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| ### GERIATRIC RESEARCH, EDUCATION AND CLINICAL CENTER                 |
|                                                                       |
| ### *Annual Report: Fiscal Year [2004]{.underline}*                   |
|                                                                       |
| ######## Part II: Accomplishments                                     |
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| **NOTE:** The **GRECC Annual Report** reflects status and             |
| accomplishments of **[GRECC Core Staff]{.underline}** (as defined     |
| below) [only]{.underline}. Report year is from [October 1 through     |
| September 30]{.underline}. [This Accomplishments report should be no  |
| more than a [total of ten pages]{.underline}.]{.mark}                 |
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| **GRECC Core Staff** includes **Primary Core**, **Affiliated Core,**  |
| and **Research Core.** **Primary Core =** positions authorized by the |
| original GRECC allocation plus any addition in ceiling from VA        |
| Central Office specifically designated for GRECC. **Affiliated Core** |
| = Staff who work full- or part-time in [direct support]{.underline}   |
| of the GRECC's research, education or clinical activity. May be       |
| either "contributed" by the VA Medical Center or acquired through     |
| centralized enhancements/awards for programs such as Home-Based       |
| Primary Care, Geriatric Evaluation and Management Program, etc. To be |
| considered Affiliated Core, staff must be organizationally aligned    |
| under the GRECC or specifically identified by the Medical Center as   |
| GRECC-affiliated staff. **Research Core** = Full-or part-time staff   |
| who devote 51% or more of their total time to GRECC research and      |
| whose salaries are supported by research funds (either VA or non-VA). |
| Includes all GRECC staff whose salaries are paid from research funds  |
| (e.g., Associate Investigator, Assistant Research Scientist, Senior   |
| Research Career Scientist; Research Career Scientist, Advanced        |
| Research Career Scientist).                                           |
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| **1. GRECC NAME/LOCATION**                                            |
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| a.  **GRECC Name:** Minneapolis GRECC                                 |
|                                                                       |
| b.  **Location** *(facility, VISN)*: VISN 23                          |
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| **2. CONTACT PERSON**                                                 |
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| a.  **Name:** Maurice Dysken, M.D.                                    |
|                                                                       |
| b.  **Position:** Director, Minneapolis GRECC                         |
|                                                                       |
| c.  **Phone, e-mail:** 612-467-3308, maurice.dysken@med.va.gov        |
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| **3. GRECC FOCUS AREA(S)**                                            |
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| **NOTE:** Each problem area should ideally be approached from the     |
| basic biomedical, clinical [and]{.underline} health services research |
| perspectives, as well as from the rehabilitation research perspective |
| where that expertise exists. The number of problem areas should be    |
| limited to one or two. If the focus of research is different for      |
| basic biomedical, clinical, health services and/or rehabilitation     |
| research, there should be no more than a [total]{.underline} of 4     |
| major areas of investigation. [Changes to GRECC focus area(s) must be |
| approved by VACO (114).]{.mark}                                       |
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| a.  **Basic Biomedical**: Neurochemistry, Pharmacology, Imaging,      |
|     Animal models                                                     |
|                                                                       |
| b.  **Applied Clinical**: Alzheimer's disease, Clinical trials,       |
|     Neuropsychology                                                   |
|                                                                       |
| c.  **Health Services**: New models of health care delivery           |
|                                                                       |
| d.  **Rehabilitation**:                                               |
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| **4. ADMINISTRATION**                                                 |
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| a.  **GRECC Impact on Host VAMC in Current Year** *([list up to       |
|     five]{.mark} most important ways in which the GRECC has had       |
|     specific impact on host VAMC research, staff education, program   |
|     evaluation, or clinical care improvements for elderly veteran,    |
|     i.e., how the GRECC has "made a difference" in these areas within |
|     the entire host VAMC; [up to five lines each]{.mark})*:           |
|                                                                       |
| -   Research funding from GRECC investigators totaled approximately   |
|     \$2.3 million in FY04                                             |
|                                                                       |
| -   Recruited and hired Dr. Kelvin Lim to the GRECC Research Core     |
