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.

By Natalie Benafield, Au.D., CCC-A
Communication Sciences and Disorders
University of Central Arkansas

 

Most of us associate aging with a decline in hearing acuity, with good reason. Two-thirds of individuals over 70 years of age have a loss in hearing that would be considered clinically significant. Communication obviously suffers, causing frustration for both the person with the hearing loss and their family members. However, it is estimated that less than one-quarter of individuals with age-related hearing loss seek treatment. Evidence is mounting that ignoring hearing as you age can have detrimental effects that go beyond difficulty communicating with others.

As far back as 1989, scientists have suggested that age-related hearing loss may contribute to cognitive decline in seniors. A pivotal study published in the Journal of the American Medical Association (Uhlmann, et.al.,1989) suggested that hearing loss in older adults was associated with a higher risk of dementia. For the past several years, other researchers have been conducting research in this area and have come to similar conclusions. Dr. Frank Lin, at Johns Hopkins University, and his team followed 639 individuals from the ages of 36-90 for twelve years to investigate the link between hearing loss and dementia. After adjustment for other factors including age, gender, educational level, diabetes, smoking and hypertension, their research suggested that those with hearing loss experiences a 30-40% accelerated rate of cognitive decline (Lin, et al., 2013). More recently a large-scale review of epidemiologic studies of age-related hearing loss and cognitive function from twelve countries was conducted. The researchers found that age-related hearing loss was significantly association with a decline in all main cognitive domains, except for Alzheimer’s disease and vascular dementia. They concluded that hearing loss related to aging is a modifiable risk factor for cognitive decline and dementia in seniors (Loughrey, et al., 2018).

While the exact mechanism underlying the relationship between age-related hearing loss and cognitive decline has not been identified, there are several theories. Some have suggested that hearing loss and cognitive decline may be caused by the same general neurodegenerative process (Stahl, 2017). Neuroimaging studies have suggested that similar changes in the temporal regions of the brain have been noted in individuals with hearing loss and with cognitive decline (Lin, et al., 2014). Other researchers suggest that hearing loss (i.e., the lack of sensory input) causes individuals to use additional cognitive resources to process auditory input, resulting in chronic cognitive “multitasking” and overload. (Tun, McCoy, & Wingfield, 2009). Exacerbating the condition may be that untreated hearing loss often leads to social isolation and even depression, which in turn leads to reduced cortical input over time, hastening atrophy in certain regions of the brain.

Will hearing aid use slow cognitive decline? It makes sense that the use of hearing devices such as hearing aids could increase auditory input, lessen cognitive load, and decrease social isolation, thereby slowing cognitive decline (Sarampalis, et al., 2009). However, we need more large-scale, longitudinal studies before being confident of that claim. Current studies have failed to show a robust protective relationship between hearing aid use and cognitive function. One recent small-scale study found that individuals with evidence of auditory- to- visual cross-modal reorganization in the brain showed evidence of reversal of the re-organization in the auditory cortex, with additional gains in speech perception and cognitive performance (Glick & Sharma, 2020).

What does this mean for current clinical care of older adults? Health care providers often see hearing loss as normal part of aging as they must focus on the numerous urgent medical needs of older adults. This research suggests that clinicians should take a proactive, rather than reactive approach to hearing health in the aging population. Rather than waiting until a patient complains of difficulty hearing, encourage early hearing screening, evaluation, and treatment for those 60 and older. Most patients will not understand the importance of their hearing to brain health. While we lack the evidence to suggest that hearing aids can reduce cognitive decline, we have plenty of evidence to say that hearing loss is not good for the brain. Early hearing evaluation and treatment is risk-free, and evidence is mounting that appropriate treatment of age-related hearing loss could have a positive impact on cognitive decline.

 

References

Glick, H. A., & Sharma, A. (2020). Cortical Neuroplasticity and Cognitive Function in Early-Stage, Mild-Moderate Hearing Loss: Evidence of Neurocognitive Benefit From Hearing Aid Use. Frontiers in Neuroscience, 1.

