fraction according to age: insights from DAPA-HF. Circulation, 141(2), 100-111.
McMurray, J. J., DeMets, D. L., Inzucchi, S. E., Køber, L., Kosiborod, M. N., Langkilde, A. M., … & Selvén, M. (2019). A trial to evaluate the effect of the sodium–glucose co‐transporter 2 inhibitor dapagliflozin on morbidity and mortality in patients with heart failure and reduced left ventricular ejection fraction (DAPA‐HF). European journal of heart failure, 21(5), 665-675.

The Importance of Vitamin D in the Wintertime

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/

Dementia Friendly Business Trainings from AGEC

Winter 2021 Newsletter

By Laura Spradley, MS
Outreach Coordinator
UAMS Arkansas Geriatric Education Collaborative (AGEC)

Local businesses owners are trying to differentiate themselves these days from the competition. Examples of how to “stand out” from the competition are providing extraordinary customer service, doing business differently than your competition, and creating a lasting impression and memorable reasons to return to your business. We at the Arkansas Geriatric Education Collaborative (AGEC) believe having front line employees and supervisors trained in “dementia friendly” business concepts and communications is another great way to “stand out!”

Business owners (including clinical venues) and their employees can receive our FREE dementia friendly business training via Zoom by trained AGEC staff. The business staff will learn many facts about dementia and Alzheimer’s disease. They will learn how to recognize possible signs of dementia in a customer, communication and interaction tips, and hints on how best to create a dementia-friendly physical environment, and they will learn about the availability of local resources to help those dealing with dementia or Alzheimer’s disease. The goal of this dementia-friendly business training is to provide increased awareness of dementia and Alzheimer’s disease, and to provide training on how to respond warmly and effectively when serving individuals who are living with dementia and their families.

The trainings are scheduled on days and times convenient for the business and their employees. The entire training takes approximately 45 minutes to complete. The necessary handouts and certificates of attendance provided by AGEC are free of charge.

The AGEC recognizes participating businesses who have completed the training with a banner announcing that they are now a dementia friendly business. AGEC can also provide customized, free, social media posts. The AGEC is available to participate with other media recognitions as needed or requested.

If your office, facility, or clinic staff could benefit from this training, or if you know a business or clinic who may be interested in becoming dementia friendly, please have them contact AGEC at agec@uams.edu or Laura Spradley at lspradley@uams.edu to request a dementia friendly business training.