From the Director’s Desk

Fall 2020 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 everyone! I just want to take a brief moment of your time to wish you a great and safe fall and winter. I know 2020 has been extremely challenging for most of us, but we are persevering. We at the AGEC have actually learned and grown a LOT. We have converted most of our programs so that they are available via virtual platforms and have actually increased our reach in many ways. We now understand (somewhat anyway) and utilize new and diverse technologies to present our programs, improve our communications, and extend our reach.

We have tried to concentrate on how we can help older adults learn about and adapt to e-visits and telemedicine and how we can use virtual platforms to keep educating older adults and healthcare professionals. We have developed “how-to” videos on such things as hand washing, using gloves, How to Join a Zoom call, and Learning the Zoom Screen. We have also developed new tools to help older adults stay active and social by providing virtual physical activity classes and informational topics on Facebook, Instagram and Twitter. We are also making an effort to reach those older adults in their homes, maybe isolated at home, by continually working with our partners who provide local services to older adults such as churches and senior centers.

I am not sure what the fall/winter of 2020/2021 will bring, but we are continually working, changing and trying to keep ready for the upcoming challenges. We are and want to continue to be part of positive change. If you have ideas for us, please let us know!

Stayed tuned to the AGEC website, Facebook page, Instagram, and Twitter accounts for upcoming exciting programs and please share the embedded links regarding the Zoom videos to your patients and family members who might benefit! Stay safe everyone, and remember to get your flu shot and to remind your patients to get theirs too!!!

Over the Counter Topical Agents for Arthritis Pain

Fall 2020 Newsletter

By Catherine Jensen, Doctor of Pharmacy Candidate, and Lisa C. Hutchison, PharmD, MPH, BCPS, BCGP
University of Arkansas for Medical Sciences (UAMS) College of Pharmacy

Osteoarthritis is the most common form of arthritis and is the leading cause of disability in adults.¹ Roughly 40% of adults in the United States will develop this disease in at least one hand by 85 years of age². Non-pharmacological therapies recommended for osteoarthritis include weight loss and resistance exercises, but these treatments are seldom enough. According to the American College of Rheumatology (ACR) osteoarthritis guidelines, topical NSAIDs like diclofenac should be considered before other topical agents and oral NSAIDs. This is due to the lower risk of systemic exposure and superior efficacy noted through clinical trials^3,4.

Ingredients of topical arthritis pain medications with example products are listed in Table 1. Topical lidocaine is also available for neuropathic or burn pain, but is not recommended for arthritis pain.

Table 1: Over The Counter Topical Medications for Arthritis Pain^1,5,6,9
Ingredients	Brand Name Examples	Advantages	Disadvantages	Usual Area of Use
Menthol, camphor	Icy Hot Gel, Biofreeze, Tigerbalm	Cooling sensation with immediate effect	Does not treat inflammation or pain	Hand, knee, back
Salicylates	Bengay, Aspercreme, Myoflex	Cooling sensationSlight anti-inflammatory effectScented/unscented	Avoid with aspirin allergy	Knee, hand, foot
Capsaicin	Capzasin-HP creamZostrix, Capsiderm	Treatment of pain Potential adjunct agent when other therapies not tolerated	Skin irritation Poorly absorbed, Difficult adherence	Knee, hands
Diclofenac (NSAID) 1% gel	Voltaren Gel	Treatment of painGI & renal effects of oral NSAIDs unlikely	Skin irritation, Delayed pain relief, Difficult adherence	Knee, hand, foot

Until recently, diclofenac 1% gel (Voltaren) was only available by prescription⁵. This product provides both analgesic and anti-inflammatory actions to the affected joints. Safety and efficacy of diclofenac 1% gel on knee osteoarthritis was proven in three randomized double-blind multicenter trials³. The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) assessed pain (scale 0-20) and physical function (0-68) after 12 weeks. Patients 65 years and older showed significant improvement in pain (-5.3 vs. -4.1 p=0.02) and physical function (-15.5 vs -11, p=0.004) from baseline compared to placebo. There was also a significant decrease in pain on movement in the diclofenac group (-33.7 vs. -26.4, p=0.02).³ Study participants had over 90% adherence despite using a medication that requires application four times daily. Patients should be counseled on the importance of adherence and to not expect immediate relief.

Capsaicin is derived from chili peppers and acts as a counterirritant to pain. The agent is also useful for neuropathic pain. Capsaicin causes a depletion of substance P from sensory neurons, resulting in a numbing effect⁶. Capsaicin also requires application 3-4 times a day however, it requires a longer time to absorb into the skin before washing^6,7. A meta-analysis of 28 randomized-controlled trials explored the efficacy of capsaicin in osteoarthritis pain. Capsaicin trials were evaluated as low quality, but did show superiority to placebo when used at recommended doses (0.41, CI 0.17-0.64)⁷. Use of capsaicin on the hands is difficult, given the need to avoid touching the face or eyes after application to avoid burning. There is also concern for long-lasting nerve desensitization with chronic capsaicin use^6,8. The low quality evidence and adverse effects limit the use of capsaicin topical products for osteoarthritis to second line therapy after topical diclofenac. This meta-analysis also evaluated topical NSAIDs and found them overall superior to placebo based on effect size (0.30, CI 0.19-0.41).

Ingredients like camphor, menthol, and salicylates provide a distraction from pain through a cooling or warming sensation on the skin. These agents may provide an immediate feeling of relief but overall studies have shown mixed efficacy^4,9. Despite having been available for many years, there is limited data on their use.⁴ Menthol, camphor, and salicylate products are not currently recommended by the ACR guidelines for osteoarthritis pain management⁴. However, side effects with menthol and camphor products are few when used topically except to note that salicylates as a derivative of salicylic acid should not be used in patients with an aspirin allergy.⁹

Use of topical agents must be carefully guided in a geriatric population due increased absorption potential with the thinning of the skin in older adults and if heat is applied to the affected joint before or after topical application. Increased permeability may increase the risk of systemic side effects like that seen in oral NSAID medications. Topical agents are an important option because of easy application for patients suffering from mild to moderate osteoarthritis pain. The introduction of topical diclofenac to store shelves increases the availability of a therapy with evidence of providing significant pain reduction and improved physical function in patients with osteoarthritis.

References:

Osteoarthritis (2020). Centers for Disease Control and Prevention. Retrieved from https://www.cdc.gov/arthritis/basics/osteoarthritis.htm
Arthritis By The Numbers: Book of Trusted Facts & Figures (2019). Arthritis Foundation. Section Two: OA Facts (p17-27). Retrieved from https://www.arthritis.org/getmedia/e1256607-fa87-4593-aa8a-8db4f291072a/2019-abtn-final-march-2019.pdf
Baraf, H. S., Gloth, F. M., Barthel, H. R., Gold, M. S., & Altman, R. D. (2011). Safety and efficacy of topical diclofenac sodium gel for knee osteoarthritis in elderly and younger patients: pooled data from three randomized, double-blind, parallel-group, placebo-controlled, multicentre trials. Drugs & aging, 28(1), 27–40. https://doi.org/10.2165/11584880-000000000-00000
Kolasinski S., Neogi T., Hochberg M.,et. al. (2020). 2019 American College of Rheumatology/Arthritis Foundation Guideline for the Management of Osteoarthritis of the Hand, Hip, and Knee. American College of Rheumatology. Vol. 72, No. 2, February 2020, pp 149–162 DOI 10.1002/acr.24131
FDA Approves Three Drugs for Nonprescription Use Through Rx-to-OTC Switch Process (2020). S. Drug & Food Administration. Retrieved from https://www.fda.gov/news-events/press-announcements/fda-approves-three-drugs-nonprescription-use-through-rx-otc-switch-process.
Altman, R. D., Barthel, H. R. (2011). Topical therapies for osteoarthritis. Drugs, 71(10), 1259-1279.
Persson, M., Stocks, J., Walsh, D. A., Doherty, M., & Zhang, W. (2018). The relative efficacy of topical non-steroidal anti-inflammatory drugs and capsaicin in osteoarthritis: a network meta-analysis of randomised controlled trials. Osteoarthritis and cartilage, 26(12), 1575–1582. https://doi.org/10.1016/j.joca.2018.08.008
van Laar, M., Pergolizzi, J. V., Jr, Mellinghoff, H. U., et al. (2012). Pain treatment in arthritis-related pain: beyond NSAIDs. The open rheumatology journal, 6, 320–330. https://doi.org/10.2174/1874312901206010320
Rubbing It In (2019). Harvard Health Publishing. Retrieved from https://www.health.harvard.edu/pain/rubbing_it_in

Telehealth: Increasing Opportunities for Student Training and Expansion of Care to Senior Adults

Fall 2020 Newsletter

By Alicia S. Landry, PhD, RD, SDN, SNS
Family and Consumer Sciences
University of Central Arkansas

Telehealth is an umbrella term that often refers to healthcare services that are delivered virtually. Examples of telehealth are telemedicine, mHealth (mobile health), and store and forward. In order to lay some groundwork, we will start with brief definitions.

Telemedicine is two-way, synchronous discussion between a patient and a healthcare provider, or between multiple providers.
Mobile health is when a patient uses an application or software to manage health. An example would be tracking dietary intake using a food log app on a smartphone and syncing it with the platform a registered dietitian monitors to give the patient feedback on diet choices.
Store and forward includes gathering patient data (like photos of a rash or an x-ray) and using the information for diagnostic decisions made by a provider at a later time.

Using accurate terminology to describe telehealth interventions becomes important when multiple providers are providing care for a single patient as well as other situations. Having a healthcare team in sync with one another is critical to positive patient outcomes.

While telehealth could potentially result in healthcare savings as well as increased safety and convenience for aging adults as well as their providers (Snoswell, Taylor, and Caffrey, 2019), concerns remain about the feasibility of telehealth use in a geriatric population. Specialties such as psychiatry and counseling, physical and occupational therapy, and medical nutrition therapy have been positively impacted by the use of telehealth and should continue to grow as demands for specialists increase and the safety of going to practitioner offices remains in question. For most Medicare patients, virtual doctor visits are covered when a doctor is not available to see the patient in person and Medicare has expanded coverage for virtual visits in the wake of COVID-19 (Medicare, 2020).

Patient acceptance, insurance reimbursement, regulatory or licensure barriers, access to high-speed broadband or wireless networks, and privacy concerns are legitimate obstacles to implementing telehealth. In Arkansas, broadband access is very poor (41st in the US), making network infrastructure in rural areas somewhat prohibitive of the use of telehealth. The Arkansas Rural Connect program is expected to use $25 million to cover underserved and rural communities, and more recently, there have been expanded efforts to make wireless and broadband coverage available in rural areas. While 26% of adults over 60 years of age reported no access to the internet, only half of 45-59-year-olds reported no access (Arkansas Broadband Report, 2019) which means age gaps do occur in the access to high-speed internet as well as in the utilization of telehealth. As always, healthcare providers communicating with senior adults must recognize challenges in hearing, sight, technology access, as well as others to ensure the best care possible.

Patients with chronic conditions like diabetes, cardiovascular disease, and obesity show favorable responses to home management via telehealth when led by an interprofessional team of healthcare providers. If it is possible that telehealth can allow seniors to remain safely at home for a longer time, ensure older adults are compliant with medication use, and reinforce support of caregivers, it may be time to take a deeper look into the possibilities for allied health professionals to grow the telehealth outlet.

During this time of physical distancing, older adults are more likely to feel socially isolated, experience food insecurity, and delay routine healthcare. In the National Poll on Healthy Aging, 45% of respondents said the pandemic made them more interested in telehealth and only 25% reported being concerned they would have difficulty seeing or hearing the provider during a video visit (Buis et al., 2020). Reduced risk of falls or decreased exposure to disease benefits the frail elderly, and telehealth can allow resource providers to maintain closer contact with older adults. In-home caregivers who may have their own families or other jobs can connect with healthcare providers which may reduce stress and improve the quality of care. Mobility (address movement and physical activity), mentation (assess cognition level), medication (identify the type, dose, supply), and what matters (determine goals, preferences, priorities) are the four M’s of age-friendly health and remembering these for telehealth visits can make these visits even more successful for the aged (Institute for Healthcare Improvement, 2019).

For registered dietitians, the expanding telehealth world has been a phenomenal way to provide integrated and patient-centered care, even with guidelines about physical distancing and preventing the spread of infectious disease. For example, a registered dietitian observing mealtimes with speech pathologists and occupational therapists allows the interprofessional team to make decisions about food consistency, swallowing risk, socialization, and other issues impacting nutrition status. For patients with at-home parenteral nutrition, registered dietitian observation along with pharmacy and medical providers reduces the risk of bloodstream infections and hospital readmission (Raphael et al., 2019). In diabetes self-management education (DSME), registered dietitians are able to teach blood glucose monitoring and follow patients in real-time as they report their blood glucose levels. Telehealth DSME has had great success and shown significant reductions in hemoglobin A1c and blood pressure in patients with diabetes (Nicoll et al., 2014). Group therapy or support groups with counselors, registered dietitians, and social workers may help alleviate distress and loneliness of isolation. The use of multidisciplinary clinics has been shown to improve outcomes in aging adults (Erskine, Griffith, & Degroat, 2013; Kozak et al., 2017) and implementing telehealth in these clinics makes scheduling less burdensome. Dietitians across the State are utilizing telehealth for DSME and dietetic interns are learning multiple telehealth platforms in order to be better equipped as they enter the dietetics profession.

During the spring of 2020, multiple hospitals and primary care provider clinics closed and only allowed medically necessary procedures. These restrictions affected dietetics education because students were no longer allowed in hospitals like during traditional internships. Turning to telehealth and working alongside registered dietitians – even at a distance – to monitor and educate patients allowed students to continue their education and graduate on time. Likewise, these opportunities often included exposure to interprofessional teams of pharmacists, physicians, and other therapists which may not have been accessible during typical rotations. Taking advantage of these technologies gave students an opportunity to participate in ground-breaking healthcare as well as provided them with the confidence to interact in a healthcare team. While we must still train healthcare professionals to have bedside manner and we need to ensure students are competent in clinical skills, considering telehealth as a significant portion of their educational experience is worthwhile.

