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| ### GERIATRIC RESEARCH, EDUCATION AND CLINICAL CENTER    |   |   |   |   |
|                                                          |   |   |   |   |
| ### *Annual Report: Fiscal Year [2008]{.underline}*      |   |   |   |   |
|                                                          |   |   |   |   |
| ######## Part II: Accomplishments                        |   |   |   |   |
+----------------------------------------------------------+---+---+---+---+
| **NOTE:** The **GRECC Annual Report** reflects status    |   |   |   |   |
| and accomplishments of **[GRECC Core Staff]{.underline}  |   |   |   |   |
| \*** (as defined below) [only]{.underline}. The          |   |   |   |   |
| **"Report Year"** is from [October 1, 2007 through       |   |   |   |   |
| September 30, 2008]{.underline}.                         |   |   |   |   |
|                                                          |   |   |   |   |
| You are welcome to use this report format for your own   |   |   |   |   |
| internal reporting purposes,                             |   |   |   |   |
|                                                          |   |   |   |   |
| in which case you may exceed the recommended limits of   |   |   |   |   |
| numbers of responses and their length                    |   |   |   |   |
|                                                          |   |   |   |   |
| ("list no more than..." "Describe the three most         |   |   |   |   |
| important..." "limit your response to five lines or      |   |   |   |   |
| fewer")                                                  |   |   |   |   |
|                                                          |   |   |   |   |
| ***\-\--BUT\--***                                        |   |   |   |   |
|                                                          |   |   |   |   |
| Please limit **to ten pages or fewer** the version       |   |   |   |   |
| **SUBMITTED TO VACO** **.**                              |   |   |   |   |
+----------------------------------------------------------+---+---+---+---+
| **\*[GRECC Core Staff ]{.underline}**is limited to       |   |   |   |   |
| either **Primary Core**, **Affiliated Core**, or         |   |   |   |   |
| **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                                        |   |   |   |   |
|                                                          |   |   |   |   |
|     -   May have been acquired through centralized       |   |   |   |   |
|         enhancements/awards for programs\                |   |   |   |   |
|         (e.g., 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.              |   |   |   |   |
+----------------------------------------------------------+---+---+---+---+
| **[IMPORTANT:]{.underline} Throughout this report,       |   |   |   |   |
| please AVOID/MINIMIZE JARGON. Each response is much more |   |   |   |   |
| likely to be included in secondary communications        |   |   |   |   |
| derived from the Annual Reports if it can be readily     |   |   |   |   |
| understood by a non-technical readership.**              |   |   |   |   |
+----------------------------------------------------------+---+---+---+---+
| **1. GRECC NAME/LOCATION**                               |   |   |   |   |
+----------------------------------------------------------+---+---+---+---+
| a.  **GRECC Name:** San Antonio GRECC                    |   |   |   |   |
|                                                          |   |   |   |   |
| b.  **Location** *(facility, VISN)*: *)*: South Texas    |   |   |   |   |
|     Veterans Health Care System-Audie L. Murphy          |   |   |   |   |
|     Division, VISN 17                                    |   |   |   |   |
+----------------------------------------------------------+---+---+---+---+
| **2. CONTACT PERSON**                                    |   |   |   |   |
+----------------------------------------------------------+---+---+---+---+
| a.  **Name:** Mary Anne Svetlik, Ph.D., FACHE            |   |   |   |   |
|                                                          |   |   |   |   |
| b.  **Position:** Administrative Officer, GRECC (182)    |   |   |   |   |
|                                                          |   |   |   |   |
| **c. Phone, e-mail:** 210-617-5197,                      |   |   |   |   |
| Mary.Svetlik@med.va.gov                                  |   |   |   |   |
+----------------------------------------------------------+---+---+---+---+
| **3. GRECC FOCUS AREA(S)**                               |   |   |   |   |
+----------------------------------------------------------+---+---+---+---+
| **NOTE:** Please succinctly list your GRECC's Focus      |   |   |   |   |
| Area(s), one per line below. After each focus area       |   |   |   |   |
| listed, please indicate with a check mark (****) which  |   |   |   |   |
| of the research type(s) suitably describes the work      |   |   |   |   |
| conducted (including planning, implementation, analysis, |   |   |   |   |
| and dissemination/publication) within that focus during  |   |   |   |   |
| the Report Year. Add additional lines by positioning     |   |   |   |   |
| your cursor at the lower right side of the table and     |   |   |   |   |
| striking the "Tab" key.                                  |   |   |   |   |
+----------------------------------------------------------+---+---+---+---+
| **GRECC Focus Area**                                     | * |   |   |   |
|                                                          | * |   |   |   |
|                                                          | R |   |   |   |
|                                                          | e |   |   |   |
|                                                          | s |   |   |   |
|                                                          | e |   |   |   |
|                                                          | a |   |   |   |
|                                                          | r |   |   |   |
|                                                          | c |   |   |   |
|                                                          | h |   |   |   |
|                                                          | T |   |   |   |
|                                                          | y |   |   |   |
|                                                          | p |   |   |   |
|                                                          | e |   |   |   |
|                                                          | * |   |   |   |
|                                                          | * |   |   |   |
+----------------------------------------------------------+---+---+---+---+
|                                                          | > | > | > | > |
|                                                          |   |   |   |   |
|                                                          | * | * | * | * |
|                                                          | * | * | * | * |
|                                                          | 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 | e | t |
|                                                          | e | i | r | i |
|                                                          | d | n | v | o |
|                                                          | i | i | i | n |
|                                                          | c | c | c | * |
