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| ### GERIATRIC RESEARCH, EDUCATION AND CLINICAL CENTER    |   |   |   |   |
|                                                          |   |   |   |   |
| ### *Annual Report: Fiscal Year [2006]{.underline}*      |   |   |   |   |
|                                                          |   |   |   |   |
| ######## Part II: Accomplishments                        |   |   |   |   |
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| **1. GRECC NAME/LOCATION**                               |   |   |   |   |
+----------------------------------------------------------+---+---+---+---+
| a.  **GRECC Name:** Durham                               |   |   |   |   |
|                                                          |   |   |   |   |
| b.  **Location** *(facility, VISN)*: Durham VA Medical   |   |   |   |   |
|     Center, VISN 6                                       |   |   |   |   |
+----------------------------------------------------------+---+---+---+---+
| **2. CONTACT PERSON**                                    |   |   |   |   |
+----------------------------------------------------------+---+---+---+---+
| c.  Name: Connie W. Bales, PhD, RD                       |   |   |   |   |
|                                                          |   |   |   |   |
| d.  **Position:** Associate Director for                 |   |   |   |   |
|     Education/Evaluation                                 |   |   |   |   |
|                                                          |   |   |   |   |
| e.  **Phone, e-mail:** 919-286-6932;                     |   |   |   |   |
|     bales001@mc.duke.edu                                 |   |   |   |   |
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| **3. GRECC FOCUS AREA(S)**                               |   |   |   |   |
+----------------------------------------------------------+---+---+---+---+
|                                                          |   |   |   |   |
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| ### GRECC Focus Area                                     | * |   |   |   |
|                                                          | * |   |   |   |
|                                                          | R |   |   |   |
|                                                          | e |   |   |   |
|                                                          | s |   |   |   |
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|                                                          | a |   |   |   |
|                                                          | r |   |   |   |
|                                                          | c |   |   |   |
|                                                          | h |   |   |   |
|                                                          | T |   |   |   |
|                                                          | y |   |   |   |
|                                                          | p |   |   |   |
|                                                          | e |   |   |   |
|                                                          | * |   |   |   |
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|                                                          | > | > | > | > |
|                                                          |   |   |   |   |
|                                                          | * | * | * | * |
|                                                          | * | * | * | * |
|                                                          | B | A | H | R |
|                                                          | a | p | e | e |
|                                                          | s | p | a | h |
|                                                          | i | l | l | a |
|                                                          | c | i | t | b |
|                                                          | > | e | h | i |
|                                                          |   | d | > | l |
|                                                          | B | > |   | i |
|                                                          | i |   | S | t |
|                                                          | o | C | e | a |
|                                                          | m | l | r | t |
|                                                          | e | i | v | i |
|                                                          | d | n | i | o |
|                                                          | i | i | c | n |
|                                                          | c | c | e | * |
|                                                          | a | a | s | * |
|                                                          | l | l | * |   |
|                                                          | * | * | * |   |
|                                                          | * | * |   |   |
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| Biology and physiology of frailty; mobility, bones and   |   |   |   |   |
| joints; cell biology of immune system and cancer         |   |   |   |   |
+----------------------------------------------------------+---+---+---+---+
| Exercise and chronic disease; cancer care; mobility,     |   |   |   |   |
| bones and joints; quality of life, care-giving and end   |   |   |   |   |
| of life care                                             |   |   |   |   |
+----------------------------------------------------------+---+---+---+---+
| Health promotion and disease prevention; medication      |   |   |   |   |
| utilization; geriatric assessment                        |   |   |   |   |
+----------------------------------------------------------+---+---+---+---+

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| **4. ADMINISTRATION**                                                 |
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| a.  **GRECC Impact on Host VAMC in Report Year***: list **the**       |
|     **most important ways** in which the GRECC has had specific       |
|     impact on **host VAMC's** research, staff education, program      |
|     evaluation, or clinical care improvements for elderly veteran.*   |
|                                                                       |
| 1\. New **[Bone Mineral Density Clinic]{.underline}** established by  |
| GRECC staff (**Dr. Kenneth Lyles**) led to improved clinical care for |
| bone health at host VAMC: We established the clinic and facilitated   |
| the acquisition of a bone mineral density device so this assessment   |
| in our veterans would not have to be out-sourced. Two LPN's were      |
| trained as technicians and all forms were implemented in CPRS so that |
| the data could be entered when the scans were analyzed. The clinic    |
| was opened 5/06 and quickly expanded to two ½ days a week. All bone   |
| mineral density scans are interpreted by Dr. Lyles; Ambulatory Care   |
| physician Marisa DeSilva, MD, is also training to interpret scans.    |
|                                                                       |