Arkansas Department of Commerce. (2019). Arkansas State Broadband Manager’s Report. Available at: https://www.arkleg.state.ar.us/Calendars/Attachment?committee=685&agenda=3195&file=Exhibit%20F%20Arkansas%20State%20Broadband%20Manager%20Report.pdf
Buis, L., Singer, D., Solway, E., Kirch, M., Kullgren, J., & Malani, P. (2020). Telehealth use among older adults before and during COVID-19. University of Michigan National Poll on Healthy Aging. August 2020. Available at: http://hdl.handle.net/2027.42/15625
Erskine, K. E., Griffith, E., & Degroat, N. (2013). An interdisciplinary approach to personalized medicine: Case studies from a cardiogenetics clinic. Personalized Medicine, 10(1), 73–80.
Institute for Healthcare Improvement. (2019). “What Matters” to older adults? A toolkit for health systems to design better care with older adults. Retrieved from: http://www.ihi.org/Engage/Initiatives/Age-Friendly-Health-Systems/Documents/IHI_Age_Friendly_What_Matters_to_Older_Adults_Toolkit.pdf
Kozak, V. N., Khorana, A. A., Amarnath, S., Glass, K. E., & Kalady, M. F. (2017). Multidisciplinary clinics for colorectal cancer care reduces treatment time. Clinical Colorectal Cancer, 16(4), 366–371.
Medicare. (2020). Available at: https://www.medicare.gov/coverage/telehealth
Nicoll, K. G., Ramser, K. L., Campbell, J. D., et al. (2014). Sustainability of improved glycemic control after diabetes self-management education. Diabetes Spectrum, 27(3), 207-211.
Raphael, B.P., Schumann, C., & Garrity-Gentille, S. (2019). Virtual telemedicine visits in pediatric home parenteral nutrition patients: A quality improvement initiative. Telemedicine Journal and E-health, 25(1), 60–65.
Snoswell, C. L., Taylor, M. L., & Caffery, L. J. (2019). The breakeven point for implementing telehealth. Journal of Telemedicine and Telecare, 25(9), 530-536. doi: 10.1177/1357633X19871403.

Dementia Training for First Responders

Fall 2020 Newsletter

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

Why do first responders need training regarding dementia and Alzheimer’s disease, you may ask? There are approximately 58,000 Arkansans aged 65 and older that have a diagnosis of Alzheimer’s disease, a specific type of dementia. This number is predicted to increase by 19% by 2025 when Arkansas will have approximately 67,000 older adults with Alzheimer’s disease (1). Because of this projection, first responders will increasingly need training in understanding dementia and Alzheimer’s disease, the behaviors sometimes associated with the disease, and how best to interact with this growing segment of our population.

The Arkansas Geriatric Education Collaborative is here to help. We have provided dementia training to over 1,200 first responders to date. The program is available in-person and virtually. The in-person program takes 2-3 hours to present and the virtual program can be viewed one module at a time or the six program modules may be complete consecutively, all at one time, in about 2 hours.

The program trains first responders in the basics of understanding dementia and Alzheimer’s disease – the signs and symptoms and then how best to communicate with someone with dementia. Helpful communication tips and visual reinforcement scenarios are included. The program discusses important behaviors and scenarios first responders may encounter such as wandering, elopement, aggressive behaviors, delusions, repetitive behaviors, hallucinations and hoarding. AGEC also felt it important to include a module about elder abuse. This module teaches both how to recognize the signs of elder abuse and how to report possible elder abuse. The final module in the series discusses tips and scenarios on how best to assist a person with dementia in the event of a natural disaster.

Upon completion of the modules, the individual requests a certification of completion by email. This free, online program is approved for 2.0 CLEST hrs. for police and 2.0 CE hours for EMS personnel. The program has been a big success and has had participation by first responders and other health care professionals in several states.

When COVID restrictions are lifted, AGEC will once again offer the two-hour program in person. To schedule a First Responder Dementia Training Program, send your request to AGEC at agec@uams.edu.

