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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** **.**]{.mark}                      |   |   |   |   |
+----------------------------------------------------------+---+---+---+---+
| **\*[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:** New England GRECC                    |   |   |   |   |
|                                                          |   |   |   |   |
| b.  **Location** *(facility, VISN)*: VISN 1, Two sites   |   |   |   |   |
|     -- Boston Health Care System and Bedford VAMC        |   |   |   |   |
+----------------------------------------------------------+---+---+---+---+
| **2. CONTACT PERSON**                                    |   |   |   |   |
+----------------------------------------------------------+---+---+---+---+
| a.  **Name:** Elizabeth A. Grant, NE GRECC               |   |   |   |   |
|     Administrative Officer (857)364-2564.                |   |   |   |   |
|     <elizabeth.grant@va.gov>                             |   |   |   |   |
|                                                          |   |   |   |   |
| b.  **Name:** Judy DeCarteret, Program Support           |   |   |   |   |
|     Assistant, Bedford Division -- (781)687-2927.        |   |   |   |   |
|     <Judith.DeCarteret@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 |   |
|                                                          | * | * | * |   |
|                                                          | * | * | * |   |
+----------------------------------------------------------+---+---+---+---+
| Alzheimer's disease                                      | * | * | * |   |
|                                                          | * | * | * |   |
|                                                          | X | X | X |   |
|                                                          | * | * | * |   |
|                                                          | * | * | * |   |
+----------------------------------------------------------+---+---+---+---+
| Age-related non-Alzheimer neurodegenerative diseases     | * |   |   |   |
| (ALS, Huntington's disease)                              | * |   |   |   |
|                                                          | X |   |   |   |
|                                                          | * |   |   |   |
|                                                          | * |   |   |   |
+----------------------------------------------------------+---+---+---+---+
| Patient safety and outcomes research (home safety for    |   |   | * |   |
| demented patients)                                       |   |   | * |   |
|                                                          |   |   | X |   |
|                                                          |   |   | * |   |
|                                                          |   |   | * |   |
+----------------------------------------------------------+---+---+---+---+
| Chronic disease epidemiology and aging (Alzheimer's      |   | * |   |   |
| disease, Cardiac disease, successful aging)              |   | * |   |   |
|                                                          |   | X |   |   |
|                                                          |   | * |   |   |
|                                                          |   | * |   |   |
+----------------------------------------------------------+---+---+---+---+
| Vascular factors associated with cognitive decline and   |   | * |   |   |
| vascular dementia                                        |   | * |   |   |
|                                                          |   | X |   |   |
|                                                          |   | * |   |   |
|                                                          |   | * |   |   |
+----------------------------------------------------------+---+---+---+---+
| Palliative care (dementia)                               |   | * |   |   |
|                                                          |   | * |   |   |
|                                                          |   | X |   |   |
|                                                          |   | * |   |   |
|                                                          |   | * |   |   |
+----------------------------------------------------------+---+---+---+---+
| Traumatic brain injury                                   | * |   |   |   |
|                                                          | * |   |   |   |
|                                                          | X |   |   |   |
|                                                          | * |   |   |   |
|                                                          | * |   |   |   |
+----------------------------------------------------------+---+---+---+---+
| Cognitive Neuroscience and neuropsychology               | * | * |   |   |
|                                                          | * | * |   |   |
|                                                          | X | X |   |   |
|                                                          | * | * |   |   |
|                                                          | * | * |   |   |
