UAMS

From the Director’s Desk

Winter 2021 Newsletter

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

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

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

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

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

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

Beyond Diabetes: Use of Antidiabetic Agents in Heart Failure

Winter 2021 Newsletter

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

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

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

Table 1. Dapagliflozin and Empagliflozin in Heart Failure Trials

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

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

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

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

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

References:

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

From the Director’s Desk

Fall 2020 Newsletter

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

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

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

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

Over the Counter Topical Agents for Arthritis Pain

Fall 2020 Newsletter

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

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

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

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

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

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

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

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

References:

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

Dementia Training for First Responders

Fall 2020 Newsletter

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

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

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

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

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

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

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

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

Meet Our 2020 Geriatric Fellows

UAMS AGEC 2020 Geriatric Fellows

Robin McAtee, PhD, RN, FACHE, Director and Ronni Chernoff, PhD, FAND, FASPEN, AGEC Associate Director are pleased to announce awardees for the 2020 Junior Faculty Fellowships in geriatrics at the Donald W. Reynolds Institute on Aging at UAMS. Obioma Nwaiwu, MD, PhD and Stephanie Trotter, PhD, RN were notified of the decision in June 2020. The fellowship program objective is to support the career development of professionals who want to specialize in academic and clinical geriatrics. The award includes $30,000 in salary support and supported attendance for each at (1) national geriatric conference.

Obioma Nwaiwu, MD, PhD

Obioma Nwaiwu, MD, PhD obtained his medical degree from University of Ibadan, Nigeria, a PhD in Health Services Research from Texas A&M Health Science Center, and completed his family medicine residency at the University of Arkansas for Medical Sciences. He was accepted into the geriatric fellowship program at UAMS in 2019 and has now joined the Department of Geriatrics as an assistant professor. His passion for improving access to care and reducing disparity for vulnerable older adults started prior to his medical education. Over the past few years, he has been involved in multiple projects aimed at improving access and care for vulnerable older adults and he has collaborated with the community leaders in this effort. He is very interested in helping older adults to reduce their fall risk and partnered with Area Agencies on Aging in Texas to implement and evaluate falls reduction programs. He is also an Aging Research in Criminal Justice & Health Network Scholars Awardee where he plans to evaluate the need, capacity, and interest in improving access to care of incarcerated older adults in Arkansas through provision of geriatric consultation services.

Stephanie Trotter, PhD, RN

Stephanie Trotter, PhD, RN began a second career in 2010, when she chose nursing as a second career path. She completed her baccalaureate nursing degree in 2012 and a PhD in nursing in 2017 both at UAMS. She loves the diversity and limitless opportunities available in this healthcare field. While obtaining her undergraduate degree, she was selected for the Hartford Center for Geriatric Nursing Excellence externship. During this experience, she developed a passion for the health and well-being of Arkansas’ geriatric population and this is where her teaching and research has since focused. Her dissertation work focused on age-specific differences in time perspectives, health beliefs, and behaviors of hypertensive adults. Dr. Trotter is a faculty member of UAMS’ College of Nursing where she strives to cultivate respect and passion for the geriatric population in undergraduate nursing students. She feels that as a nurse educator, it is her calling to prepare the next generation of nurses to care for older adults. In her free time, she enjoys family time, including her four-legged family members, and home improvement projects.

From The Director’s Desk

Spring 2020

Is this a new AGEC era?

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

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

We are converting community programs into virtual forums:

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

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

Polypharmacy: Definition, Causes, and Solutions

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

Definitions

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

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

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

Causes

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

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

Prevention and Intervention

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

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

References:

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

Age-Friendly Healthcare in Rural Arkansas

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

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

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

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

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