Winter 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 New Year to all of you from the Arkansas Geriatric Education Collaborative staff! As we have attempted to settle back into routines after the holidays, I suspect many of you may be struggling a bit, just as we are here at the AGEC. We had just begun to get back out into the communities with robust programming when Omicron decided to visit. Here we go again! 

On the positive side, after almost two years, we have all learned new skill sets! We can effectively work remotely: we can teach and learn, we can conduct community education and exercise activities, we can “meet”, we can still deliver great outcomes, and most of all – we have learned that no one cares what we look like on Zoom!

Fall of 2021 was very busy for AGEC. We met with our HRSA project officer in October and reviewed our quarterly report where we were congratulated on all of our accomplishments, including our MIPS and age-friendly training with our clinical partner, ARcare. A special thanks and shout out to our lead partner at ARcare, John Beard, and Dr. Leah Tobey, here at the AGEC, for their tireless training and reporting which is required to meet objectives of this grant!

AGEC also continued with webinars with Dr. Lee Isaac in October where he presented Diversity in Dementia, and Dr. Jonathan Laryea who spoke in December regarding Older Adults and Constipation. Dr. Tobey and Ms. Spradley from the AGEC also spoke at the Reynolds Institute on Aging 5^th Annual Dementia Update to caregivers, and I presented at the Dementia Update to the healthcare professionals regarding: What Matters Most: A critical part of the dementia care equation.

We had a plethora of special events during November that aligned with National Family Caregiver Month, and they were all very well received. AGEC Podcasts are doing well and  Vanessa Lee & Laura Spradley spent time being guests on The Vine, a KTHV Channel 11 morning program, where they spoke about AGEC caregiver-related programs in November and appeared again in December. 

As we buckle down for what are usually the worst winter months in Arkansas, January and February, let’s keep working and helping our older adults. Let’s keep learning and improving our knowledge and skills for them!

Stay warm and safe!

Winter 2022 Newsletter

By Jasmine (Sea) An, PharmD, PGY2 Geriatric Pharmacy Resident, and Lisa C Hutchison, PharmD, MPH
University of Arkansas for Medical Sciences (UAMS) College of Pharmacy

In June 2021, the U.S. Food and Drug Administration (FDA) approved the first-of-its-kind monoclonal antibody indicated for treatment of Alzheimer’s disease in patients with mild cognitive impairment or mild stage of disease. Despite this groundbreaking approval, controversy surrounds the drug.

Aducanumab (Aduhelm) is an anti-amyloid monoclonal antibody directed against aggregated amyloid beta (AAB) plaques, which is a defining pathophysiological feature of Alzheimer’s disease.¹ Administration requires infusion over a 1-hour period every 4 weeks. The dose is slowly titrated to meet the goal dose (10 mg/kg) by the seventh infusion. According to the FDA label, no diagnostic tests are required to confirm the presence of AAB plaques prior to initiating this therapy. However, patients are required to obtain magnetic resonance imaging (MRI) at baseline and prior to their seventh and twelfth dose to screen for potential adverse events. The FDA label does not specify any contraindications.

Part of the controversy with aducanumab is the limited data available to evaluate the efficacy of aducanumab. Approval was based on two phase-3 trials. Phase-3 trials help confirm effectiveness and safety of investigational drugs. Both trials were terminated early due to clinical futility. However, Biogen, the manufacturer of aducanumab, subsequently conducted post hoc analysis of the data from the terminated trials to present to the FDA.

The two trials are called ENGAGE² and EMERGE³. Both trials were 18-month, double-blind, randomized, placebo-controlled, parallel group studies. Patients received placebo, low-dose aducanumab (3 or 6 mg/kg), or high dose aducanumab (6 or 10 mg/kg). Some of the major exclusion criteria were:

• age over 85,
• transient ischemic attack or stroke within one year prior to screening,
• contraindications to having a brain MRI or PET scan, and
• use of medications with platelet antiaggregant or anticoagulant properties.^2,3

The primary endpoint was changes from baseline in Clinical Dementia Rating Scale Sum of Boxes (CDR-SB), and secondary endpoints were changes from baseline in Mini-Mental State Exam (MMSE), Alzheimer’s Disease Assessment Scale-Cognitive Subscale (ADAS-Cog), and Alzheimer’s Disease Cooperative Study Activities of Daily Living MCI (ADCS-ADL-MCI). Both trials showed statistical reduction in AAB plaque compared to baseline. However, neither trial showed statistically significant difference in clinically useful endpoints for low-dose aducanumab.⁴ As for high-dose aducanumab, there were mixed results with the EMERGE trial showing statistical significance in the primary endpoint while the ENGAGE trial not showing any statistically significant difference.⁴