+----------------------------------------------------------+---+---+---+---+
| Polypharmacy in the elderly                              |   | * |   |   |
|                                                          |   | * |   |   |
|                                                          |   | X |   |   |
|                                                          |   | * |   |   |
|                                                          |   | * |   |   |
+----------------------------------------------------------+---+---+---+---+

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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}. ***                                  |
|                                                                       |
| -   Boston Division -- Under GRECC leadership, Home Based Primary     |
|     Care Program matured and grew to a census of nearly 100 veterans. |
|     Management of the program was transitioned to Care Coordination   |
|     in early September 2008. Medical director role will transition to |
|     Ambulatory Care in late November 2008.                            |
|                                                                       |
| -   Boston Division -- continues to provide leadership and clinical   |
|     care to VA BHCS Palliative Care Programs. Drs. Gaziano and Nelson |
|     successfully recruited a fellowship trained palliative care       |
|     specialist to function as Director of the Palliative Care         |
|     Service. Lara Michal Skarf, MD, will lead and expand clinical and |
|     educational programs in hospice and palliative care for VABHCS.   |
|                                                                       |
| -   Bedford Division - the GRECC is responsible for a comprehensive   |
|     model Alzheimer Disease Program, including a 100-bed Dementia     |
|     Special Care Unit and Outpatient Clinics. GRECC received a VISN 1 |
|     Kizer Award for culture change on the dementia special care       |
|     units: "Meeting the privacy and health needs of women veterans    |
|     with advanced dementia". This small grant was instrumental in     |
|     leveraging an additional commitment from the facility to improve  |
|     the physical environment on the inpatient dementia units.         |
|                                                                       |
| -   Bedford Division - Dr. Andrew Budson has implemented a monthly    |
|     GRECC Staff Matinee, which combines a brief staff meeting with a  |
|     scientific presentation, as well as a clinicopathological case    |
|     conference (CPC) every other month. The CPC involves a            |
|     multidisciplinary discussion of the clinical history of a         |
|     resident who has recently died prior to Dr. Ann McKee presenting  |
|     the pathological report. Attendance has included physicians,      |
|     psychologists, nurse practitioners, nurses, nursing assistants,   |
|     health technicians and therapists from GRECC as well as various   |
|     hospital departments. It is well attended with an average of 40pp |
|     each month.                                                       |
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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}. ***                                  |
|                                                                       |
| -   James Rudolph, MD, Boston GRECC staff physician is actively       |
|     involved in the VISN Medical Patient Safety Center of Excellence  |
|     and presented at the National VA Quality Improvement Meeting held |
|     in Pittsburg, PA in May, 2008. Attendees consisted of 100 VA      |
|     participants from many VA's nationwide.                           |
|                                                                       |
| -   Senior GRECC staff serve as advisors to the VISN Geriatrics       |
|     Service Line and the VISN Geriatrics Council. The GRECC Associate |
|     Director for Education is a full member of the Network Education  |
|     Council. Her input this year is focused on developing the Network |
|     Strategic Plan and evaluation of distance-learning strategies.    |
|                                                                       |
| -   GRECC Associate Director of Education is the director of the      |
|     newly funded VISN 1 Patient Safety Center of Inquiry for high     |
|     risk patients in home health settings. The Center is initially    |
|     funded for two years with competitive renewal thereafter. Goals   |
|     completed for FY08-09 were LASA (look-alike sound-alike) drugs,   |
|     in particular insulin preparations, medication reconciliation,    |
|     safe home oxygen therapy, and caregiver assistance tools on       |
|     MyHealtheVet.                                                     |
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| 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. ***          |
|                                                                       |
| -   Dr Ann McKee, GRECC investigator and Chief of Neuropathology for  |
|     VISN 1, is Co-Director of the newly established Center for the    |