| 2\. Development of [**computerized** **nursing home patient care      |
| algorithms**]{.underline}, based on evidence-based clinical practice  |
| guidelines, for the assessment and treatment of fever, urinary tract  |
| infections, pneumonia, falls and osteoporosis improved clinical care  |
| in the Durham VAMC ECRC (**Drs.** **Colon, Schmader, Twersky**).      |
|                                                                       |
| 3\. GRECC staff made [**important** **contributions to the            |
| administration of research programs at our host**                     |
| **VAMC**:]{.underline} **Dr. Miriam Morey** served as [Chair of the   |
| Research and Development Committee]{.underline} of the Durham VAMC.   |
| The R&D committee provides the primary oversight of all research      |
| activities at the host facility. **Dr. Greg Taylor** served as [Chair |
| of the Durham VA Subcommittee on Biosafety]{.underline}. His          |
| responsibility in this role was to insure the safety of research      |
| personnel for all research that is performed at this site. The        |
| committee reviews all research projects, educates research staff, and |
| insures that all projects meet national VA standards.                 |
|                                                                       |
| 4\. **[Pharmacy initiative enhances clinical care as well as          |
| geriatrics training.]{.underline}** The GRECC (**Dr. Francis**)       |
| worked closely with Campbell University to recruit Jennifer Schuh,    |
| PharmD, who completed two VA residency programs and now functions as  |
| a WOC clinical pharmacist practicing within the ECRC. This            |
| collaboration increases provision of clinical pharmacy services to    |
| this complex patient population and VA staff. In addition, more       |
| pharmacy students are exposed to geriatrics to facilitate future      |
| recruitment of residents.                                             |
|                                                                       |
| 5\. Drs. Whitson, **McConnell** & Hastings have implemented Project   |
| CHAT -- a CPRS template to provide **[point of care decision support  |
| to long-term care nurses]{.underline}** when they contact on-call     |
| physicians about patients who have new symptoms or who are acutely    |
| ill, resulting in an important improvement in clinical care.          |
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| b.  **GRECC Impact on VISN in the Report Year:** list **the** **most  |
|     important ways** in which the GRECC has had specific impact on    |
|     the **host** **VISN's** research, staff education, program        |
|     evaluation, or clinical care improvements for elderly veterans.   |
|                                                                       |
| 1\. **Dr. Harvey Cohen** contributes to research, education and       |
| clinical care in geriatrics across our VISN by serving on the **[VISN |
| Geriatrics and Extended Care Sub-council]{.underline}**.              |
|                                                                       |
| 2\. **Dr. McConnell** has partnered with VISN-6 leadership to         |
| develop, fund, and begin implementation of a **[learning              |
| collaborative approach to nursing education for care of veterans with |
| dementia in LTC]{.underline}**. All 8 medical centers are             |
| participating, and the expected outcome within this fiscal year is    |
| that staff will be developed who are capable of training and          |
| validating dementia-specific competencies for all LTC nursing staff   |
| on an annual basis.                                                   |
|                                                                       |
| 3\. The Palliative Care Consult Team (PCCT) is providing an           |
| **[on-going palliative care education program in our                  |
| VISN]{.underline}**. The PCCT, in conjunction with DVAMC and EES,     |
| have provided EPEC training for members of the PCCTs at VISN 6        |
| facilities and beginning in March, 2006, a series of telephone        |
| conferences for VISN 6 addressing topics in end of life care. Drs.    |
| **Toni Cutson, MD,** (DVAMC) and Jorge Cortina, MD, (Service Line     |
| Coordinator for Geriatrics and Extended Care, VISN6) have developed   |
| an educational module regarding VHA palliative/hospice care which is  |
| available on NetSix.                                                  |
|                                                                       |
| 4\. **Dr. Connie Bales** is serving on [two **AD/EE                   |
| workgroups**]{.underline} to promote priority topics and take         |
| advantage of educational plus research resources across all GRECCs.   |
| She serves as co-chair of the **[Geriatric Oncology]{.underline}**    |
| group and a member of the **[MOVE/Diet and Physical                   |
| Activity]{.underline}** group and will be able to facilitate these    |
| specialized topics in our host VISN with the support of these work    |
| groups.                                                               |
|                                                                       |
| 5\. **Dr. Helen Hoenig** has served in the **[Stroke                  |
| QUERI]{.underline}**, which is working to translate findings relative |
| to stroke care into the broader clinical setting. She has been        |
| involved at the VISN and at the national level because of concerns    |
| that policies that were about to be implemented would be particularly |
| harmful for stroke patients being cared for by geriatricians. As a    |
| result, those policies have since undergone substantive review.       |
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| c.  **GRECC Trend-Setting Innovations since October 1,                |
|     [2001]{.underline}**: *list **the** **most significant** GRECC    |
|     research, education or clinical innovations in the past five      |
|     years.*                                                           |
|                                                                       |
| 1\. **[Development of Knock-out Mouse Models for Aging Research       |
| Applications]{.underline}: Dr. Greg Taylor's** group has: (1)         |
| developed mouse models of increased susceptibility to infectious      |
| disease by inactivating members of the p47 GTPase gene family. With   |
| this approach, they have shown that these genes encode critical       |
| factors for innate resistance to *Mycobacterium tuberculosis* and     |
| other bacteria and protozoa relevant to aging populations. Current    |
| work is focused on defining mechanisms of action of these proteins    |
| and exploring the possibility of therapeutic applications. (2) They   |
| have also developed a mouse model of cognitive impairment by          |
| inactivating the neurally expressed gene, P311. They are now          |
| completing an initial characterization of this model.                 |
|                                                                       |
| 2**[. Leader in the development of the zoster vaccine,                |
