UAMS

From The Director’s Desk

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

Hello from the Arkansas Geriatric Education Collaborative (AGEC), the Geriatric Workforce Enhancement Program for Arkansas. Spring time was very busy for the AGEC with a lot of programs happening all across the state. We had a webinar in April about the latest Shingles Vaccine and other needed adult vaccines by Dr. Bob Hopkins and Kara Jones one in March “Improving the Quality of Life of Senior Cancer Survivors” by Lisa VanHoose, PhD, one of our AGEC Geriatric Fellows from last year. Our academic partners, ASU and UCA, were also busy reaching thousands of students with geriatric content during the spring semester! We were also busy with Family Caregiver Workshops, Dementia Experiences, and Dementia Practitioner and First Responder Dementia trainings. We had wonderful audiences at these events and look forward to expanding these programs in year four.

As we currently swelter in the middle of an Arkansas summer, we are continuing to have great programs and activities throughout the state and are planning for year four activities. We have just received notice about a small GWEP supplemental grant revolving around the opioid crisis. This was developed, submitted and approved! We have also received our HRSA funding for year four of the AGEC and are very active getting the associated programs started. We continue to seek new ways to reach and teach all audiences and if you have any suggestions, please let us know.

Andexanet Alfa: Newly Approved Reversal Agent for Oral Anticoagulants

By Karah Bogoslavsky, PharmD candidate and Lisa C Hutchison, PharmD, MPH
Donald W. Reynolds Institute on Aging at UAMS

Bleeding is a serious complication of treatment with oral anticoagulants or blood thinners. Andexanet alfa (AndexXa) has recently been approved for the reversal of life-threatening or uncontrolled bleeding in patients treated with apixaban (Eliquis) and rivaroxaban (Xarelto).¹ It joins idarucizumab (Praxbind) which is marketed for bleeding with dabigatran (Pradaxa). Similar to idarucizumab, andexanet alfa binds free rivaroxaban or apixaban in the blood so they are no longer able to work. There were two major trials that were used to test the efficacy of andexanet alfa, the ANNEXA-A/ANNEXA-R trial and the ANNEXA-4 trial.^2,3

The ANNEXA-A/ANNEXA-R study tested andexanet alfa bleeding reversal activity in healthy volunteers 50 to 75 years old, with an average age of 58 years old.² Bleeding activity was rapidly reduced within 2 to 5 minutes as compared to placebo. After administration of andexanet alfa was completed, the reversal of bleeding activity persisted for 2 hours. This finding is consistent with the half-life of the drug, which is approximately 1 hour.

The ANNEXA-4 study is an ongoing open label study of patients with acute major bleeding from apixaban or rivaroxaban.³ The average age was 77 years old, and two thirds of patients had atrial fibrillation. Effectiveness was rated as “excellent” if the bleeding stopped within 1 hour after the infusion and “good” if it stopped within 4 hours. Of the 77 enrolled patients, 20 were not included in final analysis due to low or missing anti-factor Xa activity. Of the 47 patients in the effective population, 31 patients had “excellent” hemostasis and 6 had “good” hemostasis, 12 hours after the andexanet alfa infusion. Effective normalization between the bleeding and blood clotting activity was achieved 12 hours after infusion of andexanet alfa in 79% of the patients studied.

However, treatment with andexanet alfa has been associated a high rate of thrombosis including heart attacks, stroke, cardiac arrest, and sudden death. In the ANNEXA-4 study, events that involved dislodged blood clots occurred in 18% of the patients in the safety population, and 15% of the patients died during the 30-day follow-up.³ It is unknown whether andexanet alfa has a prothrombotic effect of its own, or if the absence of an anticoagulant in a high risk patient is the cause of this high rate of thrombosis and follow-up was limited to 30 days.

Andexanet alfa comes in a 100 mg vial and requires storage under refrigeration until reconstitution with sterile water for injection. A specific reconstitution technique is described in the package insert.¹ Dosage is 400 mg infusion for lower doses of apixaban or rivaroxaban, and 800 mg infusion for higher doses.

