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

Summer 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)

Welcome summer, and now to look back at spring and the rebeginning of some community programs. As the AGEC moved into spring this year, outreach programs continued and we started planning for in-person programs again, so exciting. Some of our partners have also started conducting in-person trainings and programs and we are thrilled to help them!  Most of our virtual programs continued this quarter with great attendance and participation. The AGEC staff also published an article entitled:  Caregiver Burden: Caregiving Workshops Have a Positive Impact on Those Caring for Individuals with Dementia in Arkansas. This was a study conducted in concert with our Family Caregiver Workshops and the results were very positive. A summary of these findings will be available in the newsletter next quarter!  If you want a sneak peek, you can find the article here: https://journals.sagepub.com/doi/10.1177/23743735211018085

Dr. Ronni Chernoff (AGEC Director Emeritus), myself and the AGEC staff want to take a moment and say a special “thank you” to Dr. Susan Hanrahan. Dr. Hanrahan retired at the end of June this year, but has been a great partner and leader in the ongoing goal of improving care of older Arkansans during her tenure at Arkansas State University. She overwhelmingly supported the creation, development, and implementation of geriatric content and courses in the undergraduate and graduate curriculum over the past 20 years. During that time, she supported the development of the Healthy Agers program, a groundbreaking interdisciplinary experiential program for physical therapists, nurses, social workers, and nutritionists that served as a model for other geriatric education programs in Arkansas and elsewhere.

Dr. Hanrahan created and supported the ASU annual grief seminars as well as many new courses in social work, nursing, physical therapy, nutrition, and others while consistently incorporating critical geriatric content. She was also instrumental in the nursing home initiative managed by the nursing department in her college. Not only did the participating institutions benefit, but the students gained very valuable clinical experiences. She was a strong supporter of interdisciplinary education and a willing and able collaborator in the geriatric education center and geriatric workforce enhancement program grants. Her contributions have been many and notable and she will be missed by our entire staff and partners. However, we wish her an exceptional retirement and many years of play – she has earned it!!!   Thank you, Dr. Hanrahan, for your dedication and contributions to the education of innumerable health professions students!

Thank you all for supporting AGEC in our clinical, educational, and outreach efforts!

Robin McAtee, PhD, RN, FACHE

And

Ronni Chernoff, PhD, FAND, FASPEN

Summer 2021 Newsletter

By Danette Scherer, MSN, RN, CCRN
Nurse Educator, Quality Management Coordinator
University of Arkansas for Medical Sciences

Prepare yourself for some mind bending, belief shattering insights. These truths I share with you are a part of my personal growth journey that began in February 2021 when I was hired as a nurse educator with the Arkansas Geriatric Education Collaborative (AGEC). When I went through nursing school, almost 30 years ago, the curriculum did not include specific geriatric education. There were specific classes that focused on mental health, maternity and pediatrics. But we were not provided specific education focused on gerontology.

Growing up I had minimal exposure to older people.  My parents were older when I was born, and they were also born to parents that were older. “Late in life baby” is a term commonly used for parents older than 35. My extended family had already passed on by the time I came around. The only “old folks” I knew were my own parents.  As a daughter of a military pilot, I grew up in many underdeveloped countries where the life expectancy was short, nutrition was poor, and access to medical care was scarce or nonexistent. Therefore, learning about and from older adults was not part of my initial nursing education or my early life.

So I imagine what you must be thinking.  How does somebody, especially a nurse, get through to middle age with limited exposure to old people?  Well, my knowledge of “older adults,” as I’ve learned to call them was quite limited.  I was in my twenties and a brand-new nurse, a volatile combination I might add, and my only knowledge of geriatric patients was from caring for them in the ICU.  Even being an ICU nurse for 28 years, the only thing that I truly knew about geriatrics was that old people got sick, they came to the ICU, and they died.  They all seemed to be delirious, demented, and/or combative. Their families were also very difficult, uninformed, and not accepting of the fact that death is a natural process and that we are all designed to die. I believe this was because of fear and lack of information.

