Approximately 46 percent (21 million) of older women in the United States have low bone mass, a condition that increases the risk of fracture, disability, and death, but may also be reversible. Exercise is recommended to maintain bone health in women, but the benefits of exercise may be limited by low levels of sex hormones after menopause.
A new R01 (a type of research project funded by the National Institutes of Health) study, “DHEA Augmentation of Musculoskeletal Adaptations to Exercise in Older Women,” led by CU College of Nursing Associate Professor Kathy Jankowski, PhD, FACSM, will attempt to show whether dehydroepiandrosterone (DHEA) will provide estrogenic and androgenic hormonal responses that will enhance the benefits of exercise on bone and muscle in postmenopausal women.
“This research has high impact and importance for women, who have a longer life expectancy than men, and are more prone to health issues arising from lower bone mineral density,” Jankowski says. The project is federally funded for a five-year period of study at $600,000 per year.
Exercise is recommended for postmenopausal women to maintain or increase areal bone mineral density, to improve muscular fitness and balance, and ultimately to prevent fractures. During exercise, joint-reaction and ground-reaction forces contribute to strain signals that are transduced via a mechanostat to osteocytes, causing region-specific adaptations in bone tissue.
However, age-related declines in anabolic adrenal, gonadal, and somatotropic hormones may blunt this and other musculoskeletal adaptations. DHEA is the major source of estrogen and testosterone in postmenopausal women, but adrenal DHEA production declines with age.
Jankowski’s research project proposes that DHEA therapy, by providing androgenic and estrogenic hormonal support, will augment the effects of bone-loading exercise on areal bone mineral density and fat free mass in women with low areal bone mineral density (i.e., osteopenia). This population is the focus because low area bone mineral density, an indicator of fracture risk, could be corrected with hormonal treatment.
Measuring changes to bone architecture
“There only a few anabolic hormonal therapies approved to increase bone density in women, and these are typically prescribed only for women with osteoporosis,” Jankowski says. “DHEA has the advantage of providing anabolic effects on bone, and is well-tolerated in postmenopausal women. Exercise is the only therapy that provides benefits to muscle and bone. I am looking forward to discovering whether combining exercise with DHEA provides benefits to muscle and bone that exceed that of either DHEA or exercise alone.”
Jankowski’s study will measure changes in bone architecture in addition to bone density. “Small changes in bone architecture can have profound effects on bone strength,” she says. “It is currently not known if DHEA has beneficial effects on bone architecture.”
To learn more about research projects at the CU College of Nursing Office of Research and Scholarship, contact CON.ORS@ucdenver.edu .
Smith is associate chief of the Division of Hematology at the University of Colorado School of Medicine and director of the General Hematology, Blood Cancers and BMT Programs at UCHealth University of Colorado Hospital. He and his colleagues regularly treat and manage the care of patients with blood cancers such as leukemia, multiple myeloma and lymphomas.
While many survive through stem cell transplants, chemotherapy and radiation, the treatments can be painful, debilitating and isolating. Many don’t survive. The Leukemia and Lymphoma Society predicts that more than 58,000 people in the United States will die from blood cancers or complications from them this year.
Clay Smith has seen his patients die. Many of them struggled, along with their families and loved ones, in their final days to accept and come to terms with the prospect of death.
Until recently, however, Smith admits he didn’t directly face the reality of death himself.
“I’ve been in the field for 33 years,” he said. “In the early parts of it, I focused on medicine and science. I didn’t think about my own mortality.”
That changed three years ago. Smith, now 58, began to consider the difficult moments he witnessed as a physician: patients and loved ones grappling with agonizing decisions, such as whether to continue treatments in the face of incapacitating physical decline or whether to remove a ventilator.
“I didn’t want my kids to struggle with that,” said Smith, who has two sons. “It was my responsibility as a parent to be sure my sons were never left with making those decisions.”
With that, Smith set up a living will, durable power of attorney (DPOA) and an advance-care directive to ensure that his wishes for end-of-life care were clearly stated. Reduced to the simplest terms, Smith said he will choose quality of life over quantity and reject extraordinary lifesaving measures.
