Cultivating Relationships as a Community-Based Recruitment Strategy in Transdisciplinary Aging Research: Lessons From an Academic-Community Partnership.

Participation of Black American older adults in community-engaged research remains challenging in health sciences. The objectives of this study were to describe the specific efforts, successes, and challenges in recruiting Black American older adults in research led by the Health and Wellness in Aging Across the Lifespan core, part of the Virginia Commonwealth University Institute for Inclusion, Inquiry, and Innovation (iCubed). We conducted a cross-case analysis of 6 community-engaged research projects using the community-engaged research continuum model. Successful recruitment strategies comprised a multifaceted approach to community-based collaboration, including a wellness program with a long standing relationship with the community, engaging key stakeholders and a community advisory board, and building a community-based coalition of stakeholders. Posting flyers and modest monetary compensation remain standard recruitment strategies. The cross-case analysis offered critical lessons on the community's nature and level of engagement in research. Relationship building based on trust and respect is essential to solving complex aging issues in the community.

Medication self-management capacity among older adults living in low-income housing communities.

BACKGROUND: Medication self-management capacity (MMC) is essential to safe and independent living. There is a need to understand the challenges low-income older adults face during the routine use of medications to promote safe medication use and healthy aging in place. OBJECTIVE: To assess the cognitive and physical deficiencies in MMC and the impact of using pharmaceutical aids/services on MMC among low-income older adults. METHODS: This was a cross-sectional study of 107 older residents of 5 low-income housing buildings in Richmond, VA. The Medication Management Instrument for Deficiencies in the Elderly was used to measure MMC during individual in-person interviews. Participants were asked whether they used any medication aids, including medication lists, organizers, or reminders, or pharmacy services such as specialized medication packaging, medication synchronization, prescription home delivery, or mail order services. Multiple regression modeling was used to assess the relationship between MMC and the use of pharmaceutical aids/services. RESULTS: Eighty-nine percent of participants were African American with a mean (standard deviation [±SD]) age of 68.5 (7.2) years. The mean deficit in MMC was 3 (±2.0). The most challenging skill was naming all the medications (69.2%), followed by stating their indications (46.7%) and knowing how or when all of the medications should be taken (38.3%). Seventy-nine percent used at least 1 pharmaceutical aid/service; using 1 pharmaceutical aid/service was significantly associated with better MMC (P = .0285). Low educational level and health literacy were associated with deficits in MMC (P < .05). CONCLUSION: Many older adults residing in low-income housing had impaired capacity to manage their medications independently. Inadequate medication knowledge affected their cognitive ability to manage medications. Using a pharmaceutical aid/service was associated with better MMC. Greater attention to developing medication self-management skills for older adults with low health literacy and adverse social determinants of health is needed.

Unpacking interactions among student teams in a practice-based IPE setting: a qualitative evaluation study.

In many healthcare settings, teams change composition regularly, so healthcare students must be trained to function effectively in dynamic teams before entering the workforce. Interprofessional clinical rotations provide an ideal venue for learners to practice these skills, but little is known about how student teams interact in such settings. In this qualitative observational evaluation, learners from multiple health professions at a single institution participated in scheduled clinics in low-income housing communities for older adults. Interprofessional student teams met with program participants for care coordination, health and wellness assessments, and assistance in setting and achieving health goals; team composition changed from week-to-week. A purposive sample was selected from video-recorded encounters between student teams and their program participants. The aim of this study was to explore team interactions and document learner behaviors. Two researchers independently reviewed discrete segments of each video, recorded their observations and reflections, and then the team discussed, categorized, and identified relevant examples of both effective and ineffective behaviors. Four major themes were observed: inclusiveness, leadership, joy of practice, and sharing of clinical knowledge. Students demonstrated both positive and negative examples of behaviors that aligned with each theme. Understanding how students behave on teams in dynamic settings where patient care is taking place can help educators establish practice-based interprofessional education models that better prepare learners to function effectively and strategies that may improve team interactions.

Beyond knowledge and confidence: a mixed methods evaluation of a Project ECHO course on dementia for primary care.