|                                                          | a | a | e | * |
|                                                          | l | l | s |   |
|                                                          | * | * | * |   |
|                                                          | * | * | * |   |
+----------------------------------------------------------+---+---+---+---+
| Metabolism/Endocrinology, Nutrition, Oral                | * |   |   |   |
| Health/Dentistry                                         | * |   |   |   |
|                                                          | X |   |   |   |
|                                                          | * |   |   |   |
|                                                          | * |   |   |   |
+----------------------------------------------------------+---+---+---+---+
| Metabolic Diseases, Cognitive/Sensory Impairment, Oral   |   | * |   |   |
| Health/Dentistry                                         |   | * |   |   |
|                                                          |   | X |   |   |
|                                                          |   | * |   |   |
|                                                          |   | * |   |   |
+----------------------------------------------------------+---+---+---+---+
| Functional Status and Ethnicity, Palliative Care, Health |   |   | * |   |
| Care Utilization, and Quality Assessment                 |   |   | * |   |
|                                                          |   |   | X |   |
|                                                          |   |   | * |   |
|                                                          |   |   | * |   |
+----------------------------------------------------------+---+---+---+---+
| N/A                                                      |   |   |   | * |
|                                                          |   |   |   | * |
|                                                          |   |   |   | N |
|                                                          |   |   |   | / |
|                                                          |   |   |   | A |
|                                                          |   |   |   | * |
|                                                          |   |   |   | * |
+----------------------------------------------------------+---+---+---+---+

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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 veterans    |
|     (i.e., how the GRECC has "made a difference" in these areas       |
|     within the entire host VAMC) during the Report Year. **Please     |
|     limit your response to [5 or fewer]{.underline} "ways"; and       |
|     please limit your description of each of the five "ways" to [five |
|     lines or fewer]{.underline}. ***                                  |
|                                                                       |
| -   GRECC research expenditure funding for FY 08 totals more than     |
|     \$20.9 million, representing 13% of the total research            |
|     expenditures of the South Texas Veterans Health Care System for   |
|     FY 08**.**                                                        |
|                                                                       |
| -   GRECC research staff continues to be very successful in obtaining |
|     grant funding from federal and other sources. In addition, GRECC  |
|     investigators lead a collaborative network of scientists from the |
|     host VAMC and its affiliated University of Texas Health Science   |
|     Center at San Antonio (UTHSCSA). This leadership has resulted in  |
|     the successful recruitment of many internationally renowned       |
|     biomedical gerontologists to both institutions.                   |
|                                                                       |
|     -   GRECC research staff involvement in above has resulted in the |
|         establishment of the Barshop Institute on Longevity and Aging |
|         Studies, with its animal core and researchers from both       |
|         institutions, and most recently the grant award for the NIA   |
|         Intervention Testing Center. Both initiatives serve as        |
|         resources for host VAMC investigators.                        |
|                                                                       |
|     -   The GRECC hosts weekly conferences as Geriatrics &            |
|         Gerontology Grand Rounds for the host VAMC and its            |
|         educational affiliate (UTHSCSA). Attendance includes          |
|         employees from various other services at the host VAMC.       |
|                                                                       |
|     -   The GRECC sponsored two Medical Grand Rounds, a Family and    |
|         Community Medicine Grand Rounds and three Medical Research    |
|         Seminars for employees, faculty and staff of the host VAMC    |
|         and the educational affiliate (UTHSCSA) during FY 2008. GRECC |
|         faculty and trainees submitted entries for the Department of  |
|         Medicine Annual Research Day.                                 |
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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    |
|     (i.e., how the GRECC has "made a difference" in these areas       |
|     within the entire host VISN) during the rating period. **Please   |
|     limit your response to [5 or fewer]{.underline} "ways"; and       |
|     please limit your description of each of the five "ways" to [five |
|     lines or fewer]{.underline}. ***                                  |
|                                                                       |
| -   The GRECC held its 29^th^ Annual Conference on Aging, cosponsored |
|     by the VISN, "Geriatric Primary Care: Current Perspectives & New  |
|     Horizons in Diabetes," in August 2008, with broad attendance      |
|     throughout the VISN.                                              |
|                                                                       |
| -   The GRECC continues to collaborate with the Little Rock GRECC in  |
|     VISN 19 by trading expertise in geriatric dentistry and           |
|     nutrition.                                                        |
|                                                                       |
| -   The GRECC Director has served on the VISN's Research Committee    |
|     since its inception. The committee established a VISN-wide new    |
|     investigator start-up grant program. This program continues to    |
|     fund 2-year                                                       |
|                                                                       |
| research awards to junior investigators at the three VAMCs within the |
| VISN. GRECC researcher Dr. Randy Strong has been added to the         |
| committee.                                                            |
|                                                                       |
| -   The GRECC AD/EE continued to serve on the VISN Education          |
|     Committee in FY 2008.                                             |
|                                                                       |
|     -   GRECC research staff involvement in above has resulted in the |
|         establishment of the Barshop Institute on Longevity and Aging |