Lin, F. R., Yaffe, K., Xia, J., Xue, Q.-L., Harris, T. B., Purchase-Helzner, E., Satterfield, S., Ayonayon, H. N., Ferrucci, L., & Simonsick, E. M. (2013). Hearing loss and cognitive decline in older adults. JAMA Internal Medicine, 173(4), 293–299. https://doi.org/10.1001/jamainternmed.2013.1868

Lin, F. R., & Albert, M. (2014). Hearing loss and dementia – who is listening? Aging & Mental Health, 18(6), 671–673. https://doi.org/10.1080/13607863.2014.915924

Loughrey, D. G., Kelly, M. E., Kelley, G. A., Brennan, S., & Lawlor, B. A. (2018). Association of Age-Related Hearing Loss With Cognitive Function, Cognitive Impairment, and Dementia: A Systematic Review and Meta-analysis. JAMA Otolaryngology– Head & Neck Surgery, 144(2), 115–126. https://doi-org.ucark.idm.oclc.org/10.1001/jamaoto.2017.2513

Sarampalis A, Kalluri S, Edwards B, & Hafter E. (2009). Objective measures of listening effort: effects of background noise and noise reduction. Journal of Speech, Language & Hearing Research, 52(5), 1230–1240. https://doi.org/1092-4388(2009/08-0111)

Tun PA, McCoy S, Wingfield A, Tun, P. A., McCoy, S., & Wingfield, A. (2009). Aging, hearing acuity, and the attentional costs of effortful listening. Psychology & Aging, 24(3), 761–766. https://doi.org/10.1037/a0014802

Uhlmann, R.F., Larson, E.B., Rees, R.S., Koepsell, T.D., Duckert, L.G. (1989). Relationship of hearing impairment to dementia and cognitive dysfunction in older adults. Journal of the American Medical Association 261(13), 1816-1919.

Weinstein, B.E., (2018). A primer on dementia and hearing loss. Perspectives of the ASHA Special Interest Groups, 3(6), 18-27.

 

By Kevin Rowell, PhD
Department of Psychology and Counseling
University of Central Arkansas

 

As with the implementation of the Affordable Care Act in 2017, U.S. health care continues to develop the patient-centered medical home model as a way of efficiently coordinating health care delivery. Especially for older patients where complexity of health care is the norm, the weight of responsibility in providing effective, safe, and lower cost interventions rests squarely on the primary care practitioner (PCP).  Now that baby boomers have reached late life, it is estimated that approximately one-fourth of patients seen in primary care clinics are over age 65. Although most are in good health, the natural decline in health with aging results in a greater presence of physical illness and dysfunction such that most older adults have at least two chronic conditions, as well as developing acute illnesses at prevalence rates similar to younger adults (CDC, 2013, as cited in Hunter et al, 2017).

While the public clearly understands that primary care is designed to be the first line of help in the case of medical illness and that most treatment is rendered therein, the majority of people do not realize that primary care practitioners are very often the first line of treatment for mental health issues as well (O’Donohue et al, 2005). People struggling with common disorders involving depression, anxiety, and substance abuse will more likely seek help from their PCP before considering intervention from a psychiatrist, psychologist, counselor, or clinical social worker. In fact, roughly one-third of the visits to PCPs is due to a mental health concern, and another one-third of visits involve a medical diagnosis that has a significant mental health component (Blount, 2003). The reasons are attributed to familiarity with the PCP, greater access to a PCP as compared to specialists (especially in rural areas), and fear of stigmatization in visiting a mental health clinic (Hunter, et al, 2017).

Research has shown that the most prevalent mental disorders are major depression, generalized anxiety, somatization, and substance abuse. Other common mental health issues include relationship conflict, stress, sleep disturbance, and fatigue. Not surprisingly, women are much more likely than men to report issues with mental health, which is a very consistent trend across most health care settings. Regarding patients over 65, other mental health issues involve cognitive decline, sexual dysfunction, grief/loss, isolation/loneliness, and lower motivation in managing chronic diseases (Hunter et al, 2007).