Primary care clinicians have an important role in the management of dementia and have expressed interest in continuing education. The authors describe a model they used for providing dementia education in primary care, Project ECHO (Extension for Community Healthcare Outcomes), and an overview of its major features. A partnership including academic institutions and a national healthcare association is then outlined, including the unique features of the ECHO model developed through this partnership. A mixed-methods methodology was used for programmatic evaluation. This use of mixed methods adds vital new knowledge and learner perspectives that are key to planning subsequent ECHO courses related to dementia and primary care. The discussion includes an exploration of the significance of these findings for understanding the motivations of primary care providers for participation in the educational program, as well as the limitations of the current study. A final section explores the next steps in the continued development of the model and its implications for geriatrics education in dementia care, especially the supportive role that ECHO courses can play in meeting the challenges of dementia care.

An interprofessional geriatrics faculty development program: exploration of the barriers and facilitators of capstone projects.

Faculty development programs (FDPs) are an effective, evidence-based method of promoting knowledge, skills and self-efficacy of faculty. However, implementation and sustainability of curricular capstone projects developed by faculty as part of these programs are rarely reported. Challenges to sustaining programmatic implementation of interprofessional FDP curricular content into academic and clinical settings over time were not found in peer-reviewed literature. To better understand the sustained impact of our geriatrics-focused FDP, we explored barriers and facilitators to implementation and sustainability of capstone projects designed by faculty Scholars in our FDP. Thematic analysis of virtual interviews with 17 Scholars revealed several key factors that impacted the implementation and Dynamic sustainability of curricular projects. Three major themes and sub-themes were identified: Project Implementation (Supportive Factors, Hindering Factors and Filling in Gaps in the Field); Pedagogical Development (Enhancement of Skills and Culture Change); and Sustainability Impact (Project Sustainability, Career Development and Passing the Torch). Results suggest it is important to ensure logistical support, dedicated time, and organizational or institutional support. Implementation of geriatrics-focused FDPs provides an evidence-based approach to sustainability. Further study of the ongoing barriers and facilitators to sustainability is encouraged.

Infusing geriatrics expertise in health professions education through interprofessional faculty development.

As the population of older adults continues to grow, the need for health care professionals trained in the delivery of interprofessional care for older adult patients is critical. The purpose of this paper is to detail the outcomes of an interprofessional, geriatrics training program for healthcare professionals with a faculty appointment. Specifically, we gathered outcomes at four levels: reactions/satisfaction, learning, behavioral, and organizational. Our findings suggest that programs structured like the Faculty Development Program (FDP) have the potential to increase the amount of geriatrics content introduced in already existing health professions curricula, as well as to offer faculty needed training in how to provide their students with interprofessional learning experiences.

Histone acetylation at the sulfotransferase 1a1 gene is associated with its hepatic expression in normal aging.

OBJECTIVES: Phase II drug metabolism is poorly studied in advanced age and older adults may exhibit significant variability in their expression of phase II enzymes. We hypothesized that age-related changes to epigenetic regulation of genes involved in phase II drug metabolism may contribute to these effects. METHODS: We examined published epigenome-wide studies of human blood and identified the SULT1A1 and UGT1A6 genes as the top loci showing epigenetic changes with age. To assess possible functional alterations with age in the liver, we assayed DNA methylation (5mC) and histone acetylation changes around the mouse homologs Sult1a1 and Ugt1a6 in liver tissue from mice aged 4-32 months. RESULTS: Our sample shows a significant loss of 5mC at Sult1a1 (ß = -1.08, 95% CI [-1.8, -0.2], SE = 0.38, P = 0.011), mirroring the loss of 5mC with age observed in human blood DNA at the same locus. We also detected increased histone 3 lysine 9 acetylation (H3K9ac) with age at Sult1a1 (ß = 0.11, 95% CI [0.002, 0.22], SE = 0.05, P = 0.04), but no change to histone 3 lysine 27 acetylation (H3K27ac). Sult1a1 gene expression is significantly positively associated with H3K9ac levels, accounting for 23% of the variation in expression. We did not detect any significant effects at Ugt1a6. CONCLUSIONS: Sult1a1 expression is under epigenetic influence in normal aging and this influence is more pronounced for H3K9ac than DNA methylation or H3K27ac in this study. More generally, our findings support the relevance of epigenetics in regulating key drug-metabolizing pathways. In the future, epigenetic biomarkers could prove useful to inform dosing in older adults.

