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| ### GERIATRIC RESEARCH, EDUCATION AND CLINICAL CENTER                 |
|                                                                       |
| ### *Annual Report: Fiscal Year [2004]{.underline}*                   |
|                                                                       |
| ######## Part II: Accomplishments                                     |
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| **NOTE:** The **GRECC Annual Report** reflects status and             |
| accomplishments of **[GRECC Core Staff]{.underline}** (as defined     |
| below) [only]{.underline}. Report year is from [October 1 through     |
| September 30]{.underline}.                                            |
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| **1. GRECC NAME/LOCATION**                                            |
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| a.  **GRECC Name:** New England GRECC                                 |
|                                                                       |
| b.  **Location:** VISN 1: Two sites, Bedford VA Medical Center and    |
|     Boston Health Care System (BHCS)                                  |
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| **2. CONTACT PERSON**                                                 |
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| a.  **Name:** **Liz Grant (Boston)/Linda Danner (Bedford)**           |
|                                                                       |
| b.  **Position:** Administrative Officer/Program Assistant            |
|                                                                       |
| c.  **Phone, e-mail:** (617) 232-9500 x 2564,                         |
|     <elizabeth.grant@med.va.gov/> (781) 687-3167, linda.danner        |
|     \@med.va.gov                                                      |
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| **3. GRECC FOCUS AREA(S)**                                            |
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| **a. Basic Biomedical**: Neuroscience/cognitive disorders,            |
| cardiovascular physiology & pharmacology, and metabolism.             |
|                                                                       |
| **b. Applied Clinical**: Management of advanced Alzheimer's Disease   |
| and other dementias, and aging with a long-term disability.           |
|                                                                       |
| **c. Health Services**: Ethics, advance directives, outcomes          |
| research, and decision support technology                             |
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|                                                                       |
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| a.  **GRECC Impact on Host VAMC in Current Year**                     |
|                                                                       |
| -   The Boston division has established a Home-Based Primary Care     |
|     Program at the VA Boston Health Care System (BHCS)                |
|                                                                       |
| -   The addition of Juliana Millan and Daniel Forman, new GRECC       |
|     clinicians/scientists, to the Boston Division enables the Boston  |
|     GRECC to expand its clinical and research programs. Both          |
|     physicians are former GRECC geriatric fellows.                    |
|                                                                       |
| -   GRECC has reestablished and strengthened its affiliation with the |
|     Brigham & Women's Hospital. Dr. Gaziano, Boston site leader, has  |
|     established the Division of Aging located at Brigham & Women's    |
|     Hospital.                                                         |
|                                                                       |
| -   Expansion of GRECC research at the Bedford VA Hospital, in        |
|     Alzheimer Disease, ALS, and other neurodegenerative disease,      |
|     including new preclinical and clinical trials, has greatly        |
|     impacted the local medical center.                                |
|                                                                       |
| -   GRECC is implementing a comprehensive education initiative for    |
|     nursing staff in the Alzheimer program at Bedford, including      |
|     orientation of new staff and education regarding clinical         |
|     research in Alzheimer's Disease.                                  |
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| b.  **GRECC Impact on VISN in Current Year**                          |
|                                                                       |
| -   Dr. Neil Kowall represents the GRECC on the VISN Geriatrics       |
|     Council that includes local care line managers for geriatrics     |
|     from all facilities in VISN 1.                                    |
|                                                                       |
| -   Dr. Cantor is a member of the network telehealth implementation   |
|     team and is helping to determine how to best role out telehealth  |
|     technologies for veterans with chronic illnesses.                 |
|                                                                       |
| -   A new educational initiative designed for physician and Allied    |
|     Health Professionals, a bi-monthly, VISN-wide videoconference     |
|     Case Studies in Dementia focuses on skill-based training          |
|     regarding assessment , differential diagnosis, and safe           |
|     practices. The Employee Education System (EES) is promoting this  |
|     modality for distance education and the GRECC initiative in the   |
|     VISN is the first project to be implemented.                      |
|                                                                       |
| -   GRECC investigator Dr. Ferrante, is principal investigator of new |
|     clinical trials programs including a major new trial for ALS that |
|     has given VISN 1 national prominence.                             |
|                                                                       |
| ```{=html}                                                            |
| <!-- -->                                                              |
| ```                                                                   |
| -   GRECC funds and mentors Harvard Geriatric Fellows who rotate      |
|     through the clinical programs at both sites. Mentorship of        |
|     associated health professional trainees has doubled in FY03.      |
|     Disciplines supported include nursing, social work, therapies,    |
|     pharmacy, and optometry.                                          |
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| c.  **GRECC Trend-Setting Innovations since October 1,                |
|     [1999]{.underline}**                                              |
|                                                                       |
| -   GRECC investigators play a prominent role in Alzheimer's Disease  |
|     research nationally through the NIA-funded Boston University      |
|     Alzheimer Disease Center and by leading the Alzheimer\'s Disease  |
|     VA Consortium (ADVAC). Bedford GRECC is the site for a VA-funded  |
|     REAP award focused on Parkinson's and Alzheimer's disease (Dr.    |
|     Richard Fine is principal investigator), the Bedford GRECC is a   |
|     member of the national Alzheimer\'s Disease Cooperative Study     |
|     Group (ADCS) funded by NIA. GRECC staff includes Drs. Kowall,     |
|     Ferrante, Fine, Volicer, and Morin. Dates: 1999 - present         |
|                                                                       |
| -   Advances in Home End of Life Care in Advancing Dementia (AHEAD    |
|     project) supported 38 teams from 18 VISNs nationwide to improve   |
|     recognition of dementia in outpatients, staff education,          |
|     caregiver support, and symptom management, including advanced     |
|     directives. Distance-learning methods are used to support teams   |
|     and helps them to maintain the gains while identifying new goals. |
|     GRECC staff include L. Volicer and V. Warden. Dates: 2000 -       |
|     present                                                           |
|                                                                       |
| -   The annual Harvard Medical School/Division on Aging/Department of |
|     Continuing Education Course in Geriatric Medicine educates over   |
|     100 attendees from around the country on a full spectrum of       |
|     topics in Geriatric Medicine. The program targets internists and  |
|     family practitioners. Course materials are rated "above average"  |
|     or "superior compared with other postgraduate courses" by 90% of  |
|     participants. GRECC staff: Drs. Gaziano, Cantor and Milberg, Ms.  |
|     Grant. Dates: 1999 - present                                      |
|                                                                       |
| ```{=html}                                                            |
| <!-- -->                                                              |
| ```                                                                   |
| -   *Enhancing the Quality of Life in Advanced Dementia*              |
|     (Philadelphia: Taylor and Francis) is one of a series of          |
|     educational books published over the last several years by GRECC  |
|     staff that have set national standards for Dementia Special Care  |
|     units and the treatment of advanced Alzheimer Disease. GRECC      |
|     staff Drs. Volicer, Kowall, and Hurley, V. Warden, RN. Date:      |
|     1999 - present                                                    |
|                                                                       |
| -   Innovative models of clinical care for Alzheimer's Disease,       |
|     including theDementia Special Care Unit with a focus on quality   |
|     of life: palliative care philosophy, Veteran's Club, Therapeutic  |
|     Activity Center, respite and hospice programs. GRECC developed a  |
|     tool to measure discomfort in non-communicative Alzheimer         |
|     patients, resistiveness to care scale, home safety/injury model,  |
|     and PAINAD: Pain Assessment in Advanced Dementia, the first       |
|     reliable and valid tool for pain assessment which meets JCAHO     |
|     criteria. Drs. Volicer, Kowall, Horvath, and V. Warden, RN.       |
|     Dates: 1999 - present.                                            |
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| **5. RESEARCH**                                                       |