Whereas the PCP is able to provide appropriate intervention for many of these issues, usually through medication and perhaps brief consultation, a myriad of factors limits the effectiveness of the PCP in addressing primary mental health disorders and secondary mental health issues in chronic disease management. For example, diagnosing some mental disorders usually necessitates somewhat lengthy interviews and often a screening test, yet the high volume of patients scheduled daily in primary care clinics limits the time a PCP can spend with an individual patient. Furthermore, 60-85 percent of PCPs reported being under-trained in diagnosis and treatment of mental disorders. Additionally, when PCPs decide for a referral to a mental health specialist such as a psychiatrist or psychologist, wait times for appointments can be weeks and the likelihood of the patient following through with the appointment is less than 25 percent. Finally as previously mentioned, many people, especially older adults, with mental health concerns feel stigmatized in visiting a mental health clinic and will often refuse to seek help rather than potentially feel embarrassed or shameful (Blount, 2003, Hunter et al., 2017).

To address these issues, the fully integrated behavioral health model calls for the placement of a full-time behavioral health clinician (BHC) to be employed in primary care. Typically the BHC is a licensed psychologist, professional counselor, or clinical social worker who has received special training in integrated care behavioral health. Advantages of the behavioral health clinician are many. Of utmost importance is the presence of a mental health expert in primary care whose function is to identify primary and secondary mental health issues in patients and then to collaborate with the PCP and other staff in providing effective evidence-based interventions for patients. Through research backed behavioral interventions, BHCs can address stress reduction, mindfulness, sleep hygiene, maladaptive thoughts, as well as adaptive, healthy life style changes like exercise, relaxation, diet changes, smoking cessation, and decreased alcohol/substance use, all of which directly improve mental health and chronic disease management (Hunter et al, 2017). For the older patient, BHCs can conduct screenings for dementia and other cognitive problems, address social isolation, and help with sexual dysfunction.

Research indicates that when a full-time BHC is employed in primary care, treatment effectiveness increases, patient and staff satisfaction increase, and treatment and medication costs decrease (Blount, 2003; Ogbeide, Stermensky II, & Rolin, 2016). For example, one consistent finding is that patients with mood (depression) and anxiety disorders show significant improvement, often without medication, when they work closely with a BHC. Furthermore, when a referral to a mental health specialist is necessary, patients are much more likely to meet the appointment, particularly if the BHC can meet briefly with them during the wait time before the first appointment. The BHC is also freed from the standard 8-10 minute PCP appointment duration to better gather interview information, discuss treatment goals, and even implement brief 15-20 minute follow up appointments to reinforce interventions that are working and to make adjustments where needed.

Older adult patients should be encouraged by the addition of a BHC member to the PCP staff. Such a health care provider is able to better address so many more issues than one’s PCP, and the fact that the BHC has been called in to meet with the older patient in no implies that the patient should be embarrassed or stigmatized. It simply means that he or she will be receiving optimal holistic care that has been shown to have significant benefits.

 

 

References:

Blount, A. (2003). Integrated primary care: Organizing the evidence. Families, Systems, and Health, 21, 121-134.

Centers for Disease Control and Prevention (2013). The stage of aging and health in America 2013. Retrieved from http://www.cdc.gov/health/state_of_aging_and_health_in_America_2013.pdf.

Hunter, C. L., Goodie, J. L., Oordt, M. S., & Dobmeyer, A. C. (2017). Integrated behavioral health in primary care: Step-by-step guidance for assessment and intervention (2^nd ed.). Washington DC, American Psychological Association: Washington, D.C.

O’Donohue, W. T., Byrd, M. R., Cummings, N. A., & Henderson, D. A. (2005). Behavioral integrative care: Treatments that work in the primary care setting. New York: Brunner-Rutledge.