|         Studies, with its animal core and researchers from both       |
|         institutions, and most recently the grant award for the NIA   |
|         Intervention Testing Center. Both initiatives serve as        |
|         resources for investigators throughout the VISN.              |
|                                                                       |
| ```{=html}                                                            |
| <!-- -->                                                              |
| ```                                                                   |
| -   The GRECC continues to address the South Texas Veterans Health    |
|     Care System's palliative care program. In FY-08, 20 facility-wide |
|     training sessions were held for host VAMC staff. Educational      |
|     programs are held each year for VISN 17 staff. Sandra             |
|     Sanchez-Reilly, M.D., developed and directs the combined          |
|     consultation service program in geriatrics and palliative care    |
|     for patients at the host VAMC. This ongoing clinical              |
|     demonstration program should result in a model that can be        |
|     replicated at other VAMCs in VISN 17. To that end, the GRECC has  |
|     \"begun the innovative "Palliative Care on the Road" program with |
|     a two-hour videoteleconference in late fall '06, and two day-long |
|     programs on-site at Temple and Dallas VAMCs in 2007. In 2008, a   |
|     4-day hands-on training program for VISN palliative care teams    |
|     was held at the San Antonio VAMC. More programs are planned.      |
+-----------------------------------------------------------------------+
| c.  **GRECC Trend-Setting Innovations since October 1,                |
|     [2003]{.underline}**: *list **the** **most significant** GRECC    |
|     research, education or clinical innovations in the past five      |
|     years. For each item, provide date or date range, GRECC core      |
|     staff responsible, and a description. **Please limit your         |
|     response to 5 or fewer innovations; and please limit each of the  |
|     five innovation descriptions to five lines or fewer. ***          |
|                                                                       |
| -   GRECC researcher Randy Strong, Ph.D., with UTHSCSA colleagues,    |
|     continues to utilize his \$2.5 million grant from a National      |
|     Institute on Aging (NIA) Intervention Testing Center, one of      |
|     three such U.S. centers established by the NIA to test potential  |
|     therapeutic interventions to slow the aging process (Dr. Randy    |
|     Strong, 2004).                                                    |
|                                                                       |
| -   GRECC researcher Arlan Richardson, Ph.D., continues as director   |
|     of the Barshop Institute on Longevity and Aging Studies, which    |
|     will house an extensive aging and transgenic animal core. The     |
|     Center was built at the UTHSCSA-affiliated Texas Research Park    |
|     and occupied summer 2006 (Dr. Arlan Richardson, 2006).            |
|                                                                       |
| -   In summer FY 08, the GRECC conducted, in conjunction with the     |
|     South Texas Geriatric Education Center (STGEC) at the UTHSCSA,    |
|     the fifth week-long, Interdisciplinary Summer Institute in        |
|     Geriatrics & Gerontology, "G&G 101," for health professionals who |
|     treat elderly veterans in all clinical settings and who have had  |
|     minimal training in geriatrics and gerontology. This 40-hour      |
|     program was digitally videotaped and is available for future      |
|     viewing (Dr. Michèle Saunders, 2008).                             |
|                                                                       |
| -   The GRECC continues to collaborate with the Little Rock GRECC in  |
|     VISN 19 by trading expertise in geriatric dentistry and           |
|     nutrition. Numerous hours have been taped and are available for   |
|     sharing across both VISNs for those employees who are unable to   |
|     view the videoteleconferences (Dr. Michele Saunders, 2006-08).    |
|                                                                       |
| -   Innovative clinical programs include 1) Memory Clinic, a          |
|     multidisciplinary program focusing on the diagnosis and           |
|     management of Alzheimer's disease and related disorders and their |
|     behavioral manifestations; 2) a multidisciplinary Combined        |
|     Consultation Service in Geriatric Medicine and Palliative Care;   |
|     and 3) a multidisciplinary geriatric oncology clinic developed at |
|     the affiliated NIH-designated Cancer Therapy and Research Center. |
|     (Dr. Donald Royall, #1, 2002-2008; Dr. Sandra Sanchez-Reilly, #s  |
|     2&3, 2004-2008).                                                  |
|                                                                       |
| -   GRECC staff members are engaged in active discussion with         |
|     industry and the VA Cooperative Studies Program to develop a VA   |
|     multi-center trial of metaglidasen, a new glucose-lowering agent, |
|     for the treatment of VA patients with type 2 diabetes. The drug   |
|     companies involved are Metabolex and Johnson & Johnson.\"         |
|                                                                       |
| -   The GRECC continued the innovative "Palliative Care on the Road"  |
|     program for VISN 17 with a two-hour videoteleconference in late   |
|     fall 2006, two day-long programs in spring 2007 on-site at Temple |
|     and Dallas VAMCs and a 4-day hands-on training program for VISN   |
|     Palliative Care teams at the San Antonio VAMC in 2008. More       |
|     programs are planned.                                             |
+-----------------------------------------------------------------------+
| **5. RESEARCH**                                                       |
+-----------------------------------------------------------------------+
| **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}.*                                      |
|                                                                       |
| \[Ref: Kamat, A, Yeh, C., Katz, et al. Reduced expression of          |
| epidermal growth factor (EGF) receptors in rat liver during aging.    |
| Journals of Gerontology Series A: Biological Sciences and Medical     |
| Sciences 2008. 63:683-692.\] The study showed decreased expression of |
| EGF receptors is a key determinant of reduced mitrogenic signaling    |
| responsive to EGF stimulation of liver during aging. This has         |
| implications for understanding the role of EGF in liver cell          |
| proliferation during normal aging as well as the role of EGF in a     |
| number of pathogenic conditions like hepatocarcinogenesis and         |
| hypothyroidism.                                                       |
|                                                                       |
| \[Ref: Royal, D., Palmer, R.F., Chiodo, L.K., Polk, M.J., Markides,   |
| K.S., Hazuda, H. Clock-drawing potentially mediates the effect of     |
| depression on mortality: replication in three cohorts. International  |
| Journal of Geriatric Psychiatry. 2008. 23: 821-829.\] This study      |
