Title: Community Health Worker Interventions for At-Risk Populations
Amanda S. Keddington, MSN, RN, DNP-S; Janine Roberts MSN, RN; Perry M. Gee, PhD., RN, NEA-BC, FAAN
University of Utah
Purpose:This review explores available literature regarding Community Health Worker (CHWs) led interventions with rural, older adults, Black or Hispanic populations in the United States. Current models of transitional care from hospitals are cost-prohibitive, and resource access remains difficult for rural residents. The purpose of this review is to present evidence that CHW-led interventions result in improved outcomes for rural populations.
Background: Rural populations, especially older adults, Black, or Hispanic populations consistently experience poorer health outcomes than their urban counterparts due to difficulty accessing health care services, lower socioeconomic status, and incidence of chronic diseases (Dye et al., 2018). There are additional economic burdens among rural residents, including lack of insurance and higher rates of unemployment. These burdens add to the increasing difficulty of affording healthcare (Samuel-Hodge, 2022). In the United States alone, the overall shortage of nurses is projected to be 1.1 million by the end of 2022 (Pollack, 2022), which only adds to the layers of complexity among these sensitive populations.
Methods: A literature review was performed in the following databases: Pubmed, Ageline, CINAHL, Cochrane Review, and Medline. Search terms used were related to community health workers, older, adults, and social determinants of health using subject headings and keywords, adjusted for each database. Search terms were kept broad due to significant variability in titles used globally to describe this position.
Search terms: “Community Health Workers”, “Health Services for the Aged”, “Social Determinants of Health”, “Geriatrics”, “Geriatric Nursing”, “Rural Healthcare”, “Rural Health”, and “Rural Community”.
Assessment of Findings: Several themes and identified outcomes emerged in our research. Hospital readmissions and ER visits were found to be significantly decreased. One study focused on utilization costs. Standard transitional care costs were over $11 million. These decreased to just over $4 million after CHW led interventions. CHW led interventions are varied throughout the literature, including coaching on diet and physical activity, transportation, medication management, and assistance with healthcare access. In programs measuring effectiveness of specific interventions, authors found improved systolic and diastolic blood pressure, improved management of diabetes, increased consumption of fruits, vegetables and nuts, and significant increase in physical activity. Additionally, patients’ perceptions of their care were favorable, as researchers measuring patient satisfaction found their patients to be satisfied with their care. Finally, authors measuring perceived well-being found that patients perceived their overall well-being to be improved after CHW-led interventions.
Conclusions: Promising results included decreases in hospital readmissions, ER visits, and healthcare utilization. Patient compliance increased overall, as well as perceived well-being and satisfaction with CHW-led interventions. Further research is needed to assess the impact of HCW’s on rural patients. However, this literature review provides promising results that CHW led interventions are effective and can improve healthcare utilization.
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2. Aponte, J., Jackson, T.D., Wyka, K., & Ikechi, C. (2017)., Health effectiveness of community health workers as a diabetes self-management intervention. Diabetes and Vascular Disease Research, 14(4), 316-326. https://doi.org/10.1177/1479164117696229
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4. Hofer, R., Choi, H., Mase, R., Fagerlin, A., Spencer, M., & Heisler, M. (2017). Mediators and moderators of improvement in medication adherence: Secondary analysis of a community health worker-led diabetes medication self-management support program. Health Education Behavior, 44(2), 285-296. https://doi.org/10.1177/1090198116656331
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Title: Left Atrial Appendage Occlusion Devices: A review on current guidelines for stroke prevention in patients with atrial fibrillation
Jeremy D. Bergman, MSIV
Rocky Vista University – Southern Utah
Abstract: Despite being well studied, atrial fibrillation (afib) remains the most common heart arrhythmia world wide and increases stroke risk 4-5 times when left untreated. The attributable risk for stroke in patients with afib increases with age, being as much as 23.5% in patients 80-90 years old. Because the left atrial appendage is the primary culprit for thrombus formation and embolization, occlusion devices have been studied and hypothesized to reduce stroke risk in patients with afib. The primary occlusion devices used today are the Watchman device and the Amulet. Two different RCT’s (PROTECT AF & PREVAIL) have been conducted comparing the safety and efficacy of the watchman device vs warfarin. In both trials the conclusion was that the watchman device offers a non inferior option to the gold standard treatment of stroke prevention, oral anticoagulants. Because the device has not proven to be superior to oral anticoagulants for stroke prevention, and because the procedure itself causes risks, it is recommended that only patients with with severe bleeding risk, or who are unable to take oral anticoagulants are considered for the procedure. Older adults who qualify will need to meet a list of indications and contraindications, weight the benefits vs the risks, and consider “what matters most” before having the device placed.
