From the Director’s Desk

Fall 2022 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)

Happy fall to everyone! I know most of us are very happy to see the trees turning and the temperatures dropping. The AGEC and partners have started fall programs and classes and are very busy. This quarter I want to talk a little more in-depth about the AGEC’s clinical focus on the 4M’s framework of Age-Friendly Care.

In 2017, The John A. Hartford Foundation and the Institute for Healthcare Improvement (IHI), in partnership with the American Hospital Association and the Catholic Health Association of the United States, had a vision and plan to infuse healthcare with a new concept called age-friendly care. The IHI defined age-friendly care as care that “Follows an essential set of evidence-based practices; Causes no harm; and Aligns with What Matters to the older adult and their family or other caregivers”. Therefore, if a healthcare system wants to become certified as an Age-Friendly Health System, they must provide care that meets evidence-based elements of high-quality care, known as the “4Ms,” to all older adults in their system.

The 4Ms are: What Matters, Medication, Mentation, and Mobility. The first M regarding What Matters is regarded as essential and if done properly, all of the M’s revolve around it. All care should center around what Matters most to the older adult. This is where the conversation with the patient, family, and caregiver(s) begins. The healthcare team should discuss the older adult’s health outcome goals and care preferences, including end-of-life care, across all settings. Their goals and preferences then dictate the overall plan of care. Medication, should be age-friendly and not compromise mentation, mobility or What Matters. Mentation is the next M where providers should work to prevent, identify, treat and manage dementia, delirium, depression, and other conditions that affect the mind. Finally, Mobility is considered. The team should ensure safe movement and function that supports what matters to the older adult and what promotes meaningful activities. This was a simplified and quick summary of the age-friendly framework and I would encourage you all to learn more. More information can be found at https://www.ihi.org/Engage/Initiatives/Age-Friendly-Health-Systems/Documents/IHIAgeFriendlyHealthSystems_GuidetoUsing4MsCare.pdf.

The AGEC has a wonderful rural clinical partner that is essential to our success with implementing age-friendly care, ARcare. ARcare is a federally qualified healthcare clinic (FQHC) network that works tirelessly in rural communities to ensure patients are able to benefit from accessible, affordable, quality, routine medical care. Services from ARcare include primary care, behavioral health, pharmacies, community outreach programs, and more. When approached in late 2018 about being part of the AGEC, ARcare staff were enthusiastic and embraced the concepts inherent in the 4M’s framework of Age-Friendly Care. Since beginning the partnership in 2019, Dr. Leah Tobey, our AGEC Clinical Coordinator, has taught this framework in six ARcare rural clinics. She continues to update new staff, work on quality improvement projects, and helps with rural community projects. To date, the ARcare network has five clinics that are certified level I or II as Age-Friendly by the Institute for Healthcare Improvement. We are proud of ARcare and their work with making their care age-friendly and we would encourage all who provide care to older adults to consider these 4Ms.

If you would like more information or training regarding the 4M’s of Age-Friendly care, please contact the AGEC.

Changes in Social Interactions in Older Arkansans across the COVID-19 Pandemic

Fall 2022 Newsletter

By Dr. Jennifer Peszka, Professor, Psychology
Dr. Anne Goldberg, Professor, Sociology/Anthropology
and Dr. Pete Gess, Professor, Psychology
Hendrix College

Previous research shows that loneliness is detrimental to healthy aging. When the COVID-19 pandemic struck, it led to early calls for strict limitations to in-person social interactions (lockdowns and social distancing). During Spring 2021, Hendrix College and AGEC conducted a telephone survey of nearly 867 older Arkansans to examine social connection and isolation during the COVID-19 pandemic. Those data indicated that during the early part of the pandemic, in person social interactions and satisfaction with social interactions declined. While not a completely satisfying replacement, supplementing lost in-person social interactions with technology facilitated communication did help buffer some of the negative impact on satisfaction for some participants. During Spring of 2022, we conducted a follow-up survey to replicate previous findings, look for changes as social interactions began to shift back to normal, and to add additional questions to probe further into findings seen in the original survey data.

About the participants

603 older Arkansans completed the automated telephone survey. 68.3% of the participants were between 65 and 74 years old, and 31.7% were 75 years old or older. 86.5% identified as White, non-Hispanic; 8.0% as Black; .2% as Hispanic; and 5.3% as other, preferred not to answer, or mixed. 65.9% identified as women, 33.2% as men, and 0.8% as preferred not to answer. To examine economic status, we asked them to indicate how often they worry about paying their monthly bills. 8.1% said always, 15.0% said frequently, 34.9% said seldom, and 42.0% said they never worry about paying their bills.

What they told us

Frequency of interactions: In the 2021 survey, 76% of participants reported curtailing their in-person social interactions since the pandemic began at least some, 41% were curtailing a lot. Now, when the virus is waning and vaccines are widely available, curtailment was not as widely spread with about one half reporting they were curtailing their in-person social activities at least some (50.4%) and substantially fewer were curtailing it by a lot or completely (27.6%) (See Figure 1). For in person activities, in 2021, only about one-third (31%) of the sample was engaging in in-person social activities multiple times a week, but in 2022, we saw that double (63%).