Over-the-counter medication use in residents of senior living communities: A survey study.

BACKGROUND: Self-medication with over-the-counter (OTC) products is common among older adults. Although OTC self-medication is a convenient way to manage some health issues, older persons may be at higher risk of experiencing medication-related problems. This study examines the prevalence, practices, and preferences associated with OTC medication use in older adult residents of senior living communities. OBJECTIVES: The study aimed to examine the characteristics of OTC medication users and to quantify the prevalence, attitudes, perceptions, preferences, and practices regarding OTC medication use and decision-making in 2 senior living communities in central Virginia. METHODS: The study used survey methodology. A 51-item semistructured questionnaire was designed by the research team of geriatrics specialists, and mixed-methods and evaluation researchers. The questionnaire was administered in-person to participants (N = 88). Descriptive analyses were conducted using SAS 9.4. Characteristics of those using OTC medications as directed by a health professional were compared with those of whom were self-medicating with OTC medications. RESULTS: Most of the sample were women (55%), black (61%) and had less than or equal to a high school education (55%). Analgesics were the most (76%) prevalent OTC therapeutic category used, and aspirin was the most (65%) prevalent OTC medication. A greater (82%) proportion of respondents reported self-recommended OTC medication use (self-medication with OTC medications) rather than physician recommended use (18%). A high (41%) prevalence of inappropriate use of OTC medications was observed in this sample of older adults. Most (80%) considered OTC medications safe and effective. The pharmacy was the most (93%) commonly reported purchase location to buy an OTC medication. Physicians were the most (90%) commonly reported information source for OTC medications. CONCLUSION: Considering the high percentage of self-reported self-medication, inappropriate use, and experiences of adverse effects, steps should be taken to develop consumer education and relationships with pharmacists to encourage the responsible use of OTC medications in this population.

Evaluation of an interprofessional care coordination model: Benefits to health professions students and the community served.

BACKGROUND/PURPOSE: An innovative care coordination program was developed to enhance wellness among low-income older adults living in subsidized apartment buildings and to provide rich interprofessional education experiences for health professions students. METHODS: Program effectiveness for the residents was measured through an evaluation of participation, services used, and healthcare utilization. Educational effectiveness was measured through a change in health concepts and perceptions of interprofessional practice. FINDINGS: Health care utilization among participating residents showed an 8.6% reduction in emergency department visits and 9.8% reduction in hospital admissions. Students demonstrated improved knowledge in motivational interviewing (p = .02); diabetes (p = .02); hypertension (p≤.01); and frailty (p≤.01). Changes in students perception of interprofessional practice were significant in two areas; Teamwork and Collaboration (p≥.00); and Person Centeredness (p = .00). DISCUSSION: This care coordination model may be an effective approach to reduce care resource utilization among medically complex lower income older adults and provides a rich interprofessional learning experience for students.

Changes in student pharmacists' confidence in attaining geriatrics competencies and attitudes toward older adults across the Doctor of Pharmacy curriculum.

To determine if student pharmacists' confidence in their knowledge and skills, and their attitudes toward older adults improved throughout pharmacy school with an integrated geriatrics didactic curriculum (years 1-3) and a final year of clinical training including a required advanced pharmacy practice experience (APPE) in geriatrics (year 4). A two-part voluntary anonymous survey was administered at three different time points to two large cohorts of student pharmacists. The first part of the survey assessed students' confidence in attaining geriatrics competencies. The second part of the survey used the UCLA Geriatrics Attitudes Scale to assess students' attitudes. Of the 286 students who were emailed the survey, 236 student pharmacists completed it at the first assessment. Student pharmacists showed an increase in confidence in achieving geriatrics competencies from their first year to their third year, and further increase after their clinical training. Most students also held a generally positive attitude toward older adults from P1 to P4 year. Integration of geriatrics throughout the didactic and experiential curriculum made an impact on student pharmacists' confidence in their competency toward caring for older adults, while maintaining a positive attitude toward older adults throughout pharmacy school.