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| a.  **Key Findings Published in Current Year -- GRECC Core Staff as   |
|     PI or CO-PI**                                                     |
|                                                                       |
| -   **Dedeoglu, A**, Choi, JK, Cormier, K, **Kowall, NW**, Jenkins    |
|     BG. Magnetic resonance spectroscopic analysis of Alzheimer's      |
|     disease mouse brain that express mutant human APP shows altered   |
|     neurochemical profile. Brain Res. (2004) 1012: 60-5. Research on  |
|     remote neurochemical analysis and therapeutic strategies in       |
|     transgenic mouse models of Alzheimer's Disease in collaboration   |
|     with Massachusetts General Hospital, using MRI and PET            |
|     technology.                                                       |
|                                                                       |
| -   Beal, MF, and **Ferrante, RJ.** Experimental Therapeutics in      |
|     Transgenic Mouse Models of Huntington's Disease. Nature Reviews   |
|     Neuroscience (2004) 5: 373-384. Understanding mechanisms of       |
|     neurodegeneration affecting the aging population and has provided |
|     clues to therapeutic strategies for age-related neurodegenerative |
|     disorders (e.g., amyotrophic lateral sclerosis (ALS), and         |
|     Huntington's disease, Parkinson's disease, Alzheimer's disease).  |
|     A translational program to target success therapeutic strategies  |
|     in mice has led to several NIH and VA-funded clinical human       |
|     trials.                                                           |
|                                                                       |
| -   **Morin, PJ**, Medina N, Semenov, M, Brown, AMC, and Kosik, KS.   |
|     Wnt-1 expression in PC 2 cells induces exon 15 deletion and       |
|     expression of L-APP. Neurobiol Dis. (2004) 16: 59-67. This        |
|     research examines the role of LRP6 and Wnt signaling pathways in  |
|     Alzheimer's Disease model systems. These are likely to be         |
|     important steps leading to cell death in Alzheimer's Diseasethat  |
|     may lead to new therapeutic approaches in the future.             |
|                                                                       |
| -   **Conn, K, McKee, AC, Ullman, MD, Eisenhauer, PB, Fine, RE**.     |
|     Identification of the protein disulfide isomerase family member   |
|     PDip experimental Parkinson's Disease and Lewy body pathology.    |
|     Brain Res (2004) 164-72. Dr. Fine and collaborators are examining |
|     mechanisms of neurodegeneration that are relevant to Parkinson's  |
|     Disease.                                                          |
|                                                                       |
| -   **Horvath, Kathy**. Promoting safer home environments for persons |
|     with Alzheimers Disease: The Home Safety/Injury Model. J of       |
|     Gerontological Nursing (2004) 6:43-51. The first report of        |
|     empirical findings of home safety modifications for high          |
|     frequency, high severity injury risks for veterans with           |
|     dementias.                                                        |
|                                                                       |
| ```{=html}                                                            |
| <!-- -->                                                              |
| ```                                                                   |
| -   Pugh KG, Kiely DK, **Milberg WP**, Lipsitz LA. Selective          |
|     Impairment of Frontal-Executive Cognitive Function in African     |
|     Americans with Cardiovascular Risk Factors. Journal of the        |
|     American Geriatrics Society (2003) 51(10): 1439-1444.             |
|     Cerebrovascular risk and neuropsychological function was measured |
|     in a sample of healthy older community dwelling older             |
|     African-Americans. A strong relationship between hypertension and |
|     diabetes and measures of executive function was found. There was  |
|     no relationship between these risk factors and measures of        |
|     memory.                                                           |
|                                                                       |
| -   Fortier, C., Disterhoft, J. F., Capozzi, S., & **McGlinchey, R.** |
|     Conditional discrimination learning in patients with bilateral    |
|     medial temporal lobe amnesia. Behavioral Neuroscience (2003)      |
|     117(6): 1181-95. Bilateral medial temporal (MT) lobe amnesiacs    |
|     were impaired in their ability to acquire conditional             |
|     discrimination and were unable to respond differentially to       |
|     discriminative stimuli. These findings indicate that the          |
|     hippocampal system is essential for acquiring conditional         |
|     discrimination.                                                   |
|                                                                       |
| -   **Bowman TS**, Session HD, Ma J, Kurt T, Case CS, Stumper MJ,     |
|     **Gazing JM**.Cholesterol and the risk of ischemic stroke.        |
|      Stroke (2003) 34(12):2930-4. The goal of this study was to       |
|     evaluate whether total cholesterol, high-density lipoprotein, and |