Social satisfaction: 93% of the participants rated themselves as satisfied with their social connection before the pandemic, that number reduced to 67% during the pandemic in 2021, and this has started to recover now in 2022 with 78% of the participants rating themselves as satisfied with their social connections now.

Social technology use: In 2022, we investigated a specific kind of social technology: the video chat. Video chatting was prevalent in this sample even before the pandemic, with about 40% of the sample engaging in video chatting multiple times a week before the pandemic began. About one-quarter of the participants (22.8%) reported using video chat even more during the pandemic.

In 2021, during the pandemic, 60% of the participants said they felt socially connected when engaging in online social interactions. In 2022, after an additional year of these sorts of interactions, it seems there has been a slight increase in satisfaction, with about 10% of participants being less likely to disagree with this and 10% being more likely to agree, with 70% of participants reporting feeling socially connected when engaging in these online interactions (See Figure 2).

Summary: In person social interactions and satisfaction with social interactions are still lower than during pre-pandemic times, but they are starting to recover. Nonetheless, some older Arkansans find themselves experiencing loneliness and isolation even when there is no pandemic. These findings suggest that with practice and motivation older Arkansans can increase their technological interactions and that these can serve as a reasonably satisfactory replacement to in person social interactions when necessary. We should work to develop programs to increase fluency and availability of social technology for older Arkansans.

Management of Weight Loss in Hospitalized Older Adults

Fall 2022 Newsletter

By Lisa C. Hutchison, Pharm.D., MPH, BCPS, BCGP
University of Arkansas for Medical Sciences (UAMS) College of Pharmacy

Weight loss is often identified during hospitalization when older adults are assessed. Up to 60% of hospitalized older adults are malnourished or at risk for malnutrition, and this is associated with threefold increased costs and co-morbidities such as pressure injuries, infections, and falls.1 Length of stay and mortality increase as a result. Appetite often diminishes when illness develops and patients are admitted to the hospital. Families and caregivers become more vigilant as their loved one has an acute illness, requesting interventions that would improve appetite and nutritional status.

Non-pharmacological methods often implemented during hospitalization to combat nutritional deficits usually include addition of protein/calorie supplements. An approach used less often is to liberalize the diet. For example, a low sodium diet is a standard order for individuals with cardiac disease. A low sodium diet can significantly decrease blood pressure in individuals with hypertension by 4.5mmHg/2.4mmHg on average,2 but a recent randomized controlled trial, SODIUM-HF, did not verify dietary sodium restriction to 1500mg/day was associated with a reduction in mortality or cardiovascular hospitalization/emergency department visits in ambulatory care patients over a year.3 Removing a dietary sodium restriction and encouraging family members and caregivers to select food items the patient likes should be considered. Mealtime is often a social event, and having family or friends eat along with the older adult can improve the amount of food ingested.

Careful review of a patient’s medication list may reveal drug therapy that is contributing to anorexia. Drugs well-known to cause anorexia include amiodarone, SSRI’s, SNRi’s, phenothiazines, opioids, acetylcholinesterase inhibitors, and digoxin.4 Drug-induced nausea may present with anorexia. Stopping these medications, or reducing them to their lowest effective dose, may aid in restoring a patient’s appetite. Another contributor may be drug-induced constipation which can present as anorexia. Finally, some medication regimens include a large number of oral tablets or capsules with a volume that equates to a small meal. A focused attempt to reduce pill burden or to spread out their administration may help to improve appetite.

Medications are sometimes used off-label to stimulate appetite and induce weight gain in older adults. Most commonly used are mirtazapine, megestrol, and dronabinol.4,5 Dronabinol works as a cannabinoid to increase appetite, but as would be expected, causes significant central nervous system side effects. Megestrol is approved by the US Food and Drug Administration for anorexia or cachexia associated with AIDS or cancer. As a synthetic progestin, it can increase appetite, however, small studies and retrospective data show mixed results with increasing weight or strength in older adults. So while it may cause increased dietary intake, any gain of weight is likely increased body fat. Megestrol can increase blood pressure, blood glucose, and risk for thromboembolism.

Mirtazapine is a popular choice for improving appetite due to its safety profile. This antidepressant is relatively well-tolerated with significant side effects of marked sedation, xerostomia, increased cholesterol, and constipation. Increased appetite as a side effect is reported in 17% of patients, therefore, clinicians began trying it in older adults for anorexia.6 Most studies have been in older adults with depression, and results were mixed. A retrospective study of hospitalized patients evaluating use of mirtazapine, megestrol and dronabinol showed improvement in percentage meal intake but no differences between these agents. A control group was not included so authors were unable to assess the effect of other changes, particularly the effect of improvement in admission disease/symptoms.7

So what is best practice? The Choosing Wisely campaign suggests we optimize social supports, provide feeding assistance, and clarify patient goals and expectations instead of prescribing appetite stimulants or high-calorie supplements for treatment of anorexia in older adults.8 Furthermore, we should first assess if this symptom is an adverse drug event of an already prescribed medication. Finally, as with all medications, if pharmacological interventions are subsequently tried, periodic assessment of benefit and risk is important to consider if the appetite stimulant should be continued.