| notes that depression is a significant and independent predictor of   |
| mortality in elderly populations. The association between depression  |
| and mortality is moderated by an age-related factor (e.g., structural |
| brain disease). This longitudinal study demonstrated that a           |
| visuospatial clock-drawing task attenuates and potentially mediates   |
| the otherwise robust association between depressive symptoms and      |
| mortality in both Hispanic and Non-Hispanic whites. Clock drawing     |
| represents a relatively easy means of identifying persons at risk.    |
|                                                                       |
| \[Ref: Lin, A.L., Zhu, B., WanKe, Z., Dang, H., Zhang, B-X, Katz, MS, |
| Yeh, C-K. District pathways of ERK activation by the muscarinic       |
| agonists pilocarpine and carbachol in a human salivary cell line. Am  |
| J. Physiol Cell Physiol 2008. 294: C1454-C1464.\] This study          |
| demonstrated that two muscarinic ligands induce ERK activation in HSY |
| cells by distinct signaling pathways: 1) pilocarpine via muscarinic   |
| M~3~ receptors and Src-dependent transactivation of EGF receptors and |
| 2) carbachol via M~1~/M~3~ receptors and activation of PKSs. ERK      |
| signaling by distinct muscarinic ligand-dependent pathways intrinsic  |
| to a single cell type had not been reported previously. This study    |
| has implications for the future development of effective drug         |
| therapies for salivary gland hypofunction and possibly for            |
| muscarinic-cholinergic-associated neurological disorders such as      |
| Alzheimer's disease and seizures.                                     |
+-----------------------------------------------------------------------+
| **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 item to [5 lines or                   |
| fewer]{.underline}.*                                                  |
|                                                                       |
| \[Ref: Zhang, H, Zhen-Hua, L., Zhang, M.Q., Katz, M.S., Zhang, B-X.   |
| Heat shock protein 90β1 is essential for polyunsaturated fatty        |
| acid-induced mitochondrial Ca^2+^ efflux. J Biol Chem 2008.           |
| 283:7580-7589.\] Nonesterified fatty acids may influence              |
| mitochondrial function by alterations in gene expression, metabolism, |
| and/or mitochondrial Ca^2+^ homeostasis.                              |
+-----------------------------------------------------------------------+
| **6. EDUCATION**                                                      |
+-----------------------------------------------------------------------+
| **NOTE**: **DO NOT** list trainee and conference data                 |
| here**\--**those data are reported in the GRECC Electronic Database.  |
|                                                                       |
| **NOTE:** You may list educational activities here even if they were  |
| supported by funds that qualified for inclusion in the ePROMISE       |
| (RDIS) database if you wish.                                          |
+-----------------------------------------------------------------------+
| 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.)                                          |
|                                                                       |
| -   The San Antonio GRECC cosponsored \[with the South Texas          |
|     Geriatric Education Center (STGEC)\] the fifth Summer Institute   |
|     in Geriatrics & Gerontology: "G&G 101." This program is           |
|     innovative because it is a 40-hr week-long program, is            |
|     multidisciplinary, and is for health professionals who treat      |
|     elderly veterans in all clinical settings and who have had        |
|     minimal training in geriatrics and gerontology. The program was   |
|     digitally videotaped to be available for future viewing.          |
|                                                                       |
| -   The GRECC uses the facilities of Golden Manor (GM) Jewish Home    |
|     and Services for the Aging, a community health care agency for    |
|     the elderly, as additional clinical sites for joint GRECC and     |
|     STGEC trainees. This is an innovative program because it is       |
|     interdisciplinary in nature and expands the female patient        |
|     population available for trainee education as required by the     |
|     ACGME and other accrediting bodies. Trainee rotations began in    |
|     late FY 05 and are continuing.                                    |
|                                                                       |
| -   The GRECC continued the innovative "Palliative Care on the Road"  |
|     program for VISN 17 with a two-hour videoteleconference in late   |
|     fall 2006, and two day-long programs in spring 2008 on-site at    |
|     Temple and Dallas VAMCs and a 4-day hands-on training program at  |
|     the San Antonio VAMC for VISN Palliative Care teams. More         |
|     programs are planned.                                             |
+-----------------------------------------------------------------------+
| b.  **Exportable Educational Products First Available for             |
|     Distribution in Report Year** *List five or fewer of the most     |
|     important products. For each item, limit the response to five     |
|     lines summarizing content, target audience, format, and product   |
|     evaluation plan and results. **Include educational products       |
|     developed in previous years ONLY if this is the [first            |
|     year]{.underline} they have been available for distribution.***   |
|                                                                       |
|     -   DVDs and videotapes are available of the VISN co-sponsored    |
|         24^th^ through and 29^th^ Annual Conferences on Aging ("New   |
|         Horizons in Geriatric Primary Care") for those employees who  |
|         could not attend. Multidisciplinary staff from throughout the |
|         VISN, including satellite clinics, attended. Attendees        |
|         evaluated the conferences as excellent. This is the first     |
|         time all six conferences are available on DVD or videotape.   |
|                                                                       |
| -   Forty hours of DVDs and videotapes are available for each of the  |
|     1^st^ through 5^th^ Summer Institutes on Geriatrics and           |
|     Gerontology ("G&G 101"), co-sponsored with the STGEC. This is the |
|     first time all five institutes are available.                     |
|                                                                       |
| -   Twenty-seven hours of DVDs and videotapes are available of the FY |
|     08 GRECC Geriatrics & Gerontology Grand Rounds, for a total of    |
|     108 hours for FYs 2005 through 2008.                              |
+-----------------------------------------------------------------------+
| c\. **Educational programs offered by your GRECC during the report    |
| year that were evaluated for impact both immediately and at a later   |
| time, as described in "FY08Instructions" for Performance Measure 7.** |
| *Describe at least **TWO**, each of which had at least 25             |
| participants: one in which the majority of participants was from your |
| GRECC's host facility; and one in which the majority of participants  |