In addition to the question of efficacy, safety is another concern. Specifically, amyloid-related imaging abnormalities edema (ARIA-E) occurred in 35% of patients who received aducanumab compared to 3% from the placebo group.⁴ Even though ARIA-E was found to be reversible and non-significant, symptoms such as changes in mental state, confusion, and gait disturbances may be present. Other serious adverse reactions shown on imaging were microhemorrhage and amyloid-related imaging abnormalities-hemosiderin deposition (ARIA-H) which both had ≥10% higher risk compared to placebo. Other safety concerns were headaches, falls, and diarrhea.⁴

Aducanumab was FDA approved through accelerated approval and Biogen must conduct a fourth randomized clinical trial to prove that aducanumab actually slows the progression of Alzheimer’s disease measured in clinical results, not just in changes in AAB plaque. Other barriers to utilizing this medication include cost. Initially Biogen indicated the estimated cost was $56,000 per year (excluding cost of administration and imaging), but that figure was lowered to $28,200 per year as of January 2022.⁵ Because of the lack of clear clinical improvement and safety concerns, the Department of Veterans Affairs did not include aducanumab on its national formulary⁶, and other major health systems such as the Cleveland Clinic and Mount Sinai have affirmed their opposition to the drug as well.⁷ As of January 2022, the Centers for Medicare and Medicaid Services (CMS) made a draft decision to cover aducanumab only in studies approved by CMS or supported by the National Institutes of Health. This proposal is open to public comment for 30 days and final decision will be made by April 11.⁸ 

Despite finally having the first agent for treatment of Alzheimer’s disease, we cannot celebrate just yet. There is ambiguity in data, major safety concerns, and high potential to increase disparity in care. These issues must be considered prior to initiating aducanumab therapy.

References

1. ADUHELM (aducanumab-avwa) . Biogen. Cambridge, MA. 2021.
2. 221AD301 Phase 3 Study of Aducanumab (BIIB037) in Early Alzheimer’s Disease (ENGAGE). ClinicalTrials.gov identifier: NCT02477800. Updated September 2, 2021. Accessed September 17, 2021. https://clinicaltrials.gov/ct2/show/NCT02477800
3. 221AD302 Phase 3 Study of Aducanumab (BIIB037) in Early Alzheimer’s Disease (EMERGE). ClinicalTrials.gov identifier: NCT02484547. Updated September 2, 2021. Accessed September 17, 2021. https://clinicaltrials.gov/ct2/show/NCT02484547
4. Haeberlein SB, Hehn C, Tian Y et al. EMERGE and ENGAGE Topline Results: Two Phase 3 Studies to Evaluate Aducanumab in Patients With Early Alzheimer’s Disease: Biogen Presentation. 2020.
5. Terry M. Biogen Cuts Price of Much-Debated Alzheimer’s Drug in Half. BioSpace. December 20, 2021. Accessed January 3, 2022. https://www.biospace.com/article/biogen-cuts-price-of-alzheimer-s-drug-aduhelm-in-half/
6. Kansteiner F. Biogen’s controversial Alzheimer’s med Aduhelm turned away by VA on efficacy and safety worries. FIERCE Pharma. August 11, 2021. Accessed September 3, 2021. https://www.fiercepharma.com/pharma/biogen-s-alzheimer-s-med-aduhelm-absent-from-veterans-association-formulary-efficacy-and
7. Belluck P. Cleveland Clinic and Mount Sinai Won’t Administer Aduhelm to Patients. The New York Times. July 14, 2021. Accessed September 3, 2021. https://www.nytimes.com/2021/07/14/health/cleveland-clinic-aduhelm.html
8. Mcginley L, Goldstein A. Medicare proposes covering expensive drug for early-stage Alzheimer’s, but with restrictions that will sharply limit use. The Washington Post. January 11, 2022. Accessed January 13, 2022. https://www.washingtonpost.com/health/2022/01/11/alzheimers-drug-aduhelm-medicare-coverage/

Winter 2022 Newsletter

By Robin McAtee, PhD, RN, FACHE
Director, Arkansas Geriatric Education Collaborative (AGEC)
UAMS Donald W. Reynolds Institute on Aging (DWR IOA)

The number of older adults in the United States is rapidly growing. There were 29 million adults age 65 and older in 2016. By the year 2030, adults aged 65 or greater are expected to exceed 71 million ¹. Older adults utilize the US health care system more than any other age group, and our current healthcare systems have difficulty providing evidenced-based practice care in a consistent manner to older adults².