References:

Shrader E, Baumgartel C, Gueldenzoph, et al. Nutritional status according to Mini Nutritional Assessment is related to functional status in geriatric patients—independent of health status. J Nutri Health Aging, 2014; 18:257-63.
Lai JS, Aung YN, Khalid Y, Cheah SC. Impact of different dietary sodium reduction strategies on blood pressure: a systematic review. Hypertens Res, 2022; doi: 10.1038/s41440-022-00990-5. Online ahead of print.
Ezekowitz JA, Colin-Ramirez E, Ross H, et al. Reduction of dietary sodium to less than 100 mmol in heart failure (SODIUM-HF):an international, open-label, randomized, controlled trial. Lancet, 2022; 399:1391-1400.
Cheung NC, Noviasky JA, Ulen KR, Brangman SA. Efficacy and safety of megestrol in the hospitalized older person. Sr Care Pharm, 2022; 37:284-92.
Fox CB, Treadway AK, Blaszczyk AT, Sleeper RB. Megestrol acetate and mirtazapine for the treatment of unplanned weight loss in the elderly. Pharmacotherapy, 2009; 29:383-97.
Mirtazapine In: Lexicomp® Wolters Kluwer Copyright 2022 UpToDate, Inc.
Howard ML, Hossaini R, Tolar C, Gaviola ML. Efficacy and safety of appetite-stimulating medications in the inpatient setting. Ann Pharmacother, 2019; 53:261-7.
American Geriatrics Society/American Board of Internal Medicine Foundation. Choosing Wisely. www.ChoosingWisely.org.

Caregiver Strain: Strategies for Prevention

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

Occupational Therapy Doctoral Capstone Students Create Interprofessional “Conway Brain Injury Community” to Meet Documented Community Need

Fall 2022 Newsletter

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By Emily Wish, OTD, OTR/L, PCBIS, Lorrie George Paschal, PhD, OTR, ATP, and Duston Morris, PhD, MS, CHES, ACE-HWC
Department of Occupational Therapy
University of Central Arkansas

According to the Arkansas State Plan for Traumatic Brain Injuries (UAMS, 2020), there were approximately 2,300 individuals living with a brain injury in Arkansas between 2013-2019. In the River Valley and Central Arkansas areas (including Conway, Cleburn, Johnson, Logan, Perry, Pope, Pulaski, Van Buren, White, and Yell counties) there are 685 individuals registered with the TBI registry (UAMS, 2020). As of March 2022, it is estimated that there are approximately 611 individuals hospitalized due to a TBI in the US (CDC, 2022). Stroke, which is an acquired non-traumatic brain injury, is one of the leading causes of disability in the US (Virani et al., 2020). With the risk factors for stroke increasing since 1995, it is no surprise that the prevalence of this disease has also increased in the US (Virani et al., 2020). Arkansas is one of the top 14 states in the US in rates of stroke hospitalization (CDC, 2021). According to the Brain Injury Association of America, 95% of individuals living with a brain injury do not receive the long-term treatment and support they need to be successful in their occupations (Ashley et al., 2019). Acquired brain injuries impact individuals for a lifetime, but there is a lack of local resources that address occupational and healthcare needs for this population following discharge from rehabilitation.

To address this need, recent occupational therapy doctoral students Dr. Emily Wish and Dr. Mckenzie Svebek created the Conway Brain Injury Community (CBIC) in the University of Central Arkansas’ Department of Occupational Therapy in the College of Health and Behavioral Sciences (CHBS). This community allows members, post-acquired brain injury, to come together to work on increasing their occupational performance and overall health and well-being.

The vision of the CBIC program combines Dr. Wish’s desire to facilitate occupational performance of members and Dr. Svebek’s aim to establish a supportive interprofessional approach. Together, a community-based network of community dwelling individuals post-acquired brain injury and faculty supervised occupational therapy students was established to holistically address the needs of this community. Partnership with faculty and students from a variety of CHBS disciplines enhances the program by providing a unique approach of involving professors, students, and clinicians to meet the needs of CBIC members. At this time, primary team members include occupational therapy and health coaching. Other disciplines participate based on members’ interests. For example, this semester, dietetics students provided a presentation on heart healthy food choices.

This interprofessional program was an outcome of capstone projects but has become sustainable through partnership and supervision of occupational therapy faculty member, Dr. Lorrie George-Paschal, and health sciences faculty member Dr. Duston Morris. Through an interprofessional collaborative approach, the CBIC team leads theory-based and client-centered sessions tailored to address goals the members have set for themselves.

