Winter 2023 Newsletter

By Darshon Reed, Ph.D. & Kalista Pettus
College of Health and Behavioral Sciences
University of Central Arkansas

The students in the College of Health & Behavioral Sciences at UCA are making a difference in the lives of Central Arkansans at risk for or diagnosed with Alzheimer’s Disease and Related Dementias (ADRD), as well as their caregivers through the Interprofessional Therapeutic Activity Program (I-TAP). The I-TAP consists of four sub-programs including the Student-Led Therapeutic Activity Program (S-TAP), Student-Led Dementia Caregiver Coaching Program (S-DCCP), Resilient Care Support Group, and the Student-Led Wellness Screening Clinic (S-WSC). With these four sub-programs, I-TAP meets the needs of older Central Arkansans that are at risk or already diagnosed with dementia or related diseases and their caregivers. These programs aim to improve quality of life for the participants as well as provide support and resources to the caregivers, which has been identified as a critical need in Central Arkansas. The I-TAP program is unique and innovative as all of its sub-programs utilize interprofessional collaboration of undergraduate and graduate students who are under the supervision of licensed clinicians. It is meant to increase access and quality of care as well as to provide educational resources to both those affected with such diseases and the public.

The Student-Led Therapeutic Activity Program (S-TAP) will run during the spring 2023 semester. During this time, over 75 students from Exercise Science, Physical Therapy, and Occupational Therapy will provide wellness education, physical activity, cognitive engagement, and risk assessment to improve quality of life, while providing respite and support for caregivers. Sessions for this program will be held one to two times a month. Each session will be approximately an hour to an hour and a half with part being individual activities and the other part being group focused activities.

The Alzheimer’s Disease and Dementia Arkansas State Plan 2021-2025 prioritizes the need for accessible services for ADRD including: 1) public awareness and education, 2) access and quality of care, 3) family caregiver support, & 4) dementia training and workforce development. The I-TAP addresses all four of these priority issues by engaging health professions students to perform interventions that provide education, physical activity, cognitive engagement, caregiver respite and support, and risk assessment. Involvement of students bolsters workforce development by increasing healthcare professionals’ knowledge regarding the complex needs of those with ADRD and their caregivers. Further, I-TAP programs are free of charge to all participants, which allows access despite financial resources. Financial support for the program has been generously provided through a recent grant from the Blue and You Foundation for a Healthier Arkansas in the amount of $51,801.00 which will fund the program for the entirety of 2023. Dr. Kerry Jordan and Dr. Melissa Allen received this grant from the Blue and You Foundation to continue to meet the needs of Central Arkansas while simultaneously providing training opportunities for students.

Fall 2022 Newsletter

By Emily Wish, OTD, OTR/L, PCBIS, Lorrie George Paschal, PhD, OTR, ATP, and Duston Morris, PhD, MS, CHES, ACE-HWC
Department of Occupational Therapy
University of Central Arkansas

According to the Arkansas State Plan for Traumatic Brain Injuries (UAMS, 2020), there were approximately 2,300 individuals living with a brain injury in Arkansas between 2013-2019. In the River Valley and Central Arkansas areas (including Conway, Cleburn, Johnson, Logan, Perry, Pope, Pulaski, Van Buren, White, and Yell counties) there are 685 individuals registered with the TBI registry (UAMS, 2020). As of March 2022, it is estimated that there are approximately 611 individuals hospitalized due to a TBI in the US (CDC, 2022). Stroke, which is an acquired non-traumatic brain injury, is one of the leading causes of disability in the US (Virani et al., 2020). With the risk factors for stroke increasing since 1995, it is no surprise that the prevalence of this disease has also increased in the US (Virani et al., 2020). Arkansas is one of the top 14 states in the US in rates of stroke hospitalization (CDC, 2021). According to the Brain Injury Association of America, 95% of individuals living with a brain injury do not receive the long-term treatment and support they need to be successful in their occupations (Ashley et al., 2019). Acquired brain injuries impact individuals for a lifetime, but there is a lack of local resources that address occupational and healthcare needs for this population following discharge from rehabilitation.

To address this need, recent occupational therapy doctoral students Dr. Emily Wish and Dr. Mckenzie Svebek created the Conway Brain Injury Community (CBIC) in the University of Central Arkansas’ Department of Occupational Therapy in the College of Health and Behavioral Sciences (CHBS). This community allows members, post-acquired brain injury, to come together to work on increasing their occupational performance and overall health and well-being.

The vision of the CBIC program combines Dr. Wish’s desire to facilitate occupational performance of members and Dr. Svebek’s aim to establish a supportive interprofessional approach. Together, a community-based network of community dwelling individuals post-acquired brain injury and faculty supervised occupational therapy students was established to holistically address the needs of this community. Partnership with faculty and students from a variety of CHBS disciplines enhances the program by providing a unique approach of involving professors, students, and clinicians to meet the needs of CBIC members. At this time, primary team members include occupational therapy and health coaching. Other disciplines participate based on members’ interests. For example, this semester, dietetics students provided a presentation on heart healthy food choices.

This interprofessional program was an outcome of capstone projects but has become sustainable through partnership and supervision of occupational therapy faculty member, Dr. Lorrie George-Paschal, and health sciences faculty member Dr. Duston Morris. Through an interprofessional collaborative approach, the CBIC team leads theory-based and client-centered sessions tailored to address goals the members have set for themselves.

Operating within the UCA semester schedule, the group meets weekly, with the exception of school breaks. The program is based on the theory of Occupational Adaptation which strives to improve occupational functioning by creating a change in the internal adaptation process of members through engagement in desired occupations. At the beginning of the 14-week semester-long program, participants complete Occupational-Adaptation based Instruments, developed by Dr. George-Paschal with Dr. Krusen (2019). These instruments provide structure for the program. Because the program is research-based, participants first review and sign informed consent approved by Research Compliance at UCA. If they give consent, participants complete the Occupational Adaptation Practice Guide to set meaningful goals. When goals have been set, participants evaluate their current sense of mastery on their established goal(s) using the six-item Relative Mastery Scale (George-Paschal, Krusen, & Fan, 2021). This valid and reliable instrument is used to measure individual and group outcomes. The RMS is completed again in the middle and at the end of the semester.