|     Study of Traumatic Encephalopathy (CSTE). Chronic traumatic       |
|     encephalopathy (CTE), also known as Dementia Pugilistica, is an   |
|     age-related neurofibrillary degeneration of the brain that        |
|     affects individuals with a history of repetitive traumatic brain  |
|     injury (TBI). It is a progressive disorder that often does not    |
|     become symptomatic until decades after the acute trauma. Although |
|     CTE affects athletes, it is also seen in veterans with a history  |
|     of TBI. The new IOM report to the VA emphasizes the long term     |
|     sequelae of TBI and emphasizes the importance of VA care for aged |
|     veterans with dementia. The CSTE has created a brain donation     |
|     program and registry for living athletes who wish to donate their |
|     brains after death. This brain bank is housed at the Bedford VAMC |
|     and is part of the GRECC program.                                 |
|                                                                       |
| -   Focus on safety for patients with dementia including home safety  |
|     programs and education materials. The booklet "Keep Your Home     |
|     Safe for the Person with Memory Loss" is available in PDF format  |
|     for families and persons with memory loss. Developed with clear   |
|     language and health literacy principles based on research with 62 |
|     families and 6 focus groups. These guidelines help keep patients  |
|     at home and delay the need for institutional care. Dr. Horvath.   |
|     Dates: 2003 -- present.                                           |
|                                                                       |
| -   The development and testing of the PAINAD (Pain Assessment in     |
|     Advanced Dementia) tool fills a gap in the assessment of pain in  |
|     elderly, cognitively impaired adults. Use of the PAINAD meets     |
|     JCAHO criteria for an adequate pain assessment tool by using a 10 |
|     point scale that can be taught easily to all levels of staff and  |
|     family members. This innovative scale improves the recognition of |
|     pain in demented patients who are unable to communicate and helps |
|     monitor their response to pain treatment to ensure that pain is   |
|     adequately managed. Dates: 2004- present                          |
|                                                                       |
| -   New approaches to improve the recovery of brain-damaged patients  |
|     have been developed and tested such as galvanic vestibular        |
|     stimulation (GVS). Preliminary studies on individual patients     |
|     show that this procedure may help improve visual perception in    |
|     patients and improve functional capacity after serious brain      |
|     damage caused by injury or strokes. Drs. Milberg and GRECC staff. |
|     Dates: 2005- present                                              |
|                                                                       |
| -   The Pharmacologic Intervention in Late Life (PILL) Clinic is a    |
|     multi-disciplinary approach to reduce polypharmacy and drug       |
|     interactions, provide patient and PCP education, and conduct      |
|     medication reconciliation providing education to geriatric and    |
|     pharmacy trainees. It addresses gaps in the current health care   |
|     system that can result in inappropriate medication use. Drs.      |
|     Nelson, Rudolph, and Salow. 2005-present                          |
+-----------------------------------------------------------------------+
| **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}.*                                      |
|                                                                       |
| 1.Yates LB, Djousse L, Kurth T, Buring JE, Gaziano JM. **Exceptional  |
| longevity in men:  modifiable factors associated with survival and    |
| function to age 90 years.  Arch Intern Med 2008; 168:284-90.** This   |
| paper explored the determinants of surviving to age 90 years or       |
| greater. Among physicians in the Physicians Health Study that had an  |
| opportunity to reach age 90 years of age over nearly 25 years of      |
| follow-up over 40% survived to this exceptional age.  The main        |
| factors that contributed to the achievement of longevity were         |
| traditional chronic disease risk factors such as smoking, exercise,   |
| and hypertension. These factors were present at the age of 65 or      |
| older and suggest that attention to these factors even in later       |
| middle age could\                                                     |
| impact the length and quality of our lives.                           |
|                                                                       |
| 2.Rudolph JL, Salow MJ, Angelini MC, McGlinchey RE. **The             |
| anticholinergic risk scale and anticholinergic adverse effects in     |
| older persons. Arch Intern Med. 2008;168(5):508-13.** Anticholinergic |
| medications have a litany of side effects including: mimicking        |
| Alzheimer's disease, constipation, falls, delirium, and dry mouth. In |