I seldom recall any family of an older adult that did not want all life prolonging treatments to be provided to their loved one.  Their experience of having a parent in the ICU was the very first time they realized that at some point, their parents would succumb to bodily failure and death. We participated in activities of care that for many of these patients, seemed far beyond heroic; however, they were the “norm”, they may have also been a substitute to the real conversation everyone was ignoring, death. Advanced care planning, as we know it today, did not exist in most situations.  Most healthcare providers and families ignored and even fought the inevitability of death. In hindsight, contemplating what I’ve seen and what the families may have observed, I can’t help but wonder why we did “that” to patients at the end of their life. Very few or any of us would agree to spend their last moments having all of that done to their body.  I think this is especially true for older adults.  Over time my scrubs transitioned from a work uniform, to battle fatigues.  And oh my, I was fatigued by this battle.  My heart broke and bled nearly every shift, and fear rushed over me when I thought this was to be my fate as well.  To be a frail old person and to endure the trauma of life prolonging interventions.

So here’s what I’ve learned and where the mind bending, belief shattering insights come into play.  Since joining the AGEC at UAMS and working with the Thomas and Lyon Longevity Clinic, I have ultimately been enrolled in what I’m calling an intensive learning residency in gerontology.  I have learned there is such a thing called “healthy aging.”  There is hope and people can actually age well.  When I started in the Institute on Aging, the very first day there were all of these older adults exercising in the halls and moving about like humming birds.  I simply didn’t know what to make of this.  I’d never seen such things before in my life!  I was bombarded with the visual images of older adults moving about and just living and loving life! This was a shock to my known experiences. I wondered, do such strange sights pose a threat to my way of thinking?  Well, it sure did challenge my paradigm and my belief system about aging in a good way.  Seeing these active older people was inspirational and gave me hope for myself and for all older adults!

Reflecting back on my 28 years of ICU experience, I realize that when I was taking care of older adults in the ICU, I was giving excellent ICU care.  However, I also now realize that I was not giving excellent geriatric care.  From now on when I am trusted with the care of an older adult, I will be giving excellent care that focuses on the specific needs of that person and where they are in life, paying extra special attention to what matters most to that individual.  I will actually ask them “What Matters Most?” to you.  I will work with the interdisciplinary team to ensure that Age-Friendly medications are prescribed.  I will make every effort to identify signs and symptoms of dementia and treat and prevent delirium and depression, and not just assume all older adults will be depressed or get dementia at some point.  I will promote mobility and movement to prevent the accelerated deconditioning that the older adult experiences.  I will practice Age-Friendly Healthcare and employ all of the 4Ms: What Matters, Medication, Mentation, and Mobility. For all of these epiphanies, I am grateful. I know my intensive learning experience in Gerontology will follow me in every facet of my nursing practice and life and I am excited to share what I have learned with others.

Summer 2021 Newsletter

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

Type 2 diabetes mellitus (T2DM) is a common condition that is caused by insulin resistance, resulting in an increase in blood glucose levels. Diabetes disproportionately affects adults aged 65 and older with 1 in 4 receiving a diagnosis.¹ Stabilizing glucose levels has shown to be increasingly more important in diabetes as there are on-going studies evaluating the association between glucose variability and the development of comorbidities that can have a serious impact on ones’ health including heart disease, kidney disease, and vision loss.^2,3