One of the ways this issue is being addressed in the United States is through the implementation of Age-Friendly Health Systems.  This is an initiative of the John A. Hartford Foundation and the Institute for Healthcare Improvement (IHI), in partnership with the American Hospital Association (AHA) and the Catholic Health Association of the United States CHA). ^.  This initiative is guided by a set of evidence-based practices (the 4Ms) while aligning care with what matters to older adults and their family. It is also a framework that encourages patients and their families to be full participants in their healthcare decisions. This new framework is based on the 4Ms Framework. “What Matters,” Medication, Mentation and Mobility².

Understanding What Matters to older adults promotes meaningful healthcare goals and outcomes. It also honors a patient’s care preferences. Although what matters conversations should not be limited to discussing end-of-life care, these conversations are a good place to start asking these types of care preference questions. What Matters conversations are also a starting point for discussing advanced care planning and discerning what type of treatments and care an older adult would want if there were a sudden change in health status².

 Medications should be age friendly. This means avoiding unnecessary medications and deprescribing where appropriate. There are increased chances of side effects with age so polypharmacy should be carefully examined. Raising awareness of potential side effects to providers and patients supports increased medication safety².

Age-friendly Health Systems strive to support care of the mind so that older adults can stay mentally sharp and do more of what matters to them. Focusing on Mentation means managing conditions like dementia, delirium, and depression. These conditions affect older adult’s ability to think clearly and make decisions.  Therefore, they need to be assessed and treated and early detection and diagnosis is extremely important for effective treatment.

Supporting safe Mobility is the last 4M. Maintaining mobility greatly improves quality of life while impacting activities and helping older adults to safely live independently for as long as possible. Ensuring older adults are knowledgeable about their fall risks and taking appropriate measures to maintain and/or even improve their mobility is crucial.

Utilizing the 4Ms framework of What Matters, Medication, Mentation, and Mobility provides an effective evidenced-based care model for all older adults. This framework promotes improved health outcomes, patient safety and can be applied throughout the healthcare continuum to meet the needs of older adults².  For more information on this framework please refer to the IHI reference listed below.

References

1.Providing Health for Older Adults; CDC. Centers for disease Control and Prevention. (n.d.) https://www.cdc.gov/chronicdisease/resources/publications/factsheets/promoting-health-for-older-adults.htm Retrieved June 14, 2021

2. What Is an Age-Friendly Health System?: IHI. Institute for Healthcare Improvement. (n.d.). http://www.ihi.org/Engage/Initiatives/Age-Friendly-Health-Systems/Pages/default.aspx. Retrieved June 14, 2021

Winter 2022 Newsletter

By Laura Stilwell, MEd
Education Coordinator
UAMS Arkansas Geriatric Education Collaborative (AGEC)

Arkansas Geriatric Education Collaborative, (AGEC) provides a variety of educational programs for the older adult population of Arkansas.  Exercise, along with nutrition education provides the cornerstone of creating and sustaining enhanced quality of life for the older adult. (Minett, M. et al., 2020) The program called From Our Kitchen to Yours is the live cooking show developed by AGEC to provide healthy nutrition information in an entertaining format. The program features healthy recipes prepared in real time and presented on the AGEC Facebook page. The concept for the live cooking show was developed around the recently published Dietary Guidelines for Americans 2020-2025 (the Guidelines) and the corresponding healthy dietary recommendations at Myplate.gov. The older adult life stage is the focus of chapter six of the Dietary Guidelines, making it the primary reference chapter for development of this program. (USDA, 2020)

  The research groups that focus on specific conditions such as high blood pressure, diabetes, cardiovascular disease and Alzheimer’s disease are now publishing nutritional recommendations for the remediation and prevention of these conditions. Research by the National Heart, Lung and Blood institute shows high blood pressure can be prevented and lowered by following the Dietary Approaches to Stop Hypertension (DASH) diet. (Nhlbi, 2018 p1) The Alzheimer’s Association recommends the Mediterranean-Dash Interventions for Neurodegenerative Delay (MIND) diet to slow cognitive decline, improve verbal memory and reduce the risk for developing Alzheimer’s disease by up to fifty-three percent. (Murad, A. 2019) Using one guide to address the dietary needs of the older adult population is the goal of the AGEC healthy cooking program. The Guidelines are heavily influenced by the Mediterranean diet, provide options for vegetarian and vegan dietary patterns and provide the foundation of the DASH and MIND dietary plans. (USDA, 2020 p19)(Murad, A. 2019) The Dietary Guidelines are grounded in robust scientific review of the current body of evidence on key nutrition and health topics for each life stage. (USDA, 2020. P v.)    