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9) Holmes DR, Reddy VY, Turi ZG, Doshi SK, Sievert H, Buchbinder M, Mullin CM, Sick P; PROTECT AF Investigators. Percutaneous closure of the left atrial appendage versus warfarin therapy for prevention of stroke in patients with atrial fibrillation: a randomised non-inferiority trial. Lancet. 2009 Aug 15;374(9689):534-42. doi: 10.1016/ S0140-6736(09)61343-X. Erratum in: Lancet. 2009 Nov 7;374(9701):1596. PMID: 19683639.
10) Holmes DR Jr, Kar S, Price MJ, Whisenant B, Sievert H, Doshi SK, Huber K, Reddy VY. Prospective randomized evaluation of the Watchman Left Atrial Appendage Closure device in patients with atrial fibrillation versus long-term warfarin therapy: the PREVAIL trial. J Am Coll Cardiol. 2014 Jul 8;64(1):1-12. doi: 10.1016/j.jacc.2014.04.029. Erratum in: J Am Coll Cardiol. 2014 Sep 16;64(11):1186. PMID: 24998121.
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13) January CT, Wann LS, Calkins H, Chen LY, Cigarroa JE, Cleveland JC, Ellinor PT, Ezekowitz MD, Field ME, Furie KL, Heidenreich PA, Murray KT, Shea JB, Tracy CM, Yancy CW. 2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society in Collaboration With the Society of Thoracic Surgeons. Circulation. 2019 Jul 09;140(2):e125-e151.
14) Lempereur M, Aminian A, Freixa X, Gafoor S, Kefer J, Tzikas A, Legrand V, Saw J. Deviceassociated thrombus formation after left atrial appendage occlusion: A systematic review of events reported with the Watchman, the Amplatzer Cardiac Plug and the Amulet. Catheter Cardiovasc Interv. 2017 Nov 01;90(5):E111-E121. 15) Singh SM, Douglas PS, Reddy VY. The incidence and long-term clinical outcome of iatrogenic atrial septal defects secondary to transseptal catheterization with a 12F transseptal sheath. Circ Arrhythm Electrophysiol. 2011 Apr;4(2):166-71.
Title: Dermatology Principles and Guidelines in Older Adultsmatology Principles and Guidelines in Older Adults
Emily Chanak, OMS-IV
Rocky Vista University – Southern Utah
Many dermatology conditions in older adults are the same as in younger adults; however, it is the treatment that differs. A starting point comes from the 4 ‘M’s of geriatrics; the first of these is ‘what matters most’. This starts with things like life expectancy: will treating this low-risk skin cancer give many years benefit or do the risks of the procedure outweigh the benefits? This also covers concepts like how doing a full body screening on an elderly patient with many comorbidities might be focusing on the wrong health concern. Next is the ‘M’ of mobility: more than any other age group, the elderly start to worry about pressure ulcers and wound healing. The ‘M’ of mentality comes in to play when discussing a treatment plan and how adherent a patient can be. A younger patient might have no issue with a wound dressing, but a dementia patient could forget why it’s there and continuously rip it off. Finally, the ‘M’ of medications really addresses how some of our pharmacological options that are safer for younger adults cause higher risks in older adults, such as antihistamines causing sedation and falls and steroids decreasing an already low immune system.
Older adults also have common concerns that can be addressed at large. Pruritis and xerosis, often intertwined, are very common and have the problem of few options for pharmacological treatment. Moisturizers are a savior here, as well as avoid harsh shampoos and clothing and taking lukewarm showers instead of hot ones. Another common dermatological manifestation seen in the elderly is malnutrition affecting skin fragility. Lastly, an often-overlooked cause of dermatologic complaints is STDs. Elderly populations don’t have to worry about pregnancy and thus don’t use condoms as often. Additionally, women’s vaginal tissues thin with aging and increase the risk of micro-tears. These combine with the overall decreased immune system response to make STDs prevalent in older adults.
In conclusion, it is necessary to look at geriatric dermatology through the lens of understanding the underlying physiological changes of aging and how increased epidermal barrier defects, decreased immune system health, and altered wound-healing capacity affect cutaneous skin conditions and their treatments.