To keep their blood glucose levels in a healthy range, patients must monitor their blood glucose levels and adjust their insulin accordingly.  Through the use of a glucometer and testing with finger sticks,  patients can accurately measure their glucose themselves. However, there are several limitations to self-monitoring blood glucose (SMBG) such as: user error, multiple finger pricks causing decreased compliance, and the quality and stability of the enzymatic test strips.⁴ An alternative method to measuring glucose levels is through continuous glucose monitoring (CGM), which periodically tracks blood sugar levels at different intervals throughout the day. Monitors used for CGM have the ability to sync up to smartphones and tablets, allowing  patients to see their glucose level in real time, set alarms for instances of hypoglycemia or hyperglycemia, and track meals, activity, and medications aiding a more in-depth analysis of their glucose trends. Some monitors even connect to insulin pumps, administering insulin when needed. For CGM to work, a sensor is placed under the skin typically on the abdomen or on the upper arm. This sensor measures the glucose level within the interstitial fluid, which is found between cells.The patient replaces the sensor every 3 to 7 days depending on the monitor.  In addition, they must calibrate it twice daily, as opposed to 4 – 6 finger sticks per day using SMBG methods.⁵   

While the use of CGM in type 1 diabetes mellitus (T1DM) is well established, it has yet to become commonplace for T2DM patients who require insulin therapy. Recently, there have been many studies discussing the potential benefits T2DM patients could derive from CGM such as better glycemic control, A1C reduction, and life-style modifications.⁶

Hypoglycemia is a serious risk for older patients, as it is associated with an increased risk for falls, arrhythmias, cognitive impairment, and even death. A study by Polonsky et al. showed that patients using a CGM reported fewer moderate-to-severe hypoglycemic events over the course of 6 months and greater reductions in hypoglycemic events that necessitated assistance from a caretaker, paramedic, or the ER.⁷ Both older adults and their caretakers that are burdened with the responsibility of managing diabetes may benefit from the ability to monitor real-time levels and be alerted by hypoglycemic events.

The use of CGM has shown statistically significant differences in A1C reduction  compared to SMBG in T2DM patients. Vigersky et al. performed a study on the effect of CGM in patients with T2DM that were not on prandial insulin. Those randomized to use a CGM intermittently for 12 weeks had an improved A1C at 12 weeks and continued that improvement during the 40-week follow-up compared to those that only used SMBG. The CGM decreased their A1Cs by 1.0, 1.2, 0.8, and 0.8% whereas the SMBG group decrease their A1cs by 0.5, 0.5, 0.5, and 0.2% at 12, 24, 38, and 52 weeks, respectively.⁸ Ruedy et al. shifted the focus of their study to the effectiveness of CGM in older adults >60 with both T1DM and T2DM on multidose insulin injection therapy (MDI). The results of this study showed a greater A1C reduction (−0.9 ± 0.7% versus −0.5 ± 0.7%, P < .001) and decreased glycemic variability in the CGM group as opposed to the SMBG group. The results of this trial show that while we know CGM is beneficial for T1DM, CGM also aids older patients with T2DM get closer to their goal A1C. ⁹

In addition, CMG can contribute to patient education and subsequently, behavioral change, helping patients commit to lifestyle modifications and improve blood glucose levels. A systematic review performed by Taylor et al. demonstrated that CGM use was associated with positive lifestyle modifications such as a decrease in body weight and caloric intake, adherence to diet, and increased physical activity compared to SMBG.These studies demonstrate that CGM can help control T2DM in the short term, and in the long term through an improvement in the patient’s lifestyle and adherence to their treatment.⁶

A literature review showed that in adults, ages 51.7 – 60 years old, CGM supported greater reductions in A1C, bodyweight, and caloric intake, and increased adherence to diet and physical activity. Not only that, but a >90% compliance to CGM wear-time and calibration was reported.¹⁰ Ruedy et al. states that satisfaction was high with the CGM, defined as perceived benefits, were high compared to perceived difficulties.⁹ Polonsky et al. found that regarding  patients’ quality of life, those that used the CGM reported feeling as though they were in a better state of well-being, less fearful of a hypoglycemic event, and less distressed.⁷ The high praise of the CGM system from these studies could mean that CGM has the potential to reduce burnout in those that are overwhelmed by their disease state management.

Patients with T2DM have similar goals and face similar obstacles in managing their blood glucose as those with T1DM no matter their age, and therefore, could also benefit from continuous glucose monitoring.⁶ With improvements made in the CGM technology in the future, it seems that CGM may very well become the standard of care to reduce the burden of diabetes management and improve the health outcomes for patients with T2DM.