|     triglycerides are risk factors for ischemic stroke in apparently  |
|     healthy men in a large prospective cohort. This study suggests    |
|     that an increased risk of ischemic stroke is limited to those     |
|     with the highest extreme levels of lipids.                        |
|                                                                       |
| -   **Christopher B. Brady**, Avron Spiro, III, and **J. Michael      |
|     Gaziano** Effects of Age and Hypertension Status on Cognition:    |
|     The VA Normative Aging Study. Neuropsychology. (2004) Under       |
|     review. Uncontrolled hypertension produces specific cognitive     |
|     deficits beyond those attributable to age alone.                  |
|                                                                       |
| -   **James L. Rudolph,** Edward R. Marcantonio. Diagnosis and        |
|     Prevention of Delirium. Geriatrics and Aging (2003) 6(10):14-19.  |
|     Delirium is associated with loss of independence, increased risk  |
|     of death, and a more complicated hospital course. After           |
|     controlling for age, baseline cognition, and medical comorbidity, |
|     atherosclerosis was significantly associated with postoperative   |
|     delirium.                                                         |
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| b.  **Key Findings Published in Current Year -- GRECC Core Staff as   |
|     Co-Investigators on Projects with Non-GRECC PI**                  |
|                                                                       |
| -   **Wilkinson, D.** & Halligan, P. W. (2004) The relevance of       |
|     behavioral measures for functional imaging studies of cognition.  |
|     *Nature Reviews Neuroscience, 5, 67-73.* The relevance of         |
|     behavioral measures to functional imaging studies is often        |
|     inferred from conjoint measures of behavior (i.e. reaction time), |
|     and brain activation (i.e. cerebral blood flow). In many          |
|     experiments, these measures produce divergent results. In such    |
|     circumstances, can cognitive theory be informed from brain        |
|     activation data alone? Or given the more established link between |
|     behavior and cognition, is behavioral corroboration necessary?    |
|                                                                       |
| -   **McKee, AC, Volicer, L** Dementia severity and Lewy bodies       |
|     affect circadian rhythms in Alzheimer disease. Neurobiological    |
|     aging (2004) 771-781. Sleep disturbances may be a result of       |
|     damage to specific brain regions in Alzheimer's Disease.          |
|                                                                       |
| -   **Conn, K, Ullman, MD, Eisenhauer, PB, Fine, RE, Wells, JM** cDNA |
|     microarray analysis of changes in gene expression associated with |
|     MPP+ toxicity in SH-SY5Y cells. Neurochem Res. 12/2003 1873-81    |
|     Changes in gene expression may reflect unique pattern of cell     |
|     injury in neurodegenerative disease.                              |
|                                                                       |
| -   **Ferrante RJ, Lee, J, Ryu, H, Smith, KM, Kowall, NW** Histone    |
|     Deacetylase Inhibition by sodium butyrate chemotherapy            |
|     ameliorates the neurodegenerative phenotype in Huntington's       |
|     Disease mice Neuroscience. 10/2003 9418-27 The exciting new       |
|     treatment may lead to clinical trials in people with              |
|     neurodegenerative disease.                                        |
|                                                                       |
| -   Sheridan, PL, Solomont J, **Kowall, N.,** Hausdorff, JM.          |
|     Influence of executive function on locomotor function: Divided    |
|     attention increases gait variability in Alzheimer's Disease. J of |
|     American Ger Society 2003, 51:1633-37 Specific changes in the     |
|     gait of Alzheimer's Disease patients are related to pattern of    |
|     brain damage and cognitive dysfunction.                           |
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| **6. EDUCATION**                                                      |
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| **NOTE**: Do not list trainee and conference data here. Those data    |
| are reported in the GRECC Electronic Database.                        |
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| a.  **Innovations in Educational Activities Implemented During        |
|     Current Year**                                                    |
|                                                                       |
| -   Reorganized and strengthened the Harvard Medical School Division  |
|     on Aging Geriatric Medicine Fellowship program. The program now   |
|     includes specific tracks for clinician-researchers and            |
|     clinician-educators, and curricula are being developed for each   |
|     track.                                                            |
|                                                                       |
| -   First Annual Combined New England GRECC Conference, October 1,    |
|     2003, entitled *Practice Guidelines in Older Adults.* Attendance  |
|     approximately 100 physicians, nurses, social workers,             |