Example goals of current CBIC members include improvement in upper extremity tone management and range of motion, cooking with one hand, sewing with one hand, improved handwriting with the non-dominant hand, improving awareness of the left visual field, and improving community mobility. CBIC members are partnered with one to two occupational therapy students and a health coaching student to work on their goals. Occupational therapy sessions are held for two hours each week with activities focused on each member’s specific goal(s). Activities are scaffolded to increase success. For the CBIC member who wants to sew, students and faculty created opportunities that have progressed from operating functions on the sewing machine with one-hand, to sewing straight seams, to making a drawstring bag, and most recently making their own pillow case. The next step is to meet at a local fabric store to choose Christmas fabric for the member to make a quilt top. Signs of adaptation for this member have been noted through signs of initiation and generalization as the member shared that they have visited a local sewing center to try out and consider the purchase of a sewing machine for home.

Weekly health coaching sessions are held on a separate day and last one hour. Students from occupational therapy and health coaching work together and often attend the sessions led by the other discipline. Participants feel an accountability to their health coaching goals as evidenced by one member pushing to finish a project during an occupational therapy session because they had set a goal to complete it with their health coaching student.

In addition to the individual activities, the program includes informational and support group activities. This semester, activities have included a presentation on nutrition for heart health (provided by UCA nutrition students) and various activities to promote self-worth and group connection. This supportive community provides a safe space for CBIC members to identify, establish and achieve personal and/or health-related goals throughout their rehabilitation journey. While this is not therapy, it does provide CBIC members an opportunity to reflect on their strengths through recovery and to maintain and improve their long-term occupational performance.

Starting with four members in June 2022, the program has expanded to seven members this fall and will continue to reach more individuals in the Central Arkansas area.
The goal is to provide a sustainable interprofessional program that can serve the needs of the members post-acquired brain injury while simultaneously providing opportunities for CHBS students to learn and engage in meaningful healthcare community services. UCA OT Doctoral Capstone student Kassidy Sawyer will provide program management and direction in 2023. For more information about the CBIC, please contact Dr. Emily Wish, CBIC program director at ewishotd@gmail.com.

George-Paschal, L. & Krusen, N. (2019). Occupational Adaptation Practice Guide. Copyrighted
2019.
George-Paschal, L. & Krusen, N. (2019). Relative Mastery Scale. Copyrighted 2019.
George-Paschal., L, Krusen, N.E., Fan, C.W. (2021). Psychometric evaluation of the Relative
Mastery Scale: An Occupational Adaptation instrument. OTJR: Occupation, Participation and Health. [online first 12.31.2021 Sage Journals. https://doi.org/10.1177%2F15394492211060877

Summer 2022 Newsletter

By Denise Demers, PhD, CHES and Darshon Reed, PhD
University of Central Arkansas
Department of Health Sciences and Department of Psychology

With the recent exponential growth of the aging population (from 13.1% in 2010 to 16.9% in 2020) and the projected growth by 2050 reaching 22% of the total population in the nation (U.S. Census Bureau, 2018), focus on the aging population has become paramount. Adults over the age of 65 will likely reach and affect every aspect of our society in the coming months and years. Not only will it be imperative to have resources available to assist them, but also healthcare workers to provide such care. Strategies to improve this population’s health and quality of life are both varied and multiplicitous, ranging from community programs such as “Meals on Wheels” to local recreation center physical activity programs. From Geriatrics to Gerontology, systems and structures are being developed and put in place in order to adequately provide for the aging population. Now is the time to prepare the coming health care force to administer such programs and strategies.

To adequately prepare the rising generation of healthcare professionals, it takes a multidisciplinary approach. Not only are doctors and nurses needed, but community healthcare providers such as psychologists, health education specialists, and volunteer organizations. For decades, universities and colleges throughout the nation have begun to teach using a more experiential approach to their curriculum. Included in that curriculum are simulation labs (Coyne et al., 2021) and service learning (Furco, 1996) . Service learning has exploded in recent years, becoming the go-to teaching strategy for many higher education classrooms, whether in-person or virtually.

Recently at the University of Central Arkansas, one of the psychology courses focused on healthy aging. Everything within that class was seen through the lens of the aging population – each chapter from the text, additional articles, and blogs from the American Psychological Association Aging resources. Additionally, students spent time at two local senior care facilities interacting with the residents. During their time at the facilities, students played games, visited, and colored Easter eggs with the residents.

From this experience, over 90% of the students agreed or strongly agreed that their time at the Senior Center was a valuable experience for them. It not only helped them better connect with the content of what they were learning in class, but also helped them both increase in understanding of the problems and challenges of those residents in the facility, as well as how their work can make a difference in the world.

In order to meet the needs of the aging population, programs throughout the country need to focus on aging (Grady, 2011). Whether it be in research (Croff et al., 2020) or applying theory to application through experiential learning (Efthymiou et al., 2021; Kim et al., 2021; Niman & Chagnon, 2021) or virtual simulations (Coyne et al., 2021), such experiences like this are needed in our college classrooms and courses. To prepare the coming generation for “the impending crisis, which has been foreseen for decades, is now upon us” (Institute of Medicine, 2008), courses for the future healthcare professionals in all disciplines need to provide adequate content related to the aging population. Likewise, faculty must also prepare themselves by using multidisciplinary and interprofessional programs that give students the benefits of experiential opportunities with the aging population.

References

Coyne, E., Calleja, P., Forster, E., Lin, F. (2021). A review of virtual-simulation for assessing healthcare students’ clinical competency, Nurse Education Today, Jan;96:104623. doi: 10.1016/j.nedt.2020.104623. Epub 2020 Oct 10. PMID: 33125979.

Croff, R., Tang, W., Friedman, D. B., Balbim, G. M., Belza, B. (2022). Training the next generation of aging and cognitive health researchers, Gerontology & Geriatrics Education, 43:2, 185-201, DOI: 10.1080/02701960.2020.1824912

Efthymiou,L., Ktoridou, D. Epaminonda,E. (2021) A model for experiential learning by replicating a workplace environment in virtual classes, IEEE Global Engineering Education Conference (EDUCON), pp. 1749-1753, doi: 10.1109/EDUCON46332.2021.9453966.

Furco, A. (1996). Service-Learning: A balanced approach to experiential education. Expanding Boundaries: Service and Learning 1 (1):2–6.

Grady PA. (2011). Advancing the health of our aging population: A lead role for nursing science. Nurs Outlook. Jul-Aug;59(4):207-9. doi: 10.1016/j.outlook.2011.05.017. PMID: 21757076; PMCID: PMC3197709.

Kim, M. J., Kang, H. S., De Gagne, J. C. (2021). Nursing students’ perceptions and experiences of using virtual simulation during the COVID-19 pandemic. Clinical Simulation in Nursing, 60, 11-17.