- Norman, Rob. “Ten Keys to Success in Geriatric Dermatology.” Practical Dermatology, Bryn Mawr Communications, https://practicaldermatology.com/articles/2009-mar/PD0309_03-php.
- Linos E, Chren MM, Covinsky K. Geriatric Dermatology-A Framework for Caring for Older Patients With Skin Disease. JAMA Dermatol. 2018 Jul 1;154(7):757-758. doi: 10.1001/jamadermatol.2018.0286. PMID: 29710117; PMCID: PMC6596420.
- Wollina, Uwe, MD. Geriatric Dermatology. Published January 1, 2011. Clinics in Dermatology. Volume 29, Issue 1. © 2011.
- Endo, Justin O., MD; Wong, Jillian W., MS; Norman, Robert A., DO; Chang, Anne Lynn S., MD. Geriatric Dermatology. Published April 1, 2013. Journal of the American Academy of Dermatology. Volume 68, Issue 4. © 2013.
- Chang, Anne Lynn S., MD; Wong, Jillian W., MS; Endo, Justin O., MD; Norman, Robert A., DO. Geriatric Dermatology Review: Major Changes in Skin Function in Older Patients and Their Contribution to Common Clinical Challenges. Published October 1, 2013. Journal of the American Medical Directors Association. Volume 14, Issue 10. © 2013.
Title: Supporting Caregivers for the Optimal Management of Patients with DementiaAuthor
Elzard H. Sikkema, MLS (ASCP), BS
University of Utah School of Medicine
As chronic diseases are better managed and the population of Americans born between 1946-1964 continues to enter late adulthood, the prevalence of patients with dementia will continue to increase. In 2022, there are 6.5 million Americans 65 years of age or older with Alzheimer’s dementia. It is projected that there will be 12.7 million Americans with Alzheimer’s dementia by 2050.  On average, older adults with dementia live four-to-eight years after their diagnosis.  Patients with dementia are more reliant upon assistance to complete activities of daily living than other older adults without a diagnosis of dementia.  26% of Americans currently care for a patient with dementia, and 61% of family caregivers must also remain employed for financial security.  Numerous studies have documented that caregiver burden is worse for those who care for patients with dementia. [3,4,8,9,14,15] Studies show that family caregivers are essential to maintaining optimal management of patients with dementia. [10-13] Therefore, medical providers must develop a holistic approach to evaluating patients with dementia and their caregivers, treating the pair as a dyad. [10-13] In particular, primary care providers must recognize that assessing the needs of a caregiver and providing support to caregivers is required to develop an optimal management plan for their patients with dementia. [3,13-15] Primary care providers should utilize peer-reviewed and evidence-based assessment tools for caregivers of patients with dementia. [17,23-26] Studies show that frequent anticipatory guidance, education, and utilization of caregiver interventions benefit both the caregiver and the patient with dementia. [3,13-15,23-28] However, due to the abundance of caregiver interventions that have shown benefits, and the availability or limitations of local resources, primary care providers must familiarize themselves with their local resources for the betterment of the caregivers of their patients with dementia.
Title: The Underrepresentation of Older Adults in Randomized Clinical Trials for JAK Inhibitors to Treat Atopic Dermatitis: Barriers and Recommendations
Shreya Sreekantaswamy, BS,1 Linda Edelman, PhD2
1 University of Utah School of Medicine
2 University of Utah College of Nursing
Atopic dermatitis (AD), or eczema, is classically thought of as a disease of childhood. Recent research, however, has revealed that the prevalence of AD can reach as high as 8.7% among adults over the age of 65. Yet, older adults have been found to be severely underrepresented in clinical trials for current standard AD treatments (eg. methotrexate, mycophenolate mofetil). As dermatology is turning to JAK inhibitors (JAKi) to expand the therapeutic horizon for AD, it is therefore important that older adults are adequately represented in JAKi AD clinical trials, for if not, they will be treated with medications whose efficacy and safety profile have not been explicitly evaluated in their age group. For this study, we reviewed clinicaltrials.gov to assess the age range and inclusion and exclusion criteria for Phase II and Phase III clinical trials evaluating the efficacy of JAKi (abrocitinib, baricitinib, upadacitinib, ruxolitinib, and delgocitinib) to treat atopic dermatitis. Of the 35 Phase II and Phase III AD clinical trials for these JAKi, only 14 adult trials have published data. Of these 14 trials, only five report the proportion of older adults in their participant cohort, which ranged from 2.13% - 7.95%, despite none of these trials having an upper age limit. Most trials (62.5%) had vague exclusionary criteria which stated that certain unspecified laboratory abnormalities or medical conditions could exclude participants at the discretion of the investigator, a statement which likely disproportionately excluded older adults. Underrepresentation of older adults in these trials might also be attributable to difficulty in recruiting and retaining geriatric patients in clinical research. Potential methods to increase the recruitment of older adults for studies are provided, such as assisting with transportation, or utilizing services like ResearchMatch to specifically target the older participant demographic. Ultimately, further efforts are needed to actively include and study older adults in clinical trials for JAKi so that dermatologists can make evidence-based therapeutic selections when treating older patients with atopic dermatitis.