|     pharmacists, PTs, OTs, psychologists and dietitians. Program      |
|     centered on evidence-based approaches to assessing older adults.  |
|                                                                       |
| -   Development of Interdisciplinary GRECC seminars with active and   |
|     consistent participation of faculty and trainees from different   |
|     disciplines including Social Work, Optometry, Dermatology,        |
|     Pharmacology, Neuropsychology and Geriatric Medicine.             |
|                                                                       |
| -   Development of the Geriatric Curriculum for the Internal Medicine |
|     Residency Program at the Brigham and Women's hospital in          |
|     conjunction with the internal medicine training program there.    |
|     Outline of topics in primary care geriatric medicine was created, |
|     and additional curriculum elements added with the input of GRECC  |
|     clinician-educators.                                              |
|                                                                       |
| -   Obtained grant to be a site for Harvard Upper New England         |
|     Geriatric Education Center program funded by the Health Resources |
|     and Services Administration (HRSA). First year focused on         |
|     developing understanding and reviewing use to technology to       |
|     support patient self-assessment and medication compliance, as     |
|     well as development of model curriculum module.                   |
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| b.  **Exportable Educational Products First Available for             |
|     Distribution in Current Year**                                    |
|                                                                       |
| -   AHEAD (Advances in Home Based Primary Care at End of Life for     |
|     Advanced Dementia): Two satellite broadcasts describing the AHEAD |
|     Dementia Care Improvement Model and areas of focus -- early       |
|     identification; symptom management; caregiver support, and staff  |
|     education. Videotapes available from EES.                         |
|                                                                       |
| -   Videotapes from dementia videoconference series on How to Conduct |
|     a Clock Drawing Task and Differential Diagnosis of Alzheimer's    |
|     Disease and Vascular Dementia. Videotapes are available from      |
|     GRECC.                                                            |
|                                                                       |
| ```{=html}                                                            |
| <!-- -->                                                              |
| ```                                                                   |
| -   Demonstration of use of multiple VA technologies in an e-learning |
|     application: "Clinical distance learning" Moderated by EES using  |
|     satellite broadcasts to VAKN/CON system-wide on channel 5 and     |
|     VANTs videobridge. Guidelines for the Evaluation of e-learning in |
|     Medical Education were developed under the auspices of Consortium |
|     of E-learning in Geriatrics Instruction and are available through |
|     them.                                                             |
|                                                                       |
| -   Home safety for patients with AD and other dementias. Developed   |
|     and verified educational materials to improve adherence to home   |
|     safety modifications for veterans with dementia. Program includes |
|     a booklet and home safety kit to enhance both practical skills    |
|     and self confidence of the caregiver. These are available from    |
|     GRECC.                                                            |
|                                                                       |
| -   Therapeutic Activity Center and Veteran's Club for patients in    |
|     dementia special care units targeted to improve quality of life.  |
|     Program guidelines are available for distribution to VA Medical   |
|     Centers.                                                          |
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| **7. NEW CLINICAL MODELS**                                            |
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| a.  **New Clinical Models Implemented in Current Year**               |
|                                                                       |
| -   Development of VA Boston Healthcare System Home Based Primary     |
|     Care Program. GRECC was assigned responsibility for this program  |
|     in January, 2004, and are completing program development and      |
|     recruitment phases. Plan is to incorporate telehealth technology  |
|     to support ability of older veterans to remain in the community,  |
|     and to create a research-friendly environment that will support   |
|     research into the use of telehealth and other innovations in home |
|     care. (New)                                                       |
|                                                                       |
| -   Geriatric Intake Clinic: Comprehensive assessment clinic with     |
|     multiple disciplines including medicine, nursing, social work,    |
|     pharmacy, and psychology. Currently developing protocols for care |