| 1999-present.]{.underline}** **Dr. Kenneth Schmader** is a lead       |
| investigator, Executive Committee, Operating Committee, and Clinical  |
| Evaluation Committee member and Durham VAMC Site Principal            |
| Investigator in VA CSP #403, the Shingles Prevention Study. The       |
| incidence of herpes zoster and postherpetic neuralgia increase with   |
| age in association with a progressive decline in cellular immunity to |
| varicella-zoster virus. This landmark study tested the hypothesis     |
| that the zoster vaccine would decrease the incidence and/or severity  |
| of herpes zoster and postherpetic neuralgia in older veterans and     |
| non-veterans, presumably by boosting cellular immunity. The results   |
| of the study showed that the zoster vaccine reduced the incidence of  |
| herpes zoster by 51% and postherpetic neuralgia by 66%. Based on      |
| these results, the FDA recently licensed the vaccine for preventing   |
| herpes zoster in adults 60 years of age and older.                    |
|                                                                       |
| 3\. **[Incorporating physical activity prescriptions into clinical    |
| geriatrics practice]{.underline}**: **Drs. Morey, Peterson, McConnell |
| and Ms. Crowley** have conducted a body of research (2001-2007) aimed |
| at incorporating physical activity into primary care practice.        |
| Physical activity modules have been posted on the VA research website |
| and the research team is expanding efforts aimed at dissemination of  |
| this work. Preliminary findings indicate that primary care providers  |
| are receptive to having an exercise counselor provided enhance        |
| physical activity counseling to their patients which has resulted in  |
| marked increases in physical activity. Current efforts are examining  |
| functional outcomes and health associated costs.                      |
|                                                                       |
| 4\. **[Medications Appropriateness Index and                          |
| Applications]{.underline}:** We have developed the Medications        |
|                                                                       |
| Appropriateness Index and distributed it internationally to help      |
| educate health care providers regarding prescribing appropriateness   |
| in the elderly. Investigators in the US, Europe and Australia have    |
| used the                                                              |
|                                                                       |
| MAI as an outcome measure of prescribing appropriateness in           |
| epidemiology and intervention studies in older adults. **(Dr.         |
| Schmader)**                                                           |
|                                                                       |
| 5\. **[GEM Research and applications to elderly cancer                |
| patients:]{.underline}** GRECC staff members **HJ Cohen, MD, KW       |
| Lyles, MD, and P Seo, MD,** started a research program evaluating     |
| elderly cancer patients receiving chemotherapy or chemo-radiation     |
| therapy in the ECRC unit, GEM unit and outpatient geriatric clinic    |
| using multidisciplinary geriatric assessment tools in 2003. By better |
| understanding and detecting health changes in these elderly persons,  |
| beneficial supportive measures can be provided to these persons in    |
| future endeavors. This has become a national model.                   |
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| **5. RESEARCH**                                                       |
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| **a. Key Findings Published in the Report Year on projects for which  |
| GRECC Core Staff was PI or Co-PI:\                                    |
| ***list **five or fewer;** for each item provide GRECC Core Staff     |
| name(s), journal reference, and description of topic/                 |
| method/results/clinical significance.* *Please limit each response to |
| [5 lines or fewer]{.underline}.*                                      |
|                                                                       |
| 1\. **Koenig HG** (2006). Depression outcome in medical inpatients    |
| with congestive heart failure.                                        |
|                                                                       |
| [Archives of Internal Medicine]{.underline} 166:991-996               |
|                                                                       |
| *This study, one of the largest and most detailed studies to date on  |
| older adults with depression and congestive heart failure, found that |
| the outcome of minor depression may be more dependent on physical     |
| stressors, while whereas major depression seems more affected by      |
| intrinsic vulnerability (family history of depression, etc.). Many    |
| patients with major depression were not treated, and few (\< 10%) had |
| psychiatric consultations.*                                           |
|                                                                       |
| 2\. Kaye KS, Caughlin K, Sloane R, Sexton DJ, **Schmader KE.** Risk   |
| factors for surgical site infections in the elderly. J Am Geriatr Soc |
| 2006;54:391-396.                                                      |
|                                                                       |
| *Surgical site infections (SSI) account for 11% of all nosocomial     |
| infections in older adults and are associated with substantial        |
| attributable mortality and costs. This study identified several       |
| independent predictors for SSI in the elderly, including comorbid     |
| conditions (COPD and obesity), peri-operative variables (wound class) |
| and socio-economic factors (private insurance, which was associated   |
| with decreased SSI risk). The results from this study can be used to  |
| design and implement interventions for SSI prevention geared towards  |
| high risk elders.*                                                    |
|                                                                       |
| 3**. Colon-Emeric, C**., Schenck, A., Gorospe, J., McArdle, J.,       |
| Dobson, L, DePorter, C. & **McConnell,E.S**. (2006). Translating      |
| Evidence-Based Falls Prevention into Clinical Practice in Nursing     |
| Facilities: Results and Lessons from a Quality Improvement            |
| Collaborative. [Journal of the American Geriatrics                    |
| Society]{.underline}. 54(9): 1414-1418.                               |
|                                                                       |
| *Quasi-experiment evaluating the impact of a learning collaborative   |
| on falls-risk reduction by comparing implementation of evidence-based |
| falls risk reduction strategies among 36 participating in a quality   |
| improvement organization sponsored learning collaborative and 353     |
| non-participating community nursing homes in NC who did not           |
| participate. This evaluation sheds light on some factors that may     |