The availability of a reversal agent for apixiban and rivaroxaban levels the playing field between them and dabigatran; however, much is still unknown regarding the risk of newer oral anticoagulants and reversal agents in older adults.⁴ Since the rate of serious bleeding is lower in the newer anticoagulants, and their effects wear off quickly, in most cases stopping the drug will be sufficient treatment for bleeding and no antidote will be required. Limiting use of andexanet alfa to individuals with life-threatening hemorrhage is most prudent, given the risk of thrombosis and unknown long-term outcomes in older adults.

References

Andexxa (andexanet alfa) . South San Francisco, CA: Portola Pharmaceuticals, Inc; May 2018.
Connolly SJ, Milling TJ Jr, Eikelboom JW, et al. Andexanet Alfa for Acute Major Bleeding Associated with Factor Xa Inhibitors. N Engl J Med 2016; 375:1131.
Siegal DM1, Curnutte JT, Connolly SJ, et al. Andexanet Alfa for the Reversal of Factor Xa Inhibitor Activity. N Engl J Med. 2015 Dec 17;373(25):2413-24. doi: 10.1056/NEJMoa1510991. Epub 2015 Nov 11.
Hunt BJ, Levi M. Engineering reversal—finding an antidote for direct oral anticoagulants. N Engl J Med 2016; 375:1185-6.

The Importance of Socialization As We Age

By Kathy Packard, MS, M.Ed., LPC, and Valerie Claar, MSN, RN, CNE
Oaklawn Center on Aging

Loneliness is defined as a feeling of sadness or distress about being by yourself or without friends. Loneliness can be either a response to or an effect of isolation. Loneliness can lead to isolation, which is defined as being separated from other people and your environment. Loneliness can also lead to depression and numerous health issues. As we grow older we experience losses. Family and friends may become ill and or die. We might find it easier to look for companionship through social media, or to order our groceries, clothing, etc. online, avoiding any and all human contact. As health care professionals who focus on best practices for the older adult population, we are capable of taking care of the medical, physical, and mental health needs but find we are at a loss as to how to get our consumers to get out and participate in social events with their peers. We know loneliness and social isolation are health hazards.

According to Brigham Young University study in 2010, loneliness isn’t just bad for the individual and communities; it is a legitimate public health threat. The Brigham Young study found that weak social connections can shorten a person’s life by 15 years, which is the same health impact as smoking 15 cigarettes a day.

Without the benefit of socialization, older adults who are facing medical issues do not have the support of their peers and may tend toward health decline. Research presented at the American Psychological Association’s annual convention in 2017 showed that greater social connection corresponds with a 50 percent decrease in the risk of early death.

It can be beneficial to know how to help and where to start. The answer may lie within our own reach by really working with the consumer/patient and having an honest conversation about the health benefits of socialization. It can also help to make a consumer driven plan that is achievable and enhances quality of life by decreasing loneliness.

More and more older adults are living longer and alone. Including socialization as part of the treatment plan may be one way to attack the problem. Getting the psychosocial history and writing a prescription for social activities our consumers are “willing and able to fill” may be a good first step toward increasing human contact and decreasing their loneliness. Encouraging older adults to include social activities, along with healthy eating and physical activity may help foster a healthy way of living for quality, enrichment and social engagement. Promoting local community programs such as Senior Centers, congregate meals, YWCA, YMCA, art classes, exercises classes such as Tai Chi, music programs (local orchestras, bands, etc.), and volunteering to help others are just a few of the resources at the local level.

As with any prescription, start low and go slow, it will take time for someone who has suffered from loneliness and isolation to “get back out there”. Having the consumer/patient actively participate in the development of the treatment plan and goals will be a step in the direction of self worth and motivation to achieve the desired outcome.

Statins: When Do the Benefits Outweigh the Risks in the very Elderly?

by Taylor J Neeley and Lisa C Hutchison, PharmD, MPH, UAMS

High quality studies show that statins significantly reduce all-cause mortality in older patients with established cardiovascular disease (CVD). One meta-analysis included approximately 20,000 patients between ages 65 and 82 with coronary heart disease who received either placebo or statin. There was a 22% decrease in all-cause mortality over 5 years in the statin group vs. placebo. The meta-analysis also revealed significant risk reductions in cardiovascular mortality, nonfatal myocardial infarction, and strokes of around 30% each. ¹