  The purpose of preparing food in real time is to show that food preparation can be efficient, healthy and cost effective. Many of the recipes used for the cooking segments are chosen from the MyPlate Kitchen on the Myplate.gov website. These recipes provide the portion size and the nutritional content for each recipe. In addition to nutritional information, Myplate.gov provides information to make home prepared meals cost effective. Preparing food at home allows for control over added sugar, sodium and saturated fats. Reduction of added sugar, sodium and saturated fat is the primary recommendation for a healthy dietary pattern for the older adult. (USDA, 2020).

   AGEC will continue to prepare a variety of recipes each month on Facebook during new episodes of From Our Kitchen to Yours. The recipes will reflect the recommendations for low sodium, low added sugar, low saturated fats, adequate protein and adequate fiber. A variety of dietary patterns will also be addressed. The show will feature vegan and vegetarian options as well as other regional flavors. Not only are the recipes healthy, they are delicious. By using the Dietary Guidelines, AGEC hopes to show that small changes in dietary patterns can create big results in health status for the older adult population in Arkansas. From Our Kitchen to Yours provides an entertaining and useful program to share nutritional information in a format for daily living.

References

Agency for Healthcare Research and Quality. (2018) Your Guide to Lowering Your Blood Pressure with DASH. National Heart, Lung and Blood Institute.
https://www.arqh.gov/evidencenow/heart-health/blood-pressure/dash-brief.html

Dietary Guidelines Advisory Committee. (2020) Scientific Report of the 2020 Dietary guidelines Committee: Advisory Report to the Secretary of Agriculture and Secretary of Health and Human Services. U.S. Department of Agriculture, Agriculture Research Service, Washington, D.C. P 16-22, p. 122-130
https://www.dietaryguidelines.gov

Mayo Clinic Staff, (2021) Dietary Fiber: Essential for a Healthy Diet. https://www.mayoclinic.org/healthy-lifestyle/nutrition-and-healthy-eating/in-depth/fiber/art-20043983?p=1

McDermott, Jamie L., Baum, Jamie I., the Truth About Fad Diets. (2021) University of Arkansas System Family and Consumer Sciences.
https://www.uaex.uada.edu/publications/pdf/FSFCS99pdf

Minett, M. M., Binkley, T. L., Holm, R. P., Runge, M., & Specker, B. L. (2020). Feasibility and Effects on Muscle Function of an Exercise Program for Older Adults. Medicine and science in sports and exercise, 52(2), 441–448.
https://doi.org/10.1249/MSS.0000000000002152

Murad, A., (2019) 15 Simple Diet Tweaks that could Cut Your Alzheimer’s Risk
https://www.mayoclinic.org/diseases-conditions/alzheimers-disease/in-depth/15-simple-diet-tweaks-that-could-cut-your-alzheimers-risk/art-20342112

Fall 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)

Hello from the Arkansas Geriatric Education Collaborative. As summer of 2021 ends and we begin to enjoy the cooler nights and days, we are beginning one of the busiest times of the year here at the AGEC. I know by this time we had all hoped that we would be on the “other side” of the pandemic, but we still seem to be simmering in the middle and we are all getting weary! However, despite the weariness, we have adapted and thrived in many areas. Our summer was full of exciting programs and we are still developing new partnerships, programs, and activities as we explore new methods and platforms for reaching older adults and healthcare professionals with geriatric content. Our healthcare professional webinars continue to be huge successes. In September, we had Dr. Anand Venkata who talked about COVID-19 Long Haulers: Pulmonary Complications – What to Expect, and we had 161 attendees. On October 7, Dr. Lee Isaac with UAMS PRI presented Diversity in Dementia: Incidence, Related Factors, and Considerations for Diagnosis and Treatment with 131 attendees. Our social media presences (Facebook, Twitter, and Instagram) are still growing with a lot of views and activities, so be sure to check those out. We are also having a few, socially distant, face to face, evidence-based programs and older adults seem to enjoy getting out again! In addition, many of our community-based partners are once again providing both in-person and virtual programs and activities. Many of the senior centers are open again and providing programs and UAMS Centers on Aging also reported that they are once again out in the communities they serve, providing caregiver workshops and training first responders. 