Niman, N. B., & Chagnon, J. R. (2021). Redesigning the Future of Experiential Learning. Journal of Higher Education Theory and Practice, 21(8). https://doi.org/10.33423/jhetp.v21i8.4507

U.S. Census Bureau, Current Population Reports, Estimates of the population of the United States by single years of age, color, and sex: 1900 to 1959 (Series P-25, No. 311); Estimates of the population of the United States, by age, sex, and race: April 1, 1960, to July 1, 1973 (Series P-25, No. 519); Preliminary estimates of the population of the United States by age, sex, and race: 1970 to 1981 (Series P-25, No. 917); and Intercensal estimates for 1980–1989, 1990–1999, and 2000–2009. The data for 2010 to 2020 are based on the population estimates released for July 1, 2020. Data beyond 2020 are derived from the national population projections released in September 2018. Some estimates have been revised since previous publication in America’s Children.

Verkuyl, M., Oona St-Amant, O., Lynda Atack, L., Diane MacEachern, D., Amanda Laird, A., Paula Mastrilli, P., Germayne Flores, G., Harper Soul Hamilton Gunn, H. P. S. (2022). Virtual simulations’ impact on clinical practice: A qualitative study, Clinical Simulation in Nursing, 68, 19-27. https://doi.org/10.1016/j.ecns.2022.04.001.

Spring 2022 Newsletter

By Michael Gallagher, PhD., Emily McIndoe, Robert Hogue, and Kerry Jordan, PhD, RN, CNS, CNL-BC
Department of Exercise and Sport Science and the School of Nursing
University of Central Arkansas

In the last 40+ years, the focus on patient health care has changed from a one-size-fits-all to a holistic and person-centered approach to therapy. This person-centered approach is now recognized as desirable as society moves away from reductionism and treating individuals simplistically to understanding and addressing the whole-person with regards to chronic diseases such as dementia (Greene et al., 201). The benefit of a holistic approach is care that not only applies to the person with chronic disease but also to their caretakers. Benefits also apply to the professional community through interprofessional education and collaboration.

There are six dementia care management programs used around the world that incorporate person-centered care and each of these programs includes some level of interprofessional education and collaboration ranging from care management teams of four to eight different professions. Nurses led many of these interprofessional teams. The professions for collaborative care in dementia may include nurses, physicians, counselors, psychologists, exercise specialists and therapists, occupational and speech therapists, and pharmacists (Dreier-Wolfgramm et al., 2017). However, depending on the program’s goals, care management programs do not need to include every profession for the program to be successful. For example, a person-centered approach may include collaboration among nurses, occupational or speech therapists, or just exercise specialists and speech therapists. The goals of the program dictate the number of professions involved. Care management programs for people with dementia not only help persons with dementia in the program but also may provide respite for the caretaker, further education on dementia, or both. Education for both persons with dementia and their caretakers may include signs of disease progression, approaches to slow disease progression, management of activities of daily living, management of episodes of forgetfulness and agitation, and how to stay connected and engaged with their loved one or client.

One of the most impactful pieces of information to provide those affected with dementia is that a person with dementia can live a high-quality life. The appreciation for providing a means to have a high-quality life is present in care management programs that focus on the person instead of the dementia diagnosis. Interprofessional collaboration achieves this united appreciation by providing a community that allows each profession to contribute to the benefit of an individual and/or caretaker. One such care management program, DementiaNet, highlights the role of interprofessional education to “increase collaboration, knowledge and skills acquisition” towards effective interprofessional collaboration (Oostra et al., 2021). Additionally, teams should provide access to varying levels of generalized and tailored care to promote physical, psychological, and social well-being improvements among persons with dementia (Kuipers et al., 2019). Collegiate interprofessional education can lead towards effective interprofessional collaboration as these soon-to-be professionals are able to apply the educational concepts from the classroom or online resources through the UAMS Arkansas Geriatric Education Collaborative to supervised real world situations. As a result, these students can further promote awareness of dementia and advocate to destigmatize the dementia diagnosis among persons with dementia, the caretaker, and the public. It is not every day that students get to experience and reflect on the impact they may have on persons with a chronic disease such as dementia. Those student experiences and subsequent reflections may be rewarding and open them up for a greater appreciation of the role of other professions, the benefits of collaborating in a person-centered approach to care, and potentially create new professional goals never considered before.

At the University of Central Arkansas, we recently conducted an 11-week interprofessional student-led clinic for people with dementia living in the community (S-TAP). We used three different professions in our program: exercise science, communication science, and nursing. Not only did this program demonstrate significant improvement in functional status for those who participated, but it also demonstrated significant impact on student attitudes toward people with dementia. As one student wrote after participating: “I feel I gained a greater understanding of older adults with dementia and learned how to connect with them better. My feelings toward them changed in the sense that I realized they are not completely helpless.”

References

Dreier-Wolfgramm, A., Michalowsky, B., Austrom, M.G., van der Marck, M.A., Iliffe, S., Alder, C., Vollmar, H.C., Thyrian, J.R., Wucherer, D., Zwingmann, I., Hoffmann, W. (2017). Dementia care management in primary care: Current collaborative care models and the case for interprofessional education. Zeitschrift für Gerontologie und Geriatrie, 50(Supplement 2), S67-S77

Greene, S.M., Tuzzio, L., Cherkin, D. (2012). A framework for making patient-centered care front and center. The Permanente Journal, 16(3), 49-53

Kuipers, S.J., Cramm, J.M., Nieboer, A.P. (2019). The importance of patient-centered care and co-creation of care for satisfaction with care and physical and social well-being of patients with multi-morbidity in the primary care setting. BMC Health Services Research, 19: 13

Oostra., D.L., Harmsen, A., Nieuwboer, M.S., Rikkert, M.G.M.O., Perry, M. (2021). Care integration in primary dementia care networks: A longitudinal mixed-methods study. International Journal of Integrated Care, 21(4): 29, 1-12

Winter 2022 Newsletter

By Alicia S. Landry, PhD, RD, LDN, SNS
Department of Nutrition and Family Sciences
University of Central Arkansas

Dietary supplements can be casually grouped into a broad category of vitamins and minerals – multivitamins – that can be taken once daily to help meet the dietary recommendations of certain age groups. However, the dietary supplement industry has grown to include much more than traditional vitamin and mineral supplements and has expanded to include antioxidants, fiber, amino acids, probiotics, prebiotics, synbiotics, herbals, and protein or amino acids, among others. Dietary supplements are available in pills, capsules, liquids, gummies and can be found in energy drinks, snack bars, cookies, and other commonly available foods.