References:

1. National Diabetes Statistics Report. 2020. Centers for Disease Control and Prevention. Retrieved from https://www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statistics-report.pdf.
2. Ohara, M., Fukui, T., Ouchi, M., Hayashi, T., Oba, K., & Hirano, T. 2016. Relationship between daily and day-to-day glycemic variability and increased oxidative stress in type 2 diabetes. Diabetes Research and Clinical Practice 122: 62 – 70.
3. What is diabetes? 2020. Centers for Disease Control and Prevention. Retrieved from https://www.cdc.gov/diabetes/basics/diabetes.html.
4. Jasha van Enter, B. & von Hauff, E. 2018. Challenges and perspectives in continuous glucose monitoring. Chemical Communications 54: 5032 – 5045.
5. Continuous Glucose Monitoring. 2017. National Institute of Diabetes and Digestive and Kidney Diseases. Retrieved from https://www.niddk.nih.gov/health-information/diabetes/overview/managing-diabetes/continuous-glucose-monitoring.
6. Jackson, M.A., Ahmann, A., & Shah, V.N. 2021. Type 2 Diabetes and the Use of Real-Time Continuous Glucose Monitoring. Diabetes Technology & Therapeutics 23: 27 – 34.
7. Polonsky W.H., Peters A.L., & Hessler D. 2016. The impact of real-time continuous glucose monitoring in patients 65 years and older. Journal of Diabetes Science and Technology 10: 892 – 897.
8. Vigersky, R.A., Fonda, S.J., Chellappa, M., Walker, M.S., & Ehrhardt, N.M. 2012. Short-and Long-Term Effects of Real-Time Continuous Glucose Monitoring in Patients With Type 2 Diabetes. Diabetes Care 35: 32 – 38.
9. Ruedy, K.J., Parkin, C.G., Riddlesworth, T.D., & Graham, C. 2017. Continuous Glucose Monitoring in Older Adults With Type 1 and Type 2 Diabetes Using Multiple Daily Injections of Insulin: Results from the DIAMOND Trial. Journal of Diabetes Science and Technology 11(6): 1138 – 1146.
10. Taylor, P.J., Thompson, C.H., & Brinkworth, G.D. 2018. Effectiveness and acceptability of continuous glucose monitoring for type 2 diabetes management: A narrative review. Journal of Diabetes Investigation 9: 713 – 725.

Summer 2021 Newsletter

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

The mission of Arkansas Geriatric Education Collaborative (AGEC) is to provide high quality programs that support healthy aging in Arkansas.  Two physical fitness programs used by AGEC are Tai Chi for Arthritis and Fall Prevention and Ageless Grace (AG).  AG is an exercise program that, through muscle group targeting, meets the criteria of a fitness and fall prevention program for older adults. (Grabinar, et al., 2014) The activities in AG are fun, intentional, and accessible to persons of any age and physical ability. (Medved, 2013)  For those reasons, AGEC chose AG as one of the fitness programs offered for community outreach. The focus of this article is to learn about AG, its development and its practice. 

     The Ageless Grace program was developed by Denise Medved with the intention of meeting the criteria for physical fitness as well as brain fitness.  Medved, a marketing executive and fitness instructor for over 30 years, and her development team compiled the series of exercises in the AG program based on studies in neuroplasticity. (Medved, 2013)   Neuroplasticity is defined as the capacity of neurons and neural networks in the brain to change their connections and behavior in response to new information. (Rugnetta, 2020) Each of the twenty-one exercises, or tools, emphasizes different anti-aging techniques that reinforce the theory of neuroplasticity.   The exercises use a combination of flexibility, joint mobility, right-left brain coordination, cognitive function, and many other techniques to reinforce fall prevention, confidence and playfulness. (Medved, 2013)  Medved asserts that with just ten minutes of practice every day using two or three of the “tools”, one will be aware of the positive differences in quality of life within 21 days. (Medved, 2013)

