UAMS

Geriatric Student Scholars 2022-2023 Selected

It is with great pleasure that the UAMS Arkansas Geriatric Education Collaborative (AGEC) announces its 2022-2023 selection for the Geriatric Student Scholars program – Dhielan Bustos (College of Health Professions), Ranique Daniel (College of Nursing), Stephanie Graves (College of Health Professions), Szarria Thomas (College of Pharmacy), and Julia Townsley (College of Medicine).

The purpose of the Student Scholars program (sponsored by AGEC) is to increase health professions students’ interest and exposure to older adults, to improve knowledge of older adults and the specialized care they need and to promote interprofessional collaboration among health professions students.

We are so excited to announce the Geriatric Student Scholars for FY 2023 to support emerging health professionals education and participation surrounding specialized needs for older adults, and to foster interprofessional collaboration in academic and clinical geriatrics. The goal of the Geriatric Workforce Enhancement Program (GWEP) is to enhance the quality of health care for elderly Arkansans through research, education and training. The Geriatric Student Scholars program is an excellent way to achieve this goal and mentor future healthcare team members.
AGEC Director, Robin McAtee, Ph.D., RN., FACHE

The Arkansas Geriatric Education Collaborative is a program of the University Of Arkansas for Medical Sciences – Donald W. Reynolds Institute on Aging. The collaborative is funded by a Health Resources and Services Administration grant of $3.7 million for a Geriatrics Workforce Enhancement Program.

Geriatric Student Scholars – Congrats!

Dhielan Bustos (Third-year Doctor of Physical Therapy student, NWA campus)
Ranique Daniel (Fourth-year BSN student)
Stephanie Graves (Second-year Physician Assistant student)
Szarria Thomas (Second-year Pharmacy student)
Julia Townsley (Second-year Medicine student)

Dhielan Bustos is a third-year Doctor of Physical Therapy student at the UAMS-NWA campus. He is originally from California but was raised in New Jersey and attended Rutgers University where he received his Bachelor of Science degree in Neurobiology. Dill, a nickname he goes by, has worked in many settings that led to his acceptance to PT school that included a skilled nursing facility, an outpatient sports clinic, and an outpatient geriatric clinic. Besides studying, Dill likes coffee, going to the gym, playing tennis, and spending time with friends and family. His interests in geriatrics began at his first PT tech job in a skilled nursing facility where he got to work with many geriatric patients with complex medical conditions. He recognized just how powerful the rehabilitation can be for older adults by assisting with exercises, providing care, and witnessing their incredible progression. In his career as a physical therapy student, he looks to figure out ways at which he can incorporate higher intensity interval training in the older adult population as part of their treatment plan. Dill is very thankful for being chosen to be a Geriatric Student Scholar and is excited to gain insight on how he can improve the lives of older adults.

Ranique Daniel is a Senior BSN Student from Marked Tree, Arkansas. She is a recent University of Arkansas Alumna (Woo Pig!) and first-generation college graduate with a B.S. in Public Health and minor in Medical Humanities. She is honored to have been selected as a Geriatric Student Scholar, and looks forward to expanding her knowledge on serving this special population. She had the opportunity of working with this population this past summer with a student nurse internship at Wellth, Inc., and has always had the desire to learn more about their standard of care after taking care of her own great grandmother for many years. She witnessed a deficit in the care for older adults during this time in the Delta region of Arkansas, and this made her realize the importance of how much further it is we have to go, and it starts with us! This is a wonderful opportunity to work with this interdisciplinary team and the UAMS Geriatric Education Collaborative to further advance her education, and she looks forward to what this year brings!

Szarria Thomas is a second-year pharmacy student at University of Arkansas Medical Sciences. She has a received a Bachelor of Science in Biology with a chemistry minor. Her past and current experience working in retail pharmacy with geriatric patients, exposed to her the importance of the need of more exploration of the care of geriatric population. The opportunity to immerse into the study of how medications effect geriatric patients is intriguing and imperative to the future. Her goal as an AGEC scholar is to gain knowledge through research that will propel her passion to clinically provide exceptional care as well as knowledge to the geriatric community.

