Hospice: A Transition of Care to End of Life

By Dr. Angela Schmidt, Professor Emeritus
College of Nursing and Health Professions
Arkansas State University

Transitioning from one care setting to another in the United States Healthcare system, has become complex and problematic, especially for older adults and other vulnerable populations.

Included in these transitions is hospice care, provided at home, in a hospital, a nursing home, or in a facility specifically designated for hospice care delivery. This care delivery is holistic and is delivered by an interdisciplinary team of physicians, nurses, social workers, therapists, clergy, and often volunteers. It is available to any person regardless of age, race, or illness. The goal of hospice is comfort instead of cure, to be pain free with aggressive methods as necessary. The philosophy of hospice is to provide supportive care for the patient’s emotional, social, and spiritual needs, as well as these medical symptoms, as part of holistic care delivery.

Services provided in hospice care include prescribing drugs to control pain and manage other symptoms; physical, occupational, and speech therapy; medical supplies and equipment; medical social services; dietary and other counseling; continuous home care at times of crisis if home setting; and bereavement services. Although hospice care does not aim for cure of the terminal illness, it may treat potentially curable conditions such pneumonia and bladder infections, with brief hospital stays if necessary. Hospice programs also may offer respite care workers, people who are usually trained volunteers, who take over the patient’s care so that the family or other primary caregivers can leave the house for a few hours. Some facilities where hospice care is provided also include volunteer caregivers as a part of the hospice philosophy.

In the mid-1970s when hospice came to the U.S., most hospice patients had cancer. Today, more than half of hospice patients have other illnesses for which they are medically eligible for hospice services, such as late-stage heart, lung or kidney disease, and advanced Alzheimer’s disease or dementia. Hospice also once was exclusively for adults, especially elderly people, but today many hospice programs accept infants, children and adolescents

In a significant research study, published by The Journal of American Geriatric Society (Amann & LeBlanc, 2014), researchers found that cancer and advanced dementia were the conditions that most often resulted in being admitted for hospice care. The duration of hospice care was less than 13 days for half of these study participants. The short duration of hospice suggested that healthcare providers might need to consider discussing referrals to hospice sooner with people who are approaching the end of their lives.

Further, the study revealed that older adults who were frail were least likely to be admitted for hospice. However, the most common condition leading to death was frailty (syndrome of physiologic decline in later life), followed by organ failure, advanced dementia, and then cancer. The researchers suggested that referral to hospice at the end of life should be based on an older adult’s burden of pain and other distressing symptoms including frailty, as well as consideration of earlier hospice referrals. (Amann & LeBlanc, 2014)

A National Hospice Foundation Survey noted that 90% of Americans were unaware that hospice care is a covered Medicare service. To be eligible to receive hospice services, a hospice physician and a second physician (often the individual’s attending physician or specialist) must certify that the patient meets specific medical eligibility criteria; generally, the patient’s life expectancy is 6 months or less if the illness, disease or condition runs its typical course. However, if the individual lives longer than six months and the condition continues to decline, recertification by a physician or nurse practitioner for additional time in hospice care. Similarly, if a hospice patient’s condition improves, the individual may be discharged from hospice care. The patient is eligible for hospice again if his or her condition begins to decline. The decision to consider hospice services, as recommended by the Hospice Foundation of America, should include: 6 months or less to live, according to a physician; rapidly declining despite medical treatment (weight loss, mental status decline, inability to perform activities of daily living); and readiness to live more comfortably and forego treatments aimed at prolonging life. Many health care service options for transitions of care are determined by financial considerations. The type of insurance coverage the patient has determines of-of-pocket payments for hospice care. Hospice services usually follow Medicare requirements to provide the following:

Time and services of the care team, including visits to the patient’s location by the hospice physician, nurse, medical social worker, home-health aide and chaplain/spiritual adviser;
Medication for symptom control and/or pain relief;
Medical equipment, such as wheelchairs or walkers and medical supplies like bandages and catheters;
Physical, occupational, and speech therapy if needed;
Dietary counseling;
Any other Medicare-covered services needed to manage pain and other symptoms related to the terminal illness;
Short-term inpatient care if in home setting and pain and/or symptom management cannot be achieved;
Short-term respite care if temporary relief from caregiving is needed to avoid or address “caregiver burnout”; and
Grief and loss counseling for patient and loved ones.