However, the benefits for patients 75 years and older without CVD are less clear because major statin trials have excluded patients greater than 75. Very few trials have included patients over 70 years of age, and evidence for patients >80 is largely limited and conflicting.² For example, in the Antihypertensive and Lipid Lowering treatment to prevent Heart Attack Trial (ALLHAT-LLT), initiation of pravastatin 40 mg for primary prevention in patients 65 years and older showed no risk reduction in cardiovascular events.⁴ However, in the Prospective Study of Pravastatin in Elderly at Risk (PROSPER) trial, patients of ages 70-82 with at least one cardiovascular risk factor (hypertension, smoking, and/or diabetes) were randomized to either pravastatin 40 mg or placebo. There was a significant reduction in major vascular events (stroke, fatal or non-fatal MI) in pravastatin group vs. placebo. ⁵

So, guidelines provide no specific recommendations for statin therapy in the middle and oldest old without CVD. Despite the lack of information, approximately 39% of patients 79 and older are on statin therapy for primary prevention of cardiovascular events. ³

Because this population is known to be more vulnerable to adverse drug effects, we see hospitalizations due to statin-induced rhabdomyolysis is 5 times more likely in patients 65 and older versus younger patients.²Even moderate muscle pain, a common side effect of statins, could cause already frail patients to increase their fall risk and/or immobility. And in rare cases, statins cause confusion and memory loss, especially with atorvastatin, lovastatin, simvastatin. Fortunately, these effects are reversible upon discontinuation.^{6, 7}

More research of statin benefits vs. risks, specifically in patients 75 and older at risk for CVD, are needed. So for now, patient-centered decision-making is key when the evidence is unclear.

Current ACC/AHA guidelines recommend that in patients >75 with established CVD

Begin statin therapy, but at a moderate intensity. There is strong evidence of statin cardiovascular benefit in this population.
In patients already well established on a high intensity statin with no complications, this may be continued. ⁸

In patients > 75 without established cardiovascular disease:

The decision to initiate a statin should be individualized and should weigh in heavily on patient concerns and goals. ²
- Factors that may support initiation of a statin:
  - Few comorbidities,
  - > 1 cardiovascular risk present
  - Patient priority to minimize cardiovascular risk
- Factors that may support avoiding statin initiation:
  - High comorbidities
  - Only 1 cardiovascular risk present
  - History of myopathy
  - Severe dementia
  - Frailty
  - High risk of drug-drug interactions
  - Patient priority to avoid pill burden
  - Patient priority to avoid adverse drug effects
  - Life expectancy < 1 year
In patients already well established on a statin with no complications, this may be continued.

Finally, in all elderly patients initiated on a statin, monitoring for adverse side effects should be a priority due to increased risks. Reassessment of factors such as development of dementia, frailty, and life expectancy should be made after starting therapy as these may change overtime and affect the decision to continue.

References:

Ross SD, Allen IE, Connelly JE, Korenblat BM, Smith ME, Bishop D, Luo D. Clinical Outcomes in Statin Treatment TrialsA Meta-analysis. Arch Intern Med.1999;159(15):1793–1802. doi:10.1001/archinte.159.15.1793
Pletcher, M. J., Coxson, P. G., Thekkethala, D., Guzman, D., Heller, D., Goldman, L., & Bibbins-Domingo, K. Statins for Primary Prevention in Older Adults.
Stone NJ, Robinson JG, Lichtenstein AH, et al. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2014;129(25 Suppl 2):S1-45.
ALLHAT Officers and Coordinators for the ALLHAT Col- laborative Research Group. Major outcomes in moderately hypercholesterolemic, hypertensive patients randomized to pravastatin vs. usual care: the Antihypertensive and Lipid Lowering Treatment to Prevent Heart Attack Trial (ALL- HAT-LLT). JAMA 2002; 288: 2998–3007.
Shepherd J, Blauw GJ, Murphy MB, et al. Pravastatin in eld- erly individuals at risk of vascular disease (PROSPER): a randomised controlled trial. Lancet 2002; 360: 1623–1630.
Baigent C, Blackwell L, Emberson J, et al. Efficacy and safety of more intensive lowering of LDL cholesterol: a meta-analysis of data from 170,000 participants in 26 randomised trials. Lancet2010;376:1670-81.
Haag MD, Hofman A, Koudstaal PJ, et al. Statins are associated with a reduced risk of Alzheimer disease regardless of lipophilicity. The Rotterdam Study. J Neurol Neurosurg Psychiatry 2009;80:13-7.
Lambert, M. (2014). ACC/AHA Release Updated Guideline on the Treatment of Blood Cholesterol to Reduce ASCVD Risk. American family physician, 90(4), 260.

