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.

Spring 2021 Newsletter

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

The Arkansas Geriatric Education Collaborative (AGEC) at the University of Arkansas for Medical Sciences has the mission to provide high quality programs that support healthy aging in Arkansas.  Currently the population of adults age 65 and older is 54 million, or about sixteen percent of the nation’s population (US Census Report, 2019). In Arkansas, the number of adults age 65 and older is 524,000 and represents 17.4 percent of the state population (US Census Report, 2019). By the year 2030, the population of adults age 65 and older is expected to rise to 20 percent nationally and to 26 percent statewide (US Census Report, 2020).

     The aging population, becoming the largest population sector in the future, has specific needs that must be addressed by the medical community. This age group presents with a host of chronic health problems; cardiovascular disease, hypertension, type II diabetes, osteoarthritis, muscular atrophy and dementia related illnesses. Through regular exercise and nutritional monitoring many of the chronic debilitating diseases can be improved, alleviated or prevented (Lee et al., 2017) (USDA, 2021). Of all Medicare beneficiaries, 68% suffer from 2 or more chronic diseases (Lochner et al., 2013).

     Two modalities that have a positive effect on the quality of life of older adults are exercise prescription and nutritional monitoring (Minett et al., 2019). The medical community, recommends exercise prescription as the first choice in prevention and reversal of some of the chronic diseases of the older population (Tyndall, et al., 2018). For maximum efficacy, dietary education along with the exercise prescription provide the cornerstone of creating and sustaining enhanced quality of life for the older adult (Minett et al., 2019).

     At AGEC, three programs have been implemented to address the need for regular exercise and for dietary education.  Ageless Grace, a non-weight bearing aerobic activity, and Tai Chi for Arthritis and Fall Prevention are programs that provide modalities for improving muscle mass, balance and improved cardiac output (Grabiner et al., 2014). Using the USDA’s Dietary Guidelines for 2020-2025, AGEC has developed a cooking class entitled From Our Kitchen to Yours. The recipes and content are based specifically on chapter 6 of the guidelines which is dedicated to the dietary needs of the older adult population (USDA, 2021). The nutritional guidelines found in the Dietary Guidelines for 2020-2025 provide years of research for the nutritional needs of the older adult (USDA, 2021).Information about all three programs can be found on the AGEC website (agec.uams.edu) and on our Facebook page.

     The literature cited gives a rationale for the holistic care of the older adult.  By providing education and programs that target the health issues faced by the older adult, overall wellness and quality of life can be achieved.   Students, clinicians, and physicians in tandem with the programs provided by AGEC and its partners shape this pro-active version of health care for older adult education in Arkansas.

References

Dietary Guidelines Advisory Committee (2021). Dietary Guidelines for Americans 2020-2025. https://www.dietaryguidelines.gov/sites/default/files/2021-03/Dietary_Guidelines_for_Americans-2020-2025.pdf

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

Lee, P. G., Jackson, E.A., Richardson, C. R., (2017). Exercise Prescriptions in Older Adults. American Family Physician, 95(7), 425–432.

Lochner, K. A., Goodman, R. A., Posner, S., & Parekh, A. (2013). Multiple Chronic Conditions Among Medicare Beneficiaries: State-level Variations in Prevalence, Utilization, and Cost, 2011. Medicare & Medicaid Research Review, 3(3), mmrr.003.03.b02.
https://doi.org/10.5600/mmrr.003.03.b02.

Minett, M. M., Binkley, T.L., Holm, R. P., Runge, M., & Specker, B. L. (2019). Feasibility and Effects on Muscle Function of an Exercise Program for Older Adults. Medicine and Science in Sports and Exercise, 52(2), 441–448.

Tyndall, A. V., Clark, C. M., Anderson, T. J., Hogan, D. B., Hill, M. D., Longman, R.S., & Poulin, M. J.,  (2018) Protective Effects of Exercise on Cognition and Brain Health in Older Adults, Exercise and Sport Sciences Reviews, 46(4),  215-223 
https://doi.org/10.1249/JES.0000000000000161

United States Census Bureau, (2019). American Community Survey TableID S0103.
https://data.census.gov/cedsci/table?q=S0103&tid=ACSST1Y2019.S0103&hidePreview=false

United States Census Bureau, (2019). Population Estimates for Arkansas. https://www.census.gov/quickfacts/table/AR/AGE775219

Vespa, J., Armstrong, D. M., & Medina, L., (2020). Demographic Turning Points for the United States: Population Projections for 2020 to 2060. https://www.census.gov/library/publications/2020/demo/p25-1144pdf.html

Winter 2021 Newsletter

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

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

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

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

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

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

Winter 2021 Newsletter

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

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

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

Table 1. Dapagliflozin and Empagliflozin in Heart Failure Trials

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

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

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

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

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

References:

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

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

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

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

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

Fall 2020 Newsletter

By Whitney Thomasson, MAP
Research Assistant
UAMS Arkansas Geriatric Education Collaborative

It is with great pleasure that the UAMS Arkansas Geriatric Education Collaborative (AGEC) announces its 2021 selection for the Geriatric Student Scholars program: Anusha Majagi (Doctor of Medicine and Master of Public Health student), Kristin Price (Doctorate of Pharmacy student), Harper Purifoy (Master of Public Health student), Ellie Reaves (Bachelor of Science in Nursing student), and Kashti Shah (Hendrix College Pre-Medical undergraduate).

The purpose of the Student Scholars program is to increase health professions students’ interest in and exposure to older adults, to improve knowledge of older adult health issues and the specialized care they need, and to promote interprofessional collaboration among health professions students. Throughout the program, the scholars are required to attend a minimum number of academic and community programs focused on older adults, and write reflections on their experiences. The scholars will also work collaboratively on a team project this spring, which will focus on a current geriatric-related issue.

We at AGEC are proud to support our third annual cohort of geriatric scholars. While keeping academic and community program participation at the center of the student experience, we have made modifications to this year’s program to allow for proper social distancing measures. We are encouraging all team meetings to take place virtually, along with providing numerous opportunities to participate in online community and academic programs to satisfy program requirements.

To read more about our scholar selection, please visit our 2021 Student Scholar page. We look forward to an exciting 2021 with our Geriatric Student Scholars!

Fall 2020 Newsletter

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

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

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

Table 1: Over The Counter Topical Medications for Arthritis Pain1,5,6,9
Ingredients	Brand Name Examples	Advantages	Disadvantages	Usual Area of Use
Menthol, camphor	Icy Hot Gel, Biofreeze, Tigerbalm	Cooling sensation with immediate effect	Does not treat inflammation or pain	Hand, knee, back
Salicylates	Bengay, Aspercreme, Myoflex	Cooling sensationSlight anti-inflammatory effectScented/unscented	Avoid with aspirin allergy	Knee, hand, foot
Capsaicin	Capzasin-HP creamZostrix, Capsiderm	Treatment of pain Potential adjunct agent when other therapies not tolerated	Skin irritation Poorly absorbed, Difficult adherence	Knee, hands
Diclofenac (NSAID) 1% gel	Voltaren Gel	Treatment of painGI & renal effects of oral NSAIDs unlikely	Skin irritation, Delayed pain relief, Difficult adherence	Knee, hand, foot

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

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

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

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

References:

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

Fall 2020 Newsletter

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

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

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

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

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

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

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

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