However, not all services provided to patients enrolled in hospice care are covered by the Medicare Hospice Benefit. The hospice benefit will not pay for:

Treatment intended to cure your terminal illness or unrelated to that illness;
Prescription drugs to cure your illness or unrelated to that illness;
Room and board in a nursing home or hospice residential facility; and
Care in an emergency room, inpatient facility care or ambulance transportation, unless it is either arranged by the hospice team or is unrelated to the terminal illness.

(see https://hospicefoundation.org/Hospice-Care/Hospice-Services )

Note that not covered is “room and board” which is misunderstood by consumers when most resources state, “Medicare covers hospice care”. Even care received in a hospice facility can charge the patient for room and board daily not covered by Medicare, although the above allowed services may be covered. Six months or 180 days at 140-$200 per day (totaling $25,000-$36,000) for room and board, may be an out of pocket personal expense. In addition, some medications are not included. For example, some intravenous (IV) medications that are not related to the terminal illness are not covered by hospice. Even dehydration occurring as a natural process in a terminal illness does not allow IV fluids. Further, most antibiotics are not covered by hospice unless they are for palliative needs only. What lacks clarification is that the patient can have these treatments/services but the patient would be responsible for payment. Even though there are many exceptions to coverage, Medicare Part A supplies items such as diapers, medications, and equipment related to the terminal illness, while Medicare Part B covers physician charges. The patient is responsible for any deductible amounts and for any charges not covered as described.

Most hospice patients, especially elderly ones, are eligible for Medicare, which covers most aspects of hospice care and services as long as it is related to the terminal illness. There is no deductible for hospice services although there may be a very small co-payment for prescriptions and for respite care. In most states, Medicaid offers similar coverage. Medicare coverage also includes Medicare Advantage Plans. Many private health insurance plans offer hospice benefits but the extent to which they cover hospice care and services may differ from Medicare as well as from one another. Military families have hospice coverage through Tricare. Most hospices will accept private payment, or “self-pay.” Some hospices have mechanisms by which they can provide services to people who are medically eligible but have neither insurance nor the resources to pay for their care.

Hospice care is given in benefit periods. You can get hospice care for two 90‑day periods followed by an unlimited number of 60‑day periods. Although medical eligibility generally relies on the physician’s opinion that the patient’s life expectancy is 6 months or less, neither the patient nor the physician is penalized if the patient lives longer than 6 months. The patient can be re-certified for as long as he/she continues to be medically eligible. It is also possible with hospice care that a patient’s condition stabilizes and may even improve sufficiently so they no longer meet medical eligibility for hospice services. At that time, the patient is “discharged” from the hospice program and their Medicare benefits revert to the coverage they had before electing hospice care.
(see https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/Hospice )

Hospice patients may choose to pursue curative therapies such as entering a clinical study for a new medication or procedure. In order to do so, the patient must withdraw their selection of hospice care, called “revocation.” Patients who are discharged as well as any who choose to leave hospice care can re-enroll at a later date without penalty at any time they meet the medical eligibility criteria.

To ensure health care providers, facilities, and consumers are aware of hospice service benefits, CMS announced a “Value-Based Medicare Advantage Model” in 2019. This initiative is intended to accelerate the development and testing of new payment and service delivery models for hospice. In October 2019, President Trump issued an Executive Order on “Protecting and Improving Medicare” for our nation’s seniors to include this hospice delivery model. Through both this announcement and a separate RFA that CMS released in January 2020 for other components of the VBID model, CMS is implementing key provisions of the President’s Executive Order. Medicare Advantage (MA) organizations will finalize their VBID plan designs for all components of VBID by the 2021 bid deadline of June 1, 2020.