| this study, the GRECC developed the Anticholinergic Risk Scale (ARS), |
| a ranked list of medications with anticholinergic properties. The ARS |
| was subsequently validated in a GRECC population and a VA primary     |
| care population. As a result, increased exposure to anticholinergic   |
| medications (measured with the ARS) was associated with increased     |
| side effects in both populations. Thus, the ARS is a useful screening |
| tool for anticholinergic side effects in older patients that will be  |
| useful in identifying patients at risk for taking many commonly used  |
| medications.                                                          |
|                                                                       |
| 3\. McKee AC, Carreras I, Hossain L, Ryu H, Klein WL, Oddo S, LaFerla |
| FM, Jenkins BG, Kowall NW, Dedeoglu A. **Ibuprofen reduces Abeta,     |
| hyperphosphorylated tau and memory deficits in Alzheimer mice**.      |
| Brain Res. 2008 May 1;1207:225-36. Epub 2008 Feb 16. Ibuprofen has    |
| been previously shown to reduce amyloid accumulation in mouse models  |
| of Alzheimer's disease. In this report we found that ibuprofen also   |
| reduces the development of Alzheimer-type degeneration in nerve cells |
| and memory deficits in these mice. These novel findings suggest that  |
| drugs like ibuprofen may be useful in treating degenerative brain     |
| diseases other than Alzheimer's disease such as fronto-temporal       |
| dementia which currently have no effective therapy.                   |
|                                                                       |
| 4\. Hanlon EB, Perelman LT, Vitkin EI, Greco FA, McKee AC, Kowall NW. |
| **Scattering differentiates Alzheimer disease in vitro.** Opt Lett.   |
| 2008 Mar 15;33(6):624-6. In this report we show that a novel          |
| detection method using infrared light can detect Alzheimer changes in |
| brain tissue. This may lead to the development of new non-invasive    |
| methods to diagnose Alzheimer's disease in living patients which can  |
| now only be definitively diagnosed by examining brain tissue after    |
| death.                                                                |
|                                                                       |
| 5\. Stack EC, Dedeoglu A, Smith KM, Cormier K, Kubilus JK, Bogdanov   |
| M, Matson WR, Yang L, Jenkins BG, Luthi-Carter R, Kowall NW, Hersch   |
| SM, Beal MF, Ferrante RJ. **Neuroprotective effects of synaptic       |
| modulation in Huntington\'s disease R6/2 mice.** J Neurosci. 2007 Nov |
| 21;27(47):12908-15. Huntington's disease (HD) is an inherited         |
| neurodegenerative disorder in which there is significant evidence     |
| that over excitation of neurons may lead to their death. Blocking     |
| excitatory activity lessened the disease symptoms in HD mice,         |
| suggesting that a therapy inhibiting over stimulation of neurons may  |
| be protective. These new observations could lead to the development   |
| of new treatments for this fatal condition.                           |
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| **b. Key Findings Published in the Report Year on work in which GRECC |
| Core Staff served as Co-Investigators to a Non-GRECC PI:** *list      |
| **five or fewer**; for each item provide GRECC Core Staff name(s),    |
| journal reference, and description of topic/method/results/clinical   |
| significance. Please limit each response to [5 lines or               |
| fewer]{.underline}.*                                                  |
|                                                                       |
| 1.Sorond FA, Serrador J, Schnyer D, Iloputaife L, Vyes M, Gagnon M,   |
| Milberg WP, Lipsitz LA. **Age-related alterations in cerebrovascular  |
| hemodynamics during cognitive tasks. Functional Transcranial Doppler  |
| Ultrasonography. Cortex. 2008 44. 179-184.** This paper shows how a   |
| newly developed technique for showing functional alterations in       |
| cerebral blood flow is affected by age. Young and old normal adults   |
| performed a simple working memory task while cerebral blood flow      |
| through the anterior and posterior cerebral arteries was measured     |
| using transcranial Doppler ultrasonograpy. Results showed less        |
| differentiated functional blood flow patterns in old compared to      |
| young adults. A better understanding of how blood flow changes during |
| aging may be important in detecting early changes that could lead to  |
| stroke or dementia.                                                   |
|                                                                       |
| 2\. Ramlawi B, Otu H, Rudolph JL, Mieno S, Kohane IS, Can H,          |
| Libermann TA, Marcantonio ER, Bianchi C, Sellke FW. **Genomic         |
| expression pathways associated with brain injury after                |
| cardiopulmonary bypass. J Thorac Cardiovasc Surg.                     |
| 2007;134(4):996-1005.** This study examined the genomic expression of |
| 42 patients who underwent cardiac surgery. Seventeen patients (42%)   |
| developed early cognitive decline. These pts were found to have       |