Our academic partners were busy during the summer. Our team had an intern from Hendrix who worked with AGEC outreach and social media activities. UCA opened a new interprofessional clinic where education and resources are provided for caregivers. ASU graduate nursing students began working on quality improvement projects at local long-term care facilities. Each college reported that activities are picking up more this fall with students being on-campus more and are actively engaging in geriatric clinical activities.

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

Robin E. McAtee, PhD, RN, FACHE

Fall 2021 Newsletter

Article published in the Journal of Patient Experience: May 19, 2021.  Caregiver Burden: Caregiving Workshops Have a Positive Impact on Those Caring for Individuals with Dementia in Arkansas. doi.org/10.1177/23743735211018085

Summarized by the original authors: Robin E. McAtee, PhD, RN; Laura Spradley, MS; Leah Tobey, PT, DPT, MBA; Whitney Thomasson, MAP; Gohar Azhar, MD; Cynthia Mercado, EMBA, MA (University of Arkansas for Medical Sciences).

Millions of Americans live with dementia. Caregivers of this population provide countless hours of multifaceted, complex care that frequently cause unrelenting stress which can result in immense burden. However, it is not fully understood what efforts can be made to reduce the stress among caregivers of persons with dementia (PWD). Therefore, the aim of this pretest–posttest designed study was to evaluate changes in caregiver burden after providing an educational intervention to those caring for PWD in Arkansas.

The data collection tool, the short ZBI (ZBI-12) consists of 12 questions in 2 main domains, personal strain and role strain and 4 subscales of sacrifice/strain, inadequacy, embarrassment/anger, and loss of control. Scoring of the item responses are based on a 5-point Likert-type scale ranging from 0 = never, 1 = rarely, 2 = sometimes, 3 = quite frequently, and 4 = nearly always. A cumulative score of 48 is possible and the higher scores represent higher feelings of burden. The ZBI-12 classifies cumulative scores 0 to 10 as “no to mild burden,” 10 to 20 as “mild to moderate burden,” and scores above 20 as “high burden.”  The ZBI-12 was chosen for this study since it produces comparable results to those of the full version and leads to easier administration and completion of the questionnaire.

Participants to dementia caregiver workshops that are offered across Arkansas were invited to participant in the survey study.  After the participants completed the pretest, they attended the workshop. The caregiver dementia workshop is a half-day workshop offered throughout rural Arkansas and covers many facets of dementia and caregiving. It begins with a review of dementia and Alzheimer’s disease and then moves to discuss the complexity and multifaceted aspects of caregiving and why it can be a hidden burden. Basic rules of caregiving are reviewed and time is spent in assisting the participants to understand the changes in physical functions and behaviors that occur with a PWD. They are taught various techniques about how to respond or adjust to the altered behaviors and needs of the PWD and time is spent role playing various verbal and physical communication approaches.

They are also given information about expectations regarding how they may feel as a caregiver, details about caregiver stress, and the importance of self-care. They are provided with tips about how to manage each of their roles, and how to care for themselves. Ample time is also allowed to discuss alternative options for caregiving such as respite, paid caregivers, residential dementia specialty units, and nursing homes. They are provided with printed and virtual resources to refer to later.

The participants were contacted 45-60 days via phone after their workshop to complete the post test.  Matched pre- and posttest survey (ZBI) data from 41 respondents were used for the analysis. Eighty-three percent were women, and the ages ranged from 30 to 79 years. Twenty-seven percent (n = 11) were 50 to 59 years old and a few (12%, n = 5) were younger than 50 years. More than a third of the respondents (68%, n = 28) identified as white/Caucasian, 20% (n = 8) as African-American/black, and 12% (n = 5) were of various other ethnicities.