If you are a first responder, know a first responder, or know a first responder organization that may be interested in this program please share this article or information with them. Contact Laura Spradley, Outreach Coordinator with the AGEC at 501-526-7482 with additional questions.

https://www.alz.org/media/documents/arkansas-alzheimers-facts-figures-2018.pdf

The Most Affected During COVID-19

Fall 2020 Newsletter

By Katie Axsom, SPT
College of Nursing and Health Professions
Arkansas State University

The elderly population, 65 years and older, have been the most affected by the pandemic whether they are a community dweller or living in a long-term nursing facility. With age, our immune system becomes fragile and cannot withstand the amount of distress an illness can bring. COVID-19 is primarily a respiratory illness. Aging internal body systems are weaker and individuals affected are usually unable to recover from sickness as easily, due to other health related issues that come with aging. Months into this pandemic, the elderly are still the group of people most at risk. The CDC states that older adults, 65 or older, account for 16% of the U.S. population, but 80% of the deaths from the pandemic. (CDC, Older Adults) That percentage is staggeringly high. The number continues to climb but over 100,000 elderly adults, 65 or older, have died due to COVID-19. (Freed)

From March until now, we have learned a lot about the Coronavirus, yet people are still being affected by this illness. Many states have mandated rules in place to keep the spread of the virus down. Even with these rules in place, the virus is still spreading and the elderly population continues to be the population most at risk. There are four main actions that we hear about on a daily basis to lower our risk and the risk of others obtaining the virus, which are practicing good hand hygiene, wearing a mask in public, staying six feet apart from people when possible, and disinfecting and cleaning surfaces regularly. (CDC, Older Adults) It doesn’t just take one person doing their part, it takes everyone.

Another factor that puts the elderly population at greater risk is their dependence on others whether at home or in an assisted living community. It is difficult for them to do everything on their own, so they may come in contact with more people. (LaFave) They rely on people to bring groceries and medications, help with cooking and cleaning, sorting through the mail or paying bills. It is paramount to be more cautious and aware of who we are coming into contact with. While it is good to isolate during COVID, we don’t want to isolate the older population to a point that impacts mental, physical, emotional and social health. It is important to stay connected. A few different ways to stay connected with the older population are through virtual avenues. Talking with someone virtually has gotten easier over the last few years. You can Skype, Facetime or Zoom by a click of button. Also, online you can play games with friends, through Arkadium.com or join a virtual book club to talk about your favorite books. A few things you can do outside of the virtual world is plan window visits, where you meet with your loved one through a window to keep social distancing a priority. You can rediscover sending snail mail to family and friends through letters or postcards. Something I just discovered is that you can go on a virtual vacation. There are many museums or national parks that have virtual tours. You can experience the fun and excitement of a vacation, virtually through your computer or phone. (Austrew) We need to keep our brains stimulated with positive thoughts and actions.

With no end in sight yet for this pandemic, another important task for the elderly population to do is to stay up to date with their vaccinations and continue seeing their primary care providers. In the cooler months ahead, flu season and the risk of getting pneumonia is another danger to the older population. Vaccinations reduce the risk for medical visits and hospitalizations. (CDC, Flu) The last thing the older population needs right now is to be in the hospital for the flu or pneumonia when COVID-19 is still present. Staying on top of screenings with primary care providers is also important to make sure their health hasn’t declined and that they are receiving the care that they need to remain in good physical shape for their age.

In closing, remember to keep the elderly population in mind. Know that they have challenges. Stay in contact and assist when you can. Checking in on family and friends is important. Working together to keep everyone healthy and safe in a top priority.

References:

Austrew, A. (2020, July 22). 7 Ways Families Can Stay Connected To Senior Loved Ones During Covid-19. Retrieved September 16, 2020, from https://www.care.com/c/stories/16765/stay-connected-seniors-covid/

CDC. (2020, August 28). Flu & People 65 Years and Older. Retrieved September 15, 2020, from https://www.cdc.gov/flu/highrisk/65over.htm

CDC. (2020, September 11). Older Adults and COVID-19. Retrieved September 15, 2020, from https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/older-adults.html

Freed, M. (2020, July 24). What Share of People Who Have Died of COVID-19 Are 65 and Older – and How Does It Vary By State? Retrieved September 15, 2020, from https://www.kff.org/coronavirus-covid-19/issue-brief/what-share-of-people-who-have-died-of-covid-19-are-65-and-older-and-how-does-it-vary-by-state/

LaFave, S. (2020, May 05). The impact of COVID-19 on older adults. Retrieved September 15, 2020, from https://hub.jhu.edu/2020/05/05/impact-of-covid-19-on-the-elderly/

From The Director’s Desk

Spring 2020

Is this a new AGEC era?

What a difference a few weeks make. Last time I wrote this newsletter, we at the AGEC were preparing for a very busy end of winter and early spring with several exciting programs and activities scheduled! We were all really looking forward to better weather and traveling the state to conduct programs and see our community-based and academic partners in action. And now…. we are still very busy, but differently.

As most people, we have started working part-time at home and part-time on campus. We have also greatly changed the way we are delivering programs and activities. We have had to spend time learning new systems and thinking about how to do things differently – while socially distancing ourselves! Below are a few examples of how we are adapting and changing.