From the Director’s Desk

By Ronni Chenoff, PhD, FAND, FASPEN

UAMS Arkansas Geriatric Education Collaborative

The Arkansas Geriatric Education Collaborative (AGEC), a Geriatric Workforce Enhancement Program, is working on goals and objectives for the second year of this program to educate health professionals, students, caregivers, first responders and the general public about issues and topics that affect our older population. We are proud of our achievements during the first year and are coming up to midway through year 02.

We will continue to offer video teleconferences four times/year; the first conference, broadcast in September addressed strategies to prevent and manage falls in both in-patient and outpatient settings. An upcoming video teleconference, scheduled for October 26, will be on trauma in the geriatric patient and anti-coagulant reversal strategies. Previous programs that you may have missed will be available as DVDs or on-line (unedited). Coming programs may be seen at UAMS or a site near where you or work by the interactive television network, but programs are now available through Blackboard Collaborative, a web-streaming option; this means you can stay at your computer and receive the program in real time and ask questions through the chat option. This is always true for some live programming; on November 2, we are sponsoring a Geriatric Grand Rounds to be broadcast live and video streamed. The grand rounds speaker will be Dr. Richard Zraick, professor and chairman of Speech Pathology/Audiology at the University of Central Florida, formerly professor in the College of Health Professions at UAMS and UALR. He will be addressing “Communication Impairment in Persons with Alzheimer’s disease”. We are delighted to offer you the opportunity to access AGEC programming more conveniently.

Opportunities for more education in geriatrics include the Arkansas Geriatric Education Mentors and Scholars (ARGEMS) program, a self-study for health professionals that can be completed on line and the Summer Institute, a program for faculty in the health professions. ARGEMS can be started at the participants’ convenience; more information may be obtained at our website, www.agec.org, for interested readers. Invitations for Summer Institute for Faculty will be sent out after the New Year. If you are interested, read more about it on our website. Both programs are tuition-free.

As we plan ahead, we would love to hear from you about what you would like to know more about. We will be conducting a statewide needs assessment in the spring, 2017 and hope you will take the time to answer the questions on line or using a mailed survey. In the meantime, feel free to e-mail your suggestions for topics and programs to agec@uams.edu or post a note on our website page.

We all wish you a great fall and holiday season and hope to see you soon!

10 Interesting Facts about Senior Citizens

By Regina V. Gibson, MALS, RN, CHES

UAMS Arkansas Geriatric Education Collaborative

1. Senior Citizens are Still Active in the Workforce

There are currently over 5 million senior citizens who are active in the work force. That means that 5 million older people are still sharing their skills and expertise to help make the world and their industry a better place.

2. Senior Citizens Are More Likely to Vote

Senior citizens make up the majority of registered voters. That means that they are also good citizens with a strong sense of civic pride and commitment to their country.

3. Senior Citizens Have a Day of Recognition

May is the designated month for appreciating and recognizing senior citizens. August 21st, however, is official Senior Citizens Day. Its purpose is to bring awareness about social and economic issues regarding the well-being of seniors, as well as to honor them for their contributions.

4. Senior Citizens are More Likely to Commit Suicide

The media may lead us to believe that younger people are more inclined to take their own lives. However, the truth is that people 65 and older are more likely to commit suicide than any other age group.

Men are more likely to commit suicide than women. According to the CDC, the suicide probability for women levels off in the 60’s, but continues to climb for men. Contributing factors can include depression (which is often missed, ignored or misdiagnosed in the elderly), loneliness, isolation, physical limitations (feelings of low self-worth), poverty, illness, and being recently divorced or widowed.

Suicide goes up in individuals with access to hand guns. Lethal weapons, but especially guns, are the main method for suicide among the elderly.

Montana has the highest suicide rate among seniors.

5. Poverty Is Still a Serious Issue for Senior Citizens

Over 16% of seniors live in poverty.