     Following the lesson plan of AG, each exercise session lasts 10 minutes and uses a minimum of three tools.  The exercises are performed seated in a chair, using upbeat music and can be practiced in a group setting or alone.  Each of the tools targets specific muscle groups to use during the session. The combination of muscle groups has a specific cognitive function as well as physical function during the exercise session. (Medved, 2013)  The curriculum of Ageless Grace meets the recommendations of the Physical Activity Guidelines for Americans, 2^nd
Edition in an intentional and accessible manner. (PAGA, 2018)

     Activity for the older adult is crucial for maintaining quality of life.   The recently updated Physical Activity Guidelines, 2nd Edition includes brain health benefits as part of the updated evidenced based benefits of physical activity.   The Guidelines state that physical activity can lead to improvement in cognitive function and sleep, as well as reductions in anxiety and depression risks.  The combination of physical fitness with emotional fitness and brain health combine to contribute to an improved quality of life and healthy aging.  (PAGA, 2018) According to the Guidelines, adults age sixty-five and older benefit from regular physical activity, even if that activity is below the key guidelines for exercise prescription. (PAGA, 2018)

    The success of an exercise program for the body and the brain can only be realized if participation occurs. (Cooper, 2020)  Many adults are resistant to exercise due to cost, time constraints, and fear of injury. (PAGA, 2018)  AG addresses these concerns by being cost effective, time effective, and practiced in the safety of a seated position.  It is our job as practitioners and educators to encourage participants to commit to consistent exercise habits that incorporate a balance of participant preferences with evidence based practices. (Cooper, 2020)  As educators for the older adult population, AGEC believes AG meets the criteria for physical fitness and cognitive health for older adults as outlined in the Physical Fitness Guidelines for Americans, 2^nd Edition.

References

Cooper, S. (2020) Promoting Physical Activity for Mental Well-Being, American College of Sports Medicine’s Health and Fitness Journal, 24(3), 12-14.
doi:10.1249/fit0000000000000569

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

Medved, D. (2013). Introduction to Ageless Grace, The Ageless Grace Brain Health Program Playbook, 5-7. Essay, Purple Iris Press, LLC.

Rugnetta, M. (2020, September 3). Neuroplasticity. Encyclopedia Britannica. https://www.britannica.com/science/neuroplasticity

US Department of Health and Human Services. (2018) Physical Activity Guidelines for Americans, 2^nd edition. SNAP Education Connection. 27-46, 66-87.
https://snaped.fns.usda.gov/library/materials/physica-activity-guidelines-americans-2nd-edition

Spring 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)

Wow, it has been over a year since the pandemic began and although we can see light at the end of the tunnel, we are still in the tunnel, yet thriving! The AGEC may look a little different than it did 12-15 months ago, but we are persevering and growing. We are now more diverse in our program offerings while still meeting and exceeding our goals and objectives. Over the past year we have embraced new partnerships and expanded outreach while maintaining key programs and activities.

During the past quarter, we started a new partnership with the Central Arkansas Library System that has gone state wide entitled “Learn from Home” and first aired on January 19^th. The Learn from Home Series is held monthly and covers topics such as “Understanding Dementia and Alzheimer’s Disease” and “Disaster Planning for Seniors”. We have also started monthly healthy cooking classes called “Cooking Live with AGEC: From Our Kitchen to Yours”. Both programs are going very well with thousands of online views. Programs with other partners included “Fall Prevention” with UCA Outreach and a “Memory Café” with Hendrix College featuring water stories and trivia. Those are just a sampling of the many programs we are having with our partners. Thank you partners for your continued support and vital participation during these difficult times!