No bright lines
Smith’s experience exposes one of medicine’s knottiest issues – and one that is felt especially keenly in the blood cancer field, where many patients teeter on the edge of recovery and decline, sometimes for years. Too often, Smith said, providers, patients and families view end-of-life discussions and advance care planning as code words for abandoning hope that disease can be conquered.
“When we talk about ‘getting our affairs in order,’ it’s sometimes mixed up with the idea that we are no longer devoting our energy to curing disease or prolonging life,” Smith said. “We can do both.”
The idea behind advance-care planning, he said, is that people should make decisions about how they wish to spend their final days before they become too ill to do so and the emotional turmoil that frequently accompanies dying engulfs their loved ones.
That’s just a matter of personal protection, Smith noted. As he put it, “Nobody buys car insurance thinking they are going to wreck.”
Jeanie Youngwerth, MD, Director of the Palliative Care Service at UCH, said Smith is a “great role model and advocate for advance-care planning. He speaks openly, guiding patients in having the gift of conversation with families about their values and wishes.
Families often struggle with important decision making because advance-care planning conversations never happened, Youngwerth added. “It’s important to help patients and families prepare before times of crisis and make a plan that is based on their values.”
The provider dilemma
But providers aren’t exempt. They too grope for the best ways to meld lifesaving clinical care with advance-care planning. That is particularly true for those treating blood diseases, said Tanisha Joshi, PhD, a counseling psychologist and assistant professor of Medicine at CU. Joshi is “embedded” with Smith’s team and meets regularly with them, not only to discuss their patients’ needs, but also how their patients’ struggles affect them.
The challenges are twofold, Joshi said. First, the course of treatment for blood cancers can be very unpredictable – in general, more so than for solid tumors. Patients can hover at the edge of death, then recover. Others may show encouraging signs, then quickly go downhill. In addition, patients very often spend long stints in the hospital, particularly after stem cell transplants, which leave them immunocompromised and therefore at very high risk of infection. If the donor cells come from another individual, patients may also fall prey to graft-versus-host disease, wherein the body attacks what it perceives as foreign bodies.
Yet at the same time, rapid medical advances, such as immunotherapy, continue to offer hope and may spur both patients and providers to pursue care aggressively.
These uncertainties raise the risk of compassion fatigue and burnout for providers, Joshi said. They may also create conflicts among them in discussions of care plans.
“Nurses, psychologists, social workers and physicians may see cases in different ways,” Joshi said. Some may see aggressive, lifesaving care as fulfilling a duty to do everything possible on behalf of the patient; others may see that as futile and instead advocate for easing the patient’s suffering and improving quality of life in the final days.
“It places an emotional load on the team,” Joshi said.
The volatile mix led Joshi and Elissa Kolva, PhD, assistant professor of Medical Oncology at CU, to launch a study of patients at UCH. Kolva will be analyzing the type of care provided to patients, including the site of death; end-of-life counseling provided, if any; presence of advance care and do-not-resuscitate directives; numbers of emergency department visits and hospital readmissions; access to primary care, and more.
Joshi is conducting 60- to 90-minute interviews with providers, including physicians, advanced-care practitioners, inpatient and outpatient nurses, social workers, psychologists and survivorship coordinators. She will probe their perceptions of the care they provide and search for patterns in their responses. What were the challenges? How did it impact them personally? How do they take care of themselves emotionally? Did they have enough training to deal with difficult situations? What are the patient stories that stand out to them?
The work is ongoing and data analysis will follow, but the ultimate aim is to get a clearer picture of how the team is providing end-of-life care and the effect it is having on them. Joshi calls it “bringing torches to a dark tunnel. We want to understand what is the landscape.” The study’s title speaks to answering an even more fundamental question: “When Is Enough Enough?”
Kolva notes that research supports that providers treating blood disorders have trouble answering that question. In one survey for example, 55.9 percent of hematological oncologists who participated said they believed end-of-life discussions began “too late.”
“Our project builds from that finding,” Kolva said. “We want to provide a level of comfort for hematologic oncologists to have end-of-life conversations.”
Entering those conversations can be very difficult for providers, Kolva acknowledged. The power of medical technology, in the form of a new treatment or trial or another transplant, can make the prospects for a patient’s recovery tantalizingly close. “Most providers have seen a miraculous case,” Kolva said.