“Hospice patients find themselves in a particularly vulnerable and difficult time, and the Trump Administration wants to make every provision possible to allow them to focus on their loved ones and their care, rather than government bureaucracy…….This Model is a vital element of that effort. By expanding benefits and coverage and igniting greater coordination, it promises to improve quality of care and quality of life for our nation’s seniors. The result of our efforts has been a dramatic increase of participation in the VBID Model and the value-based, coordinated care it can provide.”
(see press release https://www.cms.gov/newsroom/press-releases/cms-announces-strong-participation-value-based-medicare-advantage-model-cy-2020-and-new )

By reducing fragmentation and increasing financial accountability, CMS is enabling organizations to better coordinate palliative and hospice care for beneficiaries that choose Medicare Advantage.

Arkansans need to improve our knowledge and use of hospice care to ensure that all those who will benefit from hospice care earlier in the course of a serious illness have access to compassionate, high-quality care that proves to be an appropriate transition of care. This needed resource for many elderly people is often overlooked and underused. In 2018, the proportion of Medicare decedents enrolled in hospice at the time of death varied from a low of 13% (other) to a high of 59.4% (UT) with AR ranking 21^st at 50%. More facts and figures for hospice care in the United States and Arkansas and the use of hospice services are available from, The National Hospice and Palliative Care Organization (NHPCO), https://www.nhpco.org/wpcontent/uploads/2019/07/2018_NHPCO_Facts_Figures.pdf, in their facts and figures report.

From The Director’s Desk

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)

Winter 2020

Happy New Year and Happy New Decade from all of us at the Arkansas Geriatric Education Collaborative! I am excited to be writing to you as we begin a brand new decade! Here at the AGEC we have an exciting year planned as we being programs for healthcare professionals and students, community members, caregivers, and older adults.

Reflecting back on the last 3 months of 2019, we had several very successful programs. These included: a 2 day train-the-trainer program where six individuals were recertified in Ageless Grace and 32 individuals were certified to be lay leaders. They can now go to their perspective audiences all over Arkansas and conduct Ageless Grace classes. We also hosted our fall webinar which featured Dr. Masil George who presented on Palliative Care for People with Dementia. Attendance was great with 78 attendees. Another exciting event was National Family Caregiver Month in November where we brought in Mr. Don Guess (an advocate of older adults from the Arkansas Farm Bureau) to conduct an interview that was shown on Facebook as a video. It has had over 6,400 views! We also launched a Caregiving Tips video series that will continue throughout 2020. The AGEC also launched our First Responder Dementia and Elder Justice Online Training and have had over 70 completers to date!

As we look to the first few months of 2020, we will sponsor Geriatric Grand Rounds January 28th with Margaret Pauly, MS, RD, LD and Stephan Dehmel, MD whose program will be titled Gut Check: Are you prescribing the right foods for your elderly patients?. We will also be working closely with our clinical partner ARcare in England, AR. We will be learning with them as we endeavor to help them become the first Age-Friendly Health System in AR. “Age-Friendly Health Systems” is an initiative of the John A. Hartford foundation and the Institute for Healthcare Improvement. The initiative’s goal is to rapidly spread the 4Ms Framework (Medication, Mentation, Mobility, and what Matters to the older adult) to 20% of the US hospitals and medical practices by the end of 2020. We are excited about this challenge as is ARcare!

Our academic partners completed another great semester of training the next generation of healthcare providers and our five Geriatric Student Scholars began their work with the AGEC.