| were from VAs other than your GRECC's host facility. For each,        |
| describe the educational intervention briefly and then the            |
| evaluations, including in your description of the latter the          |
| evaluation methodologies, findings, and conclusions. If the second    |
| evaluation has not yet occurred during the report year, describe your |
| plans for it. Limit your description of each intervention and its     |
| evaluation to one-half page.*                                         |
|                                                                       |
| > This new evaluation of educational programs for impact required an  |
| > increase in the time needed to collect program data, with           |
| > inadequate numbers of staff to collect it. Newly funded Geriatric   |
| > Education Center staff were volunteered to assist. The first        |
| > program evaluated for impact was the eight-hour 29^th^ Annual       |
| > Conference on Aging, *Current Perspectives & New Horizons in        |
| > Diabetes Management*, on August 22, 2008. The following topics were |
| > presented in the conference: "Cardiovascular Disease Prevention     |
| > including Glucose Control in the Elderly," "The Chronic Care Model: |
| > Implications for Diabetes in the Elderly," "Hypertension in         |
| > Diabetes: A Conspiracy of Killers," "Peripheral Neuropathy in       |
| > Aging; Peripheral Neuropathy in Aging: The Role of Diabetes,"       |
| > "Nerve Compression in Patients with Neuropathy: Hope for Relief of  |
| > Pain, Recovery of Sensation and Balance and Prevention of           |
| > Ulceration & Amputation," "Pathophysiology of Diabetes in Aging,"   |
| > and "Treatment of Diabetic Dyslipidemia." In addition to the usual  |
| > primary evaluation conducted by the Employee Education System staff |
| > (numbers of attendees, disciplines, work location, profession,      |
| > quality of presentations, and the like---see electronic data base), |
| > secondary impact evaluation was conducted on a random sample of 25% |
| > of the attendees via telephone or personal contact three months     |
| > after the program. All of the respondents reported that they now    |
| > were 1) more vigilant in monitoring and controlling hypertension in |
| > veterans with diabetes, 2) referring veterans with possible         |
| > diabetic neuropathy for evaluation before symptoms become           |
| > exacerbated, and 3) more vigilant in monitoring and treating        |
| > dyslipidemia in veterans with diabetes. This new evaluation of      |
| > educational programs for impact required an increase in the time    |
| > needed to collect program data, with inadequate numbers of staff to |
| > collect it. Geriatric Education Center staff volunteered to assist. |
| >                                                                     |
| > The second program evaluated for impact was the four-day VISN       |
| > program, Palliative Care on the Road that had 100% attendance (42)  |
| > from the following VISN 17 medical centers: Temple, Dallas, Bonham  |
| > and Waco. The following topics were presented in the conference:    |
| > "Introduction to Palliative Care," "Clinical Criteria for Hospice   |
| > Referral," "Symptom Management in Palliative Care," "Restoring      |
| > Balance between Curative and Palliative Care," and "Ethical Issues  |
| > in Palliative Care." Hands-on palliative care experiences with      |
| > standardized patients were offered to participants at the UTHSCSA   |
| > Clinical Skills Center, with direct feedback. Specific skills       |
| > addressed included: Delivering bad news, communication skills and   |
| > interdisciplinary care. In addition to the usual primary evaluation |
| > conducted by the Employee Education System staff (numbers of        |
| > attendees, disciplines, work location, profession, quality of       |
| > presentations, and the like---see electronic data base), secondary  |
| > impact evaluation was conducted on a random sample of 25% of the    |
| > attendees via telephone or personal contact three months after the  |
| > program. All of the respondents reported that they now were 1) more |
| > skilled in providing palliative care consults, 2) better able to    |
| > determine appropriate dosage for adequate pain control in older     |
| > veterans, and 3) more skilled in conducting family conferences for  |
| > elderly veterans in palliative care.                                |
+-----------------------------------------------------------------------+
| **7. CLINICAL DEMONSTRATION PROJECTS**                                |
+-----------------------------------------------------------------------+
| **NOTE:** A clinical demonstration [program]{.underline} is defined   |
| as:                                                                   |
|                                                                       |
| -   an ongoing, clinical, cooperative collaboration between the GRECC |
|     and host VA medical center;                                       |
|                                                                       |
| -   that carries out and evaluates assessment strategies, management  |
|     approaches and/or specialized investigations                      |
|                                                                       |
| -   of a targeted or focused group of elderly patients                |
|                                                                       |
| -   with the intention that findings will be disseminated for the     |
|     advancement of the field.                                         |
|                                                                       |
| A clinical demonstration program is comprised of one or more clinical |
| demonstration [projects]{.underline}, each of which is defined as     |
|                                                                       |
| -   a set of one or more clinical activities                          |
|                                                                       |
| -   integrated and coordinated under a specified protocol             |
|                                                                       |
| -   designed to permit evaluation(s) of processes and/or outcomes.    |
|                                                                       |
| Evaluation of a clinical demonstration program may be a comprehensive |
| assessment of the activity and/or the clinical outcomes.              |
| Alternatively, evaluation may concentrate on a prioritized and        |
| feasible set of more focused or specific, project-related questions,  |
| e.g. related to improved diagnosis, quality of care, patient          |
| satisfaction, drug compliance, functional status, etc.  Ongoing and   |
| subsequent modifications of the care model may also be evaluated as   |
| may be the practicability and outcomes of exporting new clinical      |
| models or variations of models to general care settings and/or        |
| smaller, more resource-limited VA medical centers or outpatient       |
| facilities.                                                           |
+-----------------------------------------------------------------------+
| a.  **Clinical Demonstration Projects Underway in Report Year***:     |
|     list **all** GRECC Clinical Demonstration Projects underway. For  |
|     each item, indicate whether [N]{.underline}ew or                  |