Julia Townsley

Julia Townsley is a second-year MD student in the College of Medicine at UAMS. She is from Fayetteville, AR, where she grew up and would later attend college. She received a B.S. Degree in Biomedical Engineering at the University of Arkansas. Julia is the President of the UAMS Geriatric Interest Group and is completing the Honors in Underserved Primary Care Program. With experience being a caregiver for her grandmothers, Julia was drawn to geriatric medicine from a young age and is excited to work with the aging population. She is grateful for the opportunity to be an AGEC Geriatric Student Scholar and is looking forward to the experiences she will have within the program. Her future goals include working as a geriatrician to be an advocate for elder patients and to provide a supportive community for her patients. In her free time, Julia is a singer for a local church and enjoys spending time with her friends.

From the Director’s Desk

Fall 2022 Newsletter

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

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

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

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

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

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

Management of Weight Loss in Hospitalized Older Adults

Fall 2022 Newsletter

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

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

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

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

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

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

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

References:

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

From the Director’s Desk

Summer 2022 Newsletter

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

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

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

Try to stay cool the rest of the summer!!

Nutritional Biomarkers of Age-Related Muscle Loss

Summer 2022 Newsletter

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

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

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

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

References

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

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

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

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

5. Chen LK, Woo J, Assantachai P, Auyeung TW, Chou MY, Iijima K, Jang HC, Kang L, Kim M, Kim S, Kojima T, Kuzuya M, Lee JSW, Lee SY, Lee WJ, Lee Y, Liang CK, Lim JY, Lim WS, Peng LN, Sugimoto K, Tanaka T, Won CW, Yamada M, Zhang T, Akishita M, Arai H. Asian Working Group for Sarcopenia: 2019 Consensus Update on Sarcopenia Diagnosis and Treatment. J Am Med Dir Assoc. 2020 Mar;21(3):300-307.e2. PMID: 32033882

6. Cruz-Jentoft AJ, Baeyens JP, Bauer JM, Boirie Y, Cederholm T, Landi F, Martin FC, Michel JP, Rolland Y, Schneider SM, Topinková E, Vandewoude M, Zamboni M, European Working Group on Sarcopenia in Older People. Sarcopenia: European consensus on definition and diagnosis: Report of the European Working Group on Sarcopenia in Older People. Age Ageing. 2010 Jul;39(4):412–423. PMCID: PMC2886201

7. Cederholm T, Barazzoni R, Austin P, Ballmer P, Biolo G, Bischoff SC, Compher C, Correia I, Higashiguchi T, Holst M, Jensen GL, Malone A, Muscaritoli M, Nyulasi I, Pirlich M, Rothenberg E, Schindler K, Schneider SM, de van der Schueren M a. E, Sieber C, Valentini L, Yu JC, Van Gossum A, Singer P. ESPEN guidelines on definitions and terminology of clinical nutrition. Clin Nutr. 2017 Feb;36(1):49–64. PMID: 27642056

8. Moore DR. Keeping Older Muscle “Young” through Dietary Protein and Physical Activity12. Adv Nutr. 2014 Sep 1;5(5):599S-607S. PMCID: PMC4188243

9. Mitchell WK, Williams J, Atherton P, Larvin M, Lund J, Narici M. Sarcopenia, dynapenia, and the impact of advancing age on human skeletal muscle size and strength; a quantitative review. Front Physiol. 2012;3:260. PMCID: PMC3429036

10. Church DD, Hirsch KR, Park S, Kim IY, Gwin JA, Pasiakos SM, Wolfe RR, Ferrando AA. Essential Amino Acids and Protein Synthesis: Insights into Maximizing the Muscle and Whole-Body Response to Feeding. Nutrients. 2020 Dec 2;12(12). PMCID: PMC7760188

11. Pennings B, Boirie Y, Senden JMG, Gijsen AP, Kuipers H, van Loon LJC. Whey protein stimulates postprandial muscle protein accretion more effectively than do casein and casein hydrolysate in older men. Am J Clin Nutr. 2011 May;93(5):997–1005. PMID: 21367943

Choosing Wisely: Focused Recommendations to Improve Deprescribing Practices

Summer 2022 Newsletter

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

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

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

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

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

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

Two recommendations are specific to avoiding use of anticholinergic medications.