Operating within the UCA semester schedule, the group meets weekly, with the exception of school breaks. The program is based on the theory of Occupational Adaptation which strives to improve occupational functioning by creating a change in the internal adaptation process of members through engagement in desired occupations. At the beginning of the 14-week semester-long program, participants complete Occupational-Adaptation based Instruments, developed by Dr. George-Paschal with Dr. Krusen (2019). These instruments provide structure for the program. Because the program is research-based, participants first review and sign informed consent approved by Research Compliance at UCA. If they give consent, participants complete the Occupational Adaptation Practice Guide to set meaningful goals. When goals have been set, participants evaluate their current sense of mastery on their established goal(s) using the six-item Relative Mastery Scale (George-Paschal, Krusen, & Fan, 2021). This valid and reliable instrument is used to measure individual and group outcomes. The RMS is completed again in the middle and at the end of the semester.

Example goals of current CBIC members include improvement in upper extremity tone management and range of motion, cooking with one hand, sewing with one hand, improved handwriting with the non-dominant hand, improving awareness of the left visual field, and improving community mobility. CBIC members are partnered with one to two occupational therapy students and a health coaching student to work on their goals. Occupational therapy sessions are held for two hours each week with activities focused on each member’s specific goal(s). Activities are scaffolded to increase success. For the CBIC member who wants to sew, students and faculty created opportunities that have progressed from operating functions on the sewing machine with one-hand, to sewing straight seams, to making a drawstring bag, and most recently making their own pillow case. The next step is to meet at a local fabric store to choose Christmas fabric for the member to make a quilt top. Signs of adaptation for this member have been noted through signs of initiation and generalization as the member shared that they have visited a local sewing center to try out and consider the purchase of a sewing machine for home.

Weekly health coaching sessions are held on a separate day and last one hour. Students from occupational therapy and health coaching work together and often attend the sessions led by the other discipline. Participants feel an accountability to their health coaching goals as evidenced by one member pushing to finish a project during an occupational therapy session because they had set a goal to complete it with their health coaching student.

In addition to the individual activities, the program includes informational and support group activities. This semester, activities have included a presentation on nutrition for heart health (provided by UCA nutrition students) and various activities to promote self-worth and group connection. This supportive community provides a safe space for CBIC members to identify, establish and achieve personal and/or health-related goals throughout their rehabilitation journey. While this is not therapy, it does provide CBIC members an opportunity to reflect on their strengths through recovery and to maintain and improve their long-term occupational performance.

Starting with four members in June 2022, the program has expanded to seven members this fall and will continue to reach more individuals in the Central Arkansas area.
The goal is to provide a sustainable interprofessional program that can serve the needs of the members post-acquired brain injury while simultaneously providing opportunities for CHBS students to learn and engage in meaningful healthcare community services. UCA OT Doctoral Capstone student Kassidy Sawyer will provide program management and direction in 2023. For more information about the CBIC, please contact Dr. Emily Wish, CBIC program director at ewishotd@gmail.com.

George-Paschal, L. & Krusen, N. (2019). Occupational Adaptation Practice Guide. Copyrighted
2019.
George-Paschal, L. & Krusen, N. (2019). Relative Mastery Scale. Copyrighted 2019.
George-Paschal., L, Krusen, N.E., Fan, C.W. (2021). Psychometric evaluation of the Relative
Mastery Scale: An Occupational Adaptation instrument. OTJR: Occupation, Participation and Health. [online first 12.31.2021 Sage Journals. https://doi.org/10.1177%2F15394492211060877

From the Director’s Desk

Summer 2022 Newsletter

Wow, what a “hot” summer we are all experiencing. Therefore, I want to send out a special “thank you” to all of you who are out there serving and caring for our older adults! This is dangerous weather for anyone, especially for our vulnerable older adults. So, “thank you” to all healthcare professionals who continue to serve!

Our academic partners have been very persistent in their work throughout the spring and summer and are working diligently to fulfill summer obligations while preparing for a new academic year. So “thank you” also to our collaborators at ASU, UCA, Hendrix, and the Arkansas College of Health Education, we are looking forward to another exciting academic year with you and your students.

The AGEC has also been busy over the past few months. We are very excited to reintroduce the hands-on Alzheimer’s & Dementia Experience which has been on hold since the beginning of the pandemic, early in 2020. We had our first program in May with Saline Memorial Behavioral Health and we had 30 healthcare participants. Another program is schedule for August! Community programs were also busy in the spring and have continued this summer, both virtually and in-person. With a new collaboration with Arkansas Colleges of Health Education in Fort Smith, we have begun releasing a series on social media of 26 short videos in partnership their School of Occupational Therapy students and faculty, covering a variety of adaptive equipment for older adults around the home and their communities – click here to visit our Facebook page and see. We have also been very successful in the continuation of dementia support groups via phone, Zoom, and in-person where more than 130 caregivers were reached over the past quarter. AGEC Learn from Home Series continues where a different AGEC community program is presented every month via Zoom. We also continue our regular activities such as Ageless Grace, Tai Chi, and many evidence-based programs with our partners including UAMS Centers on Aging, CareLink AAA, and multiple senior centers.

Try to stay cool the rest of the summer!!