But providers must guard against allowing their commitment to treatment override patients’ values, she added. Jehovah’s Witnesses, for example, will not submit to blood transfusions. Use of stem cells collected from discarded umbilical cords may conflict with some individuals’ moral standards. Others may believe faith will deliver them from disease. These and other factors can influence end-of-life discussions, even as they challenge providers’ own beliefs, Kolva said.
“We love to pretend we know how people will feel at the end of life,” she said. “None of us know. We have to continue to check our feelings as providers when we feel we are pulling in one direction.”
For his part, Smith believes Joshi’s and Kolva’s work will lead other providers to think about the unthinkable, just as he did three years ago.
“This work will open conversations about the practice of advance-care planning and prompt providers to think more broadly about discussing end-of-life care,” he said.
The University of Colorado Anschutz Medical Campus is honored to announce a $3.3 million gift in renewal funding from the Colorado Health Foundation (TCHF) in support of the continued success of ECHO Colorado (Extensions for Community Health Outcomes) and to recognize the positive impact of the program center located here on campus.
“This funding allows ECHO Colorado to continue changing the way Coloradans receive healthcare with an innovative approach to the well-known model,” said CU Anschutz Chancellor Don Elliman. “I am proud to stand behind and beside the work of ECHO Colorado and hope you will join me in celebrating their extended program efforts.”
The ECHO Model
The ECHO model bridges specialty and primary care by linking expert specialist with providers in local communities. Together they participate in ongoing learning sessions, which operate like virtual grand rounds combining didactic presentations, mentoring and peer-presented case review.
ECHO brings ongoing learning and specialty knowledge to rural providers and their patients at no cost. They create ongoing learning communities where providers receive support and develop the skills they need to provide comprehensive, best-practice care to patients with complex health conditions, in their own neighborhood.
“What is often needed to help patients facing barriers to care is an efficient mechanism to share data and knowledge as opposed to hours of driving and the many inefficiencies of our current health care delivery model,” said Duane Pearson, MD, Medical Director of ECHO Colorado.
ECHO Colorado redefines Project ECHO
ECHO Colorado is responding to a statewide crisis: across Colorado, health care outcomes continue to be heavily influenced by zip code as an undeniable reflection of the accessibility to quality health care and specialty care. By focusing on building a virtual center to support ongoing learning, community, connection, and peer collaboration, ECHO provides the infrastructure to democratize knowledge, reduce professional isolation and improve health outcomes.
“We believe in continuously expanding our opportunities for collaboration and believe our partnerships are the pulse of what we do,” said Kory Thomas, Assistant Director of ECHO Colorado. “Working toward a common goal for health equity allows us to reduce redundancies, maximize impact, and act as a force multiplier connecting resources to those that need it most. Together, we pave a more practical pathway to achieve our goals.”
ECHO Colorado continues to grow and innovate and is part of a larger national discussion about re-envisioning and reshaping health care delivery. “We are extremely proud of what we have accomplished over these two years and, in light of the ECHO Act and the national spotlight that has been placed on the ECHO model for the next couple of years, we are well-positioned to continue to demonstrate the effectiveness and efficiency of ECHO Colorado,” said John F. “Fred” Thomas, Ph.D., Primary Investigator of the grant and Executive Director of ECHO Colorado. “We truly appreciate the support of Chancellor Elliman, and we cannot begin to thank the Colorado Health Foundation enough for their continued commitment to our efforts.”
Changing the future of health in Colorado and beyond
ECHO Colorado was established in 2015 with the belief that it would change how health care is accessed and delivered, and it is doing just that. “This initiative will not only improve the health and quality of life for countless citizens of Colorado, but it enables the university to expand and elevate its educational outreach to medical professionals across the state by leveraging our partnerships with state and regional health offices,” said John J. Reilly, MD, Vice Chancellor for Health Affairs and Dean of the School of Medicine.
This grant allows ECHO Colorado to continue program center operations, partner on efforts prioritized with collaborating organizations across the state, and examine the reach and impact of ECHO in light of the ECHO Act passed by Congress in late 2016.
The ECHO Act was approved following the Senate’s unanimous vote and signed into law by President Obama. Congratulations to the ECHO Colorado team!