We have also continued with our healthcare professions programming.  Beginning in January with Lee Kathryn Lackey talking about “Supporting Military Caregivers” followed by Dr. Leah Tobey and myself presenting at Geriatric Grand Rounds on the “4Ms of Age-Friendly Care.” In February, “Racial/Ethnic Disparities in COVID-19 Predictors and Outcomes” was presented by Drs. Clare Brown and George Pro, followed later in February by Dr. Paul Parcon presenting on “Neuroinflammation in Alzheimer’s Disease”. “Opioid Tapering” was presented by Dr. Corey Hayes on March 18^th which was in partnership with the UAMS OPAL grant. Our next webinar will be in June regarding oral hygiene in older adults.

Finally, something we are very excited about with the AGEC is our involvement in older adult mass vaccination clinics in central AR. This is one of the activities supported by the CARES portion of our GWEP grant this quarter, and it has been extremely rewarding! AGEC staff along with the UAMS College of Nursing and Pharmacy students have been active in providing thousands of COVID-19 vaccines to older adults in partnership with local pharmacies, emergency management organizations, and many other volunteer groups. What great events!

Thank you all for supporting AGEC in our clinical, educational, and outreach efforts!

Spring 2021 Newsletter

By Katharine Stockton, Pharm.D. and Lisa C. Hutchison, PharmD, MPH
University of Arkansas for Medical Sciences (UAMS) College of Pharmacy

Heart disease and stroke are leading causes of death in older adults.¹ For prevention of cardiovascular disease, aspirin works as an antiplatelet through inhibition of cyclooxygenase-1 and 2 enzymes.  It irreversibly inhibits the formation of thromboxane A₂ via acetylation of platelet cyclooxygenase, which then inhibits platelet aggregation.⁷  Aspirin is proven effective for secondary prevention of cardiovascular diseases including coronary artery disease (CAD), peripheral artery disease (PAD), and stroke/transient ischemic attack (TIA).^2-6 However, the benefit to risk ratio of aspirin for primary prevention of cardiovascular disease is not as favorable given aspirin’s potential to cause bleeding.

Prior to the 2019 guidelines update from American College of Cardiology (ACC) and American Heart Association (AHA), aspirin was recommended for primary prevention of cardiovascular disease by these groups and other revered organizations^8,9 However, the 2019 ACC and AHA give more cautious recommendations regarding aspirin for primary prevention¹⁰:

• Low-dose aspirin (75-100mg daily) might be considered for the primary prevention of ASCVD among select adults 40-70 years of age who are at a higher ASCVD risk but not at an increased risk of bleeding.
• Low-dose aspirin (75-100mg daily) should not be administered on a routine basis for the primary prevention of ASCVD among adults > 70 years of age.
• Low-dose aspirin (75-100mg daily) should not be administered for the primary prevention of ASCVD among adults of any age who are at increased risk of bleeding.

This update to guidelines and change from previous recommendations stems from recently published studies on the use of aspirin in the elderly.¹⁰  A series of articles from the Aspirin in Reducing Events in the Elderly (ASPREE) study  were published in 2018. ^11-13  The ASPREE study enrolled people 70 years of age or older who did not have cardiovascular disease, dementia, or any physical disability. Subjects were randomized to receive either aspirin or placebo.  Aspirin use did not prolong disability-free survival over a period of 5 years in the intervention group as compared to placebo (P=0.79).¹¹ However, aspirin increased all-cause mortality in the elderly compared to placebo (1.14, CI 1.01 – 1.29).¹² This was attributed to cancer-related death and was an unexpected result of the study that should be interpreted cautiously given the confidence interval.