| decreased expression of genes involved in inflammation, antigen       |
| presentation, and cellular adhesion compared to those without         |
| cognitive decline. As a result of genetic factors, some patients may  |
| be predisposed to developing cognitive decline after cardiac surgery. |
| This observation could lead to the development of new ways to         |
| identify patients at high risk for the development of cognitive       |
| decline after surgery.                                                |
|                                                                       |
| 3\. Vlad SC, Miller DR, Kowall NW, Felson DT. **Protective effects of |
| NSAIDs on the development of Alzheimer disease.** Neurology. 2008 May |
| 6;70(19):1672-7. This study examined the large VA dataset and found   |
| that the use of NSAIDs such as ibuprofen was associated with a lower  |
| risk of developing Alzheimer's disease. This confirms other studies   |
| done on small numbers of patients and supports the use of ibuprofen   |
| to prevent age-related cognitive decline and Alzheimer's disease.     |
|                                                                       |
| 4\. Yaar M, Arble BL, Stewart KB, Qureshi NH, Kowall NW, Gilchrest    |
| BA. [p75(NTR) **Antagonistic Cyclic Peptide Decreases the Size of     |
| beta Amyloid-Induced Brain                                            |
| Inflammation.**](http://www.ncbi.                                     |
| nlm.nih.gov/pubmed/18807174?ordinalpos=1&itool=EntrezSystem2.PEntrez. |
| Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum) |
| Cell Mol Neurobiol. 2008 Sep 19. \[Epub ahead of print\]. In this     |
| animal study we found that a novel peptide derivative blocks the      |
| toxicity of beta amyloid which is thought to be a major contributor   |
| to brain degeneration in Alzheimer's disease. This could lead to the  |
| development of new treatment s for Alzheimer's disease.               |
|                                                                       |
| 5\. Harper DG, Stopa EG, Kuo-Leblanc V, McKee AC, Asayama K, Volicer  |
| L, Kowall N, Satlin A.Dorsomedial **SCN neuronal subpopulations       |
| subserve different functions in human dementia.** Brain. 2008         |
| Jun;131(Pt 6):1609-17. Epub 2008 Mar 27. We found that daily patterns |
| of body temperature and activity correlate with patterns of nerve     |
| cell degeneration in a part of the hypothalamus called the            |
| suprachiasmatic nucleus in patients with Alzheimer's disease. This    |
| study furthers our understanding of how specific patterns of nerve    |
| cell degeneration affect patient activity and behavior in Alzheimer's |
| disease and will be helpful in designing new treatments targeting     |
| these behavior and activity patterns.                                 |
+-----------------------------------------------------------------------+
| **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 GRECC Associate Director of Education and Evaluation was one  |
|     of 6 members of the Dementia Training Materials Review Workgroup  |
|     convened by the Office of Geriatrics and Extended Care (OGEC) to  |
|     identify the extent and adequacy of educational materials in use  |
|     within the VA for training staff on care of veterans with         |
|     dementia. In FY 2008, the catalog was put in a web-based format   |
|     for easier navigation and posted as a prominent menu "tab" on the |
|     GEC national website.                                             |
|                                                                       |
| -   A self-learning module, Functional Assessment of the Older        |
|     Driver, was developed for CDN (content distribution network). It  |
|     is accredited for 1 CME and available on the national CDN server. |
|                                                                       |
| -   A toolkit for providers to teach patients about supplementary     |
|     insulin was developed for HBPC and Primary Care service lines. It |
|     includes cognitive aids for patients/families to decrease the     |
|     risk of mistakes with supplementary insulin.                      |
|                                                                       |
| -   A pamphlet for safe home oxygen therapy was developed and         |
|     learner-verified for attractiveness, comprehension, and           |
|     persuasion. It is being used in HBPC to teach patients/families   |
|     about safe home oxygen therapy.                                   |
|                                                                       |
| -   Dr Nelson of the Boston Division has assumed the role of          |
|     physician leader of the West Roxbury VA Schwartz Rounds which is  |
|     a monthly multidisciplinary conference with an average of 80      |
|     attendees from the medical center, geared to improving            |
|     patient-provider communication through discussion of a variety of |
|     topics such as confusion in the elderly and care of the patient   |
|     who has recently received a terminal diagnosis. Dr Rudolph        |