Knowledge and confidence level: After attending the workshop, the participants increased both their levels of knowledge and confidence in caregiving. Comparisons of the pretest versus posttest (mean ± standard deviation) for the knowledge level rose from 2.78 ± 0.79 to 3.98 ± 0.65 and for the confidence level from 3.02 ± 0.91 to 4.02 ± 0.72. Likewise, the paired samples t test showed a significant increase in the posttest means for both the caregiver’s knowledge level, t(40) = −7.61, P = .001, α = 0.95, and confidence level, t(40) = −5.845, P = 0.001, α = 0.95. The cohen’s d values indicated a large effect size in the 2 variables: knowledge (d = 1.656) and confidence (d = 1.218) suggesting that participation in the workshop was beneficial to the improvement of these 2 caregiving attributes.

For the pretest, the ZBI total scores ranged from 7 to 47, while the posttest scores ranged from 4 to 31. The higher ZBI total scores in the pretest suggested the participants’ higher family caregiver burden perception. In contrast, the lower posttest scores after the workshop indicated an improvement and a positive effect on the participant’s family caregiver burden perception. Similarly, the paired samples t test scores showed a statistically significant change between the pretest and posttest values, t(38) = 6.97, P = .0001, α = 0.95, of the ZBI total perception score means. This change was also evident in the large effect size of the Cohen’s d = 0.78. In 6 of the 12 statements asked in the ZBI-12 survey, participants indicated statistically significant improvements on the following subscales: 2 each for the sacrifice/strain and inadequacy subscale and 1 each for the embarrassment/anger and loss of control subscale. 

Finally, although caregiver burden is described in many ways, it is basically the mental, emotional, and physical state of exhaustion when caring for someone else. A caregiver can begin the day or week being positive and upbeat but after a while, they can become depressed and even apathetic not just about their own personal health but the health of their loved one as well. The work is hard and seemingly never ending. The stress of spending their time, energy, and money providing care takes a monumental toll on the most dedicated caregiver. They need help. As has been previously demonstrated in studies of those individuals caring for a PWD, interventions including educating the caregivers have been shown to increase caregiver knowledge, decrease depression and improve their moods, reduce stress, and even delaying nursing home placement for the PWD (1, 2).  This study showed how education can decrease caregiver burden, so we at the AGEC want to urge providers to also care for the caregiver.  Talk to them and see what tools they need to help them adapt.  Explore the available resources in your geographic area (and online) and share with the families, it really does help!

References

1. Selwood, A, Johnston, K, Katona, C, Lyketsos, C, Livingston, G. A systematic review of the effect of psychological interventions on family caregivers of people with dementia. J Affect Disord. 2007;101:75–89.
2. Pinquart, M, Sorensen, S. Helping caregivers of persons with dementia: which interventions work and how large are their effects? Int Psychogeriatr. 2006;18:577–95. doi:10.1017/S1041610206003462

Fall 2021 Newsletter

By Abigail Dunn, Doctor of Pharmacy Candidate, and Lisa C Hutchison, PharmD, MPH
University of Arkansas for Medical Sciences (UAMS) College of Pharmacy

Delirium occurs in 7-80% of patients who are admitted into intensive care units (ICUs) and is associated with worse outcomes including a 2-4 fold increased risk of death.¹  When non-pharmacological measures are not effective for hyperactive delirium, patients are typically treated with antipsychotics to prevent them from doing harm to themselves or to others.²  Unfortunately, recent studies indicate that more than 50% of patients with ICU-initiated antipsychotics are discharged with the antipsychotic that was newly prescribed during their inpatient stay ^3-7. Older adults, particularly those with dementia, are at increased risk of delirium, and therefore, may be prescribed an antipsychotic for short-term management of delirium.  Antipsychotics carry a boxed warning for older adults with dementia as they are at increased risk of morbidity and mortality due to exposure to antipsychotics.  So, discontinuation of these medications  should be attempted as soon as the patient’s delirium has resolved.

 As noted, discontinuation of newly started antipsychotics at ICU discharge does not always occur as soon as appropriate.  Frequency of discontinuation with ICU discharge occurs in only 50-77% of patients, and 25-39% of patients continue on antipsychotics at hospital discharge.^3-7  Studies of patients discharged from an ICU with an antipsychotic identify some risk factors.  In one study, patients who were white, male, or admitted for sepsis had increased risk of continuing antipsychotic medications after discharge.⁵  Happily, older adults are not significantly more likely to be discharged on an antipsychotic than younger adults in these studies (mean age of subjects ranging from 57-68 years).^4,5,7  However, of significance for older adults, discharge location of long-term care or advanced care facilities is an associated risk factor. ⁴