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

Integrated Care: The Role of Mental Health Practitioners on the Primary Health Care Team

By Kevin Rowell, PhD
Department of Psychology and Counseling
University of Central Arkansas

As with the implementation of the Affordable Care Act in 2017, U.S. health care continues to develop the patient-centered medical home model as a way of efficiently coordinating health care delivery. Especially for older patients where complexity of health care is the norm, the weight of responsibility in providing effective, safe, and lower cost interventions rests squarely on the primary care practitioner (PCP). Now that baby boomers have reached late life, it is estimated that approximately one-fourth of patients seen in primary care clinics are over age 65. Although most are in good health, the natural decline in health with aging results in a greater presence of physical illness and dysfunction such that most older adults have at least two chronic conditions, as well as developing acute illnesses at prevalence rates similar to younger adults (CDC, 2013, as cited in Hunter et al, 2017).

While the public clearly understands that primary care is designed to be the first line of help in the case of medical illness and that most treatment is rendered therein, the majority of people do not realize that primary care practitioners are very often the first line of treatment for mental health issues as well (O’Donohue et al, 2005). People struggling with common disorders involving depression, anxiety, and substance abuse will more likely seek help from their PCP before considering intervention from a psychiatrist, psychologist, counselor, or clinical social worker. In fact, roughly one-third of the visits to PCPs is due to a mental health concern, and another one-third of visits involve a medical diagnosis that has a significant mental health component (Blount, 2003). The reasons are attributed to familiarity with the PCP, greater access to a PCP as compared to specialists (especially in rural areas), and fear of stigmatization in visiting a mental health clinic (Hunter, et al, 2017).

Research has shown that the most prevalent mental disorders are major depression, generalized anxiety, somatization, and substance abuse. Other common mental health issues include relationship conflict, stress, sleep disturbance, and fatigue. Not surprisingly, women are much more likely than men to report issues with mental health, which is a very consistent trend across most health care settings. Regarding patients over 65, other mental health issues involve cognitive decline, sexual dysfunction, grief/loss, isolation/loneliness, and lower motivation in managing chronic diseases (Hunter et al, 2007).

Whereas the PCP is able to provide appropriate intervention for many of these issues, usually through medication and perhaps brief consultation, a myriad of factors limits the effectiveness of the PCP in addressing primary mental health disorders and secondary mental health issues in chronic disease management. For example, diagnosing some mental disorders usually necessitates somewhat lengthy interviews and often a screening test, yet the high volume of patients scheduled daily in primary care clinics limits the time a PCP can spend with an individual patient. Furthermore, 60-85 percent of PCPs reported being under-trained in diagnosis and treatment of mental disorders. Additionally, when PCPs decide for a referral to a mental health specialist such as a psychiatrist or psychologist, wait times for appointments can be weeks and the likelihood of the patient following through with the appointment is less than 25 percent. Finally as previously mentioned, many people, especially older adults, with mental health concerns feel stigmatized in visiting a mental health clinic and will often refuse to seek help rather than potentially feel embarrassed or shameful (Blount, 2003, Hunter et al., 2017).

To address these issues, the fully integrated behavioral health model calls for the placement of a full-time behavioral health clinician (BHC) to be employed in primary care. Typically the BHC is a licensed psychologist, professional counselor, or clinical social worker who has received special training in integrated care behavioral health. Advantages of the behavioral health clinician are many. Of utmost importance is the presence of a mental health expert in primary care whose function is to identify primary and secondary mental health issues in patients and then to collaborate with the PCP and other staff in providing effective evidence-based interventions for patients. Through research backed behavioral interventions, BHCs can address stress reduction, mindfulness, sleep hygiene, maladaptive thoughts, as well as adaptive, healthy life style changes like exercise, relaxation, diet changes, smoking cessation, and decreased alcohol/substance use, all of which directly improve mental health and chronic disease management (Hunter et al, 2017). For the older patient, BHCs can conduct screenings for dementia and other cognitive problems, address social isolation, and help with sexual dysfunction.

