Winter 2023 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! Can you all believe it is 2023 and we have been enduring COVID and all that has entailed for almost three years? However, we are all learning to live with it better and getting out and enjoying things again. The AGEC programs are thriving and our community partners are busy once again. It is wonderful to see older adults congregating and enjoying each other’s company again! We are also having full classes where programs based on evidence are being taught and activities being enjoyed. In addition, as we begin this new year, our academic partners are working with health professions students to ensure many complete their degrees this spring. We can all look forward to having more healthcare professionals begin their careers knowing more about how to appropriately care for older adults.

This quarter, I want to talk to you a little more about what we started discussing last quarter, the 4M’s of Age-Friendly Care. I introduced that concept last quarter and this time I want to delve into one of those 4M’s a little more and subsequently discuss one more in-depth in each quarter this year.  The first one we will review here is “What Matters”.  This is what all the other “M’s” focus around. As I mentioned in the last Directors Desk, 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 direct the overall plan of care. Ideally, this should be asked at almost every visit, just to ensure priorities haven’t changed. What matters most to someone certainly changes with time, age, and of course life events. This month it might be caring for a disabled spouse, but if that spouse passes away, then what matters also changes, so as healthcare professionals, we need ask. 

What matters should be inclusive, individualized, holistic, person-centered, patient-centered, respectful, prognosis-centered, collaborative, responsive, integrative, and of course, achievable. It also helps clinicians to build trust, treat older adults with humility and respect, maintain a patient-centered approach, create effective and actionable healthcare conversations, and frequently decreases unwanted care and treatments. Knowing what matters drives patient care goals.  So just ask: what matters, what is most important to you in this stage of your life, and how can I, as a healthcare professional, help you achieve your goals?

This was just a quick overview of “What Matters”, but I hope helps to inform and remind us all of why we are healthcare professionals and why we should always ask and listen to our patients first. If you want to learn more, additional information can be found here.

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

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.

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:

1. 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.
2. 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.
3. 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.
4. 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.
5. 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.
6. Mirtazapine In: Lexicomp® Wolters Kluwer Copyright 2022 UpToDate, Inc.
7. 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.
8. American Geriatrics Society/American Board of Internal Medicine Foundation. Choosing Wisely. www.ChoosingWisely.org.

Summer 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)

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!!

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

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.²  It 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.

1. 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.
2. 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.
3. 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.
4. 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. 

1. 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:

1. Liacos M, Page AT, Etherton-Beer C. Deprescribing in older people. Aust Prescr. 2020;43(4):114-120. Published 2020 August 03.
2. Ten Things Physicians and Patients Should Question. Choosing Wisely. American Society of Consultant Pharmacists, American Board of Internal Medicine. Published 2022 June 04.
3. 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.

Spring 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)

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!!!

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.