| influence adoption of evidence-based falls-reduction practices, as    |
| well as the importance of using multiple sources of data for          |
| evaluation of effectiveness of learning collaboratives.*              |
|                                                                       |
| 4\. **Morey MC**, **Ekelund CC, Pearson MP, Crowley GM, Peterson      |
| MJ**, Sloane R, Pieper CF, McConnell E, Bosworth H. Project LIFE: A   |
| partnership to improve physical activity in elders with multiple      |
| chronic illnesses, [Journal of Aging and Physical                     |
| Activity]{.underline}, 2006, 14:324-343.                              |
|                                                                       |
| *This article describes a randomized trial comparing usual care to a  |
| primary care based partnership between providers, veterans, and       |
| exercise health counselors aimed at increasing physical activity      |
| among older adults with multiple chronic illnesses. Patients          |
| receiving the partnership care sustained an increase in physical      |
| activity over the study period.*                                      |
|                                                                       |
| 5\. Rao AV, Hsieh F, Feussner JR, and **Cohen HJ:** Geriatric         |
| Evaluation and Management Units in the Care of the Frail Elderly      |
| Cancer Patient. Journal of Gerontology: Medical Sciences,             |
| 60A:6:798-803, 2005.                                                  |
|                                                                       |
| *This study utilized data from the National Cooperative GEM study and |
| evaluated the 100 cancer patients enrolled. The GEM inpatient         |
| intervention produced strikingly greater pain control, persisting for |
| a full year, as well as better emotional status and quality of life.* |
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| b\. Key Findings Published in the Report Year on work in which GRECC  |
| Core Staff served as Co-Investigators to a Non-GRECC PI: list five or |
| fewer; for each item provide GRECC Core Staff name(s), journal        |
| reference, and description of topic/method/results/clinical           |
| significance. Please limit each response to [5 lines or               |
| fewer]{.underline}.                                                   |
|                                                                       |
| 1\. Journal reference: Payne ME, Hybels CF, **Bales CW**, and         |
| Steffens DC. (2006) Vascular nutritional correlates of late-life      |
| depression. [American Journal Geriatric Psychiatry]{.underline}       |
| 14:787-795.                                                           |
|                                                                       |
| *Provides evidence that dietary vascular risk factors differ (higher  |
| intakes of cholesterol, higher Keys score, and lower alcohol intake)  |
| in individuals with current or prior depression when compared with    |
| individuals with no such history.*                                    |
|                                                                       |
| 2\. Denny SD, Kuchibhatla MN, and **Cohen HJ**. Impact of Anemia on   |
| Mortality, Cognition and Function in Community-Dwelling Elderly. The  |
| American Journal of Medicine, 119:327-334, 2006.                      |
|                                                                       |
| *In a population-based sample of people over age 65 years, anemia as  |
| defined by the WHO, was very common. Blacks were 3 times more likely  |
| to have anemia as whites. The presence of anemia was associated with  |
| poorer functional and cognitive status and predicted worse 4 year     |
| survival, functional status and cognitive status.*                    |
|                                                                       |
| 3\. Steinhauser KE, Voils C, **Clipp EC**, Bosworth HB, Christakis N, |
| Tulsky JA. "Are You at Peace?" One Item to Probe Spiritual Concerns   |
| at the End of Life. *Archives of Internal Medicine*, Vol 166,         |
| 101-105, 2006.                                                        |
|                                                                       |
| *This research sought to identify a practical, evidence-based         |
| approach to discussing spiritual concerns within the                  |
| physician-patient relationship. Analysis of the "at peace" construct  |
| using a sample of older patients with advanced cancer, CHF, or COPD   |
| indicate its use as a gateway to larger discussions, framed by        |
| patients' values, preferences, and life experiences. Specific         |
| language patients use in response to the question, "Are you at        |
| peace?" reveals their frame of reference, dimensions of distress, and |
| acceptable terminology for discourse.*                                |
|                                                                       |
| 4\. Demark-Wahnefried W, **Clipp EC**, **Morey M,** Pieper CF, Sloane |
| R, Snyder DC, **Cohen HJ**. A Lifestyle Intervention Development      |
| Study to Improve Physical Function in Older Adults with Cancer:       |
| Outcomes from Project LEAD (Leading the Way in Exercise and Diet).    |
| *Journal of Clinical Oncology*, Vol 24, No 21, 3465-3473, July 20,    |
| 2006.                                                                 |
|                                                                       |
| *This intervention development study suggests that home-based diet    |
| and exercise interventions are potentially useful interventions to    |
| improve physical function in older cancer survivors. Older cancer     |
| patients are receptive to making lifestyle changes that can favorably |
| alter their functional trajectory.*                                   |
|                                                                       |
| 5\. Singh SB, Davis AS, **Taylor GA**, and Deretic V (2006) Human     |
| IRGM induces autophagy to eliminate intracellular Mycobacteria.       |
| *Science* 313, 1438-1441.                                             |
|                                                                       |
| *This paper is the first to demonstrate that a human homologue of the |
| mouse p47 GTPase family is important for immune resistance to         |
| Mycobacterial infection.*                                             |
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| **6. EDUCATION**                                                      |
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|                                                                       |
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| a.  **Innovations in Educational Activities Implemented during the    |
|     Report Year** (list five or fewer. Please limit each item to [5   |
|     lines or fewer]{.underline} and include clarification of how each |
|     activity is innovative.)                                          |
|                                                                       |