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

The last recommendation focuses on tramadol in particular.

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

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

References:

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

Meet AGEC’s New Junior Faculty Development Awardees

Robin McAtee, PhD, RN, FACHE, Arkansas Geriatric Education Collaborative (AGEC) Director, and Ronni Chernoff, PhD, FAND, FASPEN, Associate Director, are pleased to announce the newest awardees of the AGEC Junior Faculty Development Fellowship in geriatrics at the Donald W. Reynolds Institute on Aging at UAMS.

Caitlin Price, Au.D., Ph.D., CCC-A and Lee Isaac, Psy.D. were notified of the decision in June 2022. Dr. Price will begin her year-long program in July 2022, and Dr. Isaac will begin in January 2023. The AGEC Junior Faculty Development program objective is to support the career development of professionals who want to specialize in academic and clinical geriatrics. The award includes $25,000 in salary support and supported attendance at one national geriatric conference.

About Dr. Caitlin Price

Caitlin Price, Au.D., Ph.D., CCC-A, is an assistant professor in the UAMS Department of Audiology and Speech Pathology and is a licensed clinical audiologist with expertise in adult diagnostics, rehabilitation, and auditory electrophysiology. She has extensive clinical experience with geriatric populations and has initiated patient-driven inquiries on best practices and other clinically applicable research topics related to cognitive aging, auditory perception, and speech-in-noise processing. In her postdoctoral fellowship, she worked with interdisciplinary teams to evaluate the impact of cognitive impairment on the auditory processing of speech in older adults. Her research aims to assess individual differences that contribute to speech-in-noise deficits and develop effective clinical interventions to foster successful communication across the lifespan.

About Dr. Lee Isaac

Lee Isaac, Psy.D., is a postdoctoral fellow in Clinical Neuropsychology at UAMS and will be joining the faculty as an assistant professor in August 2022. He graduated from La Salle University in Philadelphia, PA, with a doctoral degree in Clinical Psychology, and completed his clinical internship at UAMS. He specializes in geriatric neuropsychology, and his clinical work includes neurocognitive assessment for patients with suspected neurodegenerative conditions and movement disorders. His research presently focuses on updated assessments for dementia populations and diagnostic specificity in types of dementia, particularly with the integration of technology.

From the Director’s Desk

Spring 2022 Newsletter

Thank you to all of our AGEC health professional friends and peers for continuing to support AGEC programs and activities. We started off this year with more depressing COVID-19 Omicron news and a huge uptick in positive cases. However, we marched on and now as spring is emerging, we are once again having face-to-face programs and attending in-person events. Hooray! Our community participants have been very excited about getting back together face-to-face for evidence-based programs and activities and attendance has been great. The social isolation over the past two years has certainly taken its toll, but we are doing what we can to limit or even reverse its effect.

Over the past 3 months we have worked diligently to maintain programming and activities and our outcomes are great. For the clinical activities in March, we were excited to partner with Opioid Prevention for Aging and Longevity (OPAL) and UAMS’s Academic Detailing program at the Psychiatric Research Institute to provide 2 hours of continuing education on Naloxone to AGEC’s clinical partners at ARcare in England, Augusta, Cabot West, Bald Knob, Wynne and Benton. OPAL is also securing Naloxone kits which will be distributed to these clinics when available.

We continued to also provide many programs virtually. Highlights included several events via Zoom such as: Eat Well Live Well at the Benton Senior Center; Mental Health, Food, & Exercise with partners AARP & AR-Connect; Internet Safety via Zoom in partnership with the Central Arkansas Library System; Caregiver Resources with partner AARP; Kidney Health at the Bryant Senior Center; and Preventing Isolation in partnership with UCA students. The AGEC Age Wise podcast continues to be popular along with AGEC’s Facebook page where we now have over 2,400 followers. The program “Understanding Dementia & Alzheimer’s Disease” was presented for 28 UCA Consumer Science students in February, and a video caregiver story entitled “Dealing with Hardships While Caring for Parents” was released online for National Caregivers Day on 2/18/22, with over 2,800 views.