Research indicates that when a full-time BHC is employed in primary care, treatment effectiveness increases, patient and staff satisfaction increase, and treatment and medication costs decrease (Blount, 2003; Ogbeide, Stermensky II, & Rolin, 2016). For example, one consistent finding is that patients with mood (depression) and anxiety disorders show significant improvement, often without medication, when they work closely with a BHC. Furthermore, when a referral to a mental health specialist is necessary, patients are much more likely to meet the appointment, particularly if the BHC can meet briefly with them during the wait time before the first appointment. The BHC is also freed from the standard 8-10 minute PCP appointment duration to better gather interview information, discuss treatment goals, and even implement brief 15-20 minute follow up appointments to reinforce interventions that are working and to make adjustments where needed.

Older adult patients should be encouraged by the addition of a BHC member to the PCP staff. Such a health care provider is able to better address so many more issues than one’s PCP, and the fact that the BHC has been called in to meet with the older patient in no implies that the patient should be embarrassed or stigmatized. It simply means that he or she will be receiving optimal holistic care that has been shown to have significant benefits.

References:

Blount, A. (2003). Integrated primary care: Organizing the evidence. Families, Systems, and Health, 21, 121-134.

Centers for Disease Control and Prevention (2013). The stage of aging and health in America 2013. Retrieved from http://www.cdc.gov/health/state_of_aging_and_health_in_America_2013.pdf.

Hunter, C. L., Goodie, J. L., Oordt, M. S., & Dobmeyer, A. C. (2017). Integrated behavioral health in primary care: Step-by-step guidance for assessment and intervention (2^nd ed.). Washington DC, American Psychological Association: Washington, D.C.

O’Donohue, W. T., Byrd, M. R., Cummings, N. A., & Henderson, D. A. (2005). Behavioral integrative care: Treatments that work in the primary care setting. New York: Brunner-Rutledge.

Ogbeide, S., Stermensky II, G. & Rolin, S. (2016). Integrated primary care behavioral health for the rural older adult. Practice Innovations, 1, 145-153.

Promoting Safe Driving Among Older Adults Using Driving Simulation Technology

By Amanda Mohler, OTD, OTR/L
Department of Occupational Therapy
Arkansas State University

Driving is a dynamic task requiring the active engagement of an individual’s sensory, perceptual, cognitive, and motor systems. However, as individuals age, the systems are at risk of declining, resulting in poorer accuracy of driving performance. Research shows the effects of aging on physiologic systems often result in decreased muscle strength, coordination, and motor control. The aging systems can result in a slowing of emergency maneuvers and increased breaking time (Karthaus & Falkenstein, 2016). Furthermore, age-related degeneration of the peripheral sensory receptors results in decreased postural control of the lower limbs and decreased force production for pedal reaction (Lacherez, Wood, Anstey, & Lord, 2014; Woolnough et al., 2013). Researchers found cognitive functions relevant for safe driving decline with age as well. Imperative executive function skills such as the ability to visually scan the driving field or shift attention decreases with age. The changes in executive function result in the decreased ability to monitor the environment, react appropriately, and manage multiple tasks, therefore, resulting in an increased risk of accidents or traffic violations (Karthaus & Falkenstein, 2016; Hahn, Wild-Wall, Falkenstein, 2011; Richardson & Marottoli, 2003).

There is a misconception that stricter driving rules and policies for aging adults would resolve the behind the wheel risks.. However, research shows increased monitoring, such as undergoing medical or vision tests to renew one’s license, does not result in increased safe driving or decreased fatal accidents (Karthaus & Falkenstein, 2016). Some proponents of harsher driving laws have even recommended retracting a drivers’ license after a specific age. However, decreased access to driving often encourages individuals to use less safe methods of mobility, such as walking or driving without a license. Therefore, regulating older adult drivers with harsher policies is not the answer. Rather, the solution lies in finding strategies to promote safe driving designed explicitly for the aging population.