The ASPREE study also evaluated the effect of aspirin on cardiovascular events and bleeding. Cardiovascular disease was defined as a composite of fatal coronary heart disease, nonfatal myocardial infarction, fatal or nonfatal stroke, or hospitalization for heart failure. The study found no significant difference in the rate of cardiovascular disease with 10.7 events per 1000 person-years in the aspirin group and 11.3 events per 1000 person-years in the placebo group (0.95, CI 0.83 – 1.08). However, there was a significant difference noted in the composite rate of major hemorrhage for those in the aspirin group (1.38, CI 1.18-1.62; P < 0.001).¹³ Specifically, a significant difference was identified in subdural or extradural hemorrhage (1.79, CI 1.06-3.02) and upper gastrointestinal bleeding (1.87, CI 1.32-2.66). It is important to note that the ASPREE trial evaluated use of aspirin in the “healthy elderly” and did not meet the expected rate of cardiovascular events; therefore the potential cardiovascular advantages may be underestimated.¹³ However, the results of the ASPREE trial are similar to a recent meta-analysis evaluating use of aspirin for primary prevention in adults, which also concluded aspirin use did not significantly reduce cardiovascular endpoints, but was associated with an increased risk of bleeding.¹⁴

Given these study results and recent guideline updates, use of aspirin for primary prevention in the geriatric population should be carefully considered. Clinicians should evaluate patient history, cardiovascular risk factors, bleeding risk in discussion with older adults before recommending, starting, or continuing aspirin in patients greater than 70 years old.

References:

1. FastStats – Deaths and Mortality. Centers for Disease Control and Prevention. Published 2019. https://www.cdc.gov/nchs/fastats/deaths.htm
2. Winstein CJ, Stein J, Arena R, et al. Guidelines for Adult Stroke Rehabilitation and Recovery: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association . Stroke. 2016;47(6):e98-e169. doi:10.1161/STR.0000000000000098
3. Kulik A, Ruel M, Jneid H, et al. Secondary prevention after coronary artery bypass graft surgery: a scientific statement from the American Heart Association. Circulation. 2015;131(10):927-964. doi:10.1161/CIR.0000000000000182
4. Piepoli MF, Hoes AW, Agewall S, et al. 2016 European Guidelines on cardiovascular disease prevention in clinical practice: The Sixth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of 10 societies and by invited experts)Developed with the special contribution of the European Association for Cardiovascular Prevention & Rehabilitation (EACPR). Eur Heart J. 2016;37(29):2315-2381. doi:10.1093/eurheartj/ehw106
5. Levine GN, Bates ER, Bittl JA, et al. 2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2016;68(10):1082-1115. doi:10.1016/j.jacc.2016.03.513
6. Conte MS, Bradbury AW, Kolh P, et al. Global vascular guidelines on the management of chronic limb-threatening ischemia . J Vasc Surg. 2019;69(6S):3S-125S.e40. doi:10.1016/j.jvs.2019.02.016
7. Aspirin. Lexi-Drugs. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL. Available at: https://online.lexi.com/ . Accessed November 19, 2020.
8. Vandvik PO, Lincoff AM, Gore JM, et al. Primary and Secondary Prevention of Cardiovascular Disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(4):e637-e668. doi:10.1378/chest.141.4.1129c.
9. Kernan WN, Ovbiagele B, Black HR, et al. ). Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2017;45(7):2160-2236.
10. Arnett DK, Blumenthal RS, Albert MA, et al. 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease. Journal of the American College of Cardiology. 2019;74(10):e177-e232. doi:10.1016/j.jacc.2019.03.015.
11. McNeil JJ, Woods RL, Nelson MR, et al. Effect of Aspirin on Disability-free Survival in the Healthy Elderly . The New England Journal of Medicine . 2018;379(16):1499-1508.
12. McNeil JJ, Nelson MR, Woods RL, et al. Effect of Aspirin on All-Cause Mortality in the Healthy Elderly . The New England Journal of Medicine . 2018;379(16):1519-1528.
13. McNeil JJ, Wolfe R, Woods RL, et al. Effect of Aspirin on Cardiovascular Events and Bleeding in the Healthy Elderly . The New England Journal of Medicine . 2018;379(16):1509-1518.
14. Guirguis-Blake JM, Evans CV, Senger CA, O’Connor EA, Whitlock EP. Aspirin for the primary prevention of Cardiovascular events: a systematic evidence review for the U.S. Preventive Services Task Force. Ann Intern Med 2016; 164: 804-13.