“9.4 percent of seniors had incomes in 2006 below the poverty threshold of $9,669 for an individual, and $12,186 for a couple, nearly a quarter of older Americans (22.4 percent) had family incomes below 150 percent of the poverty line.” — Center for American Progress. This is not always due to mismanagement of funds. As the economy fluctuates, seniors often find that the value of their assets and savings may not match or exceed the rising cost of health care, medications, assisted living and other needs of aging.

6. Senior Citizens Still Have Sex

At least 73% of all senior citizens are still sexually active and not always with their spouses and partners. The elderly are also just as likely to engage in experimental sexual practices as any other age group.

The numbers don’t change much over the age groups either. Men and women in their 60’s, 70’s and beyond reported to be just as satisfied and sometimes more satisfied than when they were younger.

Elders who are single or widowed are highly likely to seek out one or more sexual partners. Rather than being appalled at the sexual preferences and practices of the aging population, more education and health screenings need to be available, since those over 60 are the least willing to implement safe-sex practices.

7. Senior Citizens are Tech Savvy

More than 40% of seniors have computer access and are active online. About 15 million Facebook users are 65 and older.

Along with social media sites where they can connect with friends and family, older computer users play online games, read news sites, sign up for dating sites, and contribute to sites related to their interests. They are bloggers, survey takers, shoppers, reviewers, photographers, and more.

8. Senior Citizens Still Drive, Even When They Shouldn’t

About 80% of seniors own a car and drive frequently. Whereas only 1% of senior deaths are due to a motor vehicle accident, they are more likely to have crashes at intersections than other age groups. Elderly men have three times higher death rate from car accidents than women. Although there are many jokes about the elderly driving too slowly, they are just as likely to get pulled over for speeding.

9. Senior Citizens Enjoy Hobbies that are Creative or Useful

The majority of senior citizens, whether working or retired, enjoy hobbies and social activities. Crafting, woodworking, dancing, exercise, pets, travel, charity work and church are some of the preferred activities.

10. Senior Citizens are Individuals

You can group them together, you can study them statistically and you can stare at infographics for days. But it still comes down to individuality.

Seniors come from all classes, all ethnicities and all educational backgrounds. They run marathons, go to college, work at jobs, take dance classes, use online dating sites, and play games on Facebook. Until you reach out and get to know a senior, you will never know for sure what makes them tick.

Reference:

http://eldercareissues.blogspot.com/2014/01/10-interesting-facts-about-senior.html

Use of Technology and Home Exercise Compliance in Older Adults

By Chad Lairamore, PhD, PT, GCS, NCS and Sarah Walker, DPT

University of Central Arkansas

Patient compliance has been a consistent challenge to ensuring appropriate treatment within all fields of healthcare.^1-3 Not only is compliance crucial to decreasing healthcare costs by minimizing wasted healthcare dollars on repeated services where benefits are not fully realized; compliance by patients may become a factor in provider viability, with reimbursement impacted by the outcomes that clients achieve.^1,4,5 As healthcare continues to move toward value and outcome-based models of reimbursement, this old problem takes on a new perspective as reimbursements may soon be incentivized by, or even directly linked with, patient outcomes.^6-8 Additionally, for patients to receive appropriate medical treatment they must have a partnership with the care provider and be engaged in managing their own health care. The choices they make every day have the greatest impact on their wellbeing.^1,5 In fact the World Health Organization states that “Increasing the effectiveness of adherence interventions may have a far greater impact on the health of the population than any improvement in specific medical treatments.”⁵ Non-compliance is of particular importance in the older adult population, as data indicate that those over the age of 65 are less likely to perform their prescribed home exercise program.^9,10

Emerging evidence suggests that providing patients with a more engaging form of home exercise program beyond either the standard written or verbal instructions can result in an increase in patient compliance. In this time of rapidly advancing personal technology, one solution to improving compliance may lie in the palm of our hand through the appropriate utilization of smart devices. Smartphone and tablet applications are a readily available, familiar, and ubiquitous tool at the fingertips of most clinicians and patients.

This technology is currently grossly underutilized and unstudied, but could potentially serve to revolutionize patient outcomes by dramatically increasing rates of patient compliance. However, Individuals over the age of 65 represent the lowest demographic for smart phone usage with only 27% reporting having a smartphone.¹¹

To bridge this gap, we partnered students from the University of Central Arkansas Physical Therapy Department with older adults participating in a pro bono clinic associated with the course Adult Neurological Rehabilitation. Clients were loaned an iPad mini if they did not already own a smart device, and students instructed the clients on use of the smart device. The goals of this learning experience were to 1) facilitate improved engagement and home exercise program compliance, and 2) educate students on the potential use of technology for increasing patient engagement and compliance compared to standard printed home exercise programs.