|     continues to operate a postoperative delirium consult service and |
|     to participate in team rounds in the SICU, providing clinical     |
|     care to veterans and education to surgical and nursing staff in   |
|     the management of patients at risk for postoperative delirium.    |
+-----------------------------------------------------------------------+
| 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.***   |
|                                                                       |
| -   A Dementia Training Materials List including individual dementia  |
|     training materials and an index by both topic and setting of care |
|     are products that resulted from the Dementia Training Materials   |
|     Workgroup. The catalog was originally sent as an Email attachment |
|     but now is in a web-based format for easier navigation and posted |
|     on the GEC national website as a prominent menu "tab".            |
|                                                                       |
| -   A new CDN module, Functional Assessment of the Older Driver, is   |
|     accredited for 1 CME and available nationally. In addition to the |
|     VA intranet, the module is posted on the website of our           |
|     affiliate, Boston University Alzheimer's Disease Center for       |
|     access by non-VA colleagues                                       |
|     ([www.bu.edu/alzresearch](http://www.bu.edu/alzresearch)).        |
|                                                                       |
| -   Supplementary insulin toolkit with teaching aids for providers    |
|     and cognitive aids for patients/families is being distributed by  |
|     the VA National Patient Safety Center and Insulin subcommittee of |
|     the Five Million Lives Campaign.                                  |
+-----------------------------------------------------------------------+
| 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.*                                         |
|                                                                       |
| -   1\) Host Facility program: Providers in primary care and HBPC     |
|     were provided information about LASA drugs and The Joint          |
|     Commission requirements for developing a list of 10 pairs.        |
|     Following review of the selected pairs, the participants          |
|     identified insulin preparations as the most frequent and          |
|     dangerous of adverse drug events because the labeling is so       |
|     similar. Subsequently, a toolkit for supplementary insulin was    |
|     developed with teaching aids for providers and cognitive aids for |
|     patients/families. Process evaluation revealed that the toolkit   |
|     was being distributed frequently by providers who also requested  |
|     an additional cognitive aid to help patients understand the "rule |
|     of 15". Outcome evaluation is underway.                           |
|                                                                       |
| -   2\) Non-host facility program: The new CDN module, Functional     |
|     Assessment of the Older Driver, was distributed by EES in August  |
|     2008 through its national Email listing of new programs. One      |
|     month later, just 2 providers had completed the evaluation        |
|     (possibly others accessed the program but did not complete the    |
|     evaluation); feedback from some network leadership indicated that |
|     the module was hard to find in the VA Catalog. The AD/EE then     |
|     sent a targeted Email to Primary Care and GEC leadership in the   |
|     Network with a "hot link" and specific directions to access the   |
|     program. Another 2 -- 3 people completed the program. Notably,    |
|     opinion leaders who viewed the program also encouraged staff to   |
|     access it. More feedback on the low utilization revealed that     |
|     providers could not find time for a self-learning activity and we |
|     are now planning to include the program in structured learning    |
|     activities such as grand rounds. Despite the disappointing        |
|     utilization results to date, the participants who completed the   |
|     program are highly complimentary of the quality and the           |
|     information has been revealing about the lack of use of CDN when  |
|     the program is not part of mandatory training.                    |
+-----------------------------------------------------------------------+
| **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.                                   |
|                                                                       |
| -   1\. "Meeting the Privacy and Health Needs of Women Veterans with  |
|     Dementia," is located at the Bedford division, Dementia Special   |
|     Care Units and led by Dr. Horvath. The project is developed in    |
|     the context of culture transformation that will benefit all       |
|     residents on the dementia units, while meeting the immediate      |
|     needs for privacy for the women veterans. The objectives focus on |
|     environmental change, staff education and family involvement.     |
