Student Projects

Title: A Case-based Approach to Caregiver Burden and the C4C Model

Author: Sheryl A. Cherian, MS, MD Candidate 2024

Affiliations: Rush Medical College, University of Utah Geriatrics Visiting Elective

Abstract: In the United States, 1 in 5 people (approximately 53 million people) provide unpaid caregiving with estimated value of $470 billion annually, with 58% of these unpaid caregivers performing medical & nursing tasks. Moreover, there are 5.5 million caregivers caring for veterans, and military caregivers more likely to be employed, younger, with less social support, and caring for a patient with a behavioral health conditions. This case presentation involves an 83 year-old male veteran with hypertension who presented with short-term memory loss, accompanied by his spouse (primary caregiver) and adult daughter at the Wahlen VA geriatric assessment clinic in Salt Lake City, Utah. Increasing layers of complexity and concerning symptoms of caregiver burden were revealed during the family interview. This case reveals the limitations for providers to support caregivers outside of resource connection, given that caregivers are often not patients themselves of the healthcare provider or clinic. This presentation argues that to truly build an age-friendly health system, we need to develop systematic ways of supporting the caregivers of our older adult patients. We examine “Caring for Caregivers” or “C4C” as a promising model for caregiver support developed by Rush University Medical Center in Chicago.

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Title: Benzodiazepine Deprescription in Older Adults

Author: Ryan Tatton, MS3

Affiliations: Mayo Clinic Alix School of Medicine

Abstract: Benzodiazepines are among the most commonly prescribed medications in American older adults¹, with the most common indication being for insomnia². Despite the strong professional society consensus regarding the inappropriateness of benzodiazepine prescription in older adults^4,5, especially for insomnia^4,6, most physicians do not view the prevalence of these prescriptions in older adults as a public health issue³. Benzodiazepines have been demonstrated to lead to many adverse side effects in this population, including increased risk of delerium⁴, development of cognitive impairment^7,8, increased falls and hip fractures^9,10, respiratory depression⁴ (particularly when combined with opiates), increased rates of motor vehicle accidents^11,12, and increased all-cause mortality¹³. On the other hand, benzodiazepine deprescription has been associated with benefits including increased mobility, increased alertness, decreased incontinence, and improved sense of well-being¹⁹.

There is significant retisence among physicians to deprescribe benzodiazepines, an attitude contributed to by percieved time limitations and poor confidence in managing the taper²⁰. That said, simply providing patients with learning materials that discuss the harms of benzodiazepines and guide the patient through a structured tapering schedule has been shown to be both safe and effective¹⁵. In one study, providing educational materials was shown to be more effective than motivational interviewing¹⁴, further emphasizing that time does not need to be the limiting factor in benzodiazepine deprescription. Free resources that can be offered to patients include the EMPOWER brochure¹⁵ and materials available at deprescription.org.

Regarding the optimal taper strategy, evidence does not support switching the patient to long acting benzodiazepines first¹⁶. Optimal taper rates have been poorly studied, but durations of 4-22 weeks have been shown safe and effective^15,17. Shorter tapers (4-6 weeks) are more likely to result in transient withdrawal symptoms⁶, so longer regimens may be better tollerated. Regarding withdrawal symptoms, patients should be advised that these are typically transient, resolving within days⁶. Symptoms which patients may experience include insomnia, anxiety, irritability, sweating, and gastrointestinal symptoms. For those patients in whom benzodiazepines were prescribed for insomnia, the taper period is an excellent time to begin CBTi in order to support transition to a more durable solution for their insomnia¹⁸.

References:

1. Olfson M, King M, Schoenbaum M. Benzodiazepine use in the United States. JAMA Psychiatry. 2015;72(2):136-142. doi:10.1001/jamapsychiatry.2014.1763
2. Simon GE, Ludman   Outcome of new benzodiazepine prescriptions to older adults in primary care.  Gen Hosp Psychiatry. 2006;28(5):374-378.
3. Cook JM, Marshall R, Masci  C, Coyne    Physicians’ perspectives on prescribing benzodiazepines for older adults: a qualitative study.  J Gen Intern Med. 2007;22(3):303-307
4. By the 2023 American Geriatrics Society Beers Criteria® Update Expert Panel. American Geriatrics Society 2023 updated AGS Beers Criteria® for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2023;71(7):2052-2081. doi:10.1111/jgs.18372
5. College of Psychiatry of Ireland. A consensus paper on the use of benzodiazepines in specialist mental health services. College of Psychiatry of Ireland website.
6. Brewster GS, Riegel B, Gehrman PR. Insomnia in the Older Adult. Sleep Med Clin. 2018;13(1):13-19. doi:10.1016/j.jsmc.2017.09.002
7. Rummans TA, Davis LJ Jr, Morse RM, Ivnik RJ. Learning and memory impairment in older, detoxified, benzodiazepine-dependent patients. Mayo Clin Proc. 1993;68(8):731-737. doi:10.1016/s0025-6196(12)60628-4
8. Barker MJ, Greenwood KM, Jackson M, Crowe SF. Persistence of cognitive effects after withdrawal from long-term benzodiazepine use: a meta-analysis. Arch Clin Neuropsychol. 2004;19(3):437-454. doi:10.1016/S0887-6177(03)00096-9
9. Wang PS, Bohn RL, Glynn RJ, Mogun H, Avorn J. Hazardous benzodiazepine regimens in the elderly: effects of half-life, dosage, and duration on risk of hip fracture. Am J Psychiatry. 2001;158(6):892-898. doi:10.1176/appi.ajp.158.6.892
10. Cumming RG, Le Couteur DG. Benzodiazepines and risk of hip fractures in older people: a review of the evidence. CNS Drugs. 2003;17(11):825-837. doi:10.2165/00023210-200317110-00004
11. Barbone F, McMahon AD, Davey PG, et al. Association of road-traffic accidents with benzodiazepine use. Lancet. 1998;352(9137):1331-1336. doi:10.1016/s0140-6736(98)04087-2
12. Fournier JP, Wilchesky M, Patenaude V, Suissa S. Concurrent Use of Benzodiazepines and Antidepressants and the Risk of Motor Vehicle Accident in Older Drivers: A Nested Case-Control Study. Neurol Ther. 2015;4(1):39-51. doi:10.1007/s40120-015-0026-0
13. Palmaro A, Dupouy J, Lapeyre-Mestre M. Benzodiazepines and risk of death: Results from two large cohort studies in France and UK. Eur Neuropsychopharmacol. 2015;25(10):1566-1577. doi:10.1016/j.euroneuro.2015.07.006
14. Darker CD, Sweeney BP, Barry JM, Farrell MF, Donnelly-Swift E. Psychosocial interventions for benzodiazepine harmful use, abuse or dependence. Cochrane Database Syst Rev. 2015;(5):CD009652. doi:10.1002/14651858.CD009652.pub2
15. Tannenbaum C, Martin P, Tamblyn R, Benedetti A, Ahmed S. Reduction of inappropriate benzodiazepine prescriptions among older adults through direct patient education: the EMPOWER cluster randomized trial. JAMA Intern Med. 2014;174(6):890-898. doi:10.1001/jamainternmed.2014.949
16. Denis C, Fatséas M, Lavie E, Auriacombe M. Pharmacological interventions for benzodiazepine mono-dependence management in outpatient settings. Cochrane Database Syst Rev. 2006;(3):CD005194. Published 2006 Jul 19. doi:10.1002/14651858.CD005194.pub2
17. Paquin AM, Zimmerman K, Rudolph JL. Risk versus risk: a review of benzodiazepine reduction in older adults. Expert Opin Drug Saf. 2014;13(7):919-934. doi:10.1517/14740338.2014.925444
18. Bélanger L., Belleville G., Morin C.: Management of hypnotic discontinuation in chronic insomnia. Sleep Med Clin 2009; 4: pp. 583-592.
19. Gilbert A, Owen N, Innes JM, Sansom L. Trial of an intervention to reduce chronic benzodiazepine use among residents of aged-care accommodation. Aust N Z J Med. 1993;23(4):343-347. doi:10.1111/j.1445-5994.1993.tb01433.x
20. Anderson K, Stowasser D, Freeman C, Scott I. Prescriber barriers and enablers to minimising potentially inappropriate medications in adults: a systematic review and thematic synthesis. BMJ Open. 2014;4(12):e006544. Published 2014 Dec 8. doi:10.1136/bmjopen-2014-006544

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Title: Social Isolation, Loneliness and Dementia: A Review of Associations, Screening, and Interventions

Author: Christy Jesme, MSIV¹

Affiliations: ¹University of North Dakota School of Medicine and Health Sciences

Abstract: According to the Alzheimer’s Association, the number of adults over age 65 with dementia is projected to reach 12.7 million by 2050 ^[2]. Research on modifiable risk factors for dementia has increased in recent years, including research on the effects of social isolation and loneliness as risk factors for dementia. Social isolation is defined as an objective lack of social contacts or engagement within a community ^[4,11]. Loneliness is defined as the subjective, unpleasant experience of perceived discrepancy between desired interpersonal relationships and actual interpersonal relationships ^[3,5]. Upon further investigation of the literature, a number of studies associated loneliness with an increased risk of the development of dementia, although the implication of these findings are not as understood as other risk factors such as diabetes and exercise ^[7]. Social isolation is associated with an increased risk of poor cognition later in life in addition to dementia ^[4,9,13].