While benefits for short-term use of antipsychotics for delirium may outweigh the harms in ICU patients, discontinuation should occur as soon as possible after delirium resolves.  Adverse effects associated with antipsychotics include QTc prolongation, increased mortality, weight gain, hyperlipidemia, and newly diagnosed diabetes mellitus ^4,5.  If discontinuation at ICU or hospital discharge cannot safely occur, information regarding the plan for discontinuation should be communicated at transition of care.  In one study evaluating this process, only 12% of patients discharged had instructions for discontinuation of the antipsychotic.⁹  Often, patients being sent home with this unnecessary medication do not have a medication review prior to discharge.⁵  

Methods should be adopted to address discontinuation of unnecessary medications.  One study described how a clinical pharmacist was responsible for intercepting an average of four medication issues per patient at discharge which included discontinuing the use of certain medications in approximately 39% of patient visits ⁵.  An additional option would be a checklist that is formatted and encouraged upon discharge to remind providers to evaluate a patient to determine if they need to continue the prescribed antipsychotic or other high risk medication.⁴  Finally, use of an antipsychotic discontinuation algorithm with multidisciplinary education at ICU discharge showed a 10% increase in discontinuation rate of antipsychotics at ICU discharge and significantly increased rates of discontinuation within 72 hours of ICU discharge and overall lower rates of antipsychotic continuation at hospital discharge .⁶

While sometimes necessary, antipsychotic initiation in hospital ICUs to treat older adults with delirium comes with increased risk.  Discontinuation before discharge from the ICU is preferred, but if continuation is required, plans for discontinuation should be communicated to the receiving medical team or primary care physician.^4.9  It is critical that ongoing evaluation of patients who are discharged with antipsychotics take place to determine if patients continue to require treatment. ^6,8

References

1. Inouye SK, Westendorp RGJ, Saczynski JS.  Delirium in elderly people.  Lancet, 2014; 383:911-22.
2. Kalish, V. B., Gillham, J. E., & Unwin, B. K. (2014, August 1). Delirium in older persons: Evaluation and management. American Family Physician. https://www.aafp.org/afp/2014/0801/p150.html.
3. Flurrie RW, Gonzales JP, Tata AL, et al.  Hospital delirium treatment: continuation of antipsychotic therapy from the intensive care unit to discharge.  Am J Health-syst Pharm, 2015; 72(suppl 3):S133-9.
4. Karamchandani, K., Schoaps, R. S., Bonavia, A., Prasad, A., Quintili, A., Lehman, E. B., & Carr, Z. J. (2019). Continuation of atypical antipsychotic medications in critically ill patients discharged from the hospital: a single-center retrospective analysis. Therapeutic Advances in Drug Safety. https://doi.org/10.1177/2042098618809933
5. Coe, A. B., Vincent, B. M., & Iwashyna, T. J. (2020). Statin discontinuation and new antipsychotic use after an acute hospital stay vary by hospital. PLOS ONE, 15(5). https://doi.org/10.1371/journal.pone.0232707
6. D’Angelo RG, Rincavage MS, Tata AL, et al.  Impact of an antipsychotic discontinuation bundle during transitions of care in critically ill patients.  J Intensive Care Med, 2019; 34:40-7.
7. Lambert J, Vermassen J, Fierens J, et al.  Discharge from hospital with newly administered antipsychotics after intensive care delirium –incidence and contributing factors.  J Crit Care, 2021; 61:162-7. 
8. Johnson KG, Fashoyin A, Madden-Fuentes R, et al.  Discharge plans for geriatric inpatients with delirium: a plan to stop antipsychotics? JAGS, 2017; 65:2278-81.

Fall 2021 Newsletter

By Laura Stilwell, MEd
Education Coordinator
UAMS Arkansas Geriatric Education Collaborative (AGEC)

Tai chi, an ancient Chinese form of exercise, is one of the activities offered by the Arkansas Geriatric Education Collaborative (AGEC). Tai Chi for Arthritis and Fall Prevention meets the criteria of exercise for older adults by providing improvement in strength, balance, endurance and flexibility (Grabiner, et al., 2014). The program used by AGEC is one developed by Doctor Paul Lam, an Australian family practice physician and Tai Chi master. Lam began his practice of Tai Chi in 1974 to alleviate his pain caused by early onset arthritis. As he recognized the benefits of his Tai Chi practice, Lam founded the Tai Chi for Health Institute in 2010 (Lam, 2017).