|     [O]{.underline}ngoing in Report Year. You may include up to five  |
|     lines of descriptive text for each Project.*                      |
|                                                                       |
| > **NOTE:** The number of Projects listed should be equal to the      |
| > number of Clinical Demonstration Projects you have listed and named |
| > in the GRECC Electronic Database.                                   |
|                                                                       |
| -   Insular and Autonomic Function in Depression. The major goals of  |
|     this project are to demonstrate whether insular blood flow        |
|     mediates depression's association with heart rate variability     |
|     (HRV). Dr. Donald Royall and colleagues have previously           |
|     demonstrated specific associations between tests of               |
|     constructional praxis and survival in well elderly persons. This  |
|     may reflect right insular mediated autonomic dysfunction in       |
|     elderly persons at risk for Alzheimer's disease (AD). They have   |
|     shown that insular AD pathology is specifically associated with   |
|     *antemortem* electrocardiographic changes, including QT           |
|     intervals, and that asymmetry in insular blood flow by functional |
|     magnetic resonance imaging (fMRI) *in vivo* is associated with    |
|     orthostatic blood pressure changes. They have also shown that     |
|     orthostatic blood pressure and heart rate partially mediate       |
|     depression's association with mortality. The present study uses   |
|     fMRI to determine whether right insular blood flow mediates the   |
|     association between depressive symptoms and HRV in non-demented   |
|     octogenarians, free of comorbid cardiovascular disease. \[New\]   |
|                                                                       |
| -   Autonomic Dyscontrol and Very Early Alzheimer\'s Disease. The     |
|     primary goals of this project conducted by Dr. Donald Royall and  |
|     colleagues are to establish specific associations between tests   |
|     of constructional praxis and insular mediated autonomic           |
|     dysfunction in elderly persons at risk for Alzheimer's disease    |
|     (AD). The PI and colleagues have previously observed a specific   |
|     association between right hemisphere visuospatial cognitive tasks |
|     and mortality in non-demented octogenarians. Similar tests        |
|     specifically predict mortality in AD. This study uses functional  |
|     magnetic resonance imaging (fMRI) to determine whether right      |
|     insular blood flow mediates the association between visuospatial  |
|     cognitive measures and measures of autonomic control in           |
|     non-demented octogenarians, free of comorbid cardiovascular       |
|     disease. \[Ongoing\]                                              |
|                                                                       |
| -   Stress-Busting Program for Caregivers of Patients with            |
|     Neurological Diseases. The overall goal of this program is to     |
|     determine the effectiveness of relaxation therapy and stress      |
|     management for caregivers of patients with Alzheimer's disease    |
|     and Parkinson's disease. This is a longitudinal study that        |
|     focuses on teaching relaxation skills to caregivers and           |
|     monitoring the effectiveness using biofeedback parameters,        |
|     immunological parameters, and self-report measures. Follow-up     |
|     studies are performed at two and four months after the completion |
|     of the study. Compliance with the study and follow-up has         |
|     exceeded 95%. \[Ongoing\]                                         |
|                                                                       |
| -   Geriatric-Specific Health Care Quality Curriculum in the Clinical |
|     Setting. In late FY04 Dr. Monica Horton was awarded a Geriatric   |
|     Academic Career Award (GACA) from the Bureau of Health            |
|     Professions of the Health Resources and Services Administration   |
|     of the USPHS. Using these funds in FY05, Dr. Horton began         |
|     development and implementation of a geriatric-specific Health     |
|     Care Quality curriculum to apply in direct patient care programs. |
|     Congress cancelled all geriatrics education programs in FY06, but |
|     restored them in FY07; and Dr. Horton was refunded in             |
|     September 2007. She is continuing this activity with these funds. |
|     \[Ongoing\]                                                       |
|                                                                       |
| -   Medical Quality Improvement in the GEM Clinic: Intervention to    |
|     Prevent Emergency Room (ER) Visits and Hospitalizations. Dr.      |
|     Monica Horton is pursuing studies of medical quality improvement  |
|     initiated under a Bureau of Health Professions Geriatric Academic |
|     Career Award (GACA). Providing patients with efficient and        |
|     effective care is a characteristic of the ideal healthcare        |
|     system, as described in the Institute of Medicine report          |
|     "Crossing the Quality Chasm". Ambulatory care sensitive           |
|     conditions are illnesses for which timely treatment in the        |
|     ambulatory care setting would be expected to prevent ER visits    |
|     and hospitalizations. In Dr. Horton's study, patients who are     |
|     enrolled in the VA Geriatric Evaluation and Management (GEM)      |
|     Clinic and who have recently been seen in the ER receive a GEM    |
|     intervention consisting of notification of clinic hours or        |
|     clinical telephone access parameters. Congress cancelled all      |
|     geriatrics education programs in FY06, but restored them in FY07; |
|     Dr. Horton was refunded in September 2007. She is continuing this |
|     activity with these funds. \[Ongoing\]                            |
|                                                                       |
| -   Longitudinal, Integrated Humanities Curriculum in the Clinical    |
|     Setting. This curriculum has been developed by a GRECC/Extended   |
|     Care clinical investigator, Dr. Sandra Sanchez-Reilly. It         |
|     incorporates a specific longitudinal, integrated humanities       |
|     curriculum with the UTHSCSA Center for Medical Humanities and     |
|     Ethics, strategically designed for the different education levels |
|     of medical students and residents, geriatric fellows and          |
|     interdisciplinary team members. Dr. Sanchez-Reilly began teaching |
|     the curriculum in FY06 and continues it. \[Ongoing\]              |
|                                                                       |
| -   Combined Consultation Service in Geriatric Medicine and           |
|     Palliative Care. This program has been developed, implemented and |
|     evaluated by Dr. Sandra Sanchez-Reilly, who was awarded a GACA    |
|     for this purpose in late FY 04. This program incorporates the     |
|     humanities curriculum Dr. Sanchez-Reilly is developing with the   |
|     UTHSCSA Center for Medical Humanities and Ethics. The literature  |
|     lacks evidence on the efficacy of combined programs in the areas  |
|     of geriatrics and palliative care. Palliative care programs       |