Nutritional Biomarkers of Age-Related Muscle Loss

Summer 2022 Newsletter

By David Church, PhD, CSCS*D
Department of Geriatrics, College of Medicine
University of Arkansas for Medical Sciences

Skeletal muscle mass, function, and strength decline with increasing age, a condition that has been coined “sarcopenia”¹. Sarcopenia increases the risk of deleterious health conditions and represents a major financial cost to healthcare systems. Among older adults who are hospitalized, those with sarcopenia on admission are 5-fold more likely to incur higher hospital costs than those who do not.² The economic burden of sarcopenia on the US healthcare system is considerable, with one estimate of the total annual cost of hospitalization for sarcopenic individuals being USD $40.4 billion³. From a clinical practice perspective, individuals with sarcopenia are at a greater risk of falling, reduced mobility and independence, and 95% more likely to be hospitalized as compared to those without sarcopenia³.

The term sarcopenia, coined in 1989, refers to the loss of muscle mass¹. Since then, greater insights into muscle strength, mass, and function have developed. It has been demonstrated that low muscle mass is associated with weakness, and that weakness is strongly associated with function and disability. However, low muscle mass alone is weakly or not associated with function and disability^2–5. As a result, current sarcopenia definitions incorporate measures aimed at muscle mass, strength, and function. The majority of sarcopenia research focuses on prevention and treatment. Of this work, there is even less attention given to the standardization of assessment and diagnostic criteria. Multiple working groups of experts have weighed in, including those previously mentioned^2,6,7; however, there are also the National Institute on Aging (NIA), the Foundation for the National Institutes of Health funded Sarcopenia Definitions and Outcomes Consortium (SDOC)⁴, and the Asian Working Group for Sarcopenia (AWGS)⁵. While important initiatives, the results have led to different definitions and clinical assessments for the same disease. Further, when looking into one working group, SDOC, the level of agreement amongst 13 different position statements varies widely⁴. Thus, uncertainty surrounding the definition and outcomes of sarcopenia is high even amongst international experts. Most striking is the fact that current diagnostic criteria and cutoffs only identify individuals with sarcopenia, NOT those “at risk” for sarcopenia. This is an important failing of the current diagnostic tests as these cut off points indicate the patient’s increased risk for falls, while independence, quality of life, and longevity are decreased^2–4,8,9. Further, the regression and management of sarcopenia becomes a major economic burden to the healthcare system³. At this point, the best possible outcome is to slow the progression of the disease. In fact, the recent Sarcopenia Definitions and Outcomes Consortium (SDOC) states that since low grip strength and usual gait speed are independent predictors of falls, mobility limitations, hip fractures, and mortality in community-dwelling older adults, they should be included in the definition of sarcopenia⁴. Thus, current techniques and diagnostic criteria can only identify sarcopenia after a physical/functional impairment has occurred. As a result, clinicians must treat and manage the disease, as opposed to identifying susceptible individuals and taking preventative steps. Stated differently, clinicians are hoping to slow the rate of decline rather than maintain or improve muscle health.

Skeletal muscle amino acid metabolism dictates muscle health and functionality. Altered amino acid metabolism lead to decrements in muscle mass, quality, and performance⁸. Our laboratory, as well as others, have documented that the circulating essential amino acids (EAA) response to protein ingestion determines muscle amino acid metabolism^10,11. This well-established phenomenon allows us characterize potential nutritional biomarkers following an EAA challenge in order to determine the state of muscle health. As no additional equipment will be required the proposed EAA challenge represents a potential low-cost solution to classifying patients’ skeletal muscle health. This initiative will leverage the well-established physiological role EAA play in muscle metabolism and health within the existing clinical infrastructure (i.e., basic phlebotomy procedures). The extrapolation of this work will be the development of a simple analytical tool that would provide clinicians the ability to discern alterations in muscle metabolism and health prior to a loss of function or overt development of sarcopenia.

References

1. Rosenberg IH. Sarcopenia: origins and clinical relevance. J Nutr. 1997 May;127(5 Suppl):990S-991S. PMID: 9164280

2. Cruz-Jentoft AJ, Bahat G, Bauer J, Boirie Y, Bruyère O, Cederholm T, Cooper C, Landi F, Rolland Y, Sayer AA, Schneider SM, Sieber CC, Topinkova E, Vandewoude M, Visser M, Zamboni M, Writing Group for the European Working Group on Sarcopenia in Older People 2 (EWGSOP2), and the Extended Group for EWGSOP2. Sarcopenia: revised European consensus on definition and diagnosis. Age Ageing. 2019 Jan 1;48(1):16–31. PMCID: PMC6322506

3. Goates S, Du K, Arensberg MB, Gaillard T, Guralnik J, Pereira SL. Economic Impact of Hospitalizations in US Adults with Sarcopenia. J Frailty Aging. 2019;8(2):93–99. PMID: 30997923

4. Bhasin S, Travison TG, Manini TM, Patel S, Pencina KM, Fielding RA, Magaziner JM, Newman AB, Kiel DP, Cooper C, Guralnik JM, Cauley JA, Arai H, Clark BC, Landi F, Schaap LA, Pereira SL, Rooks D, Woo J, Woodhouse LJ, Binder E, Brown T, Shardell M, Xue QL, DʼAgostino RB, Orwig D, Gorsicki G, Correa-De-Araujo R, Cawthon PM. Sarcopenia Definition: The Position Statements of the Sarcopenia Definition and Outcomes Consortium. J Am Geriatr Soc. 2020 Jul;68(7):1410–1418. PMID: 32150289

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Do you know the signs of elder abuse?