|     of outpatients with dementia (such as management of depression)   |
|     that permit standardization of care and innovation in allocation  |
|     of tasks to specific disciplines (e.g. pharmacists managing       |
|     patients with depression). (New)                                  |
|                                                                       |
| -   Palliative care for AD and other dementias in the community.      |
|     (Ongoing)                                                         |
|                                                                       |
| ```{=html}                                                            |
| <!-- -->                                                              |
| ```                                                                   |
| -   Home safety for patients with AD and other dementias. Home visits |
|     and home safety kit enhances both practical skills and self       |
|     confidence of the caregiver. (Ongoing)                            |
|                                                                       |
| -   Therapeutic Activity Center for patients in dementia special care |
|     units and the Veteran's Club, a social approach to providing      |
|     patient care for advanced dementia in institutional settings.     |
|     (Ongoing)                                                         |
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| **b. Current Year Evaluation Results of New Clinical Models**         |
|                                                                       |
| -   Home-Based Primary Care -- Program initiated in FY04, evaluation  |
|     data not available.                                               |
|                                                                       |
| -   Geriatric Intake Clinic initiated in FY04, evaluation data not    |
|     available.                                                        |
|                                                                       |
| -   Palliative care for AD and other dementias in the community.      |
|     Caregivers and patients are more satisfied with care and patients |
|     may be maintained in the community for a longer period of time.   |
|                                                                       |
| ```{=html}                                                            |
| <!-- -->                                                              |
| ```                                                                   |
| -   Home safety program evaluation data shows that home safety        |
|     modifications can be standardized for the high frequency/high     |
|     severity risks for injury in veterans with dementia living in a   |
|     community setting. Self --confidence of caregiver is enhanced by  |
|     family support, trusting relationship with professional           |
|     caregiver, resistance to make role changes in family, and an      |
|     understanding of the nature of Alzheimer's Disease and its impact |
|     on autonomy and decision making.                                  |
|                                                                       |
| -   Therapeutic Activities Center and Veteran's Club improves quality |
|     of life and reduces need for prn medications for inpatients on    |
|     dementia special care unit.                                       |
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| **c. New Clinical Models Exported in Current Year**                   |
|                                                                       |
| -   Palliative Care in Advanced Dementia: Site visits and educational |
|     material provided to Tewksbury State Hospital through             |
|     consultation.                                                     |
|                                                                       |
| -   Hospice of Case Western Reserve University, Education Team,       |
|     implemented pain education program which included PAINAD (Pain    |
|     Assessment in Advanced Dementia).                                 |
|                                                                       |
| -   Resistiveness to care (RTC) model and scale for conceptualizing   |
|     and measuring behavioral dimensions of resistiveness. Home        |
|     safety/Injury model for caregivers/care recipients with dementia. |
|     Educational materials are linguistically and culturally           |
|     appropriate for general population of elders. Being used by       |
|     United Methodist Homes, in Endwell, NJ and Partners Home care in  |
|     Rockland, MA.                                                     |
|                                                                       |
| ```{=html}                                                            |
| <!-- -->                                                              |
| ```                                                                   |
| -   PAINAD: Pain Assessment in Advanced Dementia is the first         |
|     reliable and valid tool for pain assessment on severely           |
|     cognitively impaired which meets JCAHO criteria for 10-point      |
|     numerical rating. Scale is being used by VA Palo Alto, and VAMCs  |
|     in San Francisco, Des Moines, and Baltimore.                      |
|                                                                       |