|     address quality of life issues, but few are specifically related  |
|     to older populations with provision of complementary geriatric    |
|     expertise. Dr. Sanchez-Reilly and colleagues have developed a     |
|     model of care at this VAMC with dual expertise in geriatrics and  |
|     palliative care. The model is being evaluated for its efficacy in |
|     addressing many needs of veteran patients, including pain         |
|     control, end-of-life care in frail patients, management of        |
|     geriatric syndromes such as delirium/acute confusion, and         |
|     functional assessment. Congress cancelled all geriatrics          |
|     education programs in FY06, but restored them in FY07; Dr.        |
|     Sanchez-Reilly was refunded in September 2007. She is continuing  |
|     this activity with these funds. \[Ongoing\]                       |
|                                                                       |
| ```{=html}                                                            |
| <!-- -->                                                              |
| ```                                                                   |
| -   Multidisciplinary Geriatric Oncology Clinic. Dr. Sandra           |
|     Sanchez-Reilly is expanding the multidisciplinary geriatric       |
|     oncology clinic at the affiliated NIH-designated Cancer Therapy   |
|     and Research Center which was developed partly as a site for      |
|     clinical outcomes research on optimization of oncological care    |
|     for older adults and for the conduct of clinical trials           |
|     specifically designed for the elderly. Currently, patient         |
|     demographic and epidemiological data are being collected. In      |
|     addition, Palliative Care and Geriatrics Fellows began rotations  |
|     in this clinic in FY06 and continued in FY07. \[Ongoing\]         |
|                                                                       |
| -   Interdisciplinary Clinical Training Program in Geriatrics at      |
|     Golden Manor Jewish Home and Services for the Aging (GM). Drs.    |
|     Michèle Saunders, Michael Katz, and Sandra Sanchez-Reilly have    |
|     developed an interdisciplinary clinical training program in       |
|     geriatrics at Golden Manor in part to meet new ACGME and          |
|     fellowship requirements for more female patients.                 |
|     Interdisciplinary teams of advanced trainees in geriatrics from   |
|     the disciplines of medicine, dentistry, dental hygiene, nursing,  |
|     PT, OT, social work, psychology, and chaplaincy rotate through    |
|     the site. \[Ongoing\]                                             |
|                                                                       |
| -   Wound Rounds Tracking Program. GRECC staff and affiliated staff   |
|     have begun a new program to track the progression of wound        |
|     healing in the ECTC using photography. Clinical photographs are   |
|     taken of wounds at each Wound Rounds, entered into the electronic |
|     medical record and assessed to determine if therapies should be   |
|     adjusted. \[Ongoing\]                                             |
+-----------------------------------------------------------------------+
| b.  **Evaluation of Clinical Demonstration Projects:** *for each      |
|     GRECC Clinical Demonstration Project listed in 7a above,          |
|     summarize the evaluation activity. If no evaluation results are   |
|     available, be explicit as to the focus of the planned evaluation, |
|     and when it is anticipated to occur. If the project has been      |
|     completed during the Report Year, provide key findings and their  |
|     significance.*\                                                   |
|     **NOTE:** Do not list patient service use data here. Those data   |
|     are reported in the GRECC Electronic Database.                    |
|                                                                       |
| -   Data from fMRI will be used to determine whether right insular    |
|     blood flow mediates the association between depressive symptoms   |
|     and HRV in non-demented octogenarians, free of comorbid           |
|     cardiovascular disease.                                           |
|                                                                       |
| -   Autonomic Dyscontrol and Very Early Alzheimer\'s Disease (closed  |
|     in 2008).  Visuospatial cognitive measures were shown to mediate  |
|     depression's association with mortality, and that both the        |
|     association between depression and mortality, and that of         |
|     visuospatial cognition and mortality, are mediated by             |
|     orthostasis.  Data suggest that there is a significant            |
|     association between asymmetric right insular blood flow           |
|     reductions and orthostasis.                                       |
|                                                                       |
| -   Stress-Busting Program for Caregivers of Patients with            |
|     Neurological Diseases. Outcomes of this intervention are assessed |
|     on both short-term and long-term bases using psychosocial         |
|     instruments as well as state-of-the-science technology including  |
|     biofeedback measurements and immune parameters. There were many   |
|     improvements for both spousal and adult children caregivers.      |
|     However, the children caregivers did not improve to the same      |
|     level as the spousal caregivers because they expressed difficulty |
|     in "letting go" of their stress.                                  |
|                                                                       |
| -   Geriatric-specific Health Care Quality Curriculum in the Clinical |
|     Setting. Evaluation is based on assessment of trainee             |
|     performance, trainee evaluation of curriculum, patient            |
|     satisfaction surveys, and improved patient outcomes. \[No         |
|     evaluation data available in FY08\]                               |
|                                                                       |
| -   Medical Quality Improvement in the GEM Clinic: Intervention to    |
|     Prevent Emergency Room (ER) Visits and Hospitalizations. The      |
|     intervention measures used in the study were found to result in a |
|     progressive decline in the number of ER visits. Dr. Horton's      |
|     ongoing research indicates that formation of a quality            |
|     improvement team and selective targeting of older patients        |
|     seeking care in an inappropriate setting will dramatically        |
|     improve the efficacy and cost of health care within the VA.       |
|                                                                       |
| -   Longitudinal, Integrated Humanities Curriculum in the Clinical    |
|     Setting. Evaluation is based on assessment of trainee             |
|     performance, trainee evaluation of curriculum, patient            |
|     satisfaction surveys, and alterations in care of elderly veteran  |
|     patients. FY08 evaluation thus far indicates the trainees found   |
|     the curriculum to be excellent in preparing them to treat elderly |
|     patients.                                                         |