Summer 2022 Newsletter

By Matthew Harmon, MSN, RN, CNE
School of Nursing
Arkansas State University

Older adults (over the age of 65) are commonly a target of abuse. In fact, one in six older adults are affected by some type of elder abuse. When one thinks of abuse, one may think of physical violence. In fact, the National Center on Elder Abuse notes seven different types including; physical abuse, sexual abuse, emotional abuse, financial/material exploitation, neglect, abandonment, and self-neglect.

Physical abuse encompasses bodily injury, impairment, or physical pain caused by physical force (NCEA, 2022). Noticing multiple bruises in different stages of healing is an important sign of abuse because it indicates separate instances of trauma at different times. Other worrisome signs would be bruises, black eyes, welts, broken bones, sudden change in behavior, broken eyeglasses, and broken hearing aids. It is not uncommon for an older adult to experience a couple of these signs after an accidental event like a fall. However, it would be more suggestive of abuse if several of these signs were noticed at different times, as it suggests recurring incidents related to abuse.

Sexual abuse is sexual contact of any kind that is not-consensual (NCEA, 2022). Signs of sexual abuse in older adults include the report of sexual abuse from the individual, or sudden change in emotional status (NCEA, 2022). This type of abuse is harder to notice for some due to the lack of observable symptoms in the abused.

Emotional abuse or psychological abuse is defined as the infliction of anguish, pain, or distress through verbal or nonverbal acts (NCEA, 2022). This type of abuse consists of signs that are more behavioral-based. Signs that may suggest emotional abuse include irritability, isolating oneself, sudden change in emotional status, or report of emotional abuse.

Financial/material exploitation refers to the illegal or improper use of an elder’s funds, property, or assets (NCEA, 2022). This type of abuse may also be difficult to identify in other individuals. The main identifiers of this type of abuse would be sudden change in financial status, addition of names to bank cards and credit cards, and abrupt changes to will or other financial documents. According to Dominguez et al. (2022), recognizing this type of abuse should show special consideration to those who may live alone or who already have a degree of isolation.

Neglect is defined as the refusal or failure to fulfill any part of a person’s obligations or duties to an elder(NCEA, 2022). Being so, this type of abuse is found in individuals who require aid/caregiver for some aspect of their care. This can be an individual who is being taken care of by family, or even those being cared for in a facility. Signs of neglect include unsafe living arrangements, dehydration, starvation, poor hygiene, bed sores, among any other sign of abuse mentioned above.

Self-neglect characterized as the behavior of an elderly person that threatens his/her own health or safety(NCEA, 2022). The signs of this type of abuse mimic that of neglect as mentioned previously. The main difference of self-neglect to the other types of abuse is that this type of abuse has no identified abuser. Self-neglect is also different from neglect in that an individual who is a victim of neglect typically requires some type of supervision with their care while those who exhibit self-neglect do not.

Abandonment is the desertion of an elderly person by an individual who has assumed responsibility for providing care for an elder, or by a person with physical custody of an elder (NCEA, 2022). Abandonment may include the individual being abandoned at their home, or being abandoned at a medical facility. In some cases individuals may be abandoned at a public facility such as a supermarket, restaurant, or recreational area (NCEA, 2022).

If you or any older adults you know shows signs of elder abuse, several resources are available to help. First and foremost, if the matter is life-threatening, call 911 for immediate assistance. If the suspected abuse is occurring within a facility that the abused is housed at, contact administration of that facility. If you feel uncomfortable doing so, and wish to remain anonymous, you may call the Arkansas Department of Human Services, Office of Long-Term care at 1-800-582-4887 for residents in long-term care facilities. Victims of abuse are not always individuals in long-term care facilities, so if the person is not in a long-term care facility, and you suspect abuse call the Arkansas Department of Human Services, Adult Protective Services at 1-800-482-8049.

References

Fraga Dominguez, S., Ozguler, B., Storey, J. E., & Rogers, M. (2022). Elder abuse vulnerability and risk factors: Is financial abuse different from other subtypes? Journal of Applied Gerontology, 41(4), 928-939. https://doi.org/10.1177/07334648211036402

National Center on Elder Abuse. (n.d.). Types of abuse. NCEA. Retrieved July 12, 2022, from https://ncea.acl.gov/Suspect-Abuse/Abuse-Types.aspx

Preparing the Rising Generation of Healthcare Professionals

Summer 2022 Newsletter

By Denise Demers, PhD, CHES and Darshon Reed, PhD
University of Central Arkansas
Department of Health Sciences and Department of Psychology

With the recent exponential growth of the aging population (from 13.1% in 2010 to 16.9% in 2020) and the projected growth by 2050 reaching 22% of the total population in the nation (U.S. Census Bureau, 2018), focus on the aging population has become paramount. Adults over the age of 65 will likely reach and affect every aspect of our society in the coming months and years. Not only will it be imperative to have resources available to assist them, but also healthcare workers to provide such care. Strategies to improve this population’s health and quality of life are both varied and multiplicitous, ranging from community programs such as “Meals on Wheels” to local recreation center physical activity programs. From Geriatrics to Gerontology, systems and structures are being developed and put in place in order to adequately provide for the aging population. Now is the time to prepare the coming health care force to administer such programs and strategies.