A case study in rapid adaptation of interprofessional education and remote visits during COVID-19.

The Richmond Health and Wellness Program (RHWP) is an innovative interprofessional care coordination program that seeks to support the health and wellness of independent-living older adults and educate future practitioners. Since 2012, RHWP has provided community-based interprofessional training to students at Virginia Commonwealth University. The sudden suspension of clinical and community-based training due to the COVID-19 pandemic created the need to transform the traditional ways students received clinical education and support the vulnerable communities served by RHWP. This paper describes RHWP's rapid transition to a hybrid telephone-based program with a virtual learning component for students which allowed RHWP to continue serving its participants and provide interprofessional training experiences. Since the transition, RHWP has served 111 participants through over 400 telephonic visits, and 12 nurse practitioner and pharmacy students completed clinical hours to fulfill graduation requirements. To meet the needs of learners, interprofessional education models can be adapted to changing circumstances posed by COVID-19.

Gaps in OTC Labeling: Potentially Inappropriate Medications for Older Adults.

As the number of available over-the-counter (OTC) products increases, many older adults are taking health care into their own hands. It is particularly important that the labeling provided with these products is precise, leading to their effective use, especially by older adults. Suboptimally designed medication labels can increase the risk of consumption errors and adverse drug interactions among seniors. This study evaluated whether the warning labels on potentially inappropriate OTC medications are consistent with evidencebased criteria for potentially inappropriate prescribing in older adults. Future action could be taken by the Food and Drug Administration to improve labeling policies.

Person-Centered Care: Evaluation of a Resident-Directed Medication Administration Program.

Objective The resident-directed medication administration program (RDMA) is a personalized medication approach designed to improve the medication administration process in long-term care facilities (LTCFs). This evaluation aimed to document staff experience with the RDMA program compared with staff working in facilities using a facility-directed medication administration program (FDMA). Design This descriptive program evaluation invited staff members to share their experiences with the medication administration process through an anonymous survey. Setting Three LTCFs using a RDMA program and three LTCFs using a FDMA program operated by a nonprofit health system in the mid-Atlantic region. Participants All medication administration staff working in six LTCFs were invited to participate (n = 28), and 22 evaluable surveys were returned. Pharmacists (n = 2), providers (n = 5), and nursing staff (n = 4) working in the RDMA facilities described their experiences with the RDMA program. Primary Outcome Measures Time spent administering medications, satisfaction with the medication administration process, medication administration error rate. Results Most staff members were satisfied with the program and would recommend it for other facilities. Medication administration staff at RDMA facilities reported that they were able to spend more time engaged with residents and less time administering medications. There were fewer medication administration errors in RDMA facilities. Conclusion Implementation of a personalized approach to medication administration is feasible and can promote a positive staff experience with the medication administration process with fewer medication errors.

Risk of fracture and the concomitant use of bisphosphonates with osteoporosis-inducing medications.

OBJECTIVE: To review the literature on the concomitant use of bisphosphonates and medications that can influence bone metabolism and potentially attenuate bisphosphonate antifracture efficacy. DATA SOURCES: MEDLINE and CINAHL were searched for articles published in English through December 2014 using the following terms: bisphosphonates, bone density conservation agents, acid-suppressive therapy, levothyroxine, thiazolidinediones (TZDs), selective serotonin reuptake inhibitors (SSRIs), bone fractures. STUDY SELECTION AND DATA EXTRACTION: Studies were included if they reported results of concomitant use of any listed medications with bisphosphonates and risk of fractures and focused on women. Articles that focused generally on the use of one of the listed medications and fractures without explicitly examining the potential antifracture efficacy or attenuation of bisphosphonates were excluded. DATA SYNTHESIS: A total of 6 relevant studies were identified. Four epidemiological studies reported a statistically significant dose-dependent increase in the risk of fractures when bisphosphonates and acid-suppressive drugs were used together. One post hoc analysis of clinical trial data suggested no attenuation of the antifracture effects of bisphosphonates when used concomitantly with acid-suppressive therapy. One study involving bisphosphonates and SSRIs noted a statistically significant association between fracture risk and SSRI use. No study examining TZDs or levothyroxine with bisphosphonates was identified. CONCLUSIONS: Existing research suggests potential attenuation of bisphosphonate antifracture efficacy among patients taking acid-suppressive medications. Based on their pharmacological actions, TZDs, SSRIs, and levothyroxine have similar implications. The paucity of evidence in the literature associating the attenuation of bisphosphonate antifracture efficacy when combined with other medications suggests that further investigation is needed.