|                                                                       |
| -   Combined Consultation Service in Geriatric Medicine and           |
|     Palliative Care. Evaluation is based on assessment of trainee     |
|     performance, trainee evaluation of rotation, patient satisfaction |
|     surveys, and improved patient outcomes. FY08 evaluation thus far  |
|     indicates the trainees found the curriculum and rotation          |
|     experience to be excellent in preparing them to treat elderly     |
|     patients and provide palliative care when appropriate.            |
|                                                                       |
| -   Multidisciplinary Geriatric Oncology Clinic. Currently, patient   |
|     demographic and epidemiologic data are being collected.           |
|     Evaluation of trainee performance is based on assessment of       |
|     trainee performance, trainee evaluation of rotation, patient      |
|     satisfaction surveys, and improved patient outcomes. FY08         |
|     evaluation thus far indicates the trainees found the curriculum   |
|     to be excellent in preparing them to treat elderly patients with  |
|     cancer and patients and their families were extremely satisfied   |
|     with their care. \[No patient outcome data available in FY08\]    |
|                                                                       |
| -   Interdisciplinary clinical training program in geriatrics at GM.  |
|     Evaluation is based on assessment of trainee performance, trainee |
|     evaluation of rotation, and patient satisfaction surveys. Results |
|     of FY08 evaluations show a significant improvement of knowledge,  |
|     attitudes and skills among trainees by the end of the rotation;   |
|     trainees enjoyed the rotation; and the GM residents enjoy working |
|     with the students during their rotations.                         |
|                                                                       |
| -   Wound Rounds Tracking Program. GRECC staff and affiliated staff   |
|     have begun a new program to track the progression of wound        |
|     healing in the ECTC using photography. Clinical photographs are   |
|     taken of wounds at each Wound Rounds, entered into the electronic |
|     medical record and assessed to determine if therapies should be   |
|     adjusted. \[Data was being analyzed toward the end of FY08.\]     |
+-----------------------------------------------------------------------+
| c.  **New Clinical Models developed at your GRECC that were exported  |
|     in the Report Year** *(list up to five examples, up to two lines  |
|     each; 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 Combined Consultation Service in Geriatrics and Palliative    |
|     Care has been presented formally at the national level with       |
|     ongoing evaluation and additional discussion for export VISN-     |
|     and/or nation-wide. Export to VISN 17 is underway with the new    |
|     Palliative Care on the Road Program.                              |
|                                                                       |
| -   The Multidisciplinary Geriatric Oncology Clinic at the CTRC       |
|     affiliate also has been presented formally at the national level  |
|     with ongoing evaluation and additional discussion for possible    |
|     export VISN- and/or nation-wide.                                  |
|                                                                       |
| -   Clinical Model for Dementia Assessment. Dr. Royall's dementia     |
|     assessment scales (the Executive Interview \[EXIT25\] and CLOX:   |
|     an executive clock drawing task) have been incorporated into      |
|     numerous longitudinal studies of aging, including the Hispanic    |
|     Established Populations for the Epidemiologic Study of the        |
|     Elderly, the San Antonio Longitudinal Study of Aging, and the     |
|     University of Alabama Longitudinal Study of Aging. These studies  |
|     provide opportunities to extend Dr. Royall's work on executive    |
|     function to community samples. The EXIT25 and CLOX have also been |
|     introduced into clinical trials, which provide the first          |
|     empirical evidence of the potential to reverse executive          |
|     impairments in the elderly. The EXIT25 and CLOX have been         |
|     translated into 14 languages; Dr. Royall has validated a Spanish  |
|     language translation of the CLOX, while Dutch, Hebrew, and        |
|     Mandarin Chinese translations of the EXIT25 have been validated   |
|     by other investigators. In addition, the British Geriatrics       |
|     Society has specifically recommended CLOX for initial dementia    |
|     screening in its most recent evidence-based guidelines, thus      |
|     assuring broad international export of this instrument for use as |
|     a clinical model for dementia assessment.                         |
+-----------------------------------------------------------------------+
| **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.              |
+-----------------------------------------------------------------------+
| **a.** **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):*                                     |
|                                                                       |
| > The GRECC continues to address the South Texas Veterans Health Care |
| > System's palliative care program. In FY-08, 20 facility-wide        |
| > training sessions were held for host VAMC staff. Attendees found    |
| > the seminars extremely helpful and have implemented screening of    |
| > patients for palliative care consultations.                         |
| >                                                                     |
| > Kerrville Division instituted a patient care screening program for  |
| > palliative care consultations after consultation with the GRECC     |
| > palliative care team. \[Ongoing\]                                   |
|                                                                       |
| **b. Previous Years' Activities Outcomes** *(list up to five          |
| examples, up to two lines each; 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.)*                                 |
|                                                                       |
| -   GRECC staff completed editing of 16 hours of dental video for the |
|     curriculum sharing project in dentistry and nutrition with the    |
|     Little Rock GRECC. These edited videos were converted to DVD      |
|     format in FY08 and are now ready for export.                      |
|                                                                       |
| -   Dental staff from the Kerrville VAMC, having completed geriatrics |
|     training, is now fully responsible for the care of their elderly  |
|     nursing home residents; therefore, GRECC dental staff no longer   |
|     has to travel to Kerrville to treat these nursing home patients.  |
|                                                                       |
| -   Because the GRECC AD/EE was officially appointed to both the host |
|     and VISN 17 Education Committees there are now more consultation  |
|     and outreach education programs within the host VAMC and          |
|     throughout the VISN.                                              |
+-----------------------------------------------------------------------+