The Food and Drug Administration (FDA) regulates dietary supplement products and dietary ingredients, but under a different set of regulations than those standards for food and drug products (Nutrition, 2020). Dietary supplements are not pre-approved by the FDA for safety or effectiveness before marketing. Claims that supplement companies make and word-of-mouth may over-promise and under-deliver results for memory health, bowel movements, joint relief, and other ailments. Some dietary supplements can be very dangerous when paired with prescription drugs (i.e. St. John’s Wort and warfarin) while others may reduce efficacy (i.e. Black Cohosh and statins) and still, others may have no effect on pharmacokinetics whatsoever. There are few evidence-based research studies that ‘prove’ the effectiveness of dietary supplements. Conducting research on these items proves difficult, especially in senior adults, because the dose of active ingredients can vary across brands, ratios of fat and lean mass affect absorption, disease states and other medications interact with absorption, and as humans age the predictability and efficiency of gut functions are altered. Controlling these extraneous variables in conducting randomized-controlled research trials can seem impossible when gathering evidence to make general evidence-based recommendations about consuming dietary supplements.

While health professionals can advocate that no pill will replace nutrients in a balanced and moderate diet, sometimes supplementation is warranted (i.e. B12 deficiency). One such example of using dietary supplements to increase absorption and help positively influence gut function is probiotics. Probiotics are “live microorganisms that, when administered in adequate amounts, confer a health benefit on the host” (Hill et al., 2014). Probiotics are usually bacterial components of the normal human intestinal flora that produce as end products of metabolism, lactate and short-chain fatty acids. Lactobacilli and bifidobacteria are examples and have well-defined benefits in human health (Ouwehand et al., 2002). Other similar terms that may be mentioned in probiotic literature are prebiotics and synbiotics. Prebiotics are defined as “a substrate that is selectively utilized by host microorganisms conferring a health benefit” (Gibson et al., 2017). Synbiotics are defined as “a mixture comprising live microorganisms and substrate(s) selectively utilized by host microorganisms that confers a health benefit on the host” (Swanson et al., 2020).

Common issues seen in aging adults that can affect nutritional status and dietary intake are inflammation-related and include constipation, undernutrition, neurodegenerative diseases, metabolic disorders, and reduced immune function (Ale & Binetti, 2021). While one’s overall health depends largely on the healthy functioning of the digestive system, the advantage of probiotic use among older adults is the prevention of antibiotic-associated diarrhea and Clostridium difficile colitis infection. Depending on the strain of probiotic taken, constipation and diarrhea (Björklund et al., 2012) as well as diverticulitis, mental conditions (Inoue et al., 2018; Kim et al., 2020), the immune system (Ibrahim et al., 2010), vitamin absorption, and metabolic disorders (Cicero et al., 2021) can all be positively affected.

In one study with elderly subjects, improved mental status and reduction of depression and anxiety were noted (Inoue et al., 2018). The probiotic treatment was paired with 12-weeks of physical activity classes including resistance training. The effect solely of the probiotics cannot be determined, but it is encouraging to consider the potential benefits of a combined program such as this one. In another study, probiotics were evaluated for their role in reducing inflammation, especially neuroinflammation seen in the early stages of Alzheimer’s disease (Leblhuber et al., 2018). All in all, there may be significant and promising results from the use of probiotics. However, probiotic effects can be attributed only to the strain or strains tested and not to the species or the whole group of lactic acid bacteria. Probiotics are defined by genus, species, and strain designation. The names sound complicated, but they are important for connecting the specific probiotic strain to the strain’s published scientific literature. Furthermore, products should contain the specific strain(s) of bacteria at the same levels used in published research. Common microorganisms are Lactobacillus and Bifidobacteria as well as Saccharomyces, Streptococcus, Enterococcus, Escherichia, and Bacillus.Probiotics must have live microorganisms in the product when they are placed on the shelf and throughout their shelf life, checking the brand reputation and evidence-based literature behind the brand and strains is very important in selecting quality supplements.

Probiotics, contained in “functional foods” (foods that provide physiological benefits or reduce the risk of chronic diseases, over and above their basic nutritional value), are available in several forms with the most common being yogurt. Some brands of yogurt specifically market patented live organisms while others contain microorganisms already present in the human gut microbiota. Fermented drinks, like buttermilk, kefir, or kombucha, and dehydrated bacteria in the form of powders are also available. As with all supplements, a healthcare provider should be consulted before use, and especially with probiotics, if the patient is immuno-compromised, probiotics should be used only under the supervision of a healthcare professional. Most probiotics are sold as dietary supplements or ingredients in foods and cannot legally claim to cure, treat, or prevent disease. Claims made on a product should be truthful and substantiated, but this may not always be the case.

Consider the following tips to help your patients or loved-ones as they explore dietary supplements: (1) recommend they visit with a registered dietitian nutritionist about their diet and lifestyle, (2) be wary of claims about curing multiple diseases, (3) fact check overly impressive-sounding terms, ancient secrets, miracle cures, and statements that suggest the product can treat or cure diseases or that it is quick and effective, (4) the term “natural” does not always mean safe, and (5) items that are extremely costly may not be warranted. As a reminder, healthy daily activities like consuming a balanced diet and being physically active remain incredibly important, our combined lifestyle factors affect our gut bacteria and gut health. The registered dietitian nutritionist is the expert on the healthcare team to ask about balanced diets and dietary supplements. Maintaining a healthy gut is about more than taking a probiotic supplement; keeping our guts functioning properly is essential to overall health and well-being. 