Recommended immunizations for older adults: a primer for pharmacists.

OBJECTIVE: To assess the effectiveness and safety of currently recommended vaccines in older adults. DATA SOURCES: PubMed was used to search for relevant articles. Key words searched included: immunosenescence, influenza vaccine efficacy, influenza vaccine safety, Tdap safety and efficacy elderly, Td safety and efficacy elderly, pneumococcal vaccine safety and efficacy elderly, pneumococcal vaccine efficacy, Recombivax safety and efficacy elderly, Zostavax safety and efficacy, influenza vaccine timing, frailty and immunosenescence. STUDY SELECTION/SATA EXTRACTION: Articles were reviewed and selected considering relevance to the subject. Selected articles were written in the English language, conducted mainly in humans, and published from 2008 to 2014, if it was a review article. Articles were then determined to be relevant or irrelevant based on their abstracts. DATA SYNTHESIS: Immunizations are a major means of preventing diseases, and pharmacists are a frontline health professional, with significant interactions with the older population. There are no recent published reviews that compile the efficacy and safety evidence for recommended immunizations in older people. Pharmacists are often asked questions about the efficacy and safety of these immunizations. CONCLUSION: Overall, efficacy and safety profiles of currently recommended vaccines are positive in the older population. The least-effective vaccine currently recommended is the varicella-zoster vaccine, with a 50% efficacy. The vaccine with the highest rates of adverse events is the tetanus booster, with local pain and swelling at the injection site.

Incidence and risk factors for postoperative cognitive dysfunction in older adults undergoing major noncardiac surgery: A prospective study.

BACKGROUND & AIMS: Postoperative cognitive dysfunction (POCD) is a decline in cognitive function that occurs after surgery. The purpose of this study was to estimate the incidence and identify potential risk factors of POCD in older adults undergoing major noncardiac surgery. MATERIALS AND METHODS: A total of 69 patients aged 65 years or older undergoing major noncardiac surgery were enrolled. Patients' cognitive function was assessed before and 3 months after surgery using a computerized neurocognitive battery. A nonsurgical control group of 54 older adults was recruited to adjust for learning effects from repeated administration of neurocognitive tests. Data about potential risk factors for POCD were collected before, during, and after surgery, including patient, medication, and surgery factors. The incidence of POCD was calculated using the Z-score method. A multivariable logistic regression model was used to identify risk factors for POCD. RESULTS: POCD was present in eleven patients (15.9%, 95% confidence interval [CI] = 7.3-24.6) 3 months after major noncardiac surgery. Carrying the apolipoprotein E4 (APOE4) genotype (odds ratio [OR] = 4.74, 95% CI = 1.09-22.19), using one or more highly anticholinergic or sedative-hypnotic drugs at home prior to surgery (OR = 5.64, 95% CI = 1.35-30.22), and receiving sevoflurane for anesthesia (OR = 6.43, 95% CI = 1.49-34.66) were associated with the development of POCD. CONCLUSIONS: POCD was observed in 15.9% of older adults after major noncardiac surgery. Risk factors for POCD in these patients were carrying the APOE4 genotype, using one or more highly anticholinergic or sedative-hypnotic drugs prior to surgery, and receiving sevoflurane for anesthesia.

Potentially inappropriate medication use is associated with clinical outcomes in critically ill elderly patients with neurological injury.