|                                                                       |
| -   GRECC is accredited to offer continuing education credits for     |
|     physicians, physician assistants, social workers, medical         |
|     administrators and psychologists                                  |
|                                                                       |
| -   Stipends are provided to the VAMC for trainees in nursing,        |
|     psychology, social work, pharmacy, and rehabilitation medicine    |
|     funded by the Associated Health Trainee program under the         |
|     auspices of the GRECC                                             |
|                                                                       |
| -   The GRECC Memory Loss Clinic is a model for the assessment and    |
|     treatment of dementia and serves as a training site for health    |
|     care trainees from numerous services at the Minneapolis VAMC      |
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| b.  **GRECC Impact on VISN in Current Year** *([list up to            |
|     five]{.mark} most important ways in which the GRECC has had       |
|     specific VISN-wide impact on research, education/training,        |
|     program evaluation, or clinical care improvements for elderly     |
|     veterans, i.e., how GRECC participation in VISN-wide activities   |
|     has "made a difference" in these areas within the entire VISN;    |
|     [up to five lines each]{.mark}.* NOTE: GRECCs are intended and    |
|     expected to serve as a [regional]{.underline}, and not merely     |
|     local resource*)*:                                                |
|                                                                       |
| -   During FY04 approximately 100 hours of accredited education was   |
|     provided to facility and VISN employees without tuition cost      |
|                                                                       |
| -   GRECC worked with professional organizations to jointly sponsor   |
|     national and international conferences that provided an           |
|     additional 50 hours of accredited education to health care        |
|     professionals from the VA and the community                       |
|                                                                       |
| -   The GRECC continues to be a major developer in the production of  |
|     national, live and interactive satellite programs for health care |
|     professionals in the VISN and VA System as well as in the         |
|     community at large                                                |
|                                                                       |
| -   The GRECC driving and dementia survey provided the basis for an   |
|     assessment algorithm used in the GRECC clinic and has been made   |
|     available to VISN facilities                                      |
|                                                                       |
| -   Michael Kuskowski provided expertise in research design and       |
|     statistical analysis for VISN 23 staff outside of GRECC           |
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| c.  **GRECC Trend-Setting Innovations since October 1,                |
|     [1999]{.underline}** *([list up to five]{.mark} most significant  |
|     GRECC research, education or clinical innovations in past five    |
|     years; for each item, provide date, GRECC staff responsible, and  |
|     [up to five line]{.mark} description)*:                           |
|                                                                       |
| -   Development of animal models for research in Alzheimer's disease  |
|     **(Karen Ashe, M.D., Ph.D. and James Cleary, Ph.D.)** Dr. Ashe's  |
|     current laboratory research is directed at understanding and      |
|     treating memory loss in Alzheimer's disease. She is involved in   |
|     four main areas of investigation: the creation of transgenic      |
|     models of Alzheimer's disease; understanding the molecular basis  |
|     of memory loss in transgenic mice modeling Alzheimer's disease;   |
|     modulating memory loss using immunological, genetic and           |
|     pharmacological approaches; and testing promising therapies in    |
|     patients with Alzheimer's disease. Dr. Cleary's research is       |
|     focused on behavioral and CNS effects of Alzheimer\'s disease and |
|     its potential treatments. The major area of interest is the       |
|     neurotoxic and behavioral effect of the beta amyloid peptide.     |
|     Beta amyloid is the major component of the plaques found in the   |
|     brains of patients suffering from Alzheimer\'s disease and is     |
|     implicated in the cascade of neurological events leading to       |
|     neural and behavioral pathogenesis. Dr. Cleary uses several       |
|     laboratory animal models of the disease to investigate pathogenic |
|     mechanisms and treatments related to this peptide.                |
|                                                                       |
| -   Regulation and Function of Brain Cholesterol **(Gibson Wood,      |
|     Ph.D.)** Dr. Wood's laboratory is studying mechanisms of          |
|     cholesterol regulation in brain and the role of cholesterol in    |
|     cell structure and function with an emphasis on cholesterol       |
|     homeostasis and Alzheimer's disease (AD). One important area of   |
|     interest is mechanisms underlying the therapeutic effects of      |
|     cholesterol lowering drugs in brain. Statins have been reported   |