References

Ale, E. C., & Binetti, A. G. (2021). Role of probiotics, prebiotics, and synbiotics in the elderly: Insights into their applications. Frontiers in Microbiology, 12, 631254. https://doi.org/10.3389/fmicb.2021.631254

Björklund, M., Ouwehand, A. C., Forssten, S. D., Nikkilä, J., Tiihonen, K., Rautonen, N., & Lahtinen, S. J. (2012). Gut microbiota of healthy elderly NSAID users is selectively modified with the administration of Lactobacillus acidophilus NCFM and lactitol. Age, 34(4), 987–999. https://doi.org/10.1007/s11357-011-9294-5

Cicero, A. F. G., Fogacci, F., Bove, M., Giovannini, M., & Borghi, C. (2021). Impact of a short-term synbiotic supplementation on metabolic syndrome and systemic inflammation in elderly patients: A randomized placebo-controlled clinical trial. European Journal of Nutrition, 60(2), 655–663. https://doi.org/10.1007/s00394-020-02271-8

Ibrahim, F., Ruvio, S., Granlund, L., Salminen, S., Viitanen, M., & Ouwehand, A. C. (2010). Probiotics and immunosenescence: Cheese as a carrier. FEMS Immunology and Medical Microbiology, 59(1), 53–59. https://doi.org/10.1111/j.1574-695X.2010.00658.x

Inoue, T., Kobayashi, Y., Mori, N., Sakagawa, M., Xiao, J.-Z., Moritani, T., Sakane, N., & Nagai, N. (2018). Effect of combined bifidobacteria supplementation and resistance training on cognitive function, body composition and bowel habits of healthy elderly subjects. Beneficial Microbes, 9(6), 843–853. https://doi.org/10.3920/BM2017.0193

Kim, C.-S., Cha, L., Sim, M., Jung, S., Chun, W. Y., Baik, H. W., & Shin, D.-M. (2020). Probiotic supplementation improves cognitive function and mood with changes in gut microbiota in community-dwelling older adults: A randomized, double-blind, placebo-controlled, multicenter trial. The Journals of Gerontology Series A: Biological Sciences and Medical Sciences, 76(1), 32–40. https://doi.org/10.1093/gerona/glaa090

Leblhuber, F., Steiner, K., Schuetz, B., Fuchs, D., & Gostner, J. M. (2018). Probiotic supplementation in patients with Alzheimer’s Dementia—An explorative intervention study. Current Alzheimer Research, 15(12), 1106–1113. https://doi.org/10.2174/1389200219666180813144834

Nutrition, C. for F. S. and A. (2020, February 4). Dietary Supplements. FDA; FDA. https://www.fda.gov/food/dietary-supplements

Ouwehand, A. C., Salminen, S., & Isolauri, E. (2002). Probiotics: An overview of beneficial effects. Antonie Van Leeuwenhoek, 82(1–4), 279–289.

Fall 2021 Newsletter

By Rebekah Csonka, OTS
Occupational Therapy, University of Central Arkansas
Faculty Mentor: Lorrie A. George-Paschal, Ph.D., OTR/L, ATP
Expert Mentor: Kerry Jordan, PhD, RN, CNS, CNL-BC
Site Supervisor: Mrs. Kim White
Site Contact: Mrs. Debra Robinson

The life changes that older adults experience as they age such as loss of a spouse, and changes in housing, health status, and income, can cause many older adults to be at an increased risk for loneliness. Research shows that loneliness is a risk factor for mortality and is comparable with other behaviors that promote negative health outcomes such as obesity and substance abuse, therefore, it is imperative that loneliness be addressed among the older adult population (Holt-Lunstad et al., 2015). Research shows that engagement in leisure, social, physical, and community activities have a positive impact on older adults’ overall health (Stav et al., 2012). Therefore, occupational therapists, due to their unique ability to promote engagement socially through meaningful activities, can play an integral role in the lives of older adults experiencing loneliness by providing interventions targeting social engagement. 

To address feelings of loneliness and decreased community and social engagement among older adults, UCA occupational therapy student, Rebekah Csonka along with the guidance and support of her expert mentors from UCA’s occupational therapy and nursing department, developed a community program as part of her student doctoral capstone project called “Sparking Community Engagement Through Occupations: Individual Guidance and Peer Support for Older Adults Experiencing Loneliness.” This community program is composed of two parts. The first half of the program focuses on meeting with each older adult weekly, collaborating with them to create goals for social and activity engagement, and carrying out their goals in the community. For the second half of the program, the older adults  participate in a small peer social group, at the Maumelle Center on the Lake and the Faulkner County Senior Wellness and Activity Center, where activities chosen for social and community engagement  promote relational building and engagement among group members as well as community participation. This program currently has six older adults participating who have self-reported feelings of loneliness or whose families have identified a need for increased social or activity engagement.

By the end of the first half of the program, these older adults show an increase in their social and community engagement and have found support through relationships built with other older adults in the community. One lady in the program, Mrs. M, had a goal to volunteer in the community. Together, we identified her strengths and previous experiences to find that she would be a wonderful support to families going through the process of losing a loved one. She is pictured holding paper flowers, as one of her sessions was spent identifying activities that she can do for or with people that she will be serving in the community, as a hospice care volunteer. Another community-dwelling older adult, Mrs. C, had a goal to make social connections with others. She is pictured standing outside of the Faulkner County Extension Office after attending her first class through the Extension Get Fit Program, where she had the chance to make connections with other older adults while engaging in an exercise program. She looks forward to staying engaged in this group to make new friends and to feel a greater sense of support and social connections.  Hopefully this capstone project will pave the way for future community programs that will focus on the needs of older adults for social and community engagement through meaningful occupations. 

References

Holt-Lunstad, J., Smith, T. B., Baker, M., Harris, T., & Stephenson, D. (2015). Loneliness and social isolation as risk factors for mortality: A meta-analytic review. Perspectives on Psychological Science, 10(2). 227-237. https://doi.org/10.1177/1745691614568352.

Stav, W. B., Hallenen, T., Lane, J., & Arbesman M. (2012). Systematic review of occupational engagement and health outcomes among community-dwelling older adults. American Journal of  Occupational Therapy, 66(3). 301–310. https://doi.org/10.5014/ajot.2012.003707

Summer 2021 Newsletter

By Ashton Howell, CBIS, OTS
Occupational Therapy, University of Central Arkansas
Faculty Mentor: Dr. Cathy Acre Ed.D., OTR/L, FAOTA
Expert Mentor: Dr. Melodee Harris Ph.D., RN, APRN
Site Supervisor: Debra Robinson

Blending the Generations is an intergenerational program created by UCA Occupational Therapy student, Ashton Howell, as part of her doctoral capstone project. Currently, the program has nineteen participants- seven from the older generations and twelve from the younger generations. Blending the Generations is designed to bridge the gap between members of different generations. Through activities, conversation, and time spent together, this program connects members of different generations and allows for a better understanding of the other’s thoughts, feelings, and experiences.