| 1*.* Veterans Affairs (VA) Research **[Career Development Awards and  |
| Aging Research Workshop]{.underline}**, at the 2006 Annual Scientific |
| Meeting of the American Geriatrics Society, Chicago, IL. **Kenneth    |
| Schmader**, MD Durham VA GRECC, Chair of VA Subcommittee of AGS       |
| Research Committee, led the development of this well attended (50     |
| attendees) program. The goals of the workshop were to educate junior  |
| and senior faculty about the new VA CDA process and the various VA    |
| research programs in aging. VA Research and Development staff         |
| provided an overview of the new CDA and VA aging research programs.   |
|                                                                       |
| 2\. A critical mass of ECRC Staff nurses have attended a 6-session    |
| continuing education series funded by the Health Resources and        |
| Resources Administration award to **Dr. McConnell** to improve        |
| nursing clinical and leadership skills to implement **[evidence-based |
| practices in geriatric nursing]{.underline}**. These nurses now       |
| provide leadership throughout the ECRC on implementation of key       |
| programs such as prompted voiding, and other evidence-based care      |
| approaches.                                                           |
|                                                                       |
| 3 [**. Teaching Geriatrics in the Medical Subspecialties: Focus on    |
| Cardiology and Oncology**.]{.underline} In September, 2006, this      |
| unique program brought together cardiologists and oncologists from VA |
| and non-VA institutions across the country, as well as from Duke and  |
| the Durham VAMC, for a three-day symposium and workshop focusing on   |
| special topics in Geriatrics relevant to the medical sub-specialist.  |
| The workshop also focused on practical information to enhance the     |
| teaching of geriatrics in the fields of cardiology and oncology. The  |
| attendees of this program are encouraged to develop and deliver       |
| educational projects in geriatrics, and will receive mentoring and    |
| support from the Mini-fellowship program faculty throughout the year  |
| ahead.                                                                |
|                                                                       |
| 4\. **[GRECC symposia at GSA on Bone Density                          |
| assessment]{.underline}** The Durham GRECC sponsored a                |
|                                                                       |
| Symposium at the annual GSA meeting in Orlando, FL, in Nov., 2005.    |
| The title was \"Osteoporosis: From Bench to Bedside\". Investigators  |
| from three GRECC\'s participated; Guy Howard, PhD and Bruce Troen,    |
| MD,PhD from the Miami GRECC, H. Michael Perry,MD from the St. Louis   |
| GRECC, and **Kenneth W. Lyles, MD,** from the Durham GRECC. The       |
| symposium was well attended and the attendees reported that the       |
| information provided was useful.                                      |
|                                                                       |
| 5\. **[Mini-fellowship offers Long-Term Care training.]{.underline}** |
| In April, 2006 we offered the first annual Mini-fellowship in         |
| Long-Term Care Education to faculty scholars from VA and non-VA       |
| institutions across the country. During this weeklong intensive       |
| faculty development workshop, participants focus on the development   |
| of a Long-Term Care educational project for implementation in their   |
| home institution. Through workshops and mentoring sessions with       |
| Mini-fellowship faculty and observation of Long-Term Care curricula   |
| in action, the scholars honed their own skills in curriculum and      |
| project development and delivery. These scholars will receive         |
| mentoring and support from Mini-fellowship faculty throughout the     |
| year to help bring their educational projects to fruition.            |
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| b.  Exportable Educational Products First Available for Distribution  |
|     in Report Year *List five or fewer of the most important          |
|     products.*                                                        |
|                                                                       |
| 1\. **[Pocket Guide]{.underline} for Project CHAT.** Dr. McConnell    |
| and other clinical staff at our GRECC developed the CPRS template to  |
| provide **[point of care decision support to long-term care           |
| nurses]{.underline}** when they contact on-call physicians about      |
| patients who have new symptoms or who are acutely ill, resulting in   |
| an important improvement in clinical care.                            |
|                                                                       |
| 2\. **Dr. Cutson** and the Palliative Care Consult Team developed a   |
| **[Palliative Care lecture series that is web- and                    |
| podcast-compatible]{.underline}** and obtained approval for CME       |
| credits. It is available for distribution in either format. In the    |
| coming year, information on the impact of the training as well as     |
| participant feedback about the training will be collected.            |
|                                                                       |
| 3\. [**Core Curriculum in geriatics training for                      |
| fellows**:]{.underline} Components of our core curriculum for         |
| geriatrics fellows have been packaged for exportation as Powerpoint   |
| presentations. New sessions available this year are: "Behavior        |
| Disorders in Dementia", "Common Infections in Long-Term Care", and    |
| "Female Urinary Incontinence". These presentations are appropriate    |
| for fellows and other learners and are available at                   |
| http://careinaging.duke.e                                             |
| du/clinicians/concept.php?method=resources&ExperienceID=27&TopicID=79 |
| with username and password \'geriatrics.\' Each of the presentations  |
| has been evaluated by the fellows to whom they were delivered and     |
| this evaluation data will be used to inform the development of next   |
| year\'s Core Curriculum series for the Geriatrics Fellows.            |
|                                                                       |
| 4\. **[Program for integration of faith communities into disaster     |
| response systems]{.underline}**: *In the Wake of Disaster: Religious  |
| Responses to Terrorism and Catastrophe*. Philadelphia: Templeton      |
| Foundation Press. GRECC staff (**Dr.Koenig**) published this book,    |
| explaining the role that faith communities can play in responding to  |
| acts of terrorism (like Sept 11) and natural disasters (like          |
| hurricane Katrina). It describes the current disaster response        |
| system, and calls for integration of faith communities into that      |
| system in order to increase the resilience of communities in bounding |
| back after these events. The target audience is emergency management  |