|     to lower the risk of developing Alzheimer's disease; however,     |
|     lowering cholesterol levels does not appear to be the primary     |
|     mechanism. To understand the molecular targets of statins in      |
|     brain, DNA microarrays were used to identify gene expression      |
|     patterns in the cerebral cortex of mice chronically treated with  |
|     lovastatin, pravastatin, and simvastatin. These studies revealed  |
|     15 genes involved in cell growth, signaling and trafficking that  |
|     were similarly changed by all three statins. Overall, simvastatin |
|     had the greatest influence on expression as demonstrated by its   |
|     ability to modify the expression of 23 genes, in addition to      |
|     those changed by all three drugs. Of particular interest, was     |
|     expression of genes associated with apoptotic pathways that were  |
|     altered by simvastatin. All three drugs were detected in the      |
|     cerebral cortex and acute experiments revealed that statins are   |
|     relatively rapidly removed from brain. These results provide new  |
|     insight into possible mechanisms for the potential efficacy of    |
|     statins in reducing the risk of Alzheimer's disease and lay the   |
|     foundation for future studies                                     |
|                                                                       |
| -   Positron Emission Tomography (PET) in Alzheimer's disease         |
|     **(Michael Kuskowski, Ph.D. and Maurice Dysken, M.D.)** Dr.       |
|     Michael Kuskowski, in collaboration with Dr. Jose Pardo           |
|     (Psychiatry Service) and Maurice Dysken, M.D. is studying ways to |
|     simplify and automate the use of PET images for diagnosis of AD.  |
|     Positron emission tomography (PET) studies have revealed          |
|     decreases in cerebral metabolism and perfusion in temporal,       |
|     parietal and posterior cingulate brain regions of AD patients     |
|     compared to age-matched controls.  Adoption of PET for clinical   |
|     diagnostic purposes in AD has been slow, in part, due to the lack |
|     of a reference database against which to assess abnormalities in  |
|     individual patient scans and the concern that scans obtained      |
|     under different laboratory conditions would not be comparable.    |
|     Scans from individual patients are compared against a database of |
|     scans from normal elderly subjects obtained under similar         |
|     experimental conditions (eyes closed, resting).  This comparison  |
|     results in brain maps, which pinpoint areas of hypometabolism in  |
|     individual patients. This pattern of hypometabolism can then be   |
|     compared to the pattern expected in AD, providing useful          |
|     diagnostic information for clinicians.  This NIH-funded research  |
|     will implement a relational web-based PET image database and      |
|     develop a clinician\'s interface specifically applied to the      |
|     diagnosis of Alzheimer\'s disease based on FDG-PET images.        |
|                                                                       |
| -   The Cognitive Performance Test (CPT) **(Theressa Burns, OT)** The |
|     Cognitive Performance Test (CPT), developed by the GRECC          |
|     Occupational Therapist, is a structured assessment of functional  |
|     ability, generating a composite score reflecting overall          |
|     functional abilities. In FY03 the test was expanded to include a  |
|     direct assessment of a patient's ability to manage medications as |
|     part of an assessment of instrumental activities of daily living. |
|     During FY04, data were collected to evaluate the utility,         |
|     validity, and reliability of this new functional indicator. Those |
|     data reveal that the new indicator is sensitive to functional     |
|     compromise in patients' ability to safely manage their own        |
|     medications.                                                      |
|                                                                       |
| -   GRECC Dementia Clinic **(Riley McCarten, M.D.)** The GRECC        |
|     Dementia Clinic is a an assessment and treatment demonstration    |
|     model that is staffed by a multidisciplinary team that includes a |
|     neurologist, psychiatrist, internist, social worker,              |
|     psychologist, pharmacist, and occupational therapist. In addition |
|     to diagnosis and treatment of the patient, clinic staff educates  |
|     patients and families regarding treatment and management of       |
|     cognitive impairment, as well as provides caregiver support. Team |
|     members are also investigators who facilitate and conduct         |
|     research on the diagnosis, treatment, natural history and         |
|     pathophysiology of cognitive impairment.                          |
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| **5. RESEARCH**                                                       |
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| a.  **Key Findings Published in Current Year -- GRECC Core Staff as   |
|     PI or CO-PI** *([list up to five]{.mark}; for each item provide   |
|     GRECC Core Staff name(s), journal reference, and [up to five      |
|     line]{.mark} description of topic/method/ results/clinical        |
|     significance; use layperson language)*:                           |
|                                                                       |
| -   Johnson-Anuna LN, Eckert GP, Keller JH, Igbavboa U, Franke C,     |
|     Fechner T, Schubert-Zsilavecz M, Karas M, Muller WM, **Wood WG**. |