In order to gauge patient compliance, we used the application Wellpepper during the pro bono clinic and for 1 month following the clinic. Wellpepper is an application that is used to create custom care plans, share and update exercises remotely, and track results.¹² The application was administered by student physical therapists using an iPad. With supervision from a licensed physical therapist, students created customized home exercise programs that were then available to clients via the application on their own personal device or the device that was lent to them. Within the app, therapists and students were able to change and update their client’s home exercises, and check in to see if they were being performed. This innovative system attempts to capitalize on the assumption that greater patient engagement and support, coupled with a more dynamic interface, can increase patient compliance.

Anecdotally, we found that clients fell into one of three categories. Those who already had a “relationship” with their smartphone or tablet were likely to engage with the application Wellpepper and perform their home exercise program on a regular basis. The clients who did not own a smartphone or tablet, but who demonstrated an interest in using the application, were also likely to engage with the home exercise program and have good compliance. In fact, several clients who fell in this category bought tablets to be able to continue their exercise routine. Finally, the clients who did not show an early interest in the technology were generally non-compliant with their home exercise program. These results are not surprising as previous research investigating elderly participants use of a home program found that compliance was influenced by the individual’s preference for the program structure and how that program was delivered.¹³

In conclusion, we found the use of smart devices may increase patient engagement and improve compliance for some older adults. However, smart device usage is not for everyone. Clinicians need to match instructional techniques with their client’s preference. Additionally, as instructors, we need to not only teach our students to use technology for increasing patient engagement, but also to use traditional instructional strategies as well as other alternative strategies to better match home programs to the patient’s preference.

References:

Martin LR, Williams SL, Haskard KB, DiMatteo MR. The challenge of patient adherence. Therapeutics and Clinical Risk Management. 2005;1(3):189-199.
Vermeire E, Hearnshaw H, Van Royen P, Denekens J. Patient adherence to treatment: three decades of research. A comprehensive review. Journal of C`linical Pharmacy and Therapeutics. 2001;26(5):331-342.
Campbell R, Evans M, Tucker M, Quilty B, Dieppe P, Donovan J. Why don’t patients do their exercises? Understanding non-compliance with physiotherapy in patients with osteoarthritis of the knee. Journal of Epidemiology and Community Health. 2001;55(2):132-138.
Jack K, McLean SM, Moffett JK, Gardiner E. Barriers to treatment adherence in physiotherapy outpatient clinics: A systematic review. Manual Therapy.15(3):220-228.
Adherence to Long Term Therapies – Evidence for Action. Wolrd Health Organization 2003: http://www.who.int/chp/knowledge/publications/adherence_report/en/.
VanLare JM, Conway PH. Value-based purchasing—national programs to move from volume to value. New England Journal of Medicine. 2012;367(4):292-295.
Miller HD. From volume to value: better ways to pay for health care. Health Affairs. 2009;28(5):1418-1428.
Roadmap for Implementing Value Driven Healthcare in the Traditional Medicare Fee-for-Service Program In: Services TUSDoHaHSaTCfMM, ed. CMS website 2009:31. ????
Henry KD, Rosemond C, Eckert LB. Effect of number of home exercises on compliance and performance in adults over 65 years of age. Physical Therapy. 1999;79(3):270-277.
Riel H, Matthews M, Vicenzino B, Bandholm T, Thorborg K, Rathleff MS. Efficacy of live feedback to improve objectively monitored compliance to prescribed, home-based, exercise therapy-dosage in 15 to 19 year old adolescents with patellofemoral pain- a study protocol of a randomized controlled superiority trial (The XRCISE-AS-INSTRUcted-1 trial). BMC Musculoskeletal Disorders. 2016;17:1-12.
Smith A. U.S. Smartphone Use in 2015. 2015; http://www.pewinternet.org/2015/04/01/us-smartphone-use-in-2015/.
Weiler A. mHealth and big data will bring meaning and value to patient-reported outcomes. mHealth. 2016;2(1).
Simek EM, McPhate L, Hill KD, Finch CF, Day L, Haines TP. What are the characteristics of home exercise programs that older adults prefer?: A cross-sectional study. American Journal of Physical Medicine & Rehabilitation. 2015;94(7):508-521.