Title: The Importance of a Comprehensive Geriatric Assessment in Older Adults with Cancer
Author: Alec Hansen
Introduction: There are more adults ages 65 and older today in the United States than at any other time in history. This number is expected to grow from 49 million to approximately 72 million by 2030. [1,2] Cancer is common in the geriatric population, with more than 50% of all cancers and more than 70% of cancer-related deaths in the United States occurring in patients ages 65 years and older.  It is important to consider more than just a patients chronological age while determining treatment options for older adults with cancer. 
Prevalence: According to the National Cancer Institute’s (NCI) Surveillance, Epidemiology, and End Results (SEER) Program, the median age of a cancer diagnosis is 66 years.  The life expectancy in the United States for Females is 81.2 years, and for Males is 76.2 years, suggesting that half of all lifetime cancer diagnoses occur in the last 10-15 years of an individual’s life.  Cancer is the leading cause of death in men and women aged 60 to 79 years. 
Treatment: The Comprehensive Geriatric Assessment (CGA) is a multidisciplinary, in-depth evaluation that assesses the objective health and well-being of older adults while evaluating multiple domains which may affect cancer prognosis, treatment choices, and tolerance.  The CGA can reveal geriatric issues that are not detected by routine oncology care. Areas of evaluation include function, mobility, polypharmacy, comorbidities, social support, cognition, psychologic problems, and nutrition. [7,8,9,10,11,12,13,14,15,16]
Community Resources: The Geriatric Oncology Assessment and Plan (GOAL) clinic through the Huntsman Cancer Institute is a referral based, supportive service lead by an Oncology and Geriatric trained Nurse Practitioner. Focused on evaluating comprehensive geriatric needs and collaborating with the geriatric and oncology teams. Performs comprehensive geriatric assessments, assists with symptom management, provides palliative care, helps connect patients to community resources, and participates in frequent and thorough goals of care conversations.
Conclusions: The prevalence of cancer in older adults will continue to increase as the population ages. Treating cancer effectively in older adults requires a comprehensive geriatric assessment. Resources such as the GOAL clinic through Huntsman Cancer Institute can help ensure that the geriatric oncology population is properly cared for.
 Smith BD, Smith GL, Hurria A, Hortobagyi GN, Buchholz TA. Future of cancer incidence in the United States: burdens upon an aging, changing nation. J Clin Oncol. 2009;27(17):2758-2765. doi:10.1200/JCO.2008.20.8983
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 Vega JN, Dumas J, Newhouse PA. Cognitive Effects of Chemotherapy and Cancer-Related Treatments in Older Adults. Am J Geriatr Psychiatry. 2017;25(12):1415-1426. doi:10.1016/j.jagp.2017.04.001
 Canoui-Poitrine F, Reinald N, Laurent M, et al. Geriatric assessment findings independently associated with clinical depression in 1092 older patients with cancer: the ELCAPA Cohort Study. Psychooncology. 2016;25(1):104-111. doi:10.1002/pon.3886
 Hurria A, Li D, Hansen K, et al. Distress in older patients with cancer. J Clin Oncol. 2009;27(26):4346-4351. doi:10.1200/JCO.2008.19.9463
 Pressoir M, Desné S, Berchery D, et al. Prevalence, risk factors and clinical implications of malnutrition in French Comprehensive Cancer Centres. Br J Cancer. 2010;102(6):966-971. doi:10.1038/sj.bjc.6605578
U of U Geriatric Poster Abstract
Title: The Geriatric Emergency Department: An Examination of Current Trends, Benefits, Barriers, and Implementation
Author: Aaron Perez, MS IV1
Affiliations: 1University of North Texas HSC at Fort Worth—Texas College of Osteopathic Medicine