|     Chronic administration of statins alters multiple gene expression |
|     patterns in mouse cerebral cortex. J Pharmacol Exp Ther. 2004 Sep |
|     9; \[Epub ahead of print\] To understand the molecular targets of |
|     statins in brain, DNA microarrays were used to identify gene      |
|     expression patterns in the cerebral cortex of mice chronically    |
|     treated with lovastatin, pravastatin, and simvastatin. Overall,   |
|     simvastatin had the greatest influence on expression as           |
|     demonstrated by its ability to modify the expression of 23 genes, |
|     in addition to those changed by all three drugs. These results    |
|     provide new insight into possible mechanisms for the potential    |
|     efficacy of statins in reducing the risk of Alzheimer\'s disease  |
|     and lay the foundation for future studies.                        |
|                                                                       |
| -   **Vatassery GT**, Adityanjee, Quach HT, Smith WE, Kuskowski MA,   |
|     Melnyk D. Alpha and gamma tocopherols in cerebrospinal fluid and  |
|     serum from older, male, human subjects. J Am Coll Nutr. 2004      |
|     Jun;23(3):233-8. The goal of this study was to obtain indirect    |
|     information about the transport of tocopherols across the         |
|     blood/spinal fluid barrier by comparing the concentrations of     |
|     alpha and gamma tocopherols in serum and cerebrospinal fluid      |
|     (CSF). The concentrations of alpha and gamma tocopherols in CSF   |
|     correlated significantly with their respective concentrations in  |
|     serum. These data suggest that the processes involved in the      |
|     entry of tocopherol from blood to the CSF do not discriminate     |
|     between the alpha and gamma tocopherols.                          |
|                                                                       |
| -   **McCarten JR**, Rottunda SJ, Kuskowski MA. Change in the         |
|     mini-mental state exam in Alzheimer\'s disease over 2 years: the  |
|     experience of a dementia clinic. J Alzheimers Dis. 2004           |
|     Feb;6(1):11-5. The decline in the Mini-Mental State Exam (MMSE)   |
|     over 2 years was assessed in males with Alzheimer\'s disease (AD; |
|     N = 136) seen in a dementia clinic. While the progression of AD   |
|     is quite variable from patient to patient, our data indicate that |
|     in most it is associated with little if any change in the MMSE    |
|     even over 2 years. The MMSE is not an adequate tool to monitor    |
|     change in the individual patient with AD.                         |
|                                                                       |
| -   **Burns T**, McCarten JR, Adler G, Bauer M, Kuskowski MA. Effects |
|     of repetitive work on maintaining function in Alzheimer\'s        |
|     disease patients. Am J Alzheimers Dis Other Demen. 2004           |
|     Jan-Feb;19(1):39-44. The effects of repetitive work on            |
|     Alzheimer\'s disease (AD) patient functioning were examined when  |
|     nine veterans were moved from a work program to a traditional     |
|     adult day care program. Subjects were reassessed four months      |
|     after the move with the Mini-Mental State Examination (MMSE),     |
|     Cognitive Performance Test (CPT), and Geriatric Depression Scale  |
|     (GDS). Observed scores at reassessment were significantly lower   |
|     than expected scores. Compared to traditional day care            |
|     activities, work activities involve sequencing skills and         |
|     practice may translate to self-care activities at home.           |
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| b.  **Key Findings Published in Current Year -- GRECC Core Staff as   |
|     Co-Investigators on Projects with Non-GRECC PI (***[list up to    |
|     five]{.mark}; for each item provide GRECC Core Staff name(s),     |
|     journal reference, [and up to five line]{.mark} description of    |
|     topic/method/ results/clinical significance; use layperson        |
|     language)*:                                                       |
|                                                                       |
| -   Kiwaki K, **Kotz CM**, Wang C, Lanningham-Foster L, Levine JA.    |
|     Orexin A (hypocretin 1) injected into hypothalamic                |
|     paraventricular nucleus and spontaneous physical activity in      |
|     rats. Am J Physiol Endocrinol Metab. 2004 Apr;286(4):E551-9. Epub |
|     2003 Dec 02. In this study, we address the hypothesis that orexin |
|     A acts in the hypothalamic paraventricular nucleus (PVN) to       |
|     increase nonfeeding-associated physical activity. Spontaneous     |
|     physical activity (SPA) was measured using arrays of infrared     |
|     activity sensors and night vision videotaped recording. It was    |
|     found that orexin A can act in PVN to increase                    |
|     nonfeeding-associated physical activity, suggesting that this     |
|     neuropeptide might be a mediator of NEAT.                         |
|                                                                       |
| ```{=html}                                                            |
| <!-- -->                                                              |
| ```                                                                   |
| -   Taylor BC, Schreiner PJ, Stone KL, **Fink HA**, Cummings SR,      |
|     Nevitt MC, Bowman PJ, Ensrud KE. Long-term prediction of incident |
|     hip fracture risk in elderly white women: study of osteoporotic   |
|     fractures. J Am Geriatr Soc. 2004 Sep;52(9):1479-86. Although hip |
|     bone mineral density (BMD) is strongly related to hip fracture    |
|     risk in elderly white women, other clinical risk factors also are |
|     independent predictors of long-term risk. Older age, previous     |
|     self-reported fracture after age 50, maternal history of hip      |
|     fracture after age 50, greater height at age 25, impaired         |
|     cognition, slower walking speed, nulliparity, type II diabetes    |
|     mellitus, Parkinson\'s disease, and depth perception each         |
|     independently predicted a 1.17- to 1.83-fold increase in hip      |
|     fracture risk. Clinicians should be alert to factors other than   |
|     BMD that place older women at a high risk of hip fracture.        |
|                                                                       |
| -   Finkel SI, Mintzer JE, **Dysken M**, Krishnan KR, Burt T,         |
|     McRae T. A randomized, placebo-controlled study of the efficacy   |
|     and safety of sertraline in the treatment of the behavioral       |
|     manifestations of Alzheimer\'s disease in outpatients treated     |
|     with donepezil. Int J Geriatr Psychiatry. 2004 Jan;19(1):9-18.    |
|     Sertraline augmentation therapy was examined for the treatment of |
|     behavioral manifestations of Alzheimer\'s disease (AD) in         |
|     outpatients treated with donepezil. Sertraline augmentation was   |
|     well-tolerated in the sample of AD outpatients. In addition, post |
|     hoc analyses demonstrated a modest but statistically significant  |
|     advantage of sertraline over placebo augmentation in mixed model  |
|     analyses and a clinically and statistically significant advantage |
|     in a subgroup of patients with moderate-to-severe behavioral and  |
|     psychological symptoms of dementia.                               |
|                                                                       |
| -   Kawarabayashi T, Shoji M, Younkin LH, Wen-Lang L, Dickson DW,     |
|     Murakami T, Matsubara E, Abe K, **Ashe KH**, Younkin SG. Dimeric  |
|     amyloid beta protein rapidly accumulates in lipid rafts followed  |
|     by apolipoprotein E and phosphorylated tau accumulation in the    |
|     Tg2576 mouse model of Alzheimer\'s disease. J Neurosci. 2004 Apr  |
|     14;24(15):3801-9. To investigate lipid rafts as a site where      |
|     amyloid beta protein (Abeta) oligomers might accumulate and cause |
|     toxicity in Alzheimer\'s disease (AD), Abeta was analyzed in the  |
|     Tg2576 transgenic mouse model of AD. We show that Abeta dimers    |
|     appear in lipid rafts at 6 months and that raft Abeta, which is   |
|     primarily dimeric, rapidly accumulates reaching levels \>500x     |
|     those in young mice by 24-28 months. A similar large accumulation |
|     of dimeric Abeta was observed in lipid rafts from AD brain.       |
|                                                                       |
| -   Dean CE, Russell JM, **Kuskowski MA**, Caligiuri MP, Nugent SM.   |
|     Clinical rating scales and instruments: how do they compare in    |
|     assessing abnormal, involuntary movements? J Clin                 |
|     Psychopharmacol. 2004 Jun;24(3):298-304. It appears that even     |
|     trained raters, utilizing standard rating scales, may             |
|     underestimate the prevalence of some motor abnormalities.         |
|     Instrumental ratings may be helpful to both the clinician and     |
|     investigator, particularly when abnormal movements are not        |
|     clinically obvious. The relationship between cognitive impairment |
|     and motor abnormalities remains an important area for further     |
|     research.                                                         |
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| **6. EDUCATION**                                                      |
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| **NOTE**: Do not list trainee and conference data here. Those data    |
| are reported in the GRECC Electronic Database.                        |
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| a.  **Innovations in Educational Activities Implemented During        |
|     Current Year** (*[list up to five]{.mark}; for each item, [up to  |
|     three lines]{.mark} on how it is innovative)*:                    |
|                                                                       |
| -   GRECC Seminar Series on Aging\-\--This seminar series celebrated  |
|     its 27^th^ year and is the longest running public lecture series  |
|     on aging in Minnesota. In FY04, the series provided a forum for   |
|     12 distinguished scientists and clinicians to present seminars on |
|     topics in the forefront of geriatrics and gerontology.            |
|                                                                       |
| -   Provider of Continuing Education Credits\-\--The Minneapolis      |
|     GRECC has the distinction of being the only GRECC that is         |
|     accredited as a provider of education credits. This valuable      |
|     resource has important benefits for the GRECC, Minneapolis VAMC,  |
|     VISN 23 and Headquarters. We provided education credits for GRECC |
|     originated programs, VA Hepatitis C Resource Centers and national |
|     satellite programs generated by Headquarters.                     |
|                                                                       |
| -   GRECC Satellite Series**\-\--**Three national satellite programs  |
|     were developed and broadcast during FY04. Programs of the         |
|     Satellite Series were: 1) Monitoring and Managing HCV Side        |
|     Effects; 2) Managing Anemia in Hepatitis C Patients; and 3)       |
|     Hepatitis C Town Hall Conference Panel.                           |
|                                                                       |
| -   VISN 23 EC&R and Education Meeting\-\--A meeting was organized by |
|     the GRECC to develop a roadmap for increasing our involvement in  |
|     VISN23 activities including education. Present at the meeting was |
|     the GRECC Director, Associate GRECC Directors and the leadership  |
|     of VISN 23 EC&R and Education PSLs. It is our intention that the  |
|     GRECC can serve as an important resource for VISN 23 endeavors    |
|     pertaining to Geriatrics, particularly Alzheimer's disease.       |
|                                                                       |
| -   GRECC Staff Presentations\-\--GRECC clinicians and scientists are |
|     recognized for their expertise and many of these individuals were |
|     involved in academic and professional lectures locally,           |
|     regionally, nationally, and internationally. GRECC clinicians and |
|     scientists provided regular lectures at the University of         |
|     Minnesota School of Medicine in the Departments of Neurology,     |
|     Pharmacology, and Psychiatry.                                     |
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| b.  **Exportable Educational Products First Available for             |
|     Distribution in Current Year** *([list up to five]{.mark} most    |
|     important products; for each item, [up to three lines]{.mark}     |
|     summarizing content, target audience, format, product evaluation  |
|     results. Include educational products developed in previous years |
|     ONLY if this is the [first year]{.underline} they have been       |
|     available for distribution)*:                                     |
|                                                                       |
| -   Instructional videotapes and CD ROMs\-\-- Alzheimer\'s Caregiving |
|     Strategies, The Mini-Mental State Examination (MMSE)              |
|     Instructional Video, Overcoming Side Effects as Obstacles to HCV  |
|     Treatment, Evaluating and Management of Patients with Advance     |
|     Liver Disease, Management and Care of Hepatitis C Patients Who    |
|     Are Not on Therapy, Severe Sepsis, Monitoring and managing HCV    |
|     Side Effects, and Managing Anemia in Hepatitis C Patients         |
|                                                                       |
| -   GRECC Pocket Guide to Geriatric Assessment\-\--This Guide was     |
|     designed to assist the clinician in making decisions concerning   |
|     assessment of geriatric patients with respect to some common      |
|     disorders                                                         |
|                                                                       |
| -   GRECC Reprints**\-\--**The GRECC also continues to send out a     |
|     large number of reprints that report on research findings of      |
|     GRECC investigators to scientists and clinicians nationwide and   |
|     around the world                                                  |
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| **7. NEW CLINICAL MODELS**                                            |
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| **NOTE:** These are new models of care for elderly veterans that the  |
| GRECC is developing and evaluating, in relation to its area(s) of     |
| focus. This is NOT a list of all Geriatrics & Extended Care clinical  |
| programs at the host VAMC.                                            |
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| a.  **New Clinical Models Implemented in Current Year** *(list all    |
|     new clinical models or significant modifications of existing      |
|     models that the GRECC is developing and evaluating. For each      |
|     item, indicate whether [N]{.underline}ew or [O]{.underline}ngoing |
|     in current year; provide [up to five line]{.mark} description)*:  |
|                                                                       |
| -   [Driving in Aging and Dementia]{.underline} (ongoing) Problems of |
|     the elderly driver continue to be a focus for the clinical staff. |
|     Following an analysis of 75 drivers with dementia and 80 normal   |
|     elderly drivers who completed a thirty-nine item test of the      |
|     rules of the road and an MMSE, it was discovered that drivers     |
|     with dementia demonstrated significantly poorer knowledge of      |
|     driving regulations, while the MMSE was not a good predictor of   |
|     driving knowledge. Using item analysis, fifteen items were        |
|     selected for a screening tool, which is now employed routinely in |
|     the GRECC Clinic, and has begun to be used in other settings of   |
|     geriatric care in the VISN and in the community                   |
|                                                                       |
| -   [Guidelines for the Use of Cognitive Enhancers in Alzheimer's     |
|     Disease]{.underline} (ongoing) In FY99, the Dementia Ad Hoc       |
|     Committee for the Pharmacy Benefits Management Strategic Health   |
|     Group released the clinical guideline, "The Pharmacologic         |
|     Management of Cognitive Changes in Alzheimer's Disease." The      |
|     treatment algorithm and reporting form developed by the           |
|     Minneapolis GRECC Clinical Staff provides the template for many   |
|     of the recommendations in the guideline. GRECC Clinical Staff     |
|     remains involved in updating the current guidelines and has       |
|     worked with the Pharmacy and Therapeutics Committee to develop    |
|     templates for the Computerized Patient Record System (CPRS) for   |
|     the prescribing of all cognitive enhancers for AD                 |
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| b.  **Current Year Evaluation Results of New Clinical Models** *([for |
|     each clinical model listed in 7-a above]{.mark}, indicate whether |
|     evaluated by [R]{.underline}esearch or [Q]{.underline}uality      |
|     [I]{.underline}mprovement project; [up to five lines]{.mark}      |
|     summarizing evaluation outcomes, such as changes in access to     |
|     care, patient functioning, satisfaction, cost-effectiveness,      |
|     organizational changes, etc. Note if no evaluation results in     |
|     current year for a particular model)*:                            |
|                                                                       |
| **NOTE:** Do not list patient service utilization data here. Those    |
| data are reported in the GRECC Electronic Database.                   |
|                                                                       |
| -   Driving in Aging and Dementia (QI)\-\--Beginning in FY02, the     |
|     VISN 23 Extended Care and Rehabilitation Patient Service Line     |
|     (EC&R PSL) initiated plans to routinely screen driving safety in  |
|     older adults. Data from the GRECC Driving in Aging and Dementia   |
|     project stimulated the interest, and GRECC will advise the VISN   |
|     PSL on the appropriate methods and tools to employ in this        |
|     initiative. The goal will be to incorporate a driving screen into |
|     all VISN 23 geriatric clinics and programs. GRECC will also work  |
|     with the VISN PSL to monitor data from this initiative.           |
|                                                                       |
| -   The Mini-Mental State Exam (MMSE) (Research)\-\--The MMSE is the  |
|     most frequently used tool to screen for and to monitor            |
|     progression in AD. We have developed videotapes to demonstrate    |
|     the proper administration of the MMSE, and we are rigorous in the |
|     manner in which we give and score the test. We examined our       |
|     clinical database to assess whether or not the rate of decline in |
|     the MMSE of AD patients was dependent upon the initial MMSE. We   |
|     compared the initial visit MMSE to a subsequent MMSE done 2 yrs   |
|     (1.75-2.25 yrs) later in all male patients (N=136) followed in    |
|     our dementia clinic with a diagnosis of probable or possible AD   |
|     at their most recent visit. Patients with an initial MMSE\<14     |
|     were excluded from the analysis. The average initial MMSE was     |
|     21.0 (SD+/-3.9; range 14-29) and declined 2.8 points (+/-4.7)     |
|     over 2 yrs. To our surprise there was no significant correlation  |
|     between the initial MMSE and the rate of change (r=0.16; p=0.06). |
|     Furthermore, 55 of the 136 (39.7%) patients had unchanged or      |
|     better MMSE scores at 2 yrs. The mode for change on the MMSE was  |
|     0 (N=22) while the median fell between 2 and 3 points lost over 2 |
|     years. Our results indicate that the MMSE is not a sensitive      |
|     measure of decline in AD for patients with mild or moderate       |
|     dementia. While it is a useful tool to communicate information    |
|     about dementia severity, it cannot stand alone in making a        |
|     diagnosis of dementia or in assessing disease progression. Its    |
|     use in research should be circumscribed.                          |
+-----------------------------------------------------------------------+
| c.  **New Clinical Models Exported in Current Year** *([list up to    |
|     five examples, up to two lines each]{.mark}; provide name of new  |
|     clinical model, name of VA or non-VA facility to which it was     |
|     exported, and method of export, such as "Falls Clinic protocol    |
|     sent to [X]{.underline} VAMC")*:                                  |
|                                                                       |
| -   The Interdisciplinary Team**\-\--**The GRECC clinic continues to  |
|     employ an interdisciplinary team for the evaluation and treatment |
|     of dementia. Through our training of primary care providers and   |
|     numerous other health care professionals, providers learn to      |
|     identify the many issues associated with evaluating and treating  |
|     dementia and to make appropriate referrals when necessary to deal |
|     with these complex issues.                                        |
|                                                                       |
| -   Training Videos\-\--GRECC training videos all employ actual       |
|     patients, caregivers, and GRECC staff to demonstrate our models   |
|     of assessment and care. The instructional video series,           |
|     "Assessing Dementia in the Clinic: Interview and Examination      |
|     Skills," has been distributed to 34 other VAs and to numerous     |
|     facilities in the private sector, and is viewed by all trainees   |
|     prior to attending their GRECC clinical rotations. Over 2000      |
|     copies of "The Mini-Mental State Examination (MMSE) Instructional |
|     Video" have been distributed throughout the VA and the private    |
|     sector, and additional copies have been ordered to fill ongoing   |
|     requests. "The Allen Cognitive Levels: Functional Testing of      |
|     Demented Patients," has been distributed to all VA Hospitals and  |
|     Clinics and to several private sector facilities. The             |
|     instructional video introduces the theory behind the Cognitive    |
|     Performance Test (CPT), a functional assessment tool developed at |
|     the Minneapolis GRECC.                                            |
|                                                                       |
| -   Clinic Trainees\-\--The GRECC model of clinical evaluation and    |
|     care is extensively exported through our training of health care  |
|     professionals. In FY04 GRECC continued to serve as a training     |
|     site for numerous programs. Trainees included the Geriatric       |
|     Psychiatry Fellows from the Minneapolis VAMC (two), the Geriatric |
|     Medicine Fellow from Hennepin County Medical Center (one),        |
|     physician residents in Neurology (seven), Psychiatry (five),      |
|     Internal Medicine (fourteen), and Family Practice (four), a       |
|     Physician Assistant (one), senior residents in Podiatry (two), a  |
|     Psychology Fellow (one), Psychology interns (two), Geriatric      |
|     PharmD Fellows (two), and pharmacy students (eight).              |
|                                                                       |
| -   The Cognitive Performance Test (CPT)\-\--The Cognitive            |
|     Performance Test (CPT), developed by the GRECC Occupational       |
|     Therapist, is a structured assessment of functional ability.      |
|     Based on the Allen Cognitive Theory, function is scored from 6.0  |
|     (normal) to 1.0 (profound impairment) on a variety of             |
|     instrumental and self-care activities of daily living, generating |
|     a composite score reflecting overall functional abilities. Though |
|     developed and validated for use in dementia, the CPT is used      |
|     extensively in the Minneapolis VAMC Occupational Therapy Clinic,  |
|     dozens of healthcare facilities throughout Minnesota, and in VAs  |
|     nationwide to evaluate a wide range of functional disabilities.   |
+-----------------------------------------------------------------------+
| **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]{.mark}, [up to two lines each]{.mark}; 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)*:                                               |
|                                                                       |
| -   The GRECC is certified to provide Continuing Medical Education    |
|     credits through the Accreditation Council for Continuing Medical  |
|     Education and the American Nurses Credentialing Center\'s         |
|     Commission on Accreditation. The ability of GRECC to certify      |
|     programs for CME and CEU credits enhances our own and             |
|     collaborative consultation/outreach activities; e.g., local VAMC  |
|     programs, VISN programs, and national programs. We are pending    |
|     approval for social work accreditation through the National       |
|     Association of Social Work Boards and the American Psychological  |
|     Association.                                                      |
|                                                                       |
| -   GRECC continues to increase collaboration with other              |
|     organizations in providing educational programs, including VA     |
|     Headquarters, the Minnesota Veterans Home, the Minnesota Area     |
|     Geriatric Education Center (MAGEC), and the Minneapolis VAMC      |
|     Departments of Medicine, Neurology, Extended Care, and the        |
|     Departments of Psychiatry and Family Medicine at the University   |
|     of Minnesota.                                                     |
|                                                                       |
| -   GRECC continues its collaboration with other VAMC neuroscience    |
|     programs, including the Brain Science Center, Psychiatry, and     |
|     Neurology, and with neuroscientists in the Research Service. In   |
|     FY04 collaboration was begun with investigators in the Brain      |
|     Sciences Center to explore the usefulness of                      |
|     magnetoencephalography for the diagnosis of dementia.             |
|                                                                       |
| -   The GRECC Memory Loss Clinic continues to serve as a training     |
|     site for several different disciplines and institutions           |
|     (see D. 3. c.). In FY04, 48 students rotated through the Memory   |
|     Loss Clinic.                                                      |
|                                                                       |
| -   The GRECC Clinical Program continues to serve as a major training |
|     site for the Geriatric Psychiatry Fellowship.                     |
+-----------------------------------------------------------------------+
| b.  **Previous Years' Activities Outcomes** (*[list up to five        |
|     examples]{.mark}, [up to two lines each]{.mark}; summarize        |
|     specific outcomes realized from previous years' [**consultation** |
|     to host VAMC]{.underline} or [**outreach** to non-host            |
|     facilities]{.underline}, where results were first realized in the |
|     current year.)*                                                   |
|                                                                       |
| -   The outcomes of the previous year's activities are indicated with |
|     the description of the activities listed above.                   |
+-----------------------------------------------------------------------+