We are converting community programs into virtual forums:

Dementia Friendly Business – Converting in-person coaching to virtual/online program
Converted our popular community forum “Understanding Dementia & Alzheimer’s Disease” to an online program via BlackBoard Collaborate
Converted Lunch & Learn series with Alzheimer’s’ AR and Community Based Organizations from in-person to online.
With our AR-IMPACT partner, we have completed four on-line programs: Alternative Pain Relief and Self-management amidst the Opioid Crisis; Tips for the Busy Clinician; Opioids and Falls; and Recognizing and Responding to Suffering
Transforming community programs (some educational and some exercise programs) to on-line versions while encouraging our older adults to participate online. For example: Presenting Ageless Grace online (via Facebook) and to date, along with our partners in this venture we have had over 5000 hits!
Working with our clinical partner with QI activities via phone conferences

As we learn new ways of delivering our programs and grant activities, we want you to stay connected with us. If you have unique ideas about how to reach and connect with health professionals who specialized in geriatrics or the older adults themselves and/or their caregivers, or the general community, please share them with us! We are all in this together and are striving to meet the needs of older Arkansans while improving their health and wellbeing!

Polypharmacy: Definition, Causes, and Solutions

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

Definitions

Polypharmacy may be defined as a number of medications, ranging from as few as two to as many as 21. The most common numerical threshold for polypharmacy is 5-6 or more medications. However, a patient with diabetes, chronic kidney disease, hypertension and heart failure is easily prescribed more than 6 medications if treated according to accepted guidelines making them all potentially appropriate for the individual. Polypharmacy may be defined as use of potentially inappropriate medications as identified by a set of criteria such as the AGS 2019 Beers Criteria.(1) These criteria list medications whose risk usually outweighs potential benefit when used in older adults. Yet another definition of polypharmacy is limited to the presence of medications in the patient’s list that are unnecessary, which is defined as medications that are not indicated, dosed in excess, continued beyond an adequate duration, duplications, or causing adverse events. The most stringent definition of polypharmacy involves evaluation of each medication a patient receives according to 10 questions which comprise the Medication Appropriateness Index.(2)

Is there an indication for the drug?
Is the medication effective for the condition?
Is the dosage correct?
Are the directions correct?
Are the directions practical?
Are there clinically significant drug-drug interactions?
Are there clinically significant drug-disease/condition interactions?
Is there unnecessary duplication with other drugs(s)?
Is the duration of therapy acceptable?
Is this drug the least expensive alternative compared to others of equal utility?

If any of the questions receives a negative response, the drug use is not appropriate and polypharmacy is present. In research applications, the first three questions are given more weight in the assessment. This helps the clinician know to focus on indication, effectiveness, and dosage.

Causes

The causes of polypharmacy are many, but include the patient’s use of multiple physicians and pharmacies, disease state guidelines recommendations for multiple medications, prescribing cascades, and direct-to-consumer advertising. When a patient sees multiple physicians, communication between providers is necessary to prevent prescription of duplicate medications. In addition, prescribing cascades may result when one prescriber is unaware of the therapy recommended or prescribed by a previous prescriber. Additional medications to be considered are over-the counter medications and supplements that the patient consumes without the knowledge of the provider. This results in a further increase in drug interactions and adverse drug events. If a patient uses different pharmacies, assessment of important drug-drug interactions may be lacking as each pharmacy will likely only have a partial list of medications.(3, 4)

The prescribing cascade is defined as when a new medication is prescribed for a symptom that is misinterpreted as a new medical condition when it is actually an adverse drug reaction or side effect. An example is shown in Figure 1.

Prevention and Intervention

The first step in prevention of inappropriate polypharmacy is to perform a medication regimen review whenever a new medication is being considered for prescription. An adverse drug effect may be the cause of a symptom and require adjustment or discontinuation of a currently prescribed agent instead of addition of a new one. Non-pharmacological interventions are preferred for many chronic illnesses and should be promoted to older adults.

Secondly, the clinician can identify inappropriate polypharmacy exists for an older adult through use of various tools that can aid in identifying medications that may be unnecessary. Annual or more frequent review of the medication regimen is recommended.(5) Taking the time to carefully consider each medication and its risk/benefit in light of a patient’s circumstances is important, especially as a patient becomes frail with an increased susceptibility to adverse effects.