Ogbeide, S., Stermensky II, G. & Rolin, S. (2016). Integrated primary care behavioral health for the rural older adult. Practice Innovations, 1, 145-153.

By Stacy Harris, DNP, APRN
School of Nursing
University of Central Arkansas

Being physically active is one of the most important lifestyle habits people of all ages can take to improve their health. Recently, the United States Department of Health and Human Services (2018), released new physical activity guidelines. The new guideline recommends adults try to achieve a minimum of 150 minutes (2 hours and 30 minutes) of moderate activity or 75 minutes (1 hour and 5 minutes) of intensive activity each week. The new guideline highlights special populations, including recommendations for the older adult. Older adults should try to achieve the adult recommendations along with balance training and muscle strengthening activities. In addition, the guideline states that older adults with chronic conditions or disabilities should engage in physical activity according to their abilities, explaining that any activity level is better than being sedentary.

As adults age and chronic conditions become common, patients may feel becoming physical fit and more active is unrealistic and not beneficial. However, numerous studies have shown older adults benefit from physical activity. Lövdén, Xu and Wangy (2013) published a critique of a meta analysis that linked increased aerobic physical activities with enhance cognition in sedentary adults.  In a randomized control trial of Tai Chi training in adults (mean age 77) with mild cognition issues 30 minutes of Tai Chi three times a week over 12 months resulted in a 4% lower conversion to dementia compared to 17% for the control group (Lövdén, Xu and Wangy, 2013).  Tai Chi is a low impact activity practiced as a graceful form of exercise involving a series of movements performed in a slow, focused manner accompanied by deep breathing.

Older adults may be overwhelmed or intimidated when a health care provider uses the word “exercise.” The word exercise suggests a level of activity that may be unattainable for older adults. Patients may be more likely to relate to leisure activities such as gardening, dancing or walking. Evidence suggests that leisure activities are beneficial to cardiovascular health. Mensink, Ziese and Kok (2009) found older adults who participated in leisure activities at 1-2 hours per week, had lower systolic blood pressure, heart rate and body mass than sedentary adults.

Besides improving cardiovascular health, physical activity is also proven to improve orthopedic issues. Half of all older adults have knee and hip pain and may worry that increasing physical activity will worsen already achy joints (Peterson, Osterloh and Graff, 2019). The good news is that this idea has been disproven by multiple scientific trials. The American College of Rheumatology and the Osteoarthritis Research Society International recommends activity as first line treatment for knee and hip pain. Activities such as water aerobics, land-based (i.e. walking) and Tai Chi are appropriate activities.

At the University of Central Arkansas (UCA), the Department of Exercise and Sport Science, developed an exercise program for older adults who reside at College Square Apartments, a retirement community on the UCA campus. A faculty member and students meet with participating residents who have been cleared by their primary care provider. Before exercise begins, the students conduct a motivational interview with the participant and create mutual agreed upon goals. The students administer the Senior Fit Test, interpret the results, then prepare and lead the participants through 6-8 weeks of exercise. At the end of the program students administer the Senior Fit Test again, and then review and debrief with the participant.

Older adults may think participating in a fitness program or purchasing expensive equipment is needed to improve fitness. Home-based items such as lifting full milk gallon jugs or carrying laundry baskets up steps are ways to increase strength. Stretch bands are low-cost items that can be used to help with flexibility and strength, too. Any physical activity is worthwhile and helps cardiovascular, joint and mental health. Just move!

 

 

References

Lövdén, M., Xu, W. & Wangy, H. X. (2013). Lifestyle change and the prevention of cognitive decline and dementia. Current Opinions in Psychiatry 26 (3): 239-243.

Mesink, B. M., Ziese, T. & Kok, F.J. (2009). Benefits of leisure-time physical activity on the cardiovascular risk profile at older age. International Journal of Epidemiology (28): 659-666.

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