|                                                                       |
| -   2\. Pharmacologic Intervention in Late Life (PILL) Clinic: is     |
|     conducted at the Boston Division and led by Dr. Millan and Dr.    |
|     Salow. This project is focused on medication reconciliation for   |
|     elders who are taking more than 14 medications, one of which is   |
|     on the Beers' List , a comprehensive assessment is performed by   |
|     the geriatrician and pharmacist and patients perception of        |
|     medications is evaluated by a standard of medication adherence    |
|     questionnaire. Medication education and reconciliation is         |
|     conducted every visit. The team also makes recommendations to     |
|     primary care providers.                                           |
|                                                                       |
| -   3\. The GRECC Memory Diagnostic Clinic provides state-of-the-art  |
|     evaluations by a neuropsychologist and neurologist. Comprehensive |
|     neurological and neuropsychological examinations are performed,   |
|     and laboratory and imaging studies are obtained. At the follow-up |
|     visit the diagnosis and treatment plan are provided as well as    |
|     practical advice for the veteran and their family. This clinic    |
|     provides an ideal training opportunity, for affiliated medical    |
|     students, residents and geriatric fellows.                        |
|                                                                       |
| -   4\. The Outpatient Palliative Care Clinic provides comprehensive  |
|     multidisciplinary care to veterans with a variety of life         |
|     threatening illnesses including cancer, dementia, end stage       |
|     pulmonary disease and congestive heart failure. Patients and      |
|     caregivers appreciate the quality of resources provided including |
|     medical, pharmacological, social and spiritual support. The       |
|     clinic provides care for families and caregivers otherwise not    |
|     easily available in other services. The outpatient palliative     |
|     care clinic is a key bridge for the inpatient palliative care     |
|     service.                                                          |
+-----------------------------------------------------------------------+
| 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.                    |
|                                                                       |
| 1\) "Meeting the Privacy and Health Needs of Women Veterans with      |
| Dementia: The environmental changes are near completion with a new    |
| bathing facility finished, a kitchen/lounge, and conversion of the    |
| dormitory to private and semi-private rooms. New flooring that is     |
| recommended to prevent serious injuries from falls ("smart cells") is |
| being reviewed for installation and will be part of the evaluation.   |
| Staff education, a second component of the project, has begun and     |
| will continue in the coming year.                                     |
|                                                                       |
| 2\) Evaluation of a "Pharmacologic Intervention in Late Life (PILL)   |
| Clinic": The Polypharmacological Intervention in Late Life (PILL)     |
| clinic underwent a transition in leadership and resources this past   |
| year. Firsts, PILL founder Dr. Juliana Millan left and leadership was |
| transitioned to Drs. Marci Salow, PharmD and James Rudolph.           |
| Additionally, the PILL clinic was partially funded under the VISN 1   |
| Medication Patient Safety Center of Excellence. The procedures and    |
| findings for the PILL clinic were presented at the VA Quality         |
| Improvement Meeting in May 2008. Overall the PILL clinic succeeded in |
| recruitment of an older cohort (mean age 79 years, range 64-92 years) |
| with \> 15 medications (mean 18 meds, range 5-30). After complete     |
| medication reconciliation, on average 1.5 interventions were made per |
| patient. Interventions included discontinuing medications (55%), dose |
| reduction (31%), switching to less toxic medications (23%). Also key  |
| in the year, was the publication of the Anticholinergic Risk Scale    |
| (1), a validated measure of anticholinergic burden. In the coming     |
| year , we will be actively working with the Department of Pharmacy    |
| and the VISN 1 Medication Patient Safety Center of Excellence to      |
| implement the ARS as our electronic screening tool for PILL clinic.   |
|                                                                       |
| 3\) The GRECC Memory Diagnostic Clinic:                               |
|                                                                       |
| By all measures the GRECC Memory Diagnostic Clinic has been a true    |
| success. All diagnoses were consistent from year 1 to year 2, and     |
| many diagnoses from other clinicians were either further specified or |
| were corrected. The most common specification in diagnosis was from   |
| "dementia" to "Alzheimer's disease," and the most common correction   |
| was from "vascular dementia" to either "Alzheimer's disease" or       |