Health Professional trainings have also been active with over 200 attendees this past quarter. Webinars included: Immunization 2022: Communication & Science Update (1/12/22); and The Importance of Hearing in Healthy Cognitive Aging (2/16/22). On 2/8/22, The Challenges and Opportunities: Working with Rural CBOs, was presented to a national audience during a GWEP-CC Peer Sharing Webinar, and the AGEC webinar for March was in partnership with OPAL with Kirk Lane, AR Drug Director, titled Arkansas Naloxone Project.

AGEC has also been excited to get back out in the community presenting evidence-based programs and activities face-to-face at local communities of faith and senior centers. Older adults are attending these programs and enjoying meeting again with their peers! We at the AGEC thank all of you for your loyalty and partnerships; we could not reach all the healthcare professionals, students, or older adults without all of you! Thank you!!!

Home Medication Management

Spring 2022 Newsletter

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

Many older adults have difficulty taking their medications every day at home. With chronic health conditions, daily medications are an important part of staying healthy just like eating a balanced diet and exercising regularly. Forgetting to take medications that are needed increases the risk of disease flare-up, hospitalization, and nursing home admission. Clinicians need to stay current on the options to help older adults stay independent in their homes or reduce the burden on caregivers.

A key factor in managing medications at home is to maintain a current list. This list should include all prescription medications as well as any medications a patient is taking without a prescription including over-the-counter medications, dietary supplements, vitamins, and herbal remedies. The medication name, dose, and directions should be included. The patient or caregiver should be educated on what each medication is for as well as how to take it and what should be expected, both therapeutic and adverse effects. It may be helpful to write this information on the medication list as a reminder or a reference. The patient/caregiver should keep this list in a convenient location such as a wallet or purse for when they have a doctor’s visit or an emergency. (Zonsius 2022)

The second factor in managing medications at home is to have a way to keep track of administration. Simple options include a calendar to mark off when medications are taken, or a daily administration record. They are available from some pharmacies, doctors’ offices, and the Internet, or a person can create their own. These charts can be posted on the refrigerator or other convenient location. Another option is a talking alarm which can be set to provide a reminder of when it is time to take your medication. See Figure 1 for examples of charts and alarms. People with smart phones can download an app which will provide reminders and allow tracking of when medications are taken. Some examples include MediSafe and DoseCast. (Treichler 2022)

Pill containers are another option that help a patient that just needs to see if they have taken their medications (or not) each day to help keep track. Also, they can be filled ahead of time by caregivers so a person can maintain independence with taking medications each day. These containers come in a wide variety. Most recognized are weekly containers with openings for 7, 14, or 30 days. These can be filled with medications that are needed for each day. Other pill containers are arranged with 4 administration times for each day of the week. (Figure 2)

Some high-tech products provide automatic dispensing of the medications when it is administration time. Alarms sound when it is time to take the medication so the patient can press a button for the tablet(s) to be dispensed. In this way, they prevent a person from opening up the containers when it isn’t time to take their medication. In addition, some can be connected to the Internet to allow monitoring of medication dispensed remotely by caregivers who can’t be present for each administration time. (Figure 3)

Individuals with low vision may benefit from larger print prescription labels. These can be request from most pharmacies. Pill containers as discussed above are often labeled in Braille for the days of the week or administration times. Other options are gadgets have been developed which are attached to prescription bottles or use a reading device programmed to provide talking prescription instructions.

Many pharmacies provide services that can be helpful in managing medications at home. Pill packing services involve preparing a blister pack for each administration time for medications. Often these are provided without additional charge. Pill packing services can be arranged by some local community pharmacies, particularly stores that are independently owned. Some mail order pharmacies also provide this service.

Another important service that community pharmacies provide is medication reconciliation and comprehensive medication review. As the number of prescriptions and over-the-counter medications a patient takes increases, it becomes more likely that a medication is continued that is no longer needed, a drug-drug interaction is occurring, or administration instructions get confused between different medications. Pharmacists are trained to review each medication to determine if any of these concerns are occurring and can work with providers to assure a patient is on an optimal medication regimen. Having fewer medications to take is another way to help with managing medications at home. A medication reconciliation and review is recommended for all older adults each time a medication is prescribed. (LeBlanc 2015)

In conclusion, health care professionals need to be aware of the many options for helping patients manage medications at home. Medication education and reconciliation go hand-in-hand with tools and devices designed to keep medication administration safe and convenient for our older patients.

Figure 1: Examples of Alarms and Charts

Figure 2: Pill Container Examples

Figure 2: Automatic Pill Dispenser Examples

References:

LeBlanc RG, Choi J. Optimizing medication safety in the home. Home Healthcare Now, 2015; 33:313-9

Treichler C. The 10 best medication reminder apps for 2022. Onlinedoctor January 16. 2022. https://www.onlinedoctor.com/best-medicine-reminder-apps/ . Accessed April 12, 2022.

Zonsius MC, Myftari K, Newman M, Emery-Tiburcio EE. Optimizing older adults’ medication use. AJN, 2022; 122:38-43.

UAMS PatientsLearn: Free Educational Programs for Older Adults and Caregivers

Spring 2022 Newsletter

By Whitney Thomasson, MAP, CRS
Research Assistant
UAMS Arkansas Geriatric Education Collaborative (AGEC)

The Arkansas Geriatric Education Collaborative (AGEC) has worked in partnership with the UAMS Institute for Digital Health & Innovation (IDHI) via PatientsLearn to provide free, on-demand, virtual educational programs for older adults on a variety of topics such as disaster preparedness and social isolation. UAMS PatientsLearn is an online medical education hub, with a patient-centered approach for health and wellness resources. In total, 7 AGEC programs are available, ranging from about 25 minutes to 1 hour in length. These programs can be valuable educational tools for older adults, caregivers, and healthcare professionals for referral resources. Registration is free, simple, and available nationwide. Click here for our available programs via UAMS PatientsLearn.

Recognizing & Preventing Social Isolation: This program educates participants on both the warning signs and the effects of isolation and loneliness. Tips for prevention are shared, along with resources for both older adults and caregivers facing these issues.
Heart Health & Brain Health: This program helps viewers better understand the connection between heart and brain health. Risk factors and prevention measures for stroke, dementia, and heart disease are also discussed.
Eat Well Live Well: Through utilization of the Dietary Guidelines for Americans, this program defines terms about diet and nutrition, and highlights reliable dietary resources. Eat Well Live Well aims to guide older adults in developing healthy dietary patterns.
Understanding Dementia & Alzheimer’s Disease: This program was created for family caregivers and community members alike to gain awareness and knowledge about dementia and Alzheimer’s disease. Normal aging vs dementia is discussed, along with risk factors, the stages of Alzheimer’s disease, and dementia-friendly communication skills.
Understanding Opioids: The definition and examples of opioids are covered in this program, along with a background of the opioid epidemic and its effect on prescriptions. Best practices after receiving a prescription opioid are addressed, along with a variety of non-opioid pain management alternatives. Free chronic pain booklets are available for viewers.
Fall Prevention & Home Safety: In this program, viewers learn about how to identify and prevent the risk of falls, the physical and mental consequences of falling, resources for safety checks, and exercises for fall prevention. Tips for improving an older adult’s balance, as well as for improving home safety, are discussed.
Disaster Preparedness for Seniors: In collaboration with the American Red Cross, preparedness tips for many types of disasters (weather, climate, home fire/flood, etc.) are covered. Emergency kits, evacuation plans, as well as best practices for caring for a loved one with dementia in a disaster are covered in this program.

All of the above programs are available 24/7, at no cost, via UAMS PatientsLearn. Be sure to check back later in 2022 for additional programming. Please share these programs with older adults and caregivers in your circles who may benefit from this education!