To address the growing population of older adults still driving, students from the Department of Occupational Therapy at Arkansas State University (AState) partnered with community civic agencies to promote older adult safe driving using driving simulation technology. Driving simulation is an evolving technology consisting of computer-aided technology to mimic real-life driving scenarios. Trained professionals use driving simulation for assessment and intervention purposes. The simulation technology allows professionals the capacity to assess one’s ability to drive, including physical and cognitive factors. The driving simulation produces real-world and evidence-based results that professionals can review with clients via a report or video replay to provide education and training on their changing needs related to aging and driving.

Because of the flexibility of driving simulation technology, all individuals benefit from it no matter age, gender, disease, or injury. At AState, educated students and faculty use the technology to assess specific human functions related to driving, aging, and older adult diseases. Common assessments include, but are not limited to, physical ability to sustain driving, reaction time, hazardous perceptions, memory, planning, safety, attention, and vehicle control. Each of the driving skills are relevant in assessing and enhancing cognitive, sensory, and motor skills. Following each drive, the health professional reviews the results with clients and provides feedback and recommendations on maintaining safe driving. If clients require additional training, they have the option to participate in a driving program using the simulator. During the driving program, clients receive education on specific impairments and safe driving skills including basic vehicle control skills (e.g., steering wheel, or gas and brake pedal), progressive roadway and driving tasks (e.g., construction zone or metropolitan city), and advanced driving safety and performance skills (e.g., defensive driving or hazard detection).

Since the simulation occurs in a controlled environment, it offers many benefits. One benefit is the ability to provide safe, objective, reliable, and repeatable performance measures (Classen & Brooks, 2014; Be ́dard, Parkkari, Weaver, Riendeau, & Dahlquist, 2010). Second, professionals can present situations that would not otherwise be available or may be too risky for the client at the time of the assessment. The simulator operator can control the simulation settings, including external conditions (e.g., weather, traffic, road surface), exposure to hazards such as school zones or pedestrians, and control the driving situations (e.g., suburban or rural).

Driving is an everyday and automatic task. For many older adults, driving is a way to remain independent and mobile. Losing the ability to drive puts one at risk for depression, isolation, and decreased health. Therefore, restricting or revoking an older adults’ ability to drive has the potential to increase the national economic burden and decrease one’s overall quality of life. It is not a matter of changing policies or restricting one’s license. Instead, professionals and policymakers should focus on educating older adults on safe driving and addressing their changing skills associated with the natural age-related process.

References

Be ́dard, M., Parkkari, M., Weaver, B., Riendeau, J., & Dahlquist, M. (2010). Brief Report— Assessment of driving performance using a simulator protocol: Validity and reproducibility. American Journal of Occupational Therapy, 64, 336–340.

Classen, S. & Brooks, J. (2014). Driving Simulators for Occupational Therapy Screening, Assessment, and Intervention. Occupational Therapy in Health Care, 28(2), 154-162. doi: 10.3109/07380577.2014.901590

Hahn, M., Wild-Wall, N., & Falkenstein, M. (2011). Age-related differences in performance and stimulus processing in dual task situation. Brain Research, 1414, 66–76.

Lacherez, P., Wood, J.M., Anstey, K.J., & Lord, S. (2014). Sensorimotor and postural control factors associated with driving safety in a community-dwelling older driver population. Journals of Gerontology Series A: Biological Sciences & Medical Sciences, 69 (2), 240–244. Retrieved from http://dx.doi.org/10.1093/gerona/glt173

Richardson, E.D. & Marottoli, R.A. (2003). Visual attention and driving behaviors among community-living older persons. Journal of Gerontology: Series A, 58, M832–M836.

Woolnough, A., Salim, D., Marshall, S.C., Weegar, K., PorterM.M., Rapoport, M.J., Man Son-Hing, M.,…Vrkljan, B. (2013). Determining the validity of the AMA guide: A historical cohort analysis of the assessment of driving related skills and crash rate among older drivers. Accident Analysis & Prevention. 61, 311–316. Retrieved from: http://dx.doi.org/10.1016/j. aap.2013.03.020

What’s New in the 2019 Guidelines for Community-Acquired Pneumonia?