Older adults use emergency services at a higher rate, their visits have a greater level of urgency, they have longer stays in the Emergency Department (ED), they are more likely to be admitted or to have repeat ED visits, and they experience higher rates of adverse health outcomes after discharge which drives up the cost of health care. [3,4] Adults 65 and older in the US are expected to grow from 49 million today to approximately 72 million by 2030 and 84 million by 2050. [1,2] With that, the expected number of ED visits by older adults is expected to increase significantly. As it stands, current ED models may not be well-equipped to address the complex care needs of older adults.  Developing a Geriatric Emergency Department (GED) can promote improved, cost-effective care with better outcomes for this growing population of patients.  According to the 2018 National Emergency Department Inventory by the Emergency Medicine Network, there are 5,533 EDs in the US. Of these, only 276 have received accreditation through the Geriatric Emergency Department Accreditation (GEDA) program with the majority being in urban areas and achieving only a Level 3 distinction.  Potential benefits to promoting geriatric-specific care protocols in the ED include lowering costs by reducing unnecessary procedures, hospital-acquired infections, and allocating appropriate resources to patients. Patients and families will also be able to make more informed decisions when seeking care. Potential barriers include the recruitment of key players due to insufficient evidence of the financial benefits of implementing a GED. Securing the appropriate number and type of well-trained staff as well as applying protocols amidst common ED problems (overcrowding, boarding, nursing shortages) are other barriers. There are a wide array of available resources to learn more about the importance of GED as well as specific interventions to make any ED more equipped to care for older adults. As more emergency departments work to achieve GED accreditation and promote care for this specific population, costs will be decreased, and outcomes improved for this growing group of patients.
 Shadyab AH, Castillo EM, Chan TC, Tolia VM. Developing and Implementing a Geriatric Emergency Department (GED): Overview and Characteristics of GED Visits. J Emerg Med. 2021 Aug;61(2):131-139. doi: 10.1016/j.jemermed.2021.02.036. Epub 2021 May 15. PMID: 34006420.
 Kahn JH, Magauran BG Jr, Olshaker JS, Shankar KN. Current Trends in Geriatric Emergency Medicine. Emerg Med Clin North Am. 2016 Aug;34(3):435-52. doi: 10.1016/j.emc.2016.04.014. PMID: 27475008.
 Aminzadeh F, Dalziel WB. Older adults in the emergency department: a systematic review of patterns of use, adverse outcomes, and effectiveness of interventions. Ann Emerg Med. 2002 Mar;39(3):238-47. doi: 10.1067/mem.2002.121523. PMID: 11867975.
 American College of Emergency Physicians. "American Geriatrics Society, Emergency Nurses Association, Society for Academic Emergency Medicine, Geriatric Emergency Department Guidelines Task Force. Geriatric emergency department guidelines." Ann Emerg Med 63.5 (2014): e7-25.
ACEP Geriatric Emergency Department Accreditation. Criteria for Levels 1, 2 & 3. American College of Emergency Physicians. Accessed October 26, 2020. https://www.acep.org/globalassets/sites/geda/ documnets/GEDA-criteria.pdf
 “GEDA Accreditation List.” American College of Emergency Physicians. acep.org/geda. Accessed November 17, 2021.
 Hwang U, Dresden SM, Vargas-Torres C, et. al.; Geriatric Emergency Department Innovations in Care Through Workforce, Informatics, and Structural Enhancement (GEDI WISE) Investigators. Association of a Geriatric Emergency Department Innovation Program With Cost Outcomes Among Medicare Beneficiaries. JAMA Netw Open. 2021 Mar 1;4(3):e2037334. doi: 10.1001/jamanetworkopen.2020.37334. Erratum in: JAMA Netw Open. 2021.PMID: 33646311; PMCID: PMC7921898.
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Title: Social Determinants of Health Create Disparities in Stroke Outcomes
Author: Courtney Reid, OMS IV
Affiliations: A.T. Still University - School of Osteopathic Medicine in Arizona
Projects from 2020:
4/22/2020- Unique Needs of the LGBTQ+ Population of Older Adults presented by Sky Dean, Fourth Year Medical Student at the University of Utah School of Medicine
3/31/20- "Art with Elders as viewed through the experience of older adult artists" - MS Gerontology Project presented by Lauren Chamberlain, past Graduate Assistant of the UGEC