Prior to the start of the program, both generation groups participate in an age sensitivity training where common stereotypes and experiences are addressed and discussed. The younger generation participates in activities that simulate hearing loss, visual impairments, and sensory deficits as well as discussion of negative thoughts towards older generations. The older generation engages in discussion, reflection, and true/false activities surrounding negative attitudes towards younger generations. In the first half of the program, participants engage in various activities such as generational trivia, concentric circles, an escape room, Family Feud, and more that require collaboration and communication all while learning about one another. During the last half of the program, participants are matched based on their interests and skills. Together they create an act that is performed in an intergenerational talent show.

Benefits that older adults receive from participation in intergenerational programming include decreased depression and loneliness, increased socialization, and improved overall health. “Elder adults who volunteer with children regularly burned 20% more calories per week, relied less on canes, had fewer falls and exhibited better memory than their peers” (“The Fun and Value,” 2019). Another benefit that intergenerational programs bring is “changes in attitudes and perceptions of both groups towards each other” (Caspar, Davis, McNeill, & Kellett, 2019). Stereotypes often lead to negative perceptions of both younger and older generations. Without engaging with members of other generations, it is often easy to fall into believing the stereotypes. A study by Caspar, et. al., 2019 found that after seven months of engaging with senior adults, youth’s perception of older adults became more positive and stereotypical thoughts were decreased. It is important to address the younger generation’s attitudes and beliefs about older adults as these, along with lack of exposure to older adults, are predictors of healthcare providers’ attitudes toward senior adults (Caspar, et. al., 2019). The current young generations will soon be the current health care providers. It is important that they respect and understand older generations so that they will provide good and fair care.

Blending the Generations is a program designed to not only benefit individuals, but communities as well. Older adults tend to be the victims of negative stigma. Blending the Generations targets those negative perceptions and works to increase the quality of life, health, and community participation of older adults. Instead of focusing on how one generation can help another, Blending the Generations is unique in that it focuses on how both generations can teach and learn from one another.

Participants for the current chapter of the program were recruited from Woodland Heights Baptist Church, the University of Central Arkansas Doctorate of Occupational Therapy program, and through social media efforts. Evaluation of the change in perceptions of different generations is being conducted throughout the entirety of the program. If you are interested in the results of this IRB approved research study, have any questions, or are interested in learning more about Blending the Generations, please contact Ashton Howell at blendingthegenerations@gmail.com.

References:

2019. The fun and value of intergenerational programming. Senior Lifestyle. Retrieved from https://www.seniorlifestyle.com/resources/blog/fun-value-intergenerational- programming/.

Caspar, S., Davis, E., McNeill, D. M. J., & Kellett, P. (2019). Intergenerational Programs: Breaking Down Ageist Barriers and Improving Youth Experiences. Therapeutic Recreation Journal, 53(2), 149–164. https://doi-org.ucark.idm.oclc.org/10.18666/TRJ- 2019-V53-I2-9126

Spring 2021 Newsletter

By Stacy E Harris, DNP, APRN, ANP-BC
School of Nursing
University of Central Arkansas

Rhinitis, commonly known as inflammation of the nasal mucous membranes, affects adults of all ages. There are two major categories of rhinitis: Allergic rhinitis (AR) and Non-allergic rhinitis (NAR). Most people are familiar with the symptoms of AR: sneezing; itching, watery eyes; conjunctival redness; and rhinorrhea, a watery nasal discharge. The most typical course of AR is exposure to a seasonal (spring or fall) allergen, such as tree, grass, or weed pollen. This type of rhinitis begins to emerge in adults around in the late teens and peaks in the 5^th decade of life. Non-allergic rhinitis presents with similar symptoms: rhinorrhea and nasal congestion, but without the sneezing or eye symptoms.  This type of rhinitis affects more adults and older adults (Yilmaz & Corey, 2006). Non-allergic rhinitis has many subtypes: vasomotor, atropic or geriatric non-allergic, rhinitis medicamentosa, drug induced, hormonal, gustatory and infectious (Kennedy-Malone, Martin-Plank and Duffy, 2019). This article will focus on NAR, specifically “geriatric “ sometimes known as physiologic rhinitis, the most common type effecting older adults.

                Physiologic age-related changes to the nose are well known. It is common for an older adult patient to verbalize a decrease in the ability to smell. Besides olfactory changes, several other physiologic changes occur in the nose. The tough structures of the nose atrophy. This causes the nose to lengthen and the nasal tip to begin to droop. When the supporting upper and lower cartilages weaken, the nasal passages begin to narrow and produce a feeling of or an actual obstruction. Previous nasal injuries of youth or septal deviation confound the narrowing. These changes explain why many older adults complain of nasal obstruction. The vascular bed of the nose undergoes microvascular changes. The turbinates receive a decrease in blood flow which reduces the size of the turbinates and predisposes the nose to dryness and crusting. The changes in the nasal mucosa are impactful too. The nasal mucosa goblet cells increase, and the function of the submucosal serous glands decrease. The submucosal glands are responsible for watery, clear, thin mucous. The goblet cells produce a thick, tenacious mucus. Both types of secretions are responsible for humidifying the air we inhale and mostly importantly, trapping and removing potential organisms from entering the respiratory tree.  These mucosal changes explain why many adults complain of daily thick, mucus production and have frequent throat clearing (Jordan and Mabry, 1998; Yilmaz & Corey, 2006).

                Older adults may present to their healthcare provider with complaints of “sinus trouble” characterized by thick post-nasal drainage, nasal congestion, and frequent throat clearing. However, differentiating these symptoms from the typical symptoms of sinusitis (post-nasal drainage, nasal congestion, face pain and pressure, fever, headache) is not always clear to the provider. This can lead to misdiagnosis and unneeded treatment. The older adult may be treated inappropriately with antibiotics or first-generation histamine blockers when more supportive treatments are indicated.  

                There are numerous pharmacologic and nonpharmacologic ways to improve the older adults’ nasal complaints. First, the provider must rule out any allergic or infectious causes for the rhinitis. Once an accurate diagnosis of geriatric rhinitis has been made, a through explanation of the age-related nasal changes must be shared with the patient. This may not be the answer the patient is expecting but it is needed for long term management. Humidification is the key to improving geriatric rhinitis. Increasing moisture inside the nose is the main goal. This can be done by increasing moisture in the home, specifically the bedroom, and using over the counter (OTC) saline nasal spray as much as 4-6 times per day. There are many types of delivery methods, such as nasal douching, water-picks or Neti pots to inject saline into the nasal mucosa. Pure sesame oil has been shown to aid in nasal dryness (Jordan and Mabry, 1998)

                Pharmacologic treatment including using mucous-thinning agents such as OTC guaifenesin has been shown to improve symptoms in patient with complaints of thick secretions. Topical and systemic decongestants can improve congestion but should be avoided due to the exacerbation of nasal mucosa dryness. Also, using first generation antihistamine (diphenhydramine, hydroxyzine) to treat nasal congestion should be avoided in older adults due to the sedating and anticholinergic activity.  Newer second-generation antihistamines (loratadine, cetirizine, fexofenadine) are safe to use in older adults particularly if patients suffer from some allergic rhinitis too. Inhaled nasal steroids (Flonase, beclomethasone) are appropriate and safe in older adults suffering from allergic rhinitis, but long term can increase nasal dryness (Yilmaz & Corey, 2006).