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

Several factors increase the frequency of infection and pneumonia in older adults including lowered immune function, the presence of comorbid conditions, and nursing home residence.¹ Community-acquired pneumonia (CAP) is defined as an acute infection of the pulmonary tissue that is acquired outside of a health care setting.² CAP is a leading cause of morbidity and mortality worldwide. The clinical presentation of CAP ranges from mild pneumonia, characterized by fever, cough, and shortness of breath, to severe pneumonia, characterized by sepsis and respiratory distress.²In 2019 the American Thoracic Society (ATS) and Infectious Disease Society of America (IDSA) released an update to their 2007 guidelines on CAP.³ This marks the first update in over a decade. This update is especially important to geriatrics because CAP is one of the most common and fatal infectious diseases seen in this patient population.⁴

Major changes introduced in the new guidelines:

Instead of defining severe CAP based on the location of treatment (inpatient or ICU), the new guidelines have introduced a validated definition in which 3 or more minor or 1 major criteria must be met in order to classify the diagnosis as severe CAP. Minor criteria are: respiratory rate ≥ 30 breaths/min, PaO2/FiO2 ratio ≤ 250, multilobar infiltrates, confusion/disorientation, blood urea nitrogen level ≥ 20 mg/dl, leukopenia, thrombocytopenia, hypothermia, and hypotension requiring aggressive fluid resuscitation. Major criteria are septic shock with need for vasopressors and respiratory failure requiring mechanical ventilation.
Sputum and blood cultures should be obtained if possible for patients with severe disease (without delaying antibiotic therapy), but the new guidelines expand this recommendation to include inpatients empirically treated for MRSA or Pseudomonas aeruginosa.
Macrolide monotherapy (i.e, azithromycin, clarithromycin) may be used for outpatients, but only in areas where pneumococcal resistance to macrolides is reported to be less than 25%.
The new guidelines do not recommend procalcitonin levels to decide if antibiotic therapy should be initiated. These are reserved for identifying when to discontinue antibiotics in hospital acquired or ventilator associated pneumonia.
Corticosteroids are not recommended, but may be considered in patients with refractory septic shock.
The healthcare associated pneumonia (HCAP) category was introduced in 2005. The most recent recommendations are to stop using this categorization to determine if extended-spectrum antibiotics should be used. Instead, the presence of local epidemiology and risk factors decide if MRSA or P. aeruginosa coverage is needed for CAP. There is an emphasis on de-escalation of antibiotic therapy based on culture results.
In the previous guidelines, empiric therapy for severe CAP was a beta lactam + macrolide or beta lactam + fluoroquinolone. Now a beta lactam + macrolide is preferred. This is due to the increase risks identified with fluoroquinolone therapy.
Finally, follow up chest imaging is not recommended for patients who are improving.¹

The approach to diagnosis and management of pneumonia in older adults is generally the same as in the general population, although older adults are more often afflicted with severe disease or sepsis.¹ The fact that most patients with community-acquired pneumonia can still be treated with tried-and-tested regimens like macrolides or macrolides and beta lactam antibiotics that have been used for decades is encouraging in the face of concerns over increasing antibiotic resistance. When treating older adults, the use of broader empiric treatment initially is common due to increased risk of drug resistance, and higher incidence of severe forms of pneumonia. The new guidelines may improve tailored antibiotic use in older adults with the change in definition of severe CAP, and focus on de-escalation of therapy when possible.

References:

Mody, L. Approach to infection in the older adult. In: UpToDate, Schmader, K.E. & Givens, J., UpToDate. Waltham, MA, 2019.
Ramirez, J.A. Overview of community-acquired pneumonia in adults. In: UpToDate, File Jr., T.M. & Bond, S., UpToDate. Waltham, MA, 2019.
Metlay, J. P., Waterer, G. W., Long, A. C., Anzueto, A., Brozek, J., Crothers, K., … & Griffin, M. R. (2019). Diagnosis and Treatment of Adults with Community-acquired Pneumonia. An Official Clinical Practice Guideline of the American Thoracic Society and Infectious Diseases Society of America. American Journal of Respiratory and Critical Care Medicine, 200 (7), e45-e67.
Niederman, M. S., & Ahmed, Q. A. (2003). Community-acquired pneumonia in elderly patients. Clinics in geriatric medicine, 19(1), 101-120.