To adequately prepare the rising generation of healthcare professionals, it takes a multidisciplinary approach. Not only are doctors and nurses needed, but community healthcare providers such as psychologists, health education specialists, and volunteer organizations. For decades, universities and colleges throughout the nation have begun to teach using a more experiential approach to their curriculum. Included in that curriculum are simulation labs (Coyne et al., 2021) and service learning (Furco, 1996) . Service learning has exploded in recent years, becoming the go-to teaching strategy for many higher education classrooms, whether in-person or virtually.

Recently at the University of Central Arkansas, one of the psychology courses focused on healthy aging. Everything within that class was seen through the lens of the aging population – each chapter from the text, additional articles, and blogs from the American Psychological Association Aging resources. Additionally, students spent time at two local senior care facilities interacting with the residents. During their time at the facilities, students played games, visited, and colored Easter eggs with the residents.

From this experience, over 90% of the students agreed or strongly agreed that their time at the Senior Center was a valuable experience for them. It not only helped them better connect with the content of what they were learning in class, but also helped them both increase in understanding of the problems and challenges of those residents in the facility, as well as how their work can make a difference in the world.

In order to meet the needs of the aging population, programs throughout the country need to focus on aging (Grady, 2011). Whether it be in research (Croff et al., 2020) or applying theory to application through experiential learning (Efthymiou et al., 2021; Kim et al., 2021; Niman & Chagnon, 2021) or virtual simulations (Coyne et al., 2021), such experiences like this are needed in our college classrooms and courses. To prepare the coming generation for “the impending crisis, which has been foreseen for decades, is now upon us” (Institute of Medicine, 2008), courses for the future healthcare professionals in all disciplines need to provide adequate content related to the aging population. Likewise, faculty must also prepare themselves by using multidisciplinary and interprofessional programs that give students the benefits of experiential opportunities with the aging population.

References

Coyne, E., Calleja, P., Forster, E., Lin, F. (2021). A review of virtual-simulation for assessing healthcare students’ clinical competency, Nurse Education Today, Jan;96:104623. doi: 10.1016/j.nedt.2020.104623. Epub 2020 Oct 10. PMID: 33125979.

Croff, R., Tang, W., Friedman, D. B., Balbim, G. M., Belza, B. (2022). Training the next generation of aging and cognitive health researchers, Gerontology & Geriatrics Education, 43:2, 185-201, DOI: 10.1080/02701960.2020.1824912

Efthymiou,L., Ktoridou, D. Epaminonda,E. (2021) A model for experiential learning by replicating a workplace environment in virtual classes, IEEE Global Engineering Education Conference (EDUCON), pp. 1749-1753, doi: 10.1109/EDUCON46332.2021.9453966.

Furco, A. (1996). Service-Learning: A balanced approach to experiential education. Expanding Boundaries: Service and Learning 1 (1):2–6.

Grady PA. (2011). Advancing the health of our aging population: A lead role for nursing science. Nurs Outlook. Jul-Aug;59(4):207-9. doi: 10.1016/j.outlook.2011.05.017. PMID: 21757076; PMCID: PMC3197709.

Kim, M. J., Kang, H. S., De Gagne, J. C. (2021). Nursing students’ perceptions and experiences of using virtual simulation during the COVID-19 pandemic. Clinical Simulation in Nursing, 60, 11-17.

Niman, N. B., & Chagnon, J. R. (2021). Redesigning the Future of Experiential Learning. Journal of Higher Education Theory and Practice, 21(8). https://doi.org/10.33423/jhetp.v21i8.4507

U.S. Census Bureau, Current Population Reports, Estimates of the population of the United States by single years of age, color, and sex: 1900 to 1959 (Series P-25, No. 311); Estimates of the population of the United States, by age, sex, and race: April 1, 1960, to July 1, 1973 (Series P-25, No. 519); Preliminary estimates of the population of the United States by age, sex, and race: 1970 to 1981 (Series P-25, No. 917); and Intercensal estimates for 1980–1989, 1990–1999, and 2000–2009. The data for 2010 to 2020 are based on the population estimates released for July 1, 2020. Data beyond 2020 are derived from the national population projections released in September 2018. Some estimates have been revised since previous publication in America’s Children.

Verkuyl, M., Oona St-Amant, O., Lynda Atack, L., Diane MacEachern, D., Amanda Laird, A., Paula Mastrilli, P., Germayne Flores, G., Harper Soul Hamilton Gunn, H. P. S. (2022). Virtual simulations’ impact on clinical practice: A qualitative study, Clinical Simulation in Nursing, 68, 19-27. https://doi.org/10.1016/j.ecns.2022.04.001.