Proton-Pump Inhibitors as Potentially Inappropriate Medications in Older Adults

Arkansas Geriatric Education Collaborative

By: Janna Hawthorne, PharmD, University of Arkansas for Medical Sciences

In October 2015 the American Geriatrics Society (AGS) released updates to the 2012 version of the Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. A. new class of drugs, proton-pump Inhibitors (PPIs), was added to the 2015 AGS Beers Criteria as potentially inappropriate in older adults.(1) PPIs are clinically indicated for use in acute ulcers, gastroesophageal reflux disease, erosive esophagitis, hypersecretory conditions, prevention of nonsteroidal anti-inflammatory drug (NSAID)-induced ulcers, and treatment of Helicobacter pylori infections.(2)

Commonly prescribed, and also available over-the counter, PPIs include omeprazole (Prilosec), esomeprazole (Nexium), and pantoprazole (Protonix). In 2015, it was reported that esomeprazole (Nexium) was the fourth highest prescribed medication in the United States, ranking with 15.2 million prescriptions annually.(3) The warning with PPIs in the 2015 AGS Beers Criteria is based upon studies which indicate that PPI use longer than eight weeks in the elderly population can put them at increased risk for developing Clostridium difficile infection (CDI) and can lead to bone loss and fractures.(1) In this update, the evidence suggesting potential for inappropriate use of PPIs in older adults is high with the strength of recommendation being strong. (1) A high quality of evidence implies that the studies were well-conducted, well-designed, and looked at the population in question. The strong recommendation informs us that the benefits of not using this class of medications outweighs the risk that is apparent with its use.(1)

The enhanced risk of Clostridium difficile infection is due to the potent acid suppressing nature of PPIs. Low acidity within the stomach provides ingested bacteria an environment in which they can flourish. If Clostridium difficile bacteria colonize the stomach, they can overpower the normal gut flora and produce toxins that lead to intestinal injury and inflammation.(2) The injury and inflammation that develop from this exposure will produce extensive diarrhea that could lead to dehydration, delirium, and other critical conditions within the elderly population. In a 2012 meta-analysis looking at the association of PPIs with development of Clostridium difficile infection, data showed that for every 3,925 patients taking a chronic PPI, one person will develop a Clostridium difficile infection, nearly twice the normal incidence of CDI.(4)

PPIs also have the added concern for increased bone loss and subsequent fracture. Theories suggest that calcium must have acid in order to be absorbed from the stomach. Therefore, the acid suppressing manner of PPIs may result in decreased calcium absorption and subsequent loss of bone mineral density (BMD).(5) Elderly women lose BMD at a rate of 10% per decade after menopause and elderly men decline at the same rate later in life. With the great decline in BMD simply due to aging alone, anything to exacerbate this decline could result in tremendous complications, such as hip fracture. In 2015 a meta-analysis was published that looked at the risk of fracture as associated with the use of PPIs. Data from this meta-analysis reported a 26% increase in hip fractures in patients who take PPIs chronically. The risk of spine and any-site fracture also increased by 58% and 33% respectively.(5)

High-risk patients who have erosive esophagitis, Barrett’s esophagitis, pathological hypersecretory conditions, are on oral corticosteroids or prolonged use with NSAIDs, or have demonstrated need for maintenance therapy may benefit from chronic PPI use.(1) If a patient does not have a medical indication for chronic use of PPIs, therapy should be tapered and discontinued. The first step in discontinuation of therapy would be to decrease the daily dose to the lowest dose possible. After a few weeks of the lowest possible dose, the PPI should be discontinued. After discontinuation, the patient should self-monitor for relapse of symptoms such as heartburn, indigestion, and chest pain. If symptoms recur, you may initiate a trail trial period of 4-8 weeks of the lowest possible dose of a preferred PPI or initiate therapy with a histamine2-receptor antagonist. The patient should then be followed closely and another trial of discontinuation should be tried.(6)

References:

1. American Geriatric Society 2015 Beers Criteria Update Expert Panel (2015). American Geriatrics Society 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. Journal of American Geriatric Society, 63, 2227-2246. doi: 10.1111/jgs.13702
2. Kapadia, A., Wynn, D., & Salzman, B. (2010). Potential adverse effects of proton pump inhibitors in the elderly. Clinical Geriatrics. 18(7), 24-31.
3. Brown. T. (2015). 100 best-selling, most prescribed branded drugs through March. Medscape Medical News. Retrieved from http://www.medscape.com/viewarticle/844317
4. Tleyjeh, I., Bin Abdulhak, Aref., Riaz, M., Alasmari, F., Garbati, M., AlGhamdi, M., Rahman Khan, A., Al Tannir, M., Erwin, P., Ibrahim, T., AlLehibi, A., Baddour, L., & Sutton, A. (2012). Association between proton pump inhibitor therapy and Clostridium difficile infection: a contemporary systematic review and meta-analysis. Plos One. 7(12), 1-12.
5. Zhou, B., Huang, Y., Li, H., Sun, W., & Liu, J. (2015). Proton-pump inhibitors and risk of fractures: an update meta-analysis. Osteoporosis International, 26(10), 1-9. doi: 10.1007/s00198-015-3365-x
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Alzheimer’s Disease and Dementia

by Kathryn A. Packard, M.Ed., MS, LPC, CDP, CADDCT UAMS Oaklawn Center on Aging / Arkansas Aging Initiative

In 2013, five million Americans were living with Alzheimer’s disease and by 2050 this number is projected to rise to 14 million according to the Centers for Disease Control and Prevention. Alzheimer’s is the sixth leading cause of death for all ages and fifth leading cause of death for people 65 years of age and older. Alzheimer’s Disease does not discriminate; it affects, women, men, and all ethnic groups, and begins at various ages. Someone will develop Alzheimer’s every 65 seconds with an annual cost of more than $203 billion.

The need to increase knowledge and to assist families and those affected by Alzheimer’s disease is growing. In the United States, there are over 15 million unpaid caregivers. Although in recent years much attention has been given to Alzheimer’s Disease, and there is more awareness of the devastation of the disease, more education and information is needed on how to best care for those who have been diagnosed.

The Arkansas Geriatric Education Collaborative is funded to train first responders in the State of Arkansas. Certified First Responder/Alzheimer’s Disease and Dementia Care Trainers will be presenting the training. The curriculum they will be offering was developed by the National Council of Certified Dementia Practitioners. The mission of the training program is “to promote, encourage and enhance the knowledge, skills and practice of all persons who provide care and or services to dementia clients by means of requiring excellent standards of education, dementia specific training and incentives for professional development of those who are dedicated to the ever growing field of dementia care”.

When first responders are called to a scene it is because the caregiver believes there are no other options available to him/her, has reached caregiver burnout, or the dementia person’s behavior has become dangerous to self or others. Knowledge about how to diffuse the situation can be priceless to someone who is afraid, doesn’t know how to handle the situation, and needs assistance. How to approach a dementia client using appropriate tone of voice and facial expressions may seem like a small thing, but to someone who is afraid and confused, knowing what to do can be extremely reassuring and comforting.

For first responders, knowing the difference between normal aging and dementia is also important. Asking appropriate questions of the caregiver to diffuse the situation can be valuable to the entire community. First responders may be the link that assists the caregiver to keep the dementia client at home or in their residential environment.

Alzheimer’s and Dementia Care Training will teach first responders about dementia diagnosis, prognosis, and treatment; how to communicate with the patient and the caregiver; what to look for and how to react with disruptive behaviors, catastrophic reactions, care concerns such as abuse and neglect, and driving issues. Included will be information on diversity, cultural competence, the importance of spiritual care and end of life issues. These are important tools for all first responders as well as for caregivers.

In addition to these special classes offered to first responders, the UAMS Centers on Aging, the Arkansas Aging Initiative, along with the Schmieding Home Caregiver Training programs offer family caregiver workshops with a focus on Alzheimer’s disease. Teaching about dementia can relieve stress for caregivers and enhance a dementia client’s chances of remaining at home. Knowing how to care for dementia patients is the first step toward improving care of our older adults who suffer from this disease. For more information, please visit www.arcargiving.org or www.agec.org.

References:
Budson, Andrew E. and Kowall, Neil W. 2014 John Wiley and Sons ltd.