| service (EMS) agencies and directors, EMS workers, and faith          |
| communities. Although there is no current evaluation plan, given the  |
| priority of this area, this is likely to occur in the near future.    |
|                                                                       |
| 5\. **[Cases for training in subspecialty care of the older           |
| adult:]{.underline}** GRECC staff (**Heflin**) created four cases     |
| specifically relevant to cardiologists and oncologists caring for     |
| older adults, complete with references, that are available for        |
| distribution on Duke\'s Care in Aging website. The cases cover the    |
| following topics: "ACS and Cardiac Surgery"; "Heart Failure/AICD";    |
| "An Approach to Fatigue, Anemia and Acute Myeloid Leukemia in the     |
| Elderly"; and "Medications and Older Patients". These cases are       |
| targeted toward fellows and residents, and can be accessed with       |
| username and password \'geriatrics\' at                               |
| http://careinagi                                                      |
| ng.duke.edu/clinicians/concept.php?method=experience&ExperienceID=40. |
| Evaluation data on these cases was collected from attendees at the    |
| Symposium where they were first presented and the results will be     |
| used to shape future educational programs of this type.               |
+-----------------------------------------------------------------------+
| **7. CLINICAL DEMONSTRATION PROJECTS---**                             |
+-----------------------------------------------------------------------+
| a.  Clinical Demonstration Projects Underway in Report Year: list all |
|     GRECC Clinical Demonstration Projects underway.                   |
|                                                                       |
| 1\. **[Establishing a Bone Mineral Density Clinic:]{.underline}** Our |
| GRECC staff (**Dr. Lyles**) led the way in establishing a bone        |
| mineral density clinic at our host VAMC, including the selection and  |
| purchase of optimal bone density scanning equipment, technician       |
| training and standardization of the performance characteristics of    |
| the machine. All of the required forms were developed in CPRS so that |
| the data could be entered when the scans were analyzed. The clinic    |
| opened in May, 2006, and is now fully functional. In addition, this   |
| model for the establishment of a bone density clinic in collaboration |
| with the host VA Medical Center can be duplicated at other            |
| facilities. This program is [**New**.]{.underline}                    |
|                                                                       |
| 2\. **Dr. Eleanor McConnell**, with Carol Feldman, RN, MSN, has       |
| implemented a model for ambulatory care nurses to engage routinely in |
| evaluation and implementation of **[evidence-based clinical practices |
| (EBCP) in the primary care clinics]{.underline}**. Two new nursing    |
| staff members are now enrolled in Dr. Heflin's Evidence-Based         |
| Geriatric Medicine Mini-Course. This program is                       |
| [**Ongoing**.]{.underline}                                            |
|                                                                       |
| 3\. **Dr. Eleanor McConnell** and the geriatrics clinic staff,        |
| including **Drs. Heflin, Ruby**, Hastings, and Potu, participated in  |
| the development and testing of a **[VISN 6-wide Clinical              |
| Reminder]{.underline}**, based on a Office of Medical Inspectors\'    |
| report on firearms and driving use, and informed by inclusion of      |
| recent evidence on dementia safety. The clinical reminder has most    |
| recently been exported to the VHA via a document circulated by Dr.    |
| Susan Cooley, Office of Geriatrics and Extended Care. We are now in   |
| the process of designing an evaluation of the reminder, designed to   |
| both assess the extent of adoption of the reminder and to identify    |
| barriers to full implementation. This program is                      |
| **[ongoing]{.underline}** this year.                                  |
|                                                                       |
| 4\. **Dr. Eleanor McConnell** worked with geriatric fellows Whitson   |
| and Hastings, and the ECRC quality improvement team to develop and    |
| implement a **[CPRS-based decision-support tool]{.underline}** for    |
| long term care nurses to use when they call physicians after hours    |
| regarding clinical problems. The project is **[ongoing]{.underline}** |
| this year.                                                            |
|                                                                       |
| 5\. Gerofit investigators (**Morey, Crowley and Peterson**) are       |
| collaborating with the **[local host VAMC to implement the Managing   |
| Overweight/Obesity in Veterans Everywhere (MOVE!) program in          |
| geriatric patients]{.underline}**. This nationally mandated program   |
| is in the process of being implemented at our VAMC and one caveat is  |
| that MOVE! is considered optional for veterans over age 69.           |
| Investigators at the Durham VA, are assisting with educational        |
| classes offered to MOVE! patients but have also facilitated entry of  |
| MOVE! patients ages 65 and over into the Gerofit program. This will   |
| give us the opportunity to examine outcomes in the subset of patients |
| who have access to facility-based exercise programs and to examine    |
| functional trajectories in older MOVE! participants. This program is  |
| [**New**.]{.underline}                                                |
|                                                                       |
| 6\. Development of **[computerized]{.underline} [nursing home patient |
| care algorithms]{.underline}**[,]{.underline} based on evidence-based |
| clinical practice guidelines, for the assessment and treatment of     |
| fever, urinary tract infections, pneumonia, falls and osteoporosis in |
| the Durham VAMC ECRC (**Drs.** **Colon, Schmader, Twersky**). This    |
| program is [**New**.]{.underline}                                     |
+-----------------------------------------------------------------------+
| b.  **Evaluation of Clinical Demonstration Projects:** [for each      |
|     GRECC Clinical Demonstration Project listed in 7a                 |
|     above,]{.underline} summarize the evaluation activity.            |
|                                                                       |
| 1\. **[Bone Mineral Density Clinic]{.underline}**. This clinic was    |
| originally scheduled for one half-day per week. It has been so        |
| successful and in demand that a second half-day has already been      |
| added. Utilization rates have been tracked since July, 2006, and are: |
| July 30%; August 57%, and September 61%. We will obtain written       |
| feedback after 9 months of clinic operation from both the patients    |
| and the providers we serve.                                           |
|                                                                       |
