LIFE-changing Scholarship

An-indepth look at the research Penn Nursing faculty members are conducting at LIFE

The Living Independently For Elders (LIFE) program at 4508 Chestnut Street paints a telling picture of what aging looks like in West and Southwest Philadelphia. Ninetyfive percent of the members are African American. The average member is 80 years old, suffers from eight medical conditions, takes eight medications, and experiences three or more limitations in daily activities.

“Cultural competence” is often used to describe the need for care that speaks directly to the cultural intricacies that exist within diverse patient populations. For our faculty who strive to change the world through research that is both evidence-based and tailored to community needs, LIFE offers a unique opportunity to produce scholarship that will impact the lives of all older adults, starting with the ones who live next door. Dr. Eileen Sullivan-Marx, PhD, CRNP, RN, FAAN, the Associate Dean for Practice and Community Affairs who oversees the LIFE center and the Shearer Term Associate Professor for Healthy Community Practices at the School of Nursing, therefore describes the LIFE center as “a living interactive environment to learn how to deliver the best care.”

In our rapidly aging society, where about one in eight Americans is 65 years of age or older, fewer older adults are adequately exercising. By the age of 75, one in three men and one in two women do not get the exercise they need, and overweight, older adults are at greater risk for hypertension, stroke, diabetes mellitus, and other pulmonary problems. Consequently, the national need for weight management in the elderly is evident, and LIFE, with 61 percent of African American women in the program overweight or obese, serves as a great exemplar of this need.

Funded by the Dean’s Investment for the Future and entitled “Short-term Exercise on Body Weight in Overweight Elderly African American Women,“ the goal of the study is to evaluate the effectiveness of a shortterm (16 weeks, four days per week) aerobic training program on body weight and on quality and variability of gait in elderly African American, urban communitydwelling women attending a long-term care facility. Dr. Volpe and her research team –which includes co-investigator Dr. Sullivan-Marx, project manager Tim Ackerson, MSSW, research associate Ingrid Sidorov, MSN, and Arcadia University professors Rebecca Craik, PhD, PT and Kathleen Kline Mangione, PhD, PT, GCS – expect this exercise program to decrease body weight by at least seven percent and improve the gait of their participants.

For their pilot project, they will randomly select 25 participants who will attend three to four 45-55 minute exercise sessions a week. The supervised exercise program will consist of proper warm-up, a main exercise period with multiple bouts of walking, and a cool-down period. Body weight, height, body mass index, waist circumference, energy expenditure, energy intake and gait analysis will be recorded at baseline, eight weeks, and 16 weeks of the study.

Serving as both a resource for finding participants and a site for conducting the research, LIFE plays an integral role in the logistics of the study. Transportation is provided, participants incur no costs, and members already attend the program at least three days per week for medical or other treatments. Finally, LIFE provides a unique opportunity for an exercise program to be sustainable, even after grant funding is completed.

“From a public health standpoint, this study is significant because, with the increased prevalence of obesity, especially among African American women, any simple and safe method of disease mitigation could have a major impact on the health of our nation,” says Dr. Volpe.

The U.S. Census Bureau has found that the top health problems in the West and Southwest Philadelphia communities include high blood pressure, obesity, diabetes mellitus, heart problems, and back pain and allergies, all of which can be improved through exercise.

Dr. Sullivan-Marx is working on a separate study that examines different outcomes of an exercise program, such as improved gait speed and physical performance, with Dr. Volpe and physical therapist researchers Drs. Mangione and Craik of Arcadia University as co-investigators. The study, entitled, “Outcomes of an Exercise Program for Older African American Women in a PACE Model,“ marks the second time that this interdisciplinary research team has partnered to generate scholarship that aims to improve the health of older adults through exercise.

Funded by the Commonwealth of Pennsylvania Department of Health, Dr. Sullivan-Marx’s two-year study aims to test the effects of a 16-week exercise program (which differs slightly from Dr. Volpe’s program in terms of energy expenditure for weight loss) to measure whether strength and endurance have increased, memory and thinking improved, and the likelihood of depression avoided for 80 older African American women who attend LIFE, including some who may be cognitively impaired.

LIFE serves as an ideal site for the study in many ways: members receive comprehensive care in one setting; information on their clinical data is available with permission and would be uniform for all participants; and finally, participants typically attend the program three to four times per week, and thus, would be available for interviews with research personnel. “The full commitment and partnership of LIFE has made this project possible,” Dr. Sullivan-Marx explains. The Council of Elders, an advisory group of nearly a dozen LIFE members, have helped her research team by sharing their experiences as members, and two caregivers at LIFE, Victoria Mott and Vanessa Covington, have taken a lead role in the study by conducting the exercise programs.

To date, preliminary analysis has shown that gait speed improves three-fold in the women, all of whom have chronic illness and are frail by geriatric standards. Dr. Sullivan-Marx is seeking NIH funds to evaluate this study design across several PACE programs.

In an earlier study, Drs. Fang Yu, Lois Evans and Sullivan-Marx examined the effects of a rehabilitation program for older adults, 77 percent of whom were African American. They found that those with cognitive impairment experienced improvements in functional gain and rehabilitation success just as those with normal cognition, demonstrating that rehabilitation should be covered by Medicare and payers for older adults with cognitive impairment. Dr. Sullivan-Marx’s current scholarship extends this work to test an exercise program for older African American women with chronic illness and functional impairment.

Prior research has shown that older African American women have higher rates of mortality than their Caucasian counterparts. Moreover, preventative measures, such as prescriptive exercise programs, are less likely to be emphasized by clinicians, paid for by providers, and adopted by older African American women.

Findings from Dr. Sullivan-Marx’s study would therefore enhance an understanding of the efficacy of a structured exercise program for older African American women living in urban settings with and without
cognitive impairment. “From a larger perspective,” Dr. Sullivan-Marx adds, “policy makers would be informed about benefits of support for exercise programs in this vulnerable population.”

While much of the research conducted at LIFE is, like Dr. Sullivan-Marx’s scholarship, designed to inform and improve the quality of life for older adults nationally, Associate Professor of Pharmacology and Therapeutics - Clinician Educator Joseph Boullata, Pharm D, RPh, BCNSP, is studying how research that is
conducted nationally affects the members of LIFE, individually.

Specifically, he is using a single-patient study design to better answer the question of whether a second generation antipsychotic (SGA) is effective in an individual member or not.

SGA’s, the newer class of antipsychotic medication used to manage some elderly patients with dementia-associated psychosis, were thought to be at least as effective as older agents but with fewer side effects. In large clinical trials, however, this has been difficult to show due to significant variability between subjects. Dr. Boullata’s current scholarship therefore analyzes the benefits and overall need of such geropsychiatric medications in individual members at LIFE.

Twenty members will participate in this yearlong study funded by the Penn Research Foundation. The double-blinded, randomized, multiple crossover, single-patient trial will test the effectiveness of olanzapine, an atypical antipsychotic used to treat schizophrenia and bipolar disorder, compared with a placebo. Each enrolled member will undergo six consecutive, six-week periods (total 36 weeks) being randomized to take either an SGA or an identical-appearing placebo during each 6-week period.

Members will be evaluated every two weeks using the Brief Psychiatric Rating Scale and the Clinical Global Impression instruments. Complaints of side effects made by the subject or family member to the primary care provider will be documented and routine documentation of body weight, serum glucose, and
triglycerides will be reviewed.

“What we want to answer is whether members really did fare better when they were on the drug,” says Dr. Boullata. “But what we think is, for many, there may not be much of a difference.” And because side
effects from these medications include serious cardiac complications that could lead to an increased risk of death, he adds, “If someone isn’t getting the benefit of the drug, then they don’t need to take it.”

Dr. Boullata’s study serves as an example of research that directly answers questions for members at LIFE, but there are other faculty members whose scholarship, designed for a broader population, has
been enriched through LIFE.

Professor Mary Naylor, PhD, RN, FAAN, is currently conducting a study at three different types of long term care (LTC) centers – 26 nursing homes, 27 assisted living facilities, and six home and community based care centers, one of which includes Penn Nursing’s LIFE program. Her goal is to examine changes in biological and physiological factors, symptom status, functional status, emotional and behavioral status, general health perceptions, and perceived overall quality of life among elders newly admitted to an LTC option and compare these differences across the three settings.

“Health-related quality of life has been identified as a focal outcome for quality assessment in elders receiving LTC, but we know very little about the natural progression for these elders in health and quality of life,” says Dr. Naylor, the Marian S. Ware Professor in Gerontology. “As a result, elders and their families have inadequate information upon which to assess the quality of various LTC options, and clinicians and policy makers do not have the knowledge base to assure high quality, cost-effective services.”

Her five-year, $2.87 million NIH-funded study has already enrolled 212 subjects, 15 of whom are from the 4508 LIFE site. Dr. Naylor’s project findings have the potential to guide needed health policy for the growing population of the chronically ill and disabled older adults by providing a distinction of what quality of care means to these elders.

It is also the first study to measure health-related quality of life outcomes in patients and members with cognitive impairments. “Through this study, we will be able to hear the voice of elders and understand how they feel their health and quality of life has changed since this recent transition,” explains project manager Katherine Abbott, PhD, MGS.

Another example of how LIFE has informed and enriched research geared toward a broader population is well evidenced in the work of Assistant Professor Lisa Lewis, PhD, RN. Two years ago, she collected data from LIFE that explored the spiritual process associated with medication adherence among older African American women diagnosed with hypertension. Her findings, presented at the American Heart Association, were disseminated in the national media, with articles in The Washington Post and U.S. News & World Report.

Through her qualitative study, Dr. Lewis found that spirituality helped older black American women with high blood pressure stick to the drug regimens that keep the condition under control. The 21 African American women whom she sampled, with an average age of 73, had been diagnosed with hypertension for an average of 16.7 years and were taking an average of 3.3 prescriptions to battle the condition.

Research has shown that older black Americans tend to have poorer antihypertensive medication adherence than either younger blacks or white patients, even though adherence helps reduce hypertension-related health problems and deaths.

All the women Dr. Lewis interviewed said they used their spirituality to manage their medication adherence. As part of this process, identified as “Partnering with God to Manage My Medications,” the women accepted personal responsibility for adhering to their medication regimen and used their spirituality as a resource to make decisions to remain adherent, cope with medication side effects, and increase their ability to deal with barriers that kept them from sticking with their medicines.

As one LIFE member noted in the study, “When I stay connected to my God, when I’m really spiritual, it just doesn’t seem so difficult anymore. It’s like I’m in tune to everything…”

The findings from this study, which suggest that incorporating patients’ beliefs into hypertension treatment may help them draw on inner resources to improve medication adherence, has helped inform Dr. Lewis’ current scholarship. Her latest study samples 300 older African Americans in an urban community to examine the relationship between spirituality and health outcomes.

“This study is built around the framework that individuals’ attitudes, beliefs, and perceptions about their disease can be used to develop interventions to manage the disease, and spirituality is one of those cultural beliefs that warrant investigation,” says Dr. Lewis.

At LIFE, a large majority of members sing gospel hymns and participate in Bible studies, a reflection of the spiritual and religious culture so deeply rooted in the African American community. For Dr. Lewis, it serves as a “good population to understand what other African Americans of a similar background might
be thinking.”

“Being a new scholar and new to Penn, having access to a resource like LIFE,” she adds, “was very instrumental in moving forward with my research.”