Choosing Wisely: Focused Recommendations to Improve Deprescribing Practices

Summer 2022 Newsletter

By Kaitlin Byrd, Pharm.D. and Lisa C. Hutchison, Pharm.D., MPH, BCPS, BCGP
University of Arkansas for Medical Sciences (UAMS) College of Pharmacy

Older patients are at a higher risk of being prescribed multiple medications increasing their risk of negative effects from polypharmacy. Polypharmacy and inappropriate use of medications can increase the patient’s risk of falls, delirium, and hospitalizations. Deprescribing can help reduce polypharmacy and minimize any use of inappropriate medications³. Choosing Wisely is a tool developed by the American Board of Internal Medicine to promote conversations between patients and clinicians. Working closely with the American Society of Consultant Pharmacists, Choosing Wisely has outlined ten recommendations targeting appropriate prescribing practices.²It can be hard to keep so many recommendations in mind, so here is an easy way to organize them for use with patient care—4-3-2-1.

It’s no surprise that older adults have polypharmacy. There are four recommendations that highlight the problems with drug-drug interactions—particularly issues with bleeding and cognition, so each area has two recommendations.

Avoid use of two or more medications that can increase a patient’s bleed risk. Direct oral anticoagulants (DOACs), warfarin, aspirin, selective serotonin reuptake inhibitors (SSRIs), antiplatelet agents, nonsteroidal anti-inflammatory drugs (NSAIDs) and corticosteroids can all increase the patient’s risk of bleeding. Carefully decide if the benefits outweigh the risk when combining these agents, and if yes, provide education and frequent monitoring.
Avoid the use of strong CYP3A4 and P-glycoprotein (p-gp) inhibitors or inducers with DOACs. DOACs (i.e., rivaroxaban, dabigatran, apixaban) combined with inhibitors of p-gp and CYP3A4 can lead to an increased risk of bleeding or therapeutic failure due to changes in metabolism.
Avoid prescribing three or more CNS-active medications. Combining antidepressants, benzodiazepines, Z-drugs (e.g., zolpidem), opioids, gabapentinoids, antipsychotics, and antiepileptics can lead to an increased risk of falls and fractures. Use non-pharmacologic options and the lowest effective dose as viable options for medication management.
Avoid combining opioids with benzodiazepines or gabapentinoids to treat pain in older adults. An increased risk of serious breathing difficulties may occur and can lead to death in those with chronic obstructive pulmonary disease or the elderly.

Three recommendations focus on reviewing the complete medication list with patient factors in mind to prevent adding/continuing drugs that are not needed.

Before prescribing medications for new symptoms, ensure that it is not an adverse drug reaction (ADR) from a current medication. Prescribing cascades can occur when new medications are added to treat ADRs from a patient’s current medication.
Perform a complete medication review prior to continuing medications at transitions of care. Negative outcomes are associated with continuing medications that are no longer indicated for the patient.
Assess goals of care, time-to-benefit for medications, and the presence of comorbidities for older adults with limited life expectancy. Many drugs (e.g., cholinesterase inhibitors, memantine, and statins) have questionable benefit when a patient is near the end of life.

Two recommendations are specific to avoiding use of anticholinergic medications.

Avoid use of highly anticholinergic medications in older adults without considering safer alternatives or non-pharmacological options. Anticholinergic medications include first generation antihistamines (diphenhydramine, doxylamine), tricyclic antidepressants, gastrointestinal antispasmodics, antiemetics, urinary incontinence medications, and medications for Parkinson’s disease. These medications are associated with an increased risk of dementia, cognitive impairment, and excess sedation.
Avoid concomitant use of anticholinergic medications with cholinesterase inhibitors for treatment of dementia. The two medication classes exhibit opposing actions; therefore, anticholinergics will decrease the efficacy of cholinesterase inhibitors.

The last recommendation focuses on tramadol in particular.

Avoid prescribing tramadol for older adults without consideration of fall risk, serotonergic excess, seizures, and drug-drug interactions. Potential for serotonin syndrome, hyponatremia, tramadol-induced seizures, and hypoglycemia are all possible side effects that are harmful for older adults contributing to falls and fractures. The risk of these effects is increased with a decrease in renal function.

Conversations about medications between pharmacists, prescribers, other health care professionals with patients and their caregivers provides awareness of the benefits and harms of medications. Shared decision-making is imperative when optimizing a patient’s medication regimen to improve outcomes, avoid unnecessary adverse effects, and better manage chronic conditions¹.

References:

Liacos M, Page AT, Etherton-Beer C. Deprescribing in older people. Aust Prescr. 2020;43(4):114-120. Published 2020 August 03.
Ten Things Physicians and Patients Should Question. Choosing Wisely. American Society of Consultant Pharmacists, American Board of Internal Medicine. Published 2022 June 04.
Wu H, Kouladjian O’Donnell L, Fujita K, Masnoon N, Hilmer SN. Deprescribing in the Older Patient: A Narrative Review of Challenges and Solutions. Int J Gen Med. 2021;14:3793-3807. Published 2021 Jul 24.