                Little research has been published regarding geriatric rhinitis. However, providers can improve the quality of life in the older patient by thoughtful education on age-related nasal changes. Also informing the older patient about OTC medications to avoid while providing them with simple treatments to increase humidification will ultimately improve rhinitis in the geriatric population.

Yilmaz, A. A. S. & Corey, J. P. (2006). Rhinitis in the elderly. Current Allergy and Asthma Reports, 6:125-131.

Jordan, J. A., & Mabry, R. L. (1998) Geriatric rhinitis: what it is and how to treat it. Geriatrics. 53(6) 76-80. Kennedy-Malone, L., Martin-Plank, l., & Duffy, E. (2019) Advanced practice nursing in the care of older adults, 2^nd Ed. FA Davis.

Winter 2021 Newsletter

By Sarah Walker, PT, DPT
Department of Physical Therapy
University of Central Arkansas

As healthcare professionals are faced with the numerous challenges of the COVID-19 pandemic, clinicians who serve geriatric clients are being met with stark statistical findings from epidemiology studies. Age in advance of 65 years is the single most important predictor of mortality from COVID-19, with elderly individuals representing a significantly higher proportion of those who perish from the disease. ^1-3 This increased risk is multifactorial, but is heavily influenced by declines in immune system function that reduce responses to viral infection.³ These findings support recommendations by community health leaders for elders to self-isolate in order to avoid infection.²

One consequence for older adults under self-isolation or quarantine is psychological trauma, including increased feelings of anxiety, stress, and anger. ^{2, 4} Anxiety and depression can also cause maladaptive changes to immune function, potentially further increasing an already vulnerable population. ⁵ In addition, geriatric individuals have an increased psychosocial burden associated with isolation as compared to other age groups.² Because self-isolation is not benign, clinicians must provide other evidence-based strategies to clients in order to decrease morbidity and increase immune system protection from this virus. ^{3, 6}

Physical activity is widely prescribed to seniors because movement has been shown to boost immune system function, reduce inflammation, improve emotional well-being, and reduce all-cause mortality.⁶ Encouraging elderly clients to engage in a more active and movement rich lifestyle can take the form of both physical activity and physical exercise. Physical activity suggestions may include dancing in their living rooms, walking outdoors, gardening, or playing with a beloved pet. Whereas physical exercise represents a planned and structured movement with a clear and purposeful intervention such as lifting weights, aerobics, or yoga.

Physical exercise of moderate intensity (64-76% of maximum heart rate) lasting 15-40 minutes in duration for 3 days per week over 6 months has demonstrated a significant increase in the number of T cells in the blood of elderly adults. Regular long-term exercise has also demonstrated enhanced immune response against both viruses and bacteria and appears to slow immunological ageing.⁶ Acute bouts of exercise, like walking for 30 minutes at a moderate intensity, likewise demonstrated enhanced immune function by a variety of mechanisms. The findings of previous research also suggest that acute moderate intensity resistance training for 45 minutes can result in increased activity.

Evidence is compelling that physical activity can be beneficial for older adults, especially during the COVID-19 pandemic.  Physical activity and exercise can increase immune system function and psychological well-being in this exceptionally vulnerable population.  Clinicians should encourage and promote physical activity in older adults in order to decrease the risk of COVID-19 complications.

References

1.         Daoust JF. Elderly people and responses to COVID-19 in 27 Countries. PLoS One. 2020 Jul 2;15(7):e0235590.

2.         Javadi SMH, Nateghi N. COVID-19 and its psychological effects on the elderly population. Disaster Med Public Health Prep. 2020 Jun;14(3):e40-e41.

3.         Abdelbasset WK. Stay Home: Role of Physical Exercise Training in Elderly Individuals’ Ability to Face the COVID-19 Infection. J Immunol Res. 2020;Nov 28;8375096.

4.         Torales J, O’Higgins M, Castaldelli-Maia JM, Ventriglio A. The outbreak of COVID-19 coronavirus and its impact on global mental health. Int J Soc Psychiatry. 2020 Jun;66(4):317-320.

5.         Kiecolt-Glaser JK, Glaser R. Depression and immune function: central pathways to morbidity and mortality. J Psychosom Res. 2002 Oct;53(4):873-6.

6.         Amatriain-Fernández S, Gronwald T, Murillo-Rodríguez E, Imperatori C, Solano AF, Latini A, Budde H. Physical Exercise Potentials Against Viral Diseases Like COVID-19 in the Elderly. Front Med (Lausanne). 2020 Jul 3;7:379.

Fall 2020 Newsletter

By Alicia S. Landry, PhD, RD, SDN, SNS
Family and Consumer Sciences
University of Central Arkansas

Telehealth is an umbrella term that often refers to healthcare services that are delivered virtually. Examples of telehealth are telemedicine, mHealth (mobile health), and store and forward. In order to lay some groundwork, we will start with brief definitions.

• Telemedicine is two-way, synchronous discussion between a patient and a healthcare provider, or between multiple providers.
• Mobile health is when a patient uses an application or software to manage health. An example would be tracking dietary intake using a food log app on a smartphone and syncing it with the platform a registered dietitian monitors to give the patient feedback on diet choices.
• Store and forward includes gathering patient data (like photos of a rash or an x-ray) and using the information for diagnostic decisions made by a provider at a later time.

Using accurate terminology to describe telehealth interventions becomes important when multiple providers are providing care for a single patient as well as other situations. Having a healthcare team in sync with one another is critical to positive patient outcomes.

While telehealth could potentially result in healthcare savings as well as increased safety and convenience for aging adults as well as their providers (Snoswell, Taylor, and Caffrey, 2019), concerns remain about the feasibility of telehealth use in a geriatric population. Specialties such as psychiatry and counseling, physical and occupational therapy, and medical nutrition therapy have been positively impacted by the use of telehealth and should continue to grow as demands for specialists increase and the safety of going to practitioner offices remains in question. For most Medicare patients, virtual doctor visits are covered when a doctor is not available to see the patient in person and Medicare has expanded coverage for virtual visits in the wake of COVID-19 (Medicare, 2020).