| 2\. **Evidence-Based Clinical Practice in Ambulatory Care:**          |
| Evaluation includes the following: 1) The Primary Care Nursing        |
| Service group in Ambulatory Care Service was awarded a \"Nursing Best |
| Practices Award\" in January, 2006 for its change in cerumen-removal  |
| procedure, based on a staff nurse-led review and application of       |
| current evidence.                                                     |
|                                                                       |
| 2\) Evaluation of the practice change in fecal occult blood testing   |
| (FOBT) dietary instructions was accomplished by comparing FOBT order  |
| and completion rates for a 6-month period before the change, and a    |
| comparable 6-month period the following year. Results showed an 11%   |
| increase in FOBT completion rate, without a concomitant rise in false |
| positives on colonoscopy.                                             |
|                                                                       |
| 3\) A similar evaluation is planned to examine the success rate in    |
| removing cerumen impactions when irrigations are preceded by the use  |
| of liquid co lace. In a prior review, the success rate for removal of |
| cerumen impactions was only 33%.                                      |
|                                                                       |
| 3\) To date, 24 ambulatory care nurses have received formal training  |
| in EBCP methods; 6 have completed Dr. Heflin's Evidence-Based         |
| Medicine in Geriatrics Mini-course, with 2 more enrolled in this      |
| fiscal year. With Ms. Feldman\'s promotion the potential exists to    |
| reach approximately 160 nursing staff in the ambulatory care service. |
|                                                                       |
| 3: **[VISN 6-wide Clinical Reminder:]{.underline}** The VISN-6        |
| Dementia safety reminder was disseminated as a part of the VA CO      |
| DEMENTIA SAFETY REVIEW WORK GROUP in March, 2006. The VISN-06 team    |
| has formed an evaluation work group that is designing a VISN-wide     |
| evaluation that will address the extent of adoption of the clinical   |
| reminder, resources required to adopt the reminder, and primary car   |
| provider perceptions of factors influencing adoption. Specific        |
| questions to be answered in this evaluation include: (1) What is the  |
| current rate of reminder completion by primary care panel? (2) What   |
| is the current rate at which driving and firearms required            |
| assessments are completed (3) What is the current rate at which       |
| optional safety issues (falls, fire, and wandering) are addressed?    |
| (4) When the reminder is completed, how frequently does patient       |
| counseling occur (5) When the reminder is completed, how frequently   |
| does reporting to the DMV occur? (6)What factors (barriers and        |
| facilitators) influence provider completion of the reminder? and (7)  |
| Is availability of interdisciplinary team resources associated with   |
| higher completion rates?                                              |
|                                                                       |
| **[4: CPRS-based decision-support tool:]{.underline}** The program    |
| has been evaluated by assessing nursing and medical staff             |
| satisfaction with the on-call encounter, and by examining health      |
| services utilization such as referrals to emergency department before |
| and after implementation of decision-support. Data collection is      |
| complete, but analyses are ongoing.                                   |
|                                                                       |
| 5\. **[Implementation of the Managing Overweight/Obesity in Veterans  |
| Everywhere (MOVE!) program for geriatric patients:]{.underline}**.    |
| Evaluation of this initiative will occur at various levels. First we  |
| will determine what percentage of MOVE! participants are over age 65; |
| second we will determine what percentage of MOVE! participants        |
| referred to Gerofit actually enroll; third, among patients enrolling  |
| in Gerofit we will evaluate physical function and baseline, and 3, 6  |
| and 12-month follow-up.                                               |
|                                                                       |
| 6: **[Computerized Nursing Home Patient Care                          |
| Algorithms]{.underline}**: Focus groups of VA and non-VA nursing home |
| personnel were conducted and the results used to design the patient   |
| care algorithms and their use in the Durham VAMC ECRC. Identified     |
| barriers include hierarchical communication patterns among care       |
| providers, excessive paperwork, time pressures, guideline length and  |
| complexity, and belief that guideline use inhibits individualized     |
| care. Facilitators include an open communication style between        |
| medical and front-line nursing providers, and some care planning      |
| structures. Current management for the 5 targeted geriatric syndromes |
| revealed inconsistent application of guideline-recommended care with  |
| some elements routinely adopted, some rarely or never adopted, and    |
| some specifically discouraged practices (e.g. restraint use to        |
| prevent falls) commonplace.                                           |
+-----------------------------------------------------------------------+
| c.  **New Clinical Models developed at your GRECC that were exported  |
|     in the Report Year**:                                             |
|                                                                       |
| 1\. **[Improving Dementia Care in LTC Units]{.underline}** through:   |
| a) Developing and applying knowledge of interplay of disease process  |
| in dementia, with individual veteran\'s life history and environment, |
| b) Developing and applying consistently positive physical approach    |
| skills and cueing skills that include visual, verbal and tactile      |
| cues, applied in that order, c) Use of hand-under-hand technique when |
| assisting with physical care and d) Dealing with distressing behavior |
| through changing words, location or activity, rather than through use |
| of restraint.                                                         |
|                                                                       |
| 2\. The **[VISN 6-wide Clinical Reminder]{.underline}**, based on a   |
| Office of Medical Inspectors\' report on firearms and driving use,    |
| and informed by inclusion of recent evidence on dementia safety was   |
| most recently been exported to the VHA via a document circulated by   |
| Dr. Susan Cooley, Office of Geriatrics and Extended Care.             |
|                                                                       |
| 3\. **[Model of Spiritual Care]{.underline}: Dr.** **Koenig** has     |
| developed a power point presentation describing a model of spiritual  |
| care that involves taking a spiritual history, supporting the         |