    The practice of Tai Chi is derived from the ancient Chinese martial arts. There are five styles of Tai Chi.  Each style varies in level of difficulty based on depth of stance, flexibility, complexity of form, and the endurance necessary to complete all the steps of a form. Lam chose the Sun (pronounced soon) style for the Arthritis and Fall Prevention method due to the nature of the upright stance maintained while performing the exercises. In Lam’s interpretation of Tai Chi, he deleted high risk movements and focused on the movements specifically related to relieve joint pain from arthritis. Other movements chosen enhance muscle strength and balance to diminish the risk of falls. The movements are slow and gentle, and the degree of exertion is easily modified for students of all abilities. Tai Chi for Arthritis and Fall Prevention is one exercise modality that, when practiced on a regular basis, provides intervention for risks faced by older adults, due to its focus on strength improvement, balance, and fluidity of movement (Lam, 2017).

     Longitudinal studies show Tai Chi to be a viable modality of exercise for the improvement of joint mobility for arthritis and for fall prevention. In Exercise for Older Adults, the American College of Sports Medicine (ACSM) recommends balance exercise for all individuals who fall frequently or for those with mobility problems (Chodzko-Zajko, 2014). Tai Chi styles that include slow continuous movements with head and neck rotation and weight shifting in standing positions are beneficial for leg strength and balance. Movements that are performed in a standing position that include arm movements, with visual focus on those movements, promote balance.  Multimodal programs of balance, strength, flexibility, and walking are shown to reduce the risk of falls (Chodzko-Zajko, 2014).

       In recent studies, the practice of Tai Chi has shown improvement in overall health. In a study released in 2021, Tai Chi is shown to reduce waist circumference, which is a predictor of overall health and relates to risk factors of heart disease and diabetes (Sui, et al., 2021). Participation in Tai Chi as a regular exercise modality can show significant improvement in overall psychological well-being; studies have linked regular physical activity with a reduced risk for dementia and cognitive decline (Chodko-Zajko, 2014).

        In addition to the ACSM, Tai Chi is recommended by the World Health Organization, (WHO, 2021) the Centers for Disease Control and Prevention, (CDC, 2019) the Arthritis Foundation, (AF, 2021) and the National Council on Aging (NCOA, 2020).

     AGEC provides a variety of exercise modalities for the older adults of Arkansas. Variety is important because each individual has unique interests. Tai Chi for Arthritis and Fall Prevention is an exercise experience that older adults may find interesting and effective, thus creating an opportunity for an exercise lifestyle. Providing this lifestyle opportunity is one of the goals of programming at AGEC.

References:

Chodzko-Zajko, Wojtek J. ACSM’s Exercise for Older Adults. Wolters Kluwer/Lippincott Williams & Wilkins, 2014

Dilonardo, Mary J. “Tai Chi FOR ARTHRITIS: Arthritis Foundation.” Tai Chi for Arthritis | Arthritis Foundation, 2021, https://www.arthritis.org/health-wellness/healthy-living/physical-activity/yoga/tai-chi-for-arthritis

Grabiner, M.D., Crenshaw, J. R., Hurt, C. P., Rosenblatt, N. J., & Troy, K. L. (2014). Exercise-based fall prevention: can you be a bit more specific? Exercise and Sport Sciences Reviews, 42(4), 161–168.
https://doi.org/10.1249/JES.0000000000000023

Lam, Paul. “Tai Chi and Arthritis.” Tai Chi for Arthritis and Fall Prevention Handbook, Tai Chi Productions, Narwee, NSW, 2017, pp. 7–14.

The National Council on Aging, Aug. 2020, https://www.ncoa.org/article/evidence-based-program-tai-chi-for-arthritis-and-fall-prevention

Siu, P. M., Yu, A. P., Chin, E. C., Yu, D. S., Hui, S. S., Woo, J., Fong, D. Y., Wei, G. X., & Irwin, M. R. (2021). Effects of Tai Chi or Conventional Exercise on Central Obesity in Middle-Aged and Older Adults : A Three-Group Randomized Controlled Trial. Annals of internal medicine, 174(8), 1050–1057. https://doi.org/10.7326/M20-7014

Tai Chi Principles for FALLS Prevention in Older People. 27 Feb. 2019, https://www.cdc.gov/HomeandRecreationalSafety/Falls/compendium/pdf/Voukelatos.pdf

Who.int, Apr. 2021, https://who.int/news-room/fact-sheets/detail/falls