Geriatric Student Scholars Selected for 2020

By Whitney Thomasson, MAP
Research Assistant
UAMS Arkansas Geriatric Education Collaborative

It is with great pleasure that the UAMS Arkansas Geriatric Education Collaborative (AGEC) announces its 2020 selection for the Geriatric Student Scholars program: Abbey Belote (Doctorate of Physical Therapy student), Caitlyn Crowder (Doctorate of Audiology student), Serena Van (Doctorate of Pharmacy student), Rebekah Ward (Physician Assistant student), and Sarah Wilson (Hendrix College Pre-Medical undergraduate).

The purpose of the Student Scholars program is to increase health professions students’ interest in and exposure to older adults, to improve knowledge of older adult health issues and the specialized care they need, and to promote interprofessional collaboration among health professions students. Throughout the program, the scholars are required to attend a minimum number of academic and community programs focused on older adults, and write reflections on their experiences. The scholars will also work collaboratively on a team project this spring, which will focus on a current geriatric-related issue.

We at AGEC are proud to support our second annual cohort of geriatric scholars. While keeping academic and community program participation at the center of the student experience, we made a couple of modifications to this year’s program for a more immersive learning opportunity. First, we extended the program from 4 months (spring semester) to 6 months (mid-fall and spring semester). This is in an effort to allow for more time for all the students to properly meet each other, to participate in more academic and community programs, and to fully plan and execute an interprofessional “capstone” project. As well, this was our first year accepting five student scholars instead of four. In fostering our partnership with Hendrix College, we accepted undergraduate applicants from the college for a fifth slot on our Student Scholars program for 2020. We are excited to see how an undergraduate perspective from another college will shape the interprofessional approach of the scholars.

To read more about our scholar selection, please visit our 2020 Student Scholar page. In addition, Hendrix College recently released a wonderful article about our undergraduate scholar Sarah Wilson, which you can read here.

We look forward to an exciting 2020 with our Geriatric Student Scholars!

From The Director’s Desk

Fall 2019

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

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

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

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

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

Leakage – Is it a Normal Part of Aging?

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

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

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

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

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

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

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

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

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

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

Medication Class and Examples

Advantages

Disadvantages

Cost

Benzodiazepines

Temazepam

Triazolam

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

Minimal effectiveness

Not for long-term use

Schedule IV controlled substance – potential for abuse

$ – $$

Non – Benzodiazepine Sedatives

Zolpidem

Zaleplon

Eszopiclone

Short half-life-less hangover

Fewer side effects at low doses

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

Not for long-term use

Schedule IV controlled substance – potential for abuse

Antidepressants Doxepin

Trazodone

Mirtazapine

Improvement significant

Doxepin: Minimal side effects at doses ≤ 6 mg

Side effects: drowsiness, dizziness, constipation

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

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

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

Except:

Doxepin

3-6 mg $$$

Antihistamines

Diphenhydramine

Available over-the-counter

Side effects: drowsiness, dizziness, cognitive impairment, falls, constipation, tolerance

Melatonin Receptor Agonists
Ramelteon, Melatonin

Minimal side effects

No rebound insomnia

Ramelteon:

Significant improvement

Melatonin:

Available over-the-counter

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

Melatonin: Dietary supplement with lack of standardization

Ramelteon $$$

Melatonin $

Orexin Receptor Antagonist

Suvorexant

Well-tolerated

Side effects: drowsiness

Schedule IV controlled substance – potential for abuse

$$$

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

References:

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

Physical Activity for Older Adults

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

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

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

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

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

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

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

References

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

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

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

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

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