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| ### GERIATRIC RESEARCH, EDUCATION AND CLINICAL CENTER                 |
|                                                                       |
| ### *Annual Report: Fiscal Year [2004]{.underline}*                   |
|                                                                       |
| ######## Part II: Accomplishments                                     |
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| **NOTE:** The **GRECC Annual Report** reflects status and             |
| accomplishments of **[GRECC Core Staff]{.underline}** (as defined     |
| below) [only]{.underline}. Report year is from [October 1 through     |
| September 30]{.underline}. [This Accomplishments report should be no  |
| more than a [total of ten pages]{.underline}.]{.mark}                 |
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| **GRECC Core Staff** includes **Primary Core**, **Affiliated Core,**  |
| and **Research Core.** **Primary Core =** positions authorized by the |
| original GRECC allocation plus any addition in ceiling from VA        |
| Central Office specifically designated for GRECC. **Affiliated Core** |
| = Staff who work full- or part-time in [direct support]{.underline}   |
| of the GRECC's research, education or clinical activity. May be       |
| either "contributed" by the VA Medical Center or acquired through     |
| centralized enhancements/awards for programs such as Home-Based       |
| Primary Care, Geriatric Evaluation and Management Program, etc. To be |
| considered Affiliated Core, staff must be organizationally aligned    |
| under the GRECC or specifically identified by the Medical Center as   |
| GRECC-affiliated staff. **Research Core** = Full-or part-time staff   |
| who devote 51% or more of their total time to GRECC research and      |
| whose salaries are supported by research funds (either VA or non-VA). |
| Includes all GRECC staff whose salaries are paid from research funds  |
| (e.g., Associate Investigator, Assistant Research Scientist, Senior   |
| Research Career Scientist; Research Career Scientist, Advanced        |
| Research Career Scientist).                                           |
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| **1. GRECC NAME/LOCATION**                                            |
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| a.  **GRECC Name:** Baltimore GRECC                                   |
|                                                                       |
| b.  **Location** *(facility, VISN)*: Baltimore VA Medical Center, VA  |
|     Maryland Health Care System, VISN 5                               |
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| **2. CONTACT PERSON**                                                 |
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| a.  **Name:** Andrew P. Goldberg, M.D.                                |
|                                                                       |
| b.  **Position:** Director, Baltimore GRECC                           |
|                                                                       |
| c.  **Phone, e-mail:** (410) 605-7183, agoldber@grecc.umaryland.edu   |
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| **3. GRECC FOCUS AREA(S)**                                            |
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| **NOTE:** Each problem area should ideally be approached from the     |
| basic biomedical, clinical [and]{.underline} health services research |
| perspectives, as well as from the rehabilitation research perspective |
| where that expertise exists. The number of problem areas should be    |
| limited to one or two. If the focus of research is different for      |
| basic biomedical, clinical, health services and/or rehabilitation     |
| research, there should be no more than a [total]{.underline} of 4     |
| major areas of investigation. [Changes to GRECC focus area(s) must be |
| approved by VACO (114).]{.mark}                                       |
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| a.  **Basic Biomedical**: Researchers address the molecular, cellular |
|     and genetic mechanisms underlying aging and associated            |
|     abnormalities in glucose, fat, and lipid metabolism, and the      |
|     effect of exercise training and weight loss in subjects with      |
|     diabetes, stroke, obesity and sedentary lifestyles.               |
|                                                                       |
| b.  **Applied Clinical**: Effects of exercise and diet modification   |
|     on risk factors for CVD in older veterans. Researchers address    |
|     the effects of gene-environment interactions on the mechanisms    |
|     underlying the effects of exercise and weight loss interventions  |
|     on hypertension, diabetes and hyperlipidemia. Researchers also    |
|     examine the effects of task-oriented treadmill training on        |
|     central and peripheral neural mechanisms, fitness levels,         |
|     cardiovascular disease risk factor profiles and functional status |
|     of older patients with chronic cardiovascular diseases, including |
|     stroke, peripheral arterial disease and coronary artery disease.  |
|                                                                       |
| c.  **Health Services**: Researchers examine the effects of exercise  |
|     and chronic rehabilitation interventions on functional            |
|     performance and quality of life in veterans with chronic          |
|     cardiovascular diseases.                                          |
|                                                                       |
| d\. **Rehabilitation**: The rehabilitation (tertiary prevention)      |
| involves studies of older patients disabled by stroke, peripheral     |
| arterial disease, and coronary artery disease.                        |
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| **4. ADMINISTRATION**                                                 |
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| a.  **GRECC Impact on Host VAMC in Current Year** *([list up to       |
|     five]{.mark} most important ways in which the GRECC has had       |
|     specific impact on host VAMC research, staff education, program   |
|     evaluation, or clinical care improvements for elderly veteran,    |
|     i.e., how the GRECC has "made a difference" in these areas within |
|     the entire host VAMC; [up to five lines each]{.mark})*:           |
|                                                                       |
| -   Interdisciplinary clinical and research programs provide          |
|     aggressive diet, exercise and drug treatment of CVD risk factors  |
|     in high risk veterans, and exercise rehabilitation for veterans   |
|     with stroke, peripheral arterial (PAD) and coronary artery        |
|     disease (CAD). A 1,000 ft^2^ Human Performance Lab will evaluate  |
|     motor outcomes (e.g. gait, balance) of exercise and aging studies |
|     in stroke and other chronic diseases.                             |
|                                                                       |
| ```{=html}                                                            |
| <!-- -->                                                              |
| ```                                                                   |
| -   Faculty provides continuing clinical and educational training in  |
|     geriatrics to VA health professionals, faculty and trainees in    |
|     weekly conferences, on the Geriatric Evaluation and Management    |
|     Unit, in the BRECC, attending on the designated "Medicine         |
|     Geriatrics Service", and in geriatric medicine outpatient         |
|     clinics.                                                          |
|                                                                       |
| -   Geriatric fellow, under the supervision of GRECC faculty, support |
|     the care of veterans in Geriatrics/Dementia Clinic, Geriatric     |
|     Pulmonary Care Clinic, the Geriatric Evaluation and Management    |
|     Unit, Home Based Primary Care and the Baltimore Rehabilitation    |
|     and Extended Care Center.                                         |
|                                                                       |
| ```{=html}                                                            |
| <!-- -->                                                              |
| ```                                                                   |
| -   GRECC faculty serve on the VISN 5 VA R&D committee that oversees  |
|     VISN5 research, the VA human subjects protection subcommittee and |
|     the UMB Institutional Review Board, the Computer Subcommittee of  |
|     the VA R&D committee and VISN 5 Advisory Council on Information   |
|     Security, the Extended Care Screening Committee that coordinates  |
|     the admission of elderly veterans to appropriate clinical         |
|     programs within the VAMHCS.                                       |
|                                                                       |
| -   GRECC faculty collaborates on the Nursing Research Initiative     |
|     project at the BRECC, "*Effect of exercise on muscle, function    |
|     and cost in VA nursing home residents to determine whether*       |
|     exercise will "make a difference" in the care of elderly veterans |
|     in nursing homes.                                                 |
|                                                                       |
| -   Dr. Shaughnessy sits on the VAMHCS Nursing Practice Council,      |
|     working with other nurse leaders to address clinical nursing      |
|     issues, and develop evidence-based policies and procedures. She   |
|     participated in 2004 Evidence-Based Practice Conference jointly   |
|     sponsored with the University of Maryland School of Nursing, and  |
|     is on the Planning committee for the 2005 meeting.                |
|                                                                       |
| -   The GRECC and the Geriatrics-LTC Service lines have implemented a |
|     monthly journal club/education meeting for the physicians and     |
|     nurse practitioners at Loch Raven and Perry Point campuses. Drs.  |
|     Heuser and Colvin participated in a two-hour panel presentation   |
|     and discussion of geriatric programs and up-date on geriatric     |
|     care for the VAMC Nursing Leadership Seminar on September         |
|     22, 2004. The focus of these meetings is new research and         |
|     developments in the care of the elderly and to educate the        |
|     clinical staff.                                                   |
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| b.  **GRECC Impact on VISN in Current Year** *([list up to            |
|     five]{.mark} most important ways in which the GRECC has had       |
|     specific VISN-wide impact on research, education/training,        |
|     program evaluation, or clinical care improvements for elderly     |
|     veterans, i.e., how GRECC participation in VISN-wide activities   |
|     has "made a difference" in these areas within the entire VISN;    |
|     [up to five lines each]{.mark}.* NOTE: GRECCs are intended and    |
|     expected to serve as a [regional]{.underline}, and not merely     |
|     local resource*)*:                                                |
|                                                                       |
| -   GRECC exercise and nutrition research programs impact older       |
|     veterans at high risk for CVD through prudent changes in          |
|     nutrition and physical activity to prevent complications of CVD   |
|     and disability. These programs have been translated into clinical |
|     practice in the national VA sponsored MOVE! Program.              |
|                                                                       |
| -   GRECC research findings that task-oriented exercise training      |
|     improves ambulatory capacity, gait, balance and free-living daily |
|     activity in older veterans with hemiparetic gait due to stroke    |
|     resulted in the award of a 5-year VA Stroke REAP entitled         |
|     "Disability Reduction and Disease Prevention in Stroke" to        |
|     examine the effects of exercise rehabilitation on molecular and   |
|     genetic regulation of inflammatory-prothrombotic mechanisms in    |
|     stroke.                                                           |
|                                                                       |
| ```{=html}                                                            |
| <!-- -->                                                              |
| ```                                                                   |
| -   Baltimore VA RR&D Center of Excellence in Exercise and Robotics   |
|     in Neurological Disease (funded 2005-2010) builds on exercise     |
|     models in aging stroke patients developed in GRECC Demonstration  |
|     Projects to investigate optimizing exercise prescriptions to      |
|     produce brain plasticity and improve cardiovascular health (GRECC |
|     Investigators), robotics assisted exercise (GRECC-MIT             |
|     collaboration), and Behavioral-Education Interventions (Dr.       |
|     Shaughnessy, GRECC).                                              |
|                                                                       |
| -   GRECC clinical programs use interdisciplinary teams led by Drs.   |
|     Katzel (AD/Clinical) and May (Clinical Director, Geriatrics       |
|     Baltimore) at Baltimore and Drs. Colvin (BRECC Director), and Dr. |
|     Heuser (G/LTC Service Line Manager) to provide clinical, hospice  |
|     and palliative care to older veterans in VAMHCS.                  |
|                                                                       |
| -   The Geriatrics/Dementia Clinic is a model clinic that evaluates   |
|     patients from other facilities in the VISN, ie.e, Washington and  |
|     Martinsburg VAMCs, and CBOCs in Cambridge and Pocomoke City.      |
|                                                                       |
| -   Education, training and evaluation strategies include semi-annual |
|     symposia conducted with CHEP, and VISN-wide onsite conference.    |
|                                                                       |
| -   Dr. Heuser established a monthly Geriatric Medicine Grand Rounds  |
|     at BVAMC that is simultaneously, two-way, video transmitted to    |
|     the extended care staff at Perry Point, Martinsburg VAMC and      |
|     Washington VAMC.                                                  |
|                                                                       |
| -   GRECC faculty provide training in geriatric medicine in long-term |
|     care, end-of-life care, geriatric psychiatry, and acute           |
|     rehabilitation to geriatric medicine and geropsychiatry fellows,  |
|     UMB residents, physicians assistant, nursing and nurse            |
|     practitioner students, physical therapy, social work and          |
|     psychology interns from local Universities (Delaware, Towson,     |
|     UMB) and community colleges at VISN 5 facilities.                 |
|                                                                       |
| -   Beyond the VA, GRECC faculty contribute to the UMB educational    |
|     mission during UMB's minimester course entitled "The Geriatric    |
|     Imperative." GRECC faculty disseminate the results of GRECC       |
|     research at professional meetings, such as the Gerontological     |
|     Society of America (GSA), North American Association for the      |
|     Study of Obesity (NAASO), Society of Behavioral Medicine (SBM),   |
|     American Geriatrics Society (AGS), American Diabetes Association  |
|     (ADA), and American College of Sports Medicine.                   |
|                                                                       |
| -   Dr. Heuser is the GRECC representative on the monthly Geriatric   |
|     Long Term Care Service Line Steering Committee that examines and  |
|     strives to improve programs in the VISN that provide care for     |
|     elderly veterans. He also provides an academic background and     |
|     assistance in interpretation of data collected in the clinical    |
|     settings, assists the managