Every month, the leadership team at the Gerontological Advanced Practice Nurses Association (GAPNA) highlights the most important published literature that impacts geriatric practice. This month, Deborah Dunn, EdD, MSN, GNP-BC, ACNS-BC, GS-C, GAPNA Immediate Past President, reviews three studies. The first describes promising findings that Tdap vaccination may reduce dementia, the second explore vaccine hesitancy among older adults, and the third looks at the health effects of the lock-down during COVID-19.

Lower risk for dementia following adult tetanus, diphtheria, and pertussis (Tdap) vaccination

J Gerontol A Biol Sci Med Sci. 2021 Jul 13;76(8):1436-1443

Summary: Tdap vaccination was associated with a 42% lower dementia risk in 2 Veterans Health Affair cohorts with different clinical and sociodemographic characteristics. This is the first study to examine if Tdap vaccination can reduce the risk of dementia. Several vaccine types are linked to decreased dementia risk, suggesting that these associations are due to nonspecific effects on inflammation rather than vaccine-induced pathogen-specific protective effects, concluded the authors.1


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Commentary by Dr. Dunn: Each day, more than 10,000 individuals turn 65 years old in the United States. Advanced practice providers who care for adults in every health care setting are seeing a growing number of older adults in their practices and are challenged to simultaneously provide excellent health promotion, disease prevention, and acute and chronic illness care. Further, an increasing number of these patients are experiencing cognitive impairment. More than 6 million persons 65 and older in the U.S. are living with Alzheimer’s dementia and this number is projected to grow to over 13 million by 2050.2 (Alzheimer’s Association, 2021).

Vaccination is one of the oldest, simplest, and most cost-effective health care interventions in the advanced practice provider’s arsenal.  Mounting evidence supports that infectious conditions may be correlated with the development and worsening of cognitive impairment and dementia. Recent studies exploring the link between dementia and vaccination show a reduced incidence of dementia in persons with a history of vaccination, such as annual influenza, pneumococcal, and herpes zoster vaccinations.

This study adds to the growing evidence in support of adult vaccination as an effective intervention in lowering the risk of dementia. In a review of electronic health records from a cohort of older adults who received health care through Veteran Health Affairs, adult tetanus, diphtheria, and pertussis (Tdap) vaccination was shown to be associated with a 42% lower risk of dementia.

Advanced practice providers who add vaccination review and counseling to every health care encounter with their patients are implementing evidence-based care for preventing infectious disease. They are also possibly lowering their patients’ risk for dementia, which in turn increases quality-of-life years, reduces health care costs, and lowers caregiver burden.

Factors indicating intention to vaccinate with a COVID-19 vaccine among older U.S. adults

PLoS One. 2021;16(5):e0251963.

Summary: Among older adults at high-risk for COVID-19 complications, 1 in 11 reported lack of willingness to receive COVID-19 vaccine in November 2020. Variability in vaccine willingness by gender, race, education, and income suggests the potential for uneven vaccine uptake, noted the authors of the study. They recommend education by health providers be directed toward assuaging concerns about vaccine safety and efficacy can help improve vaccine acceptance among those less willing.3

Commentary by Dr. Dunn: Prior to the COVID-19 pandemic, older adult vaccine hesitancy discussions generally centered on annual influenza vaccination. However, older adults have increasingly become aware of their risk for serious illness, hospitalization, and even death, from seasonal flu.  America’s Health Rankings, Senior Report shows a slow and steady increase from 2014 to 2020 in senior flu vaccination.4  In 2020, over 60% of older adults received seasonal influenza vaccination.

The COVID-19 pandemic has been particularly lethal for older adults. Rapid vaccine development and deployment has been essential to halting the spread of infection, especially among the highest-risk population: older adults, the frail, and those in congregate care settings.

To explore factors related to vaccine hesitancy, 7,621 patients age 65 and older enrolled in the HeartlineTM clinical study were surveyed to assess their willingness and intention to take the COVID-19 vaccine.

The study found an impressive 91.3% of respondents were intending to take the vaccine. Explored factors included gender, race, age, income, and health beliefs.

There were 3 main factors associated with intention to take the COVID-19 vaccine:

  • Belief that the vaccine was safe and effective
  • Desire to protect themselves and others
  • Acceptance of the risk of vaccine short-term side effects

Two of the strongest factors associated with intention to take the COVID-19 vaccine were belief that the vaccine was safe and effective and the desire to help protect self and others. The 8.7% of persons not planning to take the vaccine were largely comprised of African American patients and women. Both those willing and those less willing to take the vaccine reported that they would talk with their health care provider before making a decision.

These findings provide key insights that advanced practice providers can use to reduce vaccine hesitancy among their patients. Probably most important is that NPs ask about the patient’s health beliefs. Does the older adult understand their risk for infection, risk for serious illness or even death if infected?

NPs should explore the older adult’s knowledge and beliefs about the safety and efficacy of the vaccine and provide clear and accurate information. It’s also valuable to support the patient’s desire to protect themselves, their family, friends, and colleagues from contracting COVID-19.

BMC Public Health. 2021;21(1):755

Summary: A team of researchers conducted an online survey with 9969 adults 40 years and older between August and September 2020 in four cities in the US.  The survey included questions about pre-existing health conditions, physical activity, access to food, quality-of-life, and nutritional food status and asked participants to respond with information from pre-pandemic and pandemic conditions. The goal was to quantify the impact of COVID-19 on health and well-being in adults aged 40 years and older.5

Commentary by Dr. Dunn: A growing body of research supports the positive effect that wellness behaviors have on older adult’s health and quality of life. Staying physically and mentally active have been shown to reduce chronic illness and mental health disorders and to increase feelings of well-being.

Stay-at-home orders and self-quarantine for avoiding infection throughout the COVID-19 pandemic have caused many older adults to become socially isolated and at risk for physical inactivity, social isolation, and food insecurity.

This study explored wellness behaviors of 9969 adults 40 years old and older during the pandemic. Survey items included questions about physical activity, health conditions, quality of life, food security, and nutrition. Respondents were asked to rate their pre-pandemic state and pandemic state; and the changes in these ratings were explored for associations.

Surprisingly, this study did not find decreases in quality of life, food security or nutrition.  However, physical activity during the pandemic decreased from pre-pandemic levels across populations. The researchers concluded fewer negative effects were observed than were expected because older adults were better able to adapt to pandemic circumstances than hypothesized. The lack of negative effects on food security and nutrition were thought to be due to the positive effects of being homebound, allowing for more spending on groceries and more time spent on cooking rather spending on other discretionary items.

Continued study of the experiences and effects of the COVID-19 pandemic on the health of older adults is needed. A key takeaway from this study for advanced practice providers is the continued importance of assessing and counseling patients on the necessity of adequate physical activity in maintaining health, functional status, and avoiding frailty. 

References

1. Scherrer JF, Salas J, Wiemken TL, Jacobs C, Morley JE, Hoft DF. Lower risk for dementia following adult tetanus, diphtheria and pertussis (Tdap) vaccination. J Gerontol A Biol Sci Med Sci. 2021;76(8):1436-1443. doi:10.1093/gerona/glab115

2. Alzheimer’s Association. Alzheimer’s Disease Facts and Figures. Accessed July 22, 2021. https://www.alz.org/alzheimers-dementia/facts-figures

3.  Nikolovski J, Koldijk M, Weverling GJ, et al. Factors indicating intention to vaccinate with a COVID-19 vaccing among older US adults. PLoS One. 2021;16(5):e0251963. doi:10.1371/journal.pone.0251963

4. America’s Health Ranking. Flu vaccination — ages 65+. Accessed July 22. 2021. https://www.americashealthrankings.org/explore/senior/measure/flu_vaccine_sr/state/U.S.

5. Harrison E, Monroe-Lord L, Carson AD, et al.  COVID-19 pandemic-related changes in wellness behavior among older Americans. BMC Public Health. 2021;21(1):755. doi:10.1186/s12889-021-10825-6