References:

American Geriatrics Society 2019 Beers Criteria® Update Expert Panel. 2019 updated Beers Criteria® for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2019; 67:674-94 DOI: 10.1111/jgs.13702
Hanlon JT, Schmader KE, Samsa GP, Weinberger M, Uttech KM, Lewis IK, et al. A method for assessing drug therapy appropriateness. J Clin Epidemiol. 1992;45:1045–51.
Rochon PA, Gurwitz JH. Optimising drug treatment for elderly people: the prescribing cascade. 1997;315:1096-9.
Scott IA, Gray LC, Martin JH,Mitchell CA. Minimizing inappropriate medictions in older populations: a 10-step conceptual framework. Am J Med. 2012;125:529-37.
Choosing Wisely. An initiative of the ABIM Foundation. https://www.choosingwisely.org/societies/american-geriatrics-society/ Accessed 30 April 2020.

Age-Friendly Healthcare in Rural Arkansas

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

My name is Dr. Leah Tobey and I am the clinical coordinator for the AGEC team. As part of our HRSA Geriatric Workforce Enhancement Program, we have goals to improve clinical health outcomes of older adults in the primary care setting. Our partnered clinics are with ARcare, a federally qualified healthcare clinic network. Specifically, the two clinics where we partner with to improve outcomes for older adults are ARcare England and ARcare Augusta. I help provide up-to-date and evidenced-based trainings to clinicians, particularly focused on age-friendly work practices, tests and measures to enhance patient experiences and improve outcomes of older adults in these rural areas.

As a member of the 2020 Institute for Healthcare Improvement (IHI) Age-Friendly cohort, we at AGEC have requested the ARcare clinics to implement the 4Ms framework to optimize the care of older adults. This framework is not a program, but rather a shift in how care is provided. The 4Ms framework consists of: What Matters to the older adult, high-risk Medication review, cognitive and Mentation screens, and Mobility tests for fall prevention. Through a variety of geriatric-focused trainings, including the 4Ms framework, our first goal was to improve the clinician’s knowledge of best practices of caring for older adults. We then collected baseline data of common health related indicators for older adults, such as uncontrolled hypertension, diabetes, number of patients prescribed high-risk medications like opioids and older adults who experience frequent falls. The 4Ms framework for age-friendly care has been well-received and AGEC is continuing to monitor how and when this framework is being implemented into primary care, including Medicare annual wellness visits.

We know the population of older adults, specifically the Baby Boomer population, continues to increase, and we expect the 4Ms framework will be a helpful guide to ensure that older adults are delivered safe, age-friendly healthcare. This framework helps to ensure patients move safely every day in order to maintain function and do what Matters most to them (ihi.org). We have seen promising results in several areas, for example, assessing Mobility with fall screens has improved over 50% in one year in the ARcare England clinic. ARcare England also had a 30% increase in annual wellness visits for Medicare patients in one year. We continue to address areas of improvement, using the 4Ms framework as a helpful guide to care. As I mentioned above, the 4Ms framework includes Mentation screens specifically for the presence of the 3D’s: Dementia, Delirium and Depression. Early, accurate screening procedures will allow the clinicians to prevent, identify, treat, and manage cognitive changes noted in an older adult patient. When cases of depression or dementia are caught early, we want the ARcare clinicians to have the knowledge to treat with age-friendly care and also provide helpful community resources for patients and their families. This goal coincides with the healthy aging programs the AGEC brings to Arkansans across our state.

Despite difficult times recently, we at AGEC have been busy creating and providing clinical trainings to continue building upon the early, positive results within ARcare. I’m happy to report as of March 2020 ARcare England and Augusta have been awarded the certification of being “Age-Friendly Healthcare Systems” by the Institute for Healthcare Improvement. We are looking forward to continued improvements in health-related indicators for older adults in our rural ARcare communities and to making them more age-friendly.

Does Age-Related Hearing Loss Worsen Cognitive Decline?

By Natalie Benafield, Au.D., CCC-A
Communication Sciences and Disorders
University of Central Arkansas

Most of us associate aging with a decline in hearing acuity, with good reason. Two-thirds of individuals over 70 years of age have a loss in hearing that would be considered clinically significant. Communication obviously suffers, causing frustration for both the person with the hearing loss and their family members. However, it is estimated that less than one-quarter of individuals with age-related hearing loss seek treatment. Evidence is mounting that ignoring hearing as you age can have detrimental effects that go beyond difficulty communicating with others.

As far back as 1989, scientists have suggested that age-related hearing loss may contribute to cognitive decline in seniors. A pivotal study published in the Journal of the American Medical Association (Uhlmann, et.al.,1989) suggested that hearing loss in older adults was associated with a higher risk of dementia. For the past several years, other researchers have been conducting research in this area and have come to similar conclusions. Dr. Frank Lin, at Johns Hopkins University, and his team followed 639 individuals from the ages of 36-90 for twelve years to investigate the link between hearing loss and dementia. After adjustment for other factors including age, gender, educational level, diabetes, smoking and hypertension, their research suggested that those with hearing loss experiences a 30-40% accelerated rate of cognitive decline (Lin, et al., 2013). More recently a large-scale review of epidemiologic studies of age-related hearing loss and cognitive function from twelve countries was conducted. The researchers found that age-related hearing loss was significantly association with a decline in all main cognitive domains, except for Alzheimer’s disease and vascular dementia. They concluded that hearing loss related to aging is a modifiable risk factor for cognitive decline and dementia in seniors (Loughrey, et al., 2018).