The proposed mechanism for development of dementia in the setting of loneliness and social isolation is the activation of the hypothalamic-pituitary axis and sympathoadrenal system. Activation of the HPA axis is though to increase expression of pro-inflammatory genes and oxidative stress, which accelerates neurodegeneration ^[3,12,14,19]. This further emphasizes the importance of screening for social isolation and loneliness with the goal of implementing patient-centered interventions to reduce risk for development of dementia.

References:

1. The population 65 years and older in the United States: 2016 . Census.gov. (2016, March). Retrieved January 19, 2023, from https://usatrade.census.gov/content/dam/Census/library/publications/2018/acs/ACS-38.pdf
2. Alzheimer's disease facts and figures. Alzheimer's Disease and Dementia. (2022). Retrieved January 21, 2023, from https://www.alz.org/alzheimers-dementia/facts-figures#:~:text=More%20than%206%20million%20Americans%20of%20all%20ages%20have%20Alzheimer's,older%20(10.7%25)%20has%20Alzheimer's.
3. Lara, E., Caballero, F. F., Rico‐Uribe, L. A., Olaya, B., Haro, J. M., Ayuso‐Mateos, J. L., & Miret, M. (2019). Are loneliness and social isolation associated with cognitive decline? International Journal of Geriatric Psychiatry, 34(11), 1613–1622. https://doi.org/10.1002/gps.5174
4. Evans, I. E. M., Martyr, A., Collins, R., Brayne, C., & Clare, L. (2018). Social isolation and cognitive function in later life: A systematic review and meta-analysis. Journal of Alzheimer's Disease, 70(s1). https://doi.org/10.3233/jad-180501
5. Heinrich, L. M., & Gullone, E. (2006). The clinical significance of Loneliness: A literature review. Clinical Psychology Review, 26(6), 695–718. https://doi.org/10.1016/j.cpr.2006.04.002
6. Boss, L., Kang, D. H., & Branson, S. (2015). Loneliness and cognitive function in the older adult: a systematic review. International psychogeriatrics, 27(4), 541–553. https://doi-org.ezproxylr.med.und.edu/10.1017/S1041610214002749
7. Lara, E., Martín-María, N., De la Torre-Luque, A., Koyanagi, A., Vancampfort, D., Izquierdo, A., & Miret, M. (2019). Does loneliness contribute to mild cognitive impairment and dementia? A systematic review and meta-analysis of longitudinal studies. Ageing research reviews, 52, 7–16. https://doi-org.ezproxylr.med.und.edu/10.1016/j.arr.2019.03.002
8. Wilson, R. S., Krueger, K. R., Arnold, S. E., Schneider, J. A., Kelly, J. F., Barnes, L. L., Tang, Y., & Bennett, D. A. (2007). Loneliness and risk of Alzheimer disease. Archives of general psychiatry, 64(2), 234–240. https://doi-org.ezproxylr.med.und.edu/10.1001/archpsyc.64.2.234
9. Kuiper, J. S., Zuidersma, M., Oude Voshaar, R. C., Zuidema, S. U., van den Heuvel, E. R., Stolk, R. P., & Smidt, N. (2015). Social relationships and risk of dementia: A systematic review and meta-analysis of longitudinal cohort studies. Ageing research reviews, 22, 39–57. https://doi-org.ezproxylr.med.und.edu/10.1016/j.arr.2015.04.006
10. Wilson, R. S., Krueger, K. R., Arnold, S. E., Schneider, J. A., Kelly, J. F., Barnes, L. L., Tang, Y., & Bennett, D. A. (2007). Loneliness and risk of Alzheimer disease. Archives of general psychiatry, 64(2), 234–240. https://doi-org.ezproxylr.med.und.edu/10.1001/archpsyc.64.2.234
11. Nicholson N. R., Jr (2009). Social isolation in older adults: an evolutionary concept analysis. Journal of advanced nursing, 65(6), 1342–1352. https://doi-org.ezproxylr.med.und.edu/10.1111/j.1365-2648.2008.04959.
12. Samtani, S., Mahalingam, G., Lam, B. C., Lipnicki, D. M., Lima-Costa, M. F., Blay, S. L., Castro-Costa, E., Shifu, X., Guerchet, M., Preux, P.-M., Gbessemehlan, A., Skoog, I., Najar, J., Rydberg Sterner, T., Scarmeas, N., Kim, K.-W., Riedel-Heller, S., Röhr, S., Pabst, A., … Brodaty, H. (2022). Associations between social connections and Cognition: A Global Collaborative Individual Participant Data Meta-analysis. The Lancet Healthy Longevity, 3(11). https://doi.org/10.1016/s2666-7568(22)00199-4
13. Desai, R., John, A., Stott, J., & Charlesworth, G. (2020). Living alone and risk of dementia: A systematic review and meta-analysis. Ageing research reviews, 62, 101122. https://doi-org.ezproxylr.med.und.edu/10.1016/j.arr.2020.101122
14. Elovainio, M., Lahti, J., Pirinen, M., Pulkki-Råback, L., Malmberg, A., Lipsanen, J., Virtanen, M., Kivimäki, M., & Hakulinen, C. (2022). Association of Social Isolation, loneliness and genetic risk with incidence of dementia: UK biobank cohort study. BMJ Open, 12(2). https://doi.org/10.1136/bmjopen-2021-053936
15. Scarmeas, N., & Stern, Y. (2003). Cognitive reserve and lifestyle. Journal of clinical and experimental neuropsychology, 25(5), 625–633. https://doi-org.ezproxylr.med.und.edu/10.1076/jcen.25.5.625.14576
16. Freedman, A., & Nicolle, J. (2020). Social isolation and loneliness: the new geriatric giants. Canadian Family Physician, 66, 176–182.
17. Gardiner, C., Geldenhuys, G., & Gott, M. (2018). Interventions to reduce social isolation and loneliness among older people: an integrative review. Health & social care in the community, 26(2), 147–157. https://doi-org.ezproxylr.med.und.edu/10.1111/hsc.12367
18. Cohen-Mansfield, J., & Perach, R. (2015). Interventions for alleviating loneliness among older persons: a critical review. American journal of health promotion : AJHP, 29(3), e109–e125. https://doi-org.ezproxylr.med.und.edu/10.4278/ajhp.130418-LIT-182
19. Wainaina, M. N., Chen, Z., & Zhong, C. (2014). Environmental factors in the development and progression of late-onset Alzheimer’s disease. Neuroscience Bulletin, 30(2), 253–270. https://doi.org/10.1007/s12264-013-1425-9

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Title: Effectively Discussing What Matters Most for Rural Geriatric Patients at the Medicare Annual Wellness Visit

Author: Cora Lubchenco, OMS4

Affiliations: Pacific Northwest University of Health Sciences

Introduction:

• Navigation of the final chapter of life is one of the greatest privileges for PCPs involved in geriatric and full spectrum care
• Attention to unique goals and prioritizing dignity requires intention and preparation, and is not adequately addressed in today’s wellness care
• Primary care providers in rural areas are poised to contribute to this cause over a longitudinal course

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Title: Current Outcomes of Deep Brain Stimulation Use in Parkinson’s Disease

Author: Christian Peterson, B.S.

Affiliations: Spencer Fox Eccles School of Medicine, Salt Lake City

Abstract: Parkinson’s disease (PD) is a progressive neurodegenerative that primarily affects older adults and is characterized by dopamine depletion resulting in a variety of motor and non-motor symptoms. The mainstay treatment in PD is repletion of dopamine with levodopa and the addition of amantadine and anticholinergics in the setting of persistent symptoms. Deep brain stimulation (DBS) is another tool that may be considered for treating refractory symptoms of PD despite optimal medication management. Though ongoing research is required to better understand the mechanism behind DBS and its efficacy, the current research has yielded several considerations concerning this therapeutic tool’s implementation. Namely, the literature provides recommendations regarding appropriate candidates for DBS as well as current data regarding the effect of DBS on motor and non-motor symptoms. Furthermore, research has been pursued to elucidate the efficacy of employing DBS in early PD, its effect on neuropsychiatric features, and current results comparing DBS to levodopa therapy alone. The purpose of this poster is to display the findings from the literature concerning the afore-mentioned domains of DBS implementation. These outcomes suggest that DBS is an effective tool in ameliorating the significant motor and non-motor features of PD.

References: 

1. Kouli A, Torsney KM, Kuan WL. Parkinson’s Disease: Etiology, Neuropathology, and Pathogenesis. In: Stoker TB, Greenland JC, editors. Parkinson’s Disease: Pathogenesis and Clinical Aspects [Internet]. Brisbane (AU): Codon Publications; 2018 Dec 21. Chapter 1. Available from: https://www.ncbi.nlm.nih.gov/books/NBK536722/ doi: 10.15586/codonpublications.parkinsonsdisease.2018.ch1
2. Malek, Naveed. “Deep Brain Stimulation in Parkinson's Disease.” Neurology India 67,4 (2019): 968-978. doi:10.4103/0028-3886.266268
3. Welter, M L et al. “Clinical predictive factors of subthalamic stimulation in Parkinson's disease.” Brain : a journal of neurology 125,Pt 3 (2002): 575-83. doi:10.1093/brain/awf050
4. Kleiner-Fisman, Galit et al. “Long-term follow up of bilateral deep brain stimulation of the subthalamic nucleus in patients with advanced Parkinson disease.” Journal of neurosurgery 99,3 (2003): 489-95. doi:10.3171/jns.2003.99.3.0489
5. Pahwa, R et al. “Practice Parameter: treatment of Parkinson disease with motor fluctuations and dyskinesia (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology.” Neurology 66,7 (2006): 983-95. doi:10.1212/01.wnl.0000215250.82576.87
6. Spindler, Philipp et al. “Deep brain stimulation for Parkinson's disease-related postural abnormalities: a systematic review and meta-analysis.” Neurosurgical review 45,5 (2022): 3083-3092. doi:10.1007/s10143-022-01830-3
7. Moro, Elena et al. “A decision tool to support appropriate referral for deep brain stimulation in Parkinson's disease.” Journal of neurology 256,1 (2009): 83-8. doi:10.1007/s00415-009-0069-1
8. Vitek, Jerrold L et al. “Subthalamic nucleus deep brain stimulation with a multiple independent constant current-controlled device in Parkinson's disease (INTREPID): a multicentre, double-blind, randomised, sham-controlled study.” The Lancet. Neurology 19,6 (2020): 491-501. doi:10.1016/S1474-4422(20)30108-3
9. Kleiner-Fisman, Galit et al. “Subthalamic nucleus deep brain stimulation: summary and meta-analysis of outcomes.” Movement disorders : official journal of the Movement Disorder Society 21 Suppl 14 (2006): S290-304. doi:10.1002/mds.20962.
10. Eghlidos, Zahra et al. “Effects of subthalamic deep brain stimulation on non-motor symptoms of Parkinson's disease: A meta-analysis.” Acta neurologica Scandinavica 146,2 (2022): 115-125. doi:10.1111/ane.13652
11. Schuepbach, W M M et al. “Neurostimulation for Parkinson's disease with early motor complications.” The New England journal of medicine 368,7 (2013): 610-22. doi:10.1056/NEJMoa1205158
12. Lhommée, Eugénie et al. “Behavioural outcomes of subthalamic stimulation and medical therapy versus medical therapy alone for Parkinson's disease with early motor complications (EARLYSTIM trial): secondary analysis of an open-label randomised trial.” The Lancet. Neurology 17,3 (2018): 223-231. doi:10.1016/S1474-4422(18)30035-8
13. Hacker, Mallory L et al. “Deep brain stimulation in early-stage Parkinson disease: Five-year outcomes.” Neurology 95,4 (2020): e393-e401. doi:10.1212/WNL.0000000000009946
14. Cartmill, Tomas et al. “Deep Brain Stimulation of the Subthalamic Nucleus in Parkinson's Disease: A Meta-Analysis of Mood Effects.” Neuropsychology review 31,3 (2021): 385-401. doi:10.1007/s11065-020-09467-z
15. Bucur, Madalina, and Costanza Papagno. “Deep Brain Stimulation in Parkinson Disease: A Meta-analysis of the Long-term Neuropsychological Outcomes.” Neuropsychology review 33,2 (2023): 307-346. doi:10.1007/s11065-022-09540-9
16. Wang, Ying et al. “Apathy following Bilateral Deep Brain Stimulation of Subthalamic Nucleus in Parkinson's Disease: A Meta-Analysis.” Parkinson's disease 2018 9756468. 21 May. 2018, doi:10.1155/2018/9756468
17. Vizcarra, Joaquin A et al. “Subthalamic deep brain stimulation and levodopa in Parkinson's disease: a meta-analysis of combined effects.” Journal of neurology 266,2 (2019): 289-297. doi:10.1007/s00415-018-8936-2
18. Peng, Lilei et al. “The long-term efficacy of STN vs GPi deep brain stimulation for Parkinson disease: A meta-analysis.” Medicine 97,35 (2018): e12153. doi:10.1097/MD.0000000000012153
19. Mansouri, Alireza et al. “Deep brain stimulation for Parkinson's disease: meta-analysis of results of randomized trials at varying lengths of follow-up.” Journal of neurosurgery 128,4 (2018): 1199-1213. doi:10.3171/2016.11.JNS16715
20. Odekerken, Vincent J J et al. “Subthalamic nucleus versus globus pallidus bilateral deep brain stimulation for advanced Parkinson's disease (NSTAPS study): a randomised controlled trial.” The Lancet. Neurology 12,1 (2013): 37-44. doi:10.1016/S1474-4422(12)70264-8

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Title: An Overview of Immune Checkpoint Inhibitor (ICI) Cancer Therapy in Older Adults

Author: Parker Howe, OMS IV

Affiliations: Kansas City University College of Osteopathic Medicine

Introduction: PIn the last decade, the development, approval, and clinical use of Immune Checkpoint Inhibitors (ICIs) as a primary cancer therapy has occurred at a rapid pace²⁸. ICIs are now being used as first or second line agents in approximately 19 different tumor types1 and have shown to be more effective and less toxic as compared to other standard of care therapies.^4,8,11 Despite accounting for over half of all patients who are diagnosed with cancer², adults over the age of 65 have historically been underrepresented in cancer therapy trials³, including those investigating ICI therapy. A review of currently available literature suggests that response rates to ICI therapy is similar in adults aged 65-75 as compared to younger adults, but data in those 75 years of age and older is inconclusive.² As an explanation for the conflicting results in this population, several studies suggest a relationship between poorer outcomes and frailty status.^17,21 Another hypothesis to explain these poorer outcomes is the impact that immunosenescence, a well-established phenomenon, could have on therapies that utilize immune function to achieve their desired outcomes.^4,12 In addition to potentially having poorer outcomes, those over the age of 75 and with a more frail status may also be more prone to Immune-Related Adverse Events (irAEs) resulting from ICI therapy. While common in all patients receiving ICI therapy⁸ , some studies indicate that irAEs occur more frequenty^18,19, recur more often upon rechallenge⁷, and are more likely to be fatal in older and frail patients.⁶ With these outcomes and risks in mind, the benefits vs. risks of proceeding with ICI therapy in older and frail adults must be carefully considered. Clinical practices such as the Geriatric Assessment (GA) for cancer patients are valuable in helping to guide these types of decisions.²⁴ GA has been validated for many cancer types and therapies in predicting toxicity, treatment completion, and mortality.^15,23,26 Screening tools, such as the G-8, have been shown to have high sensitivity in identifying patients who would benefit most from GA.^16,25 While GA and G-8 have proven effective in guiding therapy for previously standard of care options, there is a lack of research evaluating how these tools correlate to ICI therapy treatment decisions and outcomes.² Results from research focused on these correlations will be indispensable in helping patients and providers better weigh the benefits and risks of older and frail adults undergoing ICI therapy.

References:

1. Vaddepally RK, Kharel P, Pandey R, Garje R, Chandra AB. Review of Indications of FDA-Approved Immune Checkpoint Inhibitors per NCCN Guidelines with the Level of Evidence. Cancers. 2020; 12(3):738. https://doi.org/10.3390/cancers12030738
2. Choucair K, Naqash AR, Nebhan CA, Nipp R, Johnson DB, Saeed A. Immune Checkpoint Inhibitors: The Unexplored Landscape of Geriatric Oncology. Oncologist. 2022;27(9):778-789. doi:10.1093/oncolo/oyac119
3. Hutchins LF, Unger JM, Crowley JJ, Coltman CA Jr, Albain KS. Underrepresentation of patients 65 years of age or older in cancer-treatment trials. N Engl J Med. 1999;341(27):2061-2067. doi:10.1056/NEJM199912303412706
4. Kanesvaran R, Cordoba R, Maggiore R. Immunotherapy in Older Adults With Advanced Cancers: Implications for Clinical Decision-Making and Future Research. American Society of Clinical Oncology educational book / ASCO American Society of Clinical Oncology Meeting. 2018(38):400–14.
5. Haslam A, Prasad V. Estimation of the Percentage of US Patients With Cancer Who Are Eligible for and Respond to Checkpoint Inhibitor Immunotherapy Drugs. JAMA Netw Open. 2019;2(5):e192535. doi:10.1001/jamanetworkopen.2019.2535
6. Wang DY, Salem J, Cohen JV, et al. Fatal Toxic Effects Associated With Immune Checkpoint Inhibitors: A Systematic Review and Meta-analysis. JAMA Oncol. 2018;4(12):1721–1728. doi:10.1001/jamaoncol.2018.3923
7. Dolladille, C. et al. Immune checkpoint inhibitor rechallenge after immune-related adverse events in patients with cancer. JAMA Oncol. 6, 865–871 (2020).
8. Bagchi S, Yuan R, Engleman EG. Immune Checkpoint Inhibitors for the Treatment of Cancer: Clinical Impact and Mechanisms of Response and Resistance. Annu Rev Pathol. 2021;16:223-249. doi:10.1146/annurev-pathol-042020-042741
9. Elias R, Morales J, Rehman Y, Khurshid H. Immune Checkpoint Inhibitors in Older Adults. Curr Oncol Rep. 2016 Aug;18(8):47. doi: 10.1007/s11912-016-0534-9. PMID: 27287329.
10. Bajwa R, Cheema A, Khan T, Amirpour A, Paul A, Chaughtai S, Patel S, Patel T, Bramson J, Gupta V, Levitt M, Asif A, Hossain MA. Adverse Effects of Immune Checkpoint Inhibitors (Programmed Death-1 Inhibitors and Cytotoxic T-Lymphocyte-Associated Protein-4 Inhibitors): Results of a Retrospective Study. J Clin Med Res. 2019 Apr;11(4):225-236. doi: 10.14740/jocmr3750. Epub 2019 Mar 18. PMID: 30937112; PMCID: PMC6436564.
11. Reck M, Rodríguez-Abreu D, Robinson AG, Hui R, Csőszi T, Fülöp A, Gottfried M, Peled N, Tafreshi A, Cuffe S, O'Brien M, Rao S, Hotta K, Leiby MA, Lubiniecki GM, Shentu Y, Rangwala R, Brahmer JR; KEYNOTE-024 Investigators. Pembrolizumab versus Chemotherapy for PD-L1-Positive Non-Small-Cell Lung Cancer. N Engl J Med. 2016 Nov 10;375(19):1823-1833. doi: 10.1056/NEJMoa1606774. Epub 2016 Oct 8. PMID: 27718847.
12. Johnstone J, Parsons R, Botelho F, Millar J, McNeil S, Fulop T, McElhaney JE, Andrew MK, Walter SD, Devereaux PJ, Malek M, Brinkman RR, Bramson J, Loeb M. T-Cell Phenotypes Predictive of Frailty and Mortality in Elderly Nursing Home Residents. J Am Geriatr Soc. 2017 Jan;65(1):153-159. doi: 10.1111/jgs.14507. Epub 2016 Oct 24. PMID: 27775813.
13. Soubeyran P, Bellera C, Goyard J, Heitz D, Curé H, Rousselot H, Albrand G, Servent V, Jean OS, van Praagh I, Kurtz JE, Périn S, Verhaeghe JL, Terret C, Desauw C, Girre V, Mertens C, Mathoulin-Pélissier S, Rainfray M. Screening for vulnerability in older cancer patients: the ONCODAGE Prospective Multicenter Cohort Study. PLoS One. 2014 Dec 11;9(12):e115060. doi: 10.1371/journal.pone.0115060. PMID: 25503576; PMCID: PMC4263738.
14. Gomes F, Lorigan P, Woolley S, Foden P, Burns K, Yorke J, Blackhall F. A prospective cohort study on the safety of checkpoint inhibitors in older cancer patients - the ELDERS study. ESMO Open. 2021 Feb;6(1):100042. doi: 10.1016/j.esmoop.2020.100042. Epub 2021 Jan 27. PMID: 33516147; PMCID: PMC7844568.
15. Hurria A, Lichtman SM, Gardes J, Li D, Limaye S, Patil S, Zuckerman E, Tew W, Hamlin P, Abou-Alfa GK, Lachs M, Kelly E. Identifying vulnerable older adults with cancer: integrating geriatric assessment into oncology practice. J Am Geriatr Soc. 2007 Oct;55(10):1604-8. doi: 10.1111/j.1532-5415.2007.01367.x. Epub 2007 Aug 14. PMID: 17697101.
16. Bellera CA, Rainfray M, Mathoulin-Pélissier S, Mertens C, Delva F, Fonck M, Soubeyran PL. Screening older cancer patients: first evaluation of the G-8 geriatric screening tool. Ann Oncol. 2012 Aug;23(8):2166-2172. doi: 10.1093/annonc/mdr587. Epub 2012 Jan 16. PMID: 22250183.
17. La J, Cheng D, Brophy MT, Do NV, Lee JSH, Tuck D, Fillmore NR. Real-World Outcomes for Patients Treated With Immune Checkpoint Inhibitors in the Veterans Affairs System. JCO Clin Cancer Inform. 2020 Oct;4:918-928. doi: 10.1200/CCI.20.00084. PMID: 33074743; PMCID: PMC7608595.
18. Singh H, Kim G, Maher VE, et al. FDA subset analysis of the safety of nivolumab in elderly patients with advanced cancers. J Clin Oncol 2016;34(15_suppl):10010. doi: 10.1200/JCO.2016.34.15 _ suppl.10010
19. Subbiah IM, Hess K, Fujii T, et al. Immuno-oncology and the elderly: A comparative analysis of participation and toxicities of senior adults aged 65 years and above vs mid age and adolescent/young adult patients on immunotherapy-based phase I clinical trials. Journal of Clinical Oncology 35, no. 15_suppl (May 20, 2017) 10034-10034. DOI: 10.1200/JCO.2017.35.15_suppl.10034
20. Alessi JV, Ricciuti B, Jiménez-Aguilar E, Hong F, Wei Z, Nishino M, Plodkowski AJ, Sawan P, Luo J, Rizvi H, Carter BW, Heymach JV, Altan M, Hellmann M, Awad M. Outcomes to first-line pembrolizumab in patients with PD-L1-high (≥50%) non-small cell lung cancer and a poor performance status. J Immunother Cancer. 2020 Aug;8(2):e001007. doi: 10.1136/jitc-2020-001007. PMID: 32753547; PMCID: PMC7406027.
21. Isaacs J, Antonia S, Clarke J. Immune Checkpoint Inhibitors in the Aged. Curr Oncol Rep. 2021 Aug 3;23(10):115. doi: 10.1007/s11912-021-01106-x. PMID: 34342733.
22. Postow MA, Sidlow R, Hellmann MD. Immune-Related Adverse Events Associated with Immune Checkpoint Blockade. N Engl J Med. 2018 Jan 11;378(2):158-168. doi: 10.1056/NEJMra1703481. PMID: 29320654. Comprehensive analysis of immune-related toxicities among older adults treated on novel immunotherapy on phase 1 clinical trials
23. Hamaker M, Lund C, Te Molder M, Soubeyran P, Wildiers H, van Huis L, Rostoft S. Geriatric assessment in the management of older patients with cancer - A systematic review (update). J Geriatr Oncol. 2022 Jul;13(6):761-777. doi: 10.1016/j.jgo.2022.04.008. Epub 2022 May 8. PMID: 35545495.
24. https://siog.org/educational-resources/comprehensive-geriatric-assessment/
25. Decoster L, Van Puyvelde K, Mohile S, Wedding U, Basso U, Colloca G, Rostoft S, Overcash J, Wildiers H, Steer C, Kimmick G, Kanesvaran R, Luciani A, Terret C, Hurria A, Kenis C, Audisio R, Extermann M. Screening tools for multidimensional health problems warranting a geriatric assessment in older cancer patients: an update on SIOG recommendations†. Ann Oncol. 2015 Feb;26(2):288-300. doi: 10.1093/annonc/mdu210. Epub 2014 Jun 16. PMID: 24936581.
26. Wildiers H, Heeren P, Puts M, Topinkova E, Janssen-Heijnen ML, Extermann M, Falandry C, Artz A, Brain E, Colloca G, Flamaing J, Karnakis T, Kenis C, Audisio RA, Mohile S, Repetto L, Van Leeuwen B, Milisen K, Hurria A. International Society of Geriatric Oncology consensus on geriatric assessment in older patients with cancer. J Clin Oncol. 2014 Aug 20;32(24):2595-603. doi: 10.1200/JCO.2013.54.8347. PMID: 25071125; PMCID: PMC4876338.
27. van Holstein Y, Kapiteijn E, Bastiaannet E, van den Bos F, Portielje J, de Glas NA. Efficacy and Adverse Events of Immunotherapy with Checkpoint Inhibitors in Older Patients with Cancer. Drugs Aging. 2019 Oct;36(10):927-938. doi: 10.1007/s40266-019-00697-2. PMID: 31317421; PMCID: PMC6764930.
28. Robert, C. A decade of immune-checkpoint inhibitors in cancer therapy. Nat Commun 11, 3801 (2020). https://doi.org/10.1038/s41467-020-17670-y

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Title: Evaluation and Management of Heart Failure in Older Adults

Author: Forest Riekhof, B.S.

Affiliations: Saint Louis University School of Medicine

Introduction: Prevalence of HF in adults is estimated to be 6.7 million between 2017 to 2020.¹ Heart Failure (HF) incidence and prevalence increase with age and is the most common cause for hospital admission in adults aged 65+.² The average age for patients admitted for acute heart failure is 75.³ HF is an important contributor to national health costs and as the population ages, costs are estimated to increase to $70 billion by 2030.⁴ It is imperative to consider the multidimensional needs of our aging population being treated for heart failure.⁵

Evaluation: Multimorbidity is common among older adults with HF, and hospitalizations and mortality are often times noncardiac.⁶ The American College of Cardiology, Geriatric section published an updated evaluation model for HF in aging adults using four domains: medical, mind and emotion, physical function, and social environment.^5,7 Within these four domains there is subdomains that include etiology/stage of HF, multimorbidity, polypharmacy, cognition/psychiatric illness, frailty, mobility, finances, and social support.⁵ Impairment in these geriatric domains are associated with worsening one year mortality.8 Screening tests and checklists can be used in the assessment to ensure a comprehensive assessment in geriatric patients to monitor for domain impairments.⁸

Management: One study showed that frailty was a barrier to receiving guideline directed medical therapy (GDMT).⁹ The definition of polypharmacy in elderly adults does not account for the well-studied benefits of GDMT; and a lack of studies at deprescribing HF medications leaves tension between GDMT and polypharmacy as patients age.¹⁰ Treatment of HF in older adults should therefore tailor current heart failure guidelines according to the goals of the individual and domain impairments.¹¹ A multidisciplinary team is crucial to providing the necessary resources to care for complex aging adults. In addition to GDMT, cardiac rehab has been shown to improve outcomes in older adults with HF.¹² Depression is common in elderly with HF and can affect cognition and treatment adherence. Exercise is shown to improve comorbid depression in adults with HF, where SSRIs did not.¹³ Nutritional intervention in malnourished HF patients can reduce risk of mortality and readmission.¹⁴

Conclusions:
Heart failure is a condition seen frequently in older adults. It is crucial these patients receive a multidimensional evaluation to assess medical, mind and emotion, physical function, and social environment domains. Care for these patients should be provided by a multidisciplinary team and tailored to their goals and domain impairments.

References:

1. Tsao CW, Aday AW, Almarzooq ZI, et al. Heart Disease and Stroke Statistics-2023 Update: A Report From the American Heart Association. Circulation. 2023;147(8):e93-e621.
2. Dharmarajan K, Rich MW. Epidemiology, Pathophysiology, and Prognosis of Heart Failure in Older Adults. Heart Fail Clin. 2017;13(3):417-426.
3. Teixeira A, Arrigo M, Tolppanen H, et al. Management of acute heart failure in elderly patients. Arch Cardiovasc Dis. 2016;109(6-7):422-430.
4. Heidenreich PA, Albert NM, Allen LA, et al. Forecasting the impact of heart failure in the United States: a policy statement from the American Heart Association. Circ Heart Fail. 2013;6(3):606-619.
5. Gorodeski EZ, Goyal P, Hummel SL, et al. Domain Management Approach to Heart Failure in the Geriatric Patient: Present and Future. J Am Coll Cardiol. 2018;71(17):1921-1936.
6. Shah KS, Xu H, Matsouaka RA, et al. Heart Failure With Preserved, Borderline, and Reduced Ejection Fraction: 5-Year Outcomes. J Am Coll Cardiol. 2017;70(20):2476-2486.
7. Engel GL. The need for a new medical model: a challenge for biomedicine. Science. 1977;196(4286):129-136.
8. Wiersinga JHI, Rhodius-Meester HFM, Kleipool EEF, et al. Managing older patients with heart failure calls for a holistic approach. ESC Heart Fail. 2021;8(3):2111-2119.
9. Hamada T, Kubo T, Kawai K, et al. Frailty interferes with the guideline-directed medical therapy in heart failure patients with reduced ejection fraction. ESC Heart Fail. 2023;10(1):223-233.
10. Sukumar S, Orkaby AR, Schwartz JB, et al. Polypharmacy in Older Heart Failure Patients: a Multidisciplinary Approach. Curr Heart Fail Rep. 2022;19(5):290-302.
11. Alghamdi F, Chan M. Management of heart failure in the elderly. Curr Opin Cardiol. 2017;32(2):217-223.
12. Kitzman DW, Whellan DJ, Duncan P, et al. Physical Rehabilitation for Older Patients Hospitalized for Heart Failure. N Engl J Med. 2021;385(3):203-216.
13. O'Connor CM, Jiang W, Kuchibhatla M, et al. Safety and efficacy of sertraline for depression in patients with heart failure: results of the SADHART-CHF (Sertraline Against Depression and Heart Disease in Chronic Heart Failure) trial. J Am Coll Cardiol. 2010;56(9):692-699.
14. Bonilla-Palomas JL, Gamez-Lopez AL, Castillo-Dominguez JC, et al. Nutritional Intervention in Malnourished Hospitalized Patients with Heart Failure. Arch Med Res. 2016;47(7):535-540.

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Title: Statin Therapy in Old Age-An “Age Friendly Health Systems” Approach

Author: McKenzi Yocus, BA

Affiliations: University of Utah Spencer Fox Eccles School of Medicine

Since their discovery, statins have become the mainstay for prevention and treatment of cardiovascular disease. There is, however, mixed data on the safety and effectiveness of statins in primary prevention of ASCVD in individuals >75 years old, leading AHA guidelines to state that statins for individuals >75 warrants “clinical assessment and risk discussion” ^[19]. Even though there have been some studies showing cardiovascular benefit in this age group ^{[13, 14, 15]}, it should be remembered that statins are not without risk (myositis, hepatotoxicity, rhabdomyolysis, drug-drug interactions) ^[1,2,3,5,8]. Even though it is important for the healthcare provider to be aware of the risks and benefits of statin therapy and to be aware of ASCVD risk factors that their patients may have, when presented with mixed data, instead of providing patients with all of the available information, physicians could, instead, frame the conversation using an “Age Friendly-Health Systems” approach with the 4 M’s (1. What matters most, 2. Medication, 3. Mentation and 4. Mobility) ^[6]. The health care provider should explore what brings the patient joy, their goals and what they are willing to sacrifice when it comes to their health. For example, treatment approaches will be vastly different for an individual whose goal is to work outside in their garden until they drop than they would be for someone who wants to live as long as possible to see their grandkids grow up. Next, drug interactions should be assessed and the provider must ask themselves if the current dose of statin is appropriate. Statins potentially affect mentation and mobility ^{[4, 12, 17]}, however data is mixed. It would be best to assess patient’s mobility and mentation every visit and to consider adjusting their statin if new changes occur. Although existing data remains unclear on the effectiveness and safety of statins for primary prevention of ASCVD in those >75, and data from upcoming RCTs are being anxiously anticipated, using the 4 M’s approach to guide conversations with the patients about what we currently know about statins, can be very useful when deciding on whether or not a statin is the best choice.

References:

1. ^[1]Am Fam Physician 2001 Feb 15;63(4):636
2. ^[2]Am Fam Physician 2005 Jul 15;72(2):online
3. ^[3]Bellosta S, Corsini A. Statin drug interactions and related adverse reactions: an update. Expert Opin Drug Saf. 2018 Jan;17(1):25-37. doi: 10.1080/14740338.2018.1394455. Epub 2017 Oct 30. PMID: 29058944.
4. ^[4]Chu CS, Tseng PT, Stubbs B, Chen TY, Tang CH, Li DJ, Yang WC, Chen YW, Wu CK, Veronese N, Carvalho AF, Fernandes BS, Herrmann N, Lin PY. Use of statins and the risk of dementia and mild cognitive impairment: A systematic review and meta-analysis. Sci Rep. 2018 Apr 11;8(1):5804. doi: 10.1038/s41598-018-24248-8. PMID: 29643479; PMCID: PMC5895617.
5. ^[5]DynaMed. Statins. EBSCO Information Services. Accessed March 14, 2022. https://www.dynamed.com/drug-review/statins
6. ^[6]Fulmer, T, Pelton, L, Zhang, J, Huang, W. Age-Friendly Health Systems a guide to using the 4Ms while caring for older adults. Las Vegas NV: Institute For Healthcare Improvement; 2022.
7. ^[7]Galicia-Garcia U, Jebari S, Larrea-Sebal A, Uribe KB, Siddiqi H, Ostolaza H, Benito-Vicente A, Martín C. Statin Treatment-Induced Development of Type 2 Diabetes: From Clinical Evidence to Mechanistic Insights. Int J Mol Sci. 2020 Jul 2;21(13):4725. doi: 10.3390/ijms21134725. PMID: 32630698; PMCID: PMC7369709.
8. ^[8]Gladding P, Pilmore H, Edwards C. Potentially fatal interaction between diltiazem and statins. Ann Intern Med. 2004 Apr 20;140(8):W31. doi: 10.7326/0003-4819-140-8-200404200-00037-w1. PMID: 15096363.
9. ^[9]Horodinschi RN, Stanescu AMA, Bratu OG, Pantea Stoian A, Radavoi DG, Diaconu CC. Treatment with Statins in Elderly Patients. Medicina (Kaunas). 2019 Oct 30;55(11):721. doi: 10.3390/medicina55110721. PMID: 31671689; PMCID: PMC6915405.
10. ^[10]Huesch MD. Serious Adverse Events Among SPRINT Trial Participants Taking Statins at Baseline. Drugs R D. 2017 Dec;17(4):623-629. doi: 10.1007/s40268-017-0213-9. PMID: 29058304; PMCID: PMC5694426.
11. ^[11]Mansi IA, Chansard M, Lingvay I, Zhang S, Halm EA, Alvarez CA. Association of statin therapy initiation with diabetes progression: a retrospective matched-cohort study. JAMA Intern Med. Published online October 4, 2021. doi:10.1001/jamainternmed.2021.5714
12. ^[12]Odden MC, Pletcher MJ, Coxson PG, Thekkethala D, Guzman D, Heller D, Goldman L, Bibbins-Domingo K. Cost-effectiveness and population impact of statins for primary prevention in adults aged 75 years or older in the United States. Ann Intern Med. 2015 Apr 21;162(8):533-41. doi: 10.7326/M14-1430. PMID: 25894023; PMCID: PMC4476404.
13. ^[13]Orkaby AR, Driver JA, Ho Y-L, Lu B, Costa L, Honerlaw J, et al. Association of statin use with all-cause and cardiovascular mortality in US veterans 75 years and older. JAMA. 2020;324(1):68.
14. ^[14]Ridker PM, Lonn E, Paynter NP, Glynn R, Yusuf S. Primary Prevention With Statin Therapy in the Elderly: New Meta-Analyses From the Contemporary JUPITER and HOPE-3 Randomized Trials. Circulation. 2017 May 16;135(20):1979-1981. doi: 10.1161/CIRCULATIONAHA.117.028271. Epub 2017 Apr 6. PMID: 28385949.
15. ^[15]Shepherd J, Blauw GJ, Murphy MB, Bollen EL, Buckley BM, Cobbe SM, Ford I, Gaw A, Hyland M, Jukema JW, Kamper AM, Macfarlane PW, Meinders AE, Norrie J, Packard CJ, Perry IJ, Stott DJ, Sweeney BJ, Twomey C, Westendorp RG; PROSPER study group. PROspective Study of Pravastatin in the Elderly at Risk. Pravastatin in elderly individuals at risk of vascular disease (PROSPER): a randomised controlled trial. Lancet. 2002 Nov 23;360(9346):1623-30. doi: 10.1016/s0140-6736(02)11600-x. PMID: 12457784.
16. ^[16]Whiting J. Politics in medical journals. Lancet. 2004 Jan 24;363(9405):328; author reply 328-9. doi: 10.1016/S0140-6736(03)15397-4. PMID: 14751712..
17. ^[17]Zhou Z, Ofori-Asenso R, Curtis AJ, Breslin M, Wolfe R, McNeil JJ, Murray AM, Ernst ME, Reid CM, Lockery JE, Woods RL, Tonkin AM, Nelson MR. Association of Statin Use With Disability-Free Survival and Cardiovascular Disease Among Healthy Older Adults. J Am Coll Cardiol. 2020 Jul 7;76(1):17-27. doi: 10.1016/j.jacc.2020.05.016. PMID: 32616158; PMCID: PMC7967891.
18. ^[18]Zigmont VA, Shoben AB, Lu B, Kaye GL, Clinton SK, Harris RE, Olivo-Marston SE. Statin users have an elevated risk of dysglycemia and new-onset-diabetes. Diabetes Metab Res Rev. 2019 Nov;35(8):e3189. doi: 10.1002/dmrr.3189. Epub 2019 Jul 7. PMID: 31125480.
19. ^[19]2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2019;March 17:^{[Epub ahead of print]}.

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Title: Dementia among Indigenous Americans: A Discussion of the Cultural Perspectives of American Indian/Alaska Native People and Recommendations For Care

Author: Ria Sandhu, MSIV1

Affiliations: ¹Rocky Vista University College of Osteopathic Medicine, Southern Utah

As the older indigenous population increases in America, it is important to overcome barriers to effective dementia care, while respecting cultural attitudes. More of the indigenous population of the United States is reaching older age. About 9.7 million American Indian/Alaska Native (AI/AN) people were in the United States in 2021, with 10.2% aged 65 and older ^[1]. The population of older AI/AN people aged 65 and older is projected to increase 4-fold by 2050, and 8-fold for those aged 85 and older ^[1]. The prevalence of risk factors for dementia, including chronic conditions such as diabetes among indigenous peoples has increased significantly ^[2,3]. As many as 1 in 3 indigenous older adults will develop Alzheimer's or some other form of dementia ^[3]. It is difficult to identify the dementia care needs of indigenous older adults due to limited research on dementia prevalence ^[2]. Moreover, AI/AN knowledge and perspectives differ from biomedical understandings on dementia ^[12-17]. Therefore, health care professionals need to comprehend indigenous views of dementia to provide culturally appropriate care.

This literature review will concentrate on the prevalence of dementia, barriers in care, and perspectives of aging among American Indian/Alaska Native communities. Furthermore, recommendations of culturally appropriate education and care will be discussed. These recommendations for care include storytelling as a form of education, patient-centered care, and respectful communication ^[18-22]. These methods have resulted in positive health outcomes and could be applied to dementia research and interventions. The goal should be educating the indigenous community in recognizing dementia as an illness, and facilitating earlier diagnosis and access to care.

Citations:

1. Bureau USC. Facts for features: American Indian and Alaska native heritage month: November 2022. Census.gov. https://www.census.gov/newsroom/facts-for-features/2022/aian-month.html. Published October 25, 2022. Accessed March 30, 2023.
2. Cho P, Geiss LS, Burrows NR, Roberts DL, Bullock AK, Toedt ME. Diabetes-related mortality among American Indians and Alaska Natives, 1990-2009. Am J Public Health. 2014;104 Suppl 3(Suppl 3):S496-S503. doi:10.2105/AJPH.2014.301968
3. Trojanczyk C, Zuelsdorff M, Summers M, et al. P4-623: Lessons from a research collaboration with the Oneida Nation of Wisconsin. Alzheimer's & Dementia. 2019;15. doi:10.1016/j.jalz.2019.08.172
4. Trends C. Child trends on linkedin: Latest Census estimates show disproportionate poverty among American... Child Trends on LinkedIn: Latest Census Estimates Show Disproportionate Poverty Among American... https://www.linkedin.com/posts/child-trends_latest-census-estimates-show-disproportionate-activity-7000520461738553344-ToUr. Published November 21, 2022. Accessed March 30, 2023.
5. Garrett M, McGuire L. Family caregivers declining for American Indians and Alaska Natives. Aging Today. 2008;29:11.
6. Bureau USCB. 2019 American Community Survey Table S0201. Explore census data. https://data.census.gov/table?q=S0201. Published 2019. Accessed March 30, 2023.
7. browsermedia.com BM-. Housing & Infrastructure. NCAI. https://www.ncai.org/policy-issues/economic-development-commerce/housing-infrastructure. Accessed March 30, 2023.
8. Sotero M. A Conceptual Model of Historical Trauma: Implications for Public Health Practice and Research. Journal of Health Disparities Research and Practice. 2006;1:93-108.
9. S. Department of Health and Human Services, Health Resources and Services Administration, National Center for Health Workforce Analysis. 2017. Sex, Race, and Ethnic Diversity of U.S, Health Occupations (2011-2015), Rockville, Maryland.
10. Chakanyuka C, Bacsu JR, DesRoches A, et al. Indigenous-specific cultural safety within health and dementia care: A scoping review of reviews. Soc Sci Med. 2022;293:114658. doi:10.1016/j.socscimed.2021.114658
11. Alzheimer’s Association. 2021 Alzheimer’s Disease Facts and Figures. Alzheimers Dement 2021;17(3).
12. Lynch C. World alzheimer report 2019: Attitudes to dementia, a global survey. Alzheimer's & Dementia. 2020;16(S10). doi:10.1002/alz.038255
13. Henderson JN, Henderson LC. Cultural construction of disease: A “supernormal” construct of dementia in an American Indian tribe. Journal of Cross-Cultural Gerontology. 2002;17(3):197-212. doi:10.1023/a:1021268922685
14. Hodge FS, Pasqua A, Marquez CA, Geishirt-Cantrell B. Utilizing traditional storytelling to promote wellness in American Indian Communities. Journal of Transcultural Nursing. 2002;13(1):6-11. doi:10.1177/104365960201300102
15. Goins RT, Spencer SM, McGuire LC, Goldberg J, Wen Y, Henderson JA. Adult caregiving among American Indians: The role of cultural factors. The Gerontologist. 2010;51(3):310-320. doi:10.1093/geront/gnq101
16. Jacklin KM, Walker JD, Shawande M. The emergence of dementia as a health concern among First Nations populations in Alberta, Canada. Canadian Journal of Public Health. 2013;104(1). doi:10.1007/bf03405652
17. Quigley R, Russell SG, Larkins S, et al. Aging well for Indigenous Peoples: A scoping review. Frontiers in Public Health. 2022;10. doi:10.3389/fpubh.2022.780898
18. Truer A. The River Story. Dementia Friends For American and Alaska Native Communities. https://wai.wisc.edu/wp-content/uploads/sites/1129/2020/05/DFWI-The-River-Context-NATIVE-AMERICAN.pdf. Published 2018. Accessed March 30, 2023.
19. Browne CV, Muneoka S, Ka’opua LS, et al. Developing a culturally responsive dementia storybook with Native Hawaiian youth. Gerontology & Geriatrics Education. 2021;43(3):315-327. doi:10.1080/02701960.2021.1885398
20. Browne CV, Ka’opua LS, Jervis LL, Alboroto R, Trockman ML. United States indigenous populations and dementia: Is there a case for culture-based psychosocial interventions? The Gerontologist. 2016. doi:10.1093/geront/gnw059
21. Lewis J, Thibedeau D. Incorporating culture into care: The Denali Center elder care experience. Academic.oup.com. https://academic.oup.com/gerontologist/article/57/6/1011/2632081. Published October 2015. Accessed March 30, 2023.
22. Loutfi D, Law S, McCutcheon C, Carlin R, Torrie J, Macdonald ME. Health Planning for Indigenous Populations: A Rapid Evidence Review. International Indigenous Policy Journal. 2018;9(1). doi:10.18584/iipj.2018.9.1.7

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Title: Community Health Worker Interventions for At-Risk Populations

Author
Amanda S. Keddington, MSN, RN, DNP-S; Janine Roberts MSN, RN; Perry M. Gee, PhD., RN, NEA-BC, FAAN

Affiliations
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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Citations:
1. Alam, R.B., Ashrafi, S.A., Pionke, J.J., & Schwingel, A. (2021). Role of community health workers in addressing dementia: A scoping review and global perspective. Journal of Applied Gerontology, 40(12), 1881-1892. https://doi.org/10.1177/07334648211001190
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
3. Dye, C., Willoughby, D., Aybar-Damali, B., Grady, C., Oran, R., & Knudson, A. (2018). Improving chronic disease self-management by older home health patients through community health coaching. International Journal of Environmental Research and Public Health, 15, 660. https://doi.org/10.3390/ijerph15040660
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
5. Kennedy, M.A., Hatchell, K.E., DiMilia, P.R., Kelly, S.M., Blunt, H.B., Bagley, P.J., LaMantia, M.A., Reynolds, C.F., Crow, R.S., Maden, T.N., Kelly, S.L., Kihwele, J.M., & Batsis, J.A. (2021). Journal of the American Geriatrics Society, 69, 1670-1682. https://doi.org/10.1111/jgs.17078
6. Moreno, G., Mangione, C.M., Tseng, C., Weir, M., Loza, R., Desai, L., Grotts, J., & Gelb, E. (2021). Journal of the American Geriatrics Society, 69, 1627-1637. https://doi.org/10.1111/jgs.17071
7. Ohuabunwa, U., Johnson, E., Turner, J., Jordan, Q., Popoola, V., & Flacker, J. (2021). An integrated model of care utilizing community health workers to promote safe transitions of care. Journal of the American Geriatrics Society, 69, 2638-2647. https://doi.org/10.1111/jgs.17325
8. Pollack, R. (2022, January 27). Hospital Workforce Shortage Crisis Demands Immediate Action. American Hospital Association. https://www.aha.org/lettercomment/2022-01-27-hospital-workforce-shortage-crisis-demands-immediate-action
9. Samuel-Hodge, C.D., Gizlice, Z., Allgood, S.D., Bunton, A.J., Erskine, A., Leeman, J., & Cykert, S. (2022). A hybrid implementation-effectiveness study of a community health worker-delivered disease risk in a rural, underserved non-Hispanic Black population: The CHANGE study. American Journal of Health Promotion, 36(6), 943-958. https://doi.org/10.1177/08901171221078272
10. Sharp, L.K., Tilton, J.J., Touchette, D.R., Xia, Y., Mihailescu, D., Berbaum, M.L., & Gerber, B.S. (2018). Community health workers supporting clinical pharmacists in diabetes management: A randomized-controlled trial. https://doi.org/10.1002/phar.2058
11. Vasan, A., Morgan, J.W., Mitra, N., Xu, C., Long, J.A., Asch, D.A., & Kangovi, S. (2020). Effects of a standardized community health worker intervention on hospitalization among disadvantaged patients with multiple chronic conditions: A pooled analysis of three clinical trials. Health Services Research, 55(2), 894-901. https://doi.org/10.1111/1475-6773.13321
12. Vargas, S.M, Wennerstrom, A., Alfaro, N., Belin, T., Griffith, K., Haywood, C., Jones, F., Lunn, M.R., Meyers, D., Miranda, J., Obedin-Maliver, J., Pollock, M., Sherbourne, C.D., Springgate, B.F., Sugarman, O.K., Rey, E., Williams, C., Williams, P. & Chung, B. (2019). Resilience against depression disparities (RADD): A protocol for a randomized comparative effecrtiveness trial for depression among predominantly low-income, racial/ethnic, sexual and gender minorities. BMJ Open, 9(e031099). https://doi.org/10.1136/bmjopen-2019-031099
13. Zgibor, J.C., Ye, L., Boudreau, R.M., Conroy, M.B., Vander Bilt, J., Rodgers, E.A., Schlenk, E.A., Jacob, M.E., Brandenstein, J., Albert, S.M., & Newman, A.B. (2017). Community-based healthy aging interventions for older adults with arthritis and multimorbidity. Journal of Community Health, 42, 390-399. https://doi.org/10.1007/s10900-016-0268-5

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Title: Left Atrial Appendage Occlusion Devices: A review on current guidelines for stroke prevention in patients with atrial fibrillation

Author
Jeremy D. Bergman, MSIV

Affiliations
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.


Citations: 
1) Go AS, Hylek EM, Phillips KA, Chang Y, Henault LE, Selby JV, Singer DE. Prevalence of diagnosed atrial fibrillation in adults: national implications for rhythm management and stroke prevention: the AnTicoagulation and Risk Factors in Atrial Fibrillation (ATRIA) Study. JAMA. 2001 May 09;285(18):2370-5.
2) Benjamin EJ, Blaha MJ, Chiuve SE, Cushman M, Das SR, Deo R, de Ferranti SD, Floyd J, Fornage M, Gillespie C, Isasi CR, Jiménez MC, Jordan LC, Judd SE, Lackland D, Lichtman JH, Lisabeth L, Liu S, Longenecker CT, Mackey RH, Matsushita K, Mozaffarian D, Mussolino ME, Nasir K, Neumar RW, Palaniappan L, Pandey DK, Thiagarajan RR, Reeves MJ, Ritchey M, Rodriguez CJ, Roth GA, Rosamond WD, Sasson C, Towfighi A, Tsao CW, Turner MB, Virani SS, Voeks JH, Willey JZ, Wilkins JT, Wu JH, Alger HM, Wong SS, Muntner P., American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart Disease and Stroke Statistics-2017 Update: A Report From the American Heart Association. Circulation. 2017 Mar 07;135(10):e146-e603. 3) Wolf PA, Abbott RD, Kannel WB. Atrial fibrillation as an independent risk factor for stroke: the Framingham Study. Stroke. 1991 Aug;22(8):983-8.
4) Preventing stroke in atrial fibrillation: Left atrial appendage closure. Preventing Stroke in Atrial Fibrillation: Left Atrial Appendage Closure | UCSF Cardiology. (n.d.). Retrieved November 17, 2022, from https://ucsfhealthcardiology.ucsf.edu/care/patients/stories 5) Hart RG, Benavente O, McBride R, Pearce LA. Antithrombotic therapy to prevent stroke in patients with atrial fibrillation: a meta-analysis. Ann Intern Med. 1999 Oct 05;131(7):492-501. 
6) Umerah Co, Momodu II. Anticoagulation. ^{[Updated 2022 Jul 18]}. In: StatPearls ^[Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https:// www.ncbi.nlm.nih.gov/books/NBK560651/
7) Dionyssiotis Y. Analyzing the problem of falls among older people. Int J Gen Med. 2012;5:805-13. doi: 10.2147/IJGM.S32651. Epub 2012 Sep 28. PMID: 23055770; PMCID: PMC3468115.
8) Saad M, Risha O, Sano M, Fink T, Heeger CH, Vogler J, Sciacca V, Eitel C, Stiermaier T, Joost A, Keelani A, Fuernau G, Meyer-Saraei R, Kuck KH, Eitel I, Richard Tilz R. Comparison between Amulet and Watchman left atrial appendage closure devices: A realworld, single center experience. Int J Cardiol Heart Vasc. 2021 Oct 19;37:100893. doi: 10.1016/j.ijcha.2021.100893. PMID: 34712772; PMCID: PMC8529070.
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.
11) Agasthi P, Arsanjani R. Catheter Management Of Left Atrial Appendage Closure Devices. ^{[Updated 2022 Oct 1]}. In: StatPearls ^[Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK557458/
12) Daimee UA, Wang Y, Masoudi FA, Varosy PD, Friedman DJ, Du C, Koutras C, Reddy VY, Saw J, Price MJ, Kusumoto FM, Curtis JP, Freeman JV. Indications for Left Atrial Appendage Occlusion in the United States and Associated In-Hospital Outcomes: Results From the NCDR LAAO Registry. Circ Cardiovasc Qual Outcomes. 2022 Aug;15(8):e008418. doi: 10.1161/CIRCOUTCOMES.121.008418. Epub 2022 Aug 12. PMID: 35959677; PMCID: PMC9388561.
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. 

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Title: Dermatology Principles and Guidelines in Older Adultsmatology Principles and Guidelines in Older Adults

Author
Emily Chanak, OMS-IV

Affiliations
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.


Citations:

1. Norman, Rob. “Ten Keys to Success in Geriatric Dermatology.” Practical Dermatology, Bryn Mawr Communications, https://practicaldermatology.com/articles/2009-mar/PD0309_03-php.
2. 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.
3. Wollina, Uwe, MD. Geriatric Dermatology. Published January 1, 2011. Clinics in Dermatology. Volume 29, Issue 1. © 2011.
4. 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.
5. 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. 

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Title: Supporting Caregivers for the Optimal Management of Patients with Dementia

Author
Elzard H. Sikkema, MLS (ASCP), BS

Affiliations
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.^[1] It is projected that there will be 12.7 million Americans with Alzheimer’s dementia by 2050. ^[1] On average, older adults with dementia live four-to-eight years after their diagnosis. ^[3] Patients with dementia are more reliant upon assistance to complete activities of daily living than other older adults without a diagnosis of dementia. ^[4] 26% of Americans currently care for a patient with dementia, and 61% of family caregivers must also remain employed for financial security. ^[7] 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.

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Title: The Underrepresentation of Older Adults in Randomized Clinical Trials for JAK Inhibitors to Treat Atopic Dermatitis: Barriers and Recommendations

Authors
Shreya Sreekantaswamy, BS,¹ Linda Edelman, PhD²

Affiliations
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.   

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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. ^[2] It is important to consider more than just a patients chronological age while determining treatment options for older adults with cancer. ^[3]

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. ^[4] 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. ^[5] Cancer is the leading cause of death in men and women aged 60 to 79 years. ^[6]

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. ^[7] 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. 

Citations:
^[1] https://www.nia.nih.gov/about/aging-strategic-directions-research.
^[2] 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
^[3] Mohile SG, Dale W, Somerfield MR, et al. Practical Assessment and Management of Vulnerabilities in Older Patients Receiving Chemotherapy: ASCO Guideline for Geriatric Oncology. J Clin Oncol. 2018;36(22):2326-2347. doi:10.1200/JCO.2018.78.8687
^[4] https://www.cancer.gov/about-cancer/causes-prevention/risk/age
^[5] www.cdc.gov/nchs/products/databriefs/db355.htm
^[6] Siegel RL, Miller KD, Fuchs HE, Jemal A. Cancer Statistics, 2021 ^{[published correction appears in CA Cancer J Clin. 2021 Jul;71(4):359]}. CA Cancer J Clin. 2021;71(1):7-33. doi:10.3322/caac.21654
^[7] https://jnccn.org/view/journals/jnccn/19/9/article-p1006.xml
^[8] Pal SK, Katheria V, Hurria A. Evaluating the older patient with cancer: understanding frailty and the geriatric assessment. CA Cancer J Clin. 2010;60(2):120-132. doi:10.3322/caac.20059
^[9] Katz, Sidney, et al. "Studies of illness in the aged: the index of ADL: a standardized measure of biological and psychosocial function." jama 185.12 (1963): 914-919.
^[10] Pal SK, Hurria A. Impact of age, sex, and comorbidity on cancer therapy and disease progression. J Clin Oncol. 2010;28(26):4086-4093. doi:10.1200/JCO.2009.27.0579
^[11] Tomaka J, Thompson S, Palacios R. The relation of social isolation, loneliness, and social support to disease outcomes among the elderly. J Aging Health. 2006;18(3):359-384. doi:10.1177/0898264305280993
^[12] Chew ML, Mulsant BH, Pollock BG, et al. Anticholinergic activity of 107 medications commonly used by older adults. J Am Geriatr Soc. 2008;56(7):1333-1341. doi:10.1111/j.1532-5415.2008.01737.x
^[13] 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
^[14] 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
^[15] 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
^[16] 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

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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. ^[3] Developing a Geriatric Emergency Department (GED) can promote improved, cost-effective care with better outcomes for this growing population of patients. ^[5] 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. ^[7] 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.

^[1] 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.
^[2] https://www.nia.nih.gov/about/aging-strategic-directions-research.
^[3] 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.
^[4] 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.
^[5] 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.
^[6]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
^[7] “GEDA Accreditation List.” American College of Emergency Physicians. acep.org/geda. Accessed November 17, 2021.
^[8] 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.
^[9] Kennedy M, Lesser A, Israni J, Liu SW, Santangelo I, Tidwell N, Southerland LT, Carpenter CR, Biese K, Ahmad S, Hwang U. Reach and Adoption of a Geriatric Emergency Department Accreditation Program in the United States. Ann Emerg Med. 2021 Aug 10:S0196-0644(21)00513-8. doi: 10.1016/j.annemergmed.2021.06.013. Epub ahead of print. PMID: 34389196.
^[10] Rosenberg M, Rosenberg L. The Geriatric Emergency Department. Emerg Med Clin North Am. 2016 Aug;34(3):629-48. doi: 10.1016/j.emc.2016.04.011. PMID: 27475018.
^[11] “Accreditation Process Faqs.” ACEP.org, ACEP Geriatric Emergency Department Accreditation, https://www.acep.org/geda/faqs/. 
^[12] https://geri-em.com
^[13] https://gedcollaborative.com

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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

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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