Patient acceptance, insurance reimbursement, regulatory or licensure barriers, access to high-speed broadband or wireless networks, and privacy concerns are legitimate obstacles to implementing telehealth. In Arkansas, broadband access is very poor (41st in the US), making network infrastructure in rural areas somewhat prohibitive of the use of telehealth. The Arkansas Rural Connect program is expected to use $25 million to cover underserved and rural communities, and more recently, there have been expanded efforts to make wireless and broadband coverage available in rural areas. While 26% of adults over 60 years of age reported no access to the internet, only half of 45-59-year-olds reported no access (Arkansas Broadband Report, 2019) which means age gaps do occur in the access to high-speed internet as well as in the utilization of telehealth. As always, healthcare providers communicating with senior adults must recognize challenges in hearing, sight, technology access, as well as others to ensure the best care possible.

Patients with chronic conditions like diabetes, cardiovascular disease, and obesity show favorable responses to home management via telehealth when led by an interprofessional team of healthcare providers. If it is possible that telehealth can allow seniors to remain safely at home for a longer time, ensure older adults are compliant with medication use, and reinforce support of caregivers, it may be time to take a deeper look into the possibilities for allied health professionals to grow the telehealth outlet.

During this time of physical distancing, older adults are more likely to feel socially isolated, experience food insecurity, and delay routine healthcare. In the National Poll on Healthy Aging, 45% of respondents said the pandemic made them more interested in telehealth and only 25% reported being concerned they would have difficulty seeing or hearing the provider during a video visit (Buis et al., 2020). Reduced risk of falls or decreased exposure to disease benefits the frail elderly, and telehealth can allow resource providers to maintain closer contact with older adults. In-home caregivers who may have their own families or other jobs can connect with healthcare providers which may reduce stress and improve the quality of care. Mobility (address movement and physical activity), mentation (assess cognition level), medication (identify the type, dose, supply), and what matters (determine goals, preferences, priorities) are the four M’s of age-friendly health and remembering these for telehealth visits can make these visits even more successful for the aged (Institute for Healthcare Improvement, 2019).

For registered dietitians, the expanding telehealth world has been a phenomenal way to provide integrated and patient-centered care, even with guidelines about physical distancing and preventing the spread of infectious disease. For example, a registered dietitian observing mealtimes with speech pathologists and occupational therapists allows the interprofessional team to make decisions about food consistency, swallowing risk, socialization, and other issues impacting nutrition status. For patients with at-home parenteral nutrition, registered dietitian observation along with pharmacy and medical providers reduces the risk of bloodstream infections and hospital readmission (Raphael et al., 2019). In diabetes self-management education (DSME), registered dietitians are able to teach blood glucose monitoring and follow patients in real-time as they report their blood glucose levels. Telehealth DSME has had great success and shown significant reductions in hemoglobin A1c and blood pressure in patients with diabetes (Nicoll et al., 2014). Group therapy or support groups with counselors, registered dietitians, and social workers may help alleviate distress and loneliness of isolation. The use of multidisciplinary clinics has been shown to improve outcomes in aging adults (Erskine, Griffith, & Degroat, 2013; Kozak et al., 2017) and implementing telehealth in these clinics makes scheduling less burdensome. Dietitians across the State are utilizing telehealth for DSME and dietetic interns are learning multiple telehealth platforms in order to be better equipped as they enter the dietetics profession.

During the spring of 2020, multiple hospitals and primary care provider clinics closed and only allowed medically necessary procedures. These restrictions affected dietetics education because students were no longer allowed in hospitals like during traditional internships. Turning to telehealth and working alongside registered dietitians – even at a distance – to monitor and educate patients allowed students to continue their education and graduate on time. Likewise, these opportunities often included exposure to interprofessional teams of pharmacists, physicians, and other therapists which may not have been accessible during typical rotations. Taking advantage of these technologies gave students an opportunity to participate in ground-breaking healthcare as well as provided them with the confidence to interact in a healthcare team. While we must still train healthcare professionals to have bedside manner and we need to ensure students are competent in clinical skills, considering telehealth as a significant portion of their educational experience is worthwhile.

1. Arkansas Department of Commerce. (2019). Arkansas State Broadband Manager’s Report. Available at: https://www.arkleg.state.ar.us/Calendars/Attachment?committee=685&agenda=3195&file=Exhibit%20F%20Arkansas%20State%20Broadband%20Manager%20Report.pdf
2. Buis, L., Singer, D., Solway, E., Kirch, M., Kullgren, J., & Malani, P. (2020). Telehealth use among older adults before and during COVID-19. University of Michigan National Poll on Healthy Aging. August 2020. Available at: http://hdl.handle.net/2027.42/15625
3. Erskine, K. E., Griffith, E., & Degroat, N. (2013). An interdisciplinary approach to personalized medicine: Case studies from a cardiogenetics clinic. Personalized Medicine, 10(1), 73–80.
4. Institute for Healthcare Improvement. (2019). “What Matters” to older adults? A toolkit for health systems to design better care with older adults. Retrieved from: http://www.ihi.org/Engage/Initiatives/Age-Friendly-Health-Systems/Documents/IHI_Age_Friendly_What_Matters_to_Older_Adults_Toolkit.pdf
5. Kozak, V. N., Khorana, A. A., Amarnath, S., Glass, K. E., & Kalady, M. F. (2017). Multidisciplinary clinics for colorectal cancer care reduces treatment time. Clinical Colorectal Cancer, 16(4), 366–371.
6. Medicare. (2020). Available at: https://www.medicare.gov/coverage/telehealth
7. Nicoll, K. G., Ramser, K. L., Campbell, J. D., et al. (2014). Sustainability of improved glycemic control after diabetes self-management education. Diabetes Spectrum, 27(3), 207-211.
8. Raphael, B.P., Schumann, C., & Garrity-Gentille, S. (2019). Virtual telemedicine visits in pediatric home parenteral nutrition patients: A quality improvement initiative. Telemedicine Journal and E-health, 25(1), 60–65.
9. Snoswell, C. L., Taylor, M. L., & Caffery, L. J. (2019). The breakeven point for implementing telehealth. Journal of Telemedicine and Telecare, 25(9), 530-536. doi: 10.1177/1357633X19871403.