While the exact mechanism underlying the relationship between age-related hearing loss and cognitive decline has not been identified, there are several theories. Some have suggested that hearing loss and cognitive decline may be caused by the same general neurodegenerative process (Stahl, 2017). Neuroimaging studies have suggested that similar changes in the temporal regions of the brain have been noted in individuals with hearing loss and with cognitive decline (Lin, et al., 2014). Other researchers suggest that hearing loss (i.e., the lack of sensory input) causes individuals to use additional cognitive resources to process auditory input, resulting in chronic cognitive “multitasking” and overload. (Tun, McCoy, & Wingfield, 2009). Exacerbating the condition may be that untreated hearing loss often leads to social isolation and even depression, which in turn leads to reduced cortical input over time, hastening atrophy in certain regions of the brain.

Will hearing aid use slow cognitive decline? It makes sense that the use of hearing devices such as hearing aids could increase auditory input, lessen cognitive load, and decrease social isolation, thereby slowing cognitive decline (Sarampalis, et al., 2009). However, we need more large-scale, longitudinal studies before being confident of that claim. Current studies have failed to show a robust protective relationship between hearing aid use and cognitive function. One recent small-scale study found that individuals with evidence of auditory- to- visual cross-modal reorganization in the brain showed evidence of reversal of the re-organization in the auditory cortex, with additional gains in speech perception and cognitive performance (Glick & Sharma, 2020).

What does this mean for current clinical care of older adults? Health care providers often see hearing loss as normal part of aging as they must focus on the numerous urgent medical needs of older adults. This research suggests that clinicians should take a proactive, rather than reactive approach to hearing health in the aging population. Rather than waiting until a patient complains of difficulty hearing, encourage early hearing screening, evaluation, and treatment for those 60 and older. Most patients will not understand the importance of their hearing to brain health. While we lack the evidence to suggest that hearing aids can reduce cognitive decline, we have plenty of evidence to say that hearing loss is not good for the brain. Early hearing evaluation and treatment is risk-free, and evidence is mounting that appropriate treatment of age-related hearing loss could have a positive impact on cognitive decline.

References

Glick, H. A., & Sharma, A. (2020). Cortical Neuroplasticity and Cognitive Function in Early-Stage, Mild-Moderate Hearing Loss: Evidence of Neurocognitive Benefit From Hearing Aid Use. Frontiers in Neuroscience, 1.

Lin, F. R., Yaffe, K., Xia, J., Xue, Q.-L., Harris, T. B., Purchase-Helzner, E., Satterfield, S., Ayonayon, H. N., Ferrucci, L., & Simonsick, E. M. (2013). Hearing loss and cognitive decline in older adults. JAMA Internal Medicine, 173(4), 293–299. https://doi.org/10.1001/jamainternmed.2013.1868

Lin, F. R., & Albert, M. (2014). Hearing loss and dementia – who is listening? Aging & Mental Health, 18(6), 671–673. https://doi.org/10.1080/13607863.2014.915924

Loughrey, D. G., Kelly, M. E., Kelley, G. A., Brennan, S., & Lawlor, B. A. (2018). Association of Age-Related Hearing Loss With Cognitive Function, Cognitive Impairment, and Dementia: A Systematic Review and Meta-analysis. JAMA Otolaryngology– Head & Neck Surgery, 144(2), 115–126. https://doi-org.ucark.idm.oclc.org/10.1001/jamaoto.2017.2513

Sarampalis A, Kalluri S, Edwards B, & Hafter E. (2009). Objective measures of listening effort: effects of background noise and noise reduction. Journal of Speech, Language & Hearing Research, 52(5), 1230–1240. https://doi.org/1092-4388(2009/08-0111)

Tun PA, McCoy S, Wingfield A, Tun, P. A., McCoy, S., & Wingfield, A. (2009). Aging, hearing acuity, and the attentional costs of effortful listening. Psychology & Aging, 24(3), 761–766. https://doi.org/10.1037/a0014802

Uhlmann, R.F., Larson, E.B., Rees, R.S., Koepsell, T.D., Duckert, L.G. (1989). Relationship of hearing impairment to dementia and cognitive dysfunction in older adults. Journal of the American Medical Association 261(13), 1816-1919.

Weinstein, B.E., (2018). A primer on dementia and hearing loss. Perspectives of the ASHA Special Interest Groups, 3(6), 18-27.