| -   Home Safety/Injury model for caregivers/care recipients with      |
|     dementia. Guidelines are being used by VA Palo Alto education     |
|     repository, Bedford VAMC outpatient dementia clinic, Hallmark     |
|     Home Health, Woburn, MA; Landmark Senior Living, Beverly, MA; and |
|     the Tampa VAMC.                                                   |
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| **8. CONSULTATION AND OUTREACH**                                      |
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| **a. Current Year Activity Outcomes**                                 |
|                                                                       |
| CONSULTATION                                                          |
|                                                                       |
| -   Host VAMC dementia units implemented and evaluated protocol to    |
|     prevent constipation in veterans with AD in institutional         |
|     settings. Outcomes are better than reported in literature.        |
|                                                                       |
| -   Primary care providers at host VAMC were educated regarding the   |
|     monitoring of creatine clearance in patients on memantine.        |
|                                                                       |
| -   Presentation (and videotape) at host VAMC on conducting and       |
|     scoring a clock drawing task -- requested by primary care         |
|     providers who wanted to incorporate clock drawing task into       |
|     cognitive assessment.                                             |
|                                                                       |
| OUTREACH                                                              |
|                                                                       |
| -   St. Augustine VA OPC is utilizing VA Long-Term Care Proxy         |
|     Planning form after consultation with GRECC staff.                |
|                                                                       |
| PAINAD: Pain Assessment in Advanced Dementia, the first reliable and  |
| valid tool for pain assessment on the severely cognitively impaired   |
| which meets JCAHO criteria for 10-point numerical rating. Scale is    |
| being used by VA Palo Alto, and VAMCs in San Francisco, Des Moines,   |
| and Baltimore.                                                        |
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| b.  **Previous Years' Activities Outcomes**                           |
|                                                                       |
| CONSULTATION                                                          |
|                                                                       |
| -   The Dining Experience represents continued work by Home           |
|     Improvement Committee (HIC) to create a home-like atmosphere on   |
|     dementia inpatient units at the host VAMC showed increased        |
|     satisfaction by survey.                                           |
|                                                                       |
|     -   Quarterly memorial services are held for veterans with        |
|         dementia who died in previous three months at eht host VAMC.  |
|         High satisfaction for both families and staff to complete the |
|         caring experience.                                            |
|                                                                       |
| OUTREACH                                                              |
|                                                                       |
| -   VA Palo Alto AHEAD team has developed and implemented a template  |
|     (Dementia Continuity of Care) that shows a posting (or alert) on  |
|     the electronic medical record of patients with dementia. This     |
|     template makes information available to all health care           |
|     professionals who might see the patient across the continuum of   |
|     care. Information includes activities of daily living, sleep,     |
|     pain, communication, and behavioral issues. Survey results were   |
|     positive.                                                         |
|                                                                       |
| ```{=html}                                                            |
| <!-- -->                                                              |
| ```                                                                   |
| -   Home Safety/Injury model for caregivers/care recipients with      |
|     dementia. This model is being used by VA Palo Alto education      |
|     repository, Bedford VAMC outpatient dementia clinic, Hallmark     |
|     Home Health, Woburn, MA; Landmark Senior Living, Beverly, MA; and |
|     the Tampa VAMC.                                                   |
|                                                                       |
| -   The Discomfort Scale in Dementia of the Alzheimer Type (DS-DAT)   |
|     has been adapted internationally as an evaluation tool for        |
|     comfort-promoting interventions. Among facilities using the scale |
|     are the University of Western Ontario, Canada, Massachusetts      |
|     General Hospital, and the Jewish Home in San Francisco, CA        |
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