| "mixed dementia (Alzheimer's disease plus vascular)." Both patient    |
| and family satisfaction were extremely high; comments made frequently |
| were that no other doctor spent as much time or did such a thorough   |
| evaluation of their memory. After explaining to patients and families |
| realistic goals of the medications, medication compliance was         |
| extremely high.                                                       |
|                                                                       |
| 4\) The GRECC Palliative Care Clinic and Consult Service: Dr. Lara    |
| Skarf, is the recently appointed full time Director for this Program. |
| She is fellowship trained palliative care and is the GRECC based      |
| specialist now overseeing this expanding program. PCCT consults have  |
| increased substantially from 13 to 29 in 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"):*           |
|                                                                       |
| -   Educational pocket card to identify and differentiate between     |
|     delirium depression and dementia sent to Puget Sound, Palo Alto   |
|     and St Louis VA's                                                 |
|                                                                       |
| -   PAINAD scale for pain assessment in advanced dementia has been    |
|     exported widely to VA's throughout the country including VAMC     |
|     Long Beach, Asheville VAMC, WBVAMC, Allentown. Non-VA facilities  |
|     requesting educational resources to implement usage of the PAINAD |
|     in the past include Mercy Hospice, Sacramento, CA; Long Island    |
|     Jewish Medical Center, New York; Suburban Hospital, MD; and St.   |
|     John's Hospital, Springfield, IL.                                 |
+-----------------------------------------------------------------------+
| **8. COLLABORATION ACTIVITY**                                         |
+-----------------------------------------------------------------------+
| NOTE: Increasingly, VACO is seeking to characterize the GRECCs as not |
| only isolated programs of excellence, but also, as a group, a potent  |
| and effective system for investigating issues, demonstrating          |
| efficacy, and implementing change. In order to assist the GEC office  |
| in building a resource set of examples of GRECCs working in           |
| complementary manners to advance their own goals and those of the     |
| Department, you asked to provide up to five (5) examples of           |
| collaborative activities you have underway with one or more GRECCs    |
| other than your own. If possible, please try to include at least one  |
| Clinical Demonstration, one Education, and one Research example. Be   |
| sure to specify the GRECC or GRECCs with whom you are collaborating;  |
| and a description, limited to 6 or fewer lines, of the collaborative  |
| activity.                                                             |
+-----------------------------------------------------------------------+
| -   On Feb 5, 2008, Dr Rudolph participated in a GRECC teleconference |
|     entitled \"Delirium in the elderly: evolving models of clinical   |
|     management\". Collaborators included the St Louis GRECC, The      |
|     Tennessee Valley GRECC, the Maryland GRECC, the Ann Arbor GRECC,  |
|     and the Salt Lake City GRECC                                      |
|                                                                       |
| -   Dr Rudolph continues to be an active member of the VA GRECC       |
|     Delirium Working Group                                            |
|                                                                       |
|     -   At the AGS meeting, Dr Rudolph collaborated with the Puget    |
|         Sound GRECC to present at a VA SIG sponsored symposium        |
|         entitled, \"Developing your career in academic geriatrics,    |
|         from fellowship to independence\"                             |
|                                                                       |
| ```{=html}                                                            |
| <!-- -->                                                              |
| ```                                                                   |
| -   Educational collaboration with the Pittsburg GRECC: consultation  |
|     on role of AD of Education and Evaluation, John Hennon            |
|                                                                       |
| -   Clinical consultation with the Pittsburg GRECC: The Associate     |
|     Directors of Clinical Care from Pittsburg and Bedford             |
|     collaborated where a patient with Alzheimer's disease was         |
|     evaluated in Pittsburg for admission the Dementia Care Unit in    |
|     Bedford which helped us to better serve a family with a           |
|     complicated family situation.                                     |
|                                                                       |
| -                                                                     |
+-----------------------------------------------------------------------+