| spiritual beliefs of patients, referring to pastoral care, and        |
| working together with faith communities to ensure care in the         |
| community after hospital discharge. It has been exported to the       |
| following sites:Southern Medical Association (Atlanta, GA);           |
| Stonybrook University (Long Island, NY); Lutheran Medical Center      |
| (Brooklyn, NY); Saginaw State University (Saginaw, MI); University of |
| Saskachuwan (Saskatoon, SK, Canada); and University of Wisconsin (Eau |
| Claire, WI)                                                           |
|                                                                       |
| 4\. **Dr. Kenneth Lyles** and colleagues work on **[Paget's           |
| disease]{.underline}** \[Reid et al. [N Eng J Med]{.underline} 2005:  |
| Sept 1;353(9):898-908\] led to a new **[model of care]{.underline}**  |
| for this disease. The results of this work were used by Novartis to   |
| submit an application to the FDA to use intravenous zoledronic acid   |
| as a treatment for Paget\'s disease of bone.                          |
|                                                                       |
| 5\. As a geriatrics fellow, Dr. Ted Suh observed the geriatric        |
| oncology programs developed by our GRECC at the Durham VA. Upon       |
| completing his fellowship, Dr. Suh took a faculty position at the     |
| Cleveland Clinic and has begun a **[geriatric]{.underline}**          |
| **[oncology clinic utilizing geriatric evaluation and management      |
| principles developed at the Durham GRECC]{.underline}** for use with  |
| elderly cancer patients, as described in this paper: Rao AV, Hsieh F, |
| Feussner JR, and **Cohen HJ:** Geriatric Evaluation and Management    |
| Units in the Care of the Frail Elderly Cancer Patient. [J Gerontol:   |
| Med Sci]{.underline}, 60A:6:798-803, 2005.                            |
+-----------------------------------------------------------------------+
| **8. CONSULTATION AND OUTREACH**                                      |
+-----------------------------------------------------------------------+
| NOTE: **Consultation** = GRECC staff going to sites **[within host    |
| VAMC]{.underline}** or having those staff come to the GRECC, to       |
| assist in development of research, education or clinical programs at  |
| those sites. **Outreach** = GRECC staff going to **[non-host VAMC     |
| facilities]{.underline}** or having those staff come to the GRECC (in |
| person or by video or other technology) to assist in development of   |
| research, education or clinical programs at those sites.              |
+-----------------------------------------------------------------------+
| b.  **Current Year Activity Outcomes** (list up to five examples, up  |
|     to two lines each; summarize specific outcomes realized from      |
|     current year **consultation**, e.g., "Host VAMC instituted a      |
|     Falls Clinic after consultation from GRECC staff;" or             |
|     **outreach**, e.g., [X]{.underline} VAMC instituted a Falls       |
|     Clinic after GRECC outreach via series of videoconferences).      |
|                                                                       |
| **Consultation:**                                                     |
|                                                                       |
| 1\. **[Bone density measurement clinic]{.underline}** established:    |
| Our GRECC staff (**Dr. Lyles**) led the way in establishing a bone    |
| mineral density clinic at our host VAMC. The clinic opened in May,    |
| 2006.                                                                 |
|                                                                       |
| 2\. Two part-**[lecture series on Anti-psychotic Use in Elderly       |
| Patients]{.underline}** by GRECC staff emphasized medication safety   |
| and highlighted new data on the need for appropriate use to help      |
| improve utilization practices for these medications (**Dr.            |
| Francis**).                                                           |
|                                                                       |
| **Outreach:**                                                         |
|                                                                       |
| 3\. **[Computerized]{.underline} [nursing home patient care           |
| algorithms]{.underline}**[,]{.underline} based on evidence-based      |
| clinical practice guidelines, for the assessment and treatment of     |
| fever, urinary tract infections, pneumonia, falls and osteoporosis,   |
| are being developed at Salisbury VAMC (**Drs.** **Colon, Schmader,    |
| Twersky**).                                                           |
|                                                                       |
| 4\. **[GRECC symposia at GSA on Bone Density                          |
| assessment]{.underline}**: The Durham GRECC collaborated on a         |
|                                                                       |
| Symposium at the annual GSA meeting in Orlando, FL, in Nov., 2005.    |
| The title was \"Osteoporosis: From Bench to Bedside\".                |
|                                                                       |
| 5\. **[Dementia Conference call series]{.underline}**; **Dr.          |
| McConnell** has partnered with VISN-6 leadership to develop, fund,    |
| and begin implementation of a learning collaborative approach to      |
| nursing education for care of veterans with dementia in LTC. All 8    |
| medical centers in our VISN are participating.                        |
+-----------------------------------------------------------------------+
| **Previous Years' Activities Outcomes**                               |
|                                                                       |
| **1.** In the past 1-2 years, **Dr. Koenig** gave                     |
| [in-depth]{.underline} presentations on integrating spirituality into |
| patient care at: (a) all the Ohio VISN VA\'s (Cleveland, Columbia,    |
| Cincinnati, Dayton, Chillicothe) in 2005;                             |
|                                                                       |
| \(b\) Johnson City (TN) VA in 2004;                                   |
|                                                                       |
| \(c\) Salisbury (NC) VA and, especially, all [Pennsylvania VISN       |
| VA\'s]{.underline} in 2003.                                           |
|                                                                       |
| Partly as a result of these efforts, this year (2006) Dr. Ira Katz    |
| (University of Pennsylvania, Philadelphia) initiated a major          |
| **[collaborative effort between all of the chaplains in the VA        |
| system]{.underline}** and the VA mental health division to develop a  |
| **[joint project for meeting the mental health (and spiritual) needs  |
| of veterans]{.underline}** in the United States. Dr. Katz is          |
| currently working with Dr. Keith Meador to develop this system.       |
+-----------------------------------------------------------------------+