BACKGROUND: Limited data suggest that potentially inappropriate medications (PIMs) impact outcomes in critically ill elderly patients. No data are available on the association between PIM use as well as drug burden index (DBI), which is a measure of PIM use, and clinical outcomes in neurocritical care elderly patients. This study evaluates whether PIM use and a higher DBI are associated with poor clinical outcomes in neurocritical care elderly patients. METHODS: PIMs were retrospectively identified in critically ill elderly patients admitted to the neuroscience intensive care unit (NSICU) from March to July 2011. DBI was calculated based on PIM doses. Relationships with clinical outcomes were evaluated. RESULTS: PIMs were prescribed to a majority (81.3 %) of the 112 patients. Opioids were most commonly associated with a decrease in Richmond Agitation Sedation Scale (RASS) scores (56 % of PIM doses). Time to recovery was significantly longer in patients with a higher PIM burden (≤2 PIMs: 8 h, >2 PIMs: 29 h; p = 0.02). There was a significantly longer NSICU and hospital length of stay (9 vs 2; 15 vs 5 days; p < 0.0001) as well as a lower Glasgow Coma Scale score upon discharge (14 vs 15, p = 0.02) in patients with a higher DBI after 72 h of hospitalization. There was no difference in mortality. CONCLUSIONS: PIM use and higher DBI scores were associated with poor clinical outcomes and longer lengths of stay. Further studies are needed to determine the impact of PIMs and DBI on mortality in neurocritical care elderly patients.

Epigenetic regulation of drug metabolism in aging: utilizing epigenetics to optimize geriatric pharmacotherapy.

We explore the relationship between epigenetic aging and drug metabolism. We review current evidence for changes in drug metabolism in normal aging, followed by a description of how epigenetic modifications associated with age can regulate the expression and functionality of genes. In particular, we focus on the role of epigenome-wide studies of human and mouse liver in understanding these age-related processes with respect to xenobiotic processing. We highlight genes encoding drug metabolizing enzymes and transporters revealed to be affected by epigenetic aging in these studies. We conclude that substantial evidence exists for epigenetic aging impacting drug metabolism and transport genes, but more work is needed. We further highlight the promise of pharmacoepigenetics applied to enhancing drug safety in older adults.

Genome-wide analysis of hepatic DNA methylation reveals impact of epigenetic aging on xenobiotic metabolism and transport genes in an aged mouse model.

Hepatic xenobiotic metabolism and transport decline with age, while intact xenobiotic metabolism is associated with longevity. However, few studies have examined the genome-wide impact of epigenetic aging on these processes. We used reduced representation bisulfite sequencing (RRBS) to map DNA methylation changes in liver DNA from mice ages 4 and 24 months. We identified several thousand age-associated differentially methylated sites (a-DMS), many of which overlapped genes encoding Phase I and Phase II drug metabolizing enzymes, in addition to ABC and SLC classes of transporters. Notable genes harboring a-DMS were Cyp1a2, Cyp2d9, and Abcc2 that encode orthologs of the human drug metabolizing enzymes CYP1A2 and CYP2D6, and the multidrug resistance protein 2 (MRP2) transporter. Cyp2d9 hypermethylation with age was significantly associated with reduced gene expression, while Abcc2 expression was unchanged with age. Cyp1a2 lost methylation with age while, counterintuitively, its expression also reduced with age. We hypothesized that age-related dysregulation of the hepatic transcriptional machinery caused down-regulation of genes despite age-related hypomethylation. Bioinformatic analysis of hypomethylated a-DMS in our sample found them to be highly enriched for hepatic nuclear factor 4 alpha (HNF4α) binding sites. HNF4α promotes Cyp1a2 expression and is downregulated with age, which could explain the reduction in Cyp1a2 expression. Overall, our study supports the broad impact of epigenetic aging on xenobiotic metabolism and transport. Future work should evaluate the interplay between hepatic nuclear receptor function and epigenetic aging. These results may have implications for studies of longevity and healthy aging.

A core process in receptor function, general anesthesia, sleep, and aging.

The diffusion of ligands and proteins was proposed to be guided by chreodes in water organized by protein-surface side chains with varying hydropathic states. These chreodes are proposed to be the target of volatile general anesthetic agents. The similarity between this effect and sleep deprivation leads to a proposal of an external agent responsible for sleep. This agent is elemental nitrogen. An extension of this effect is the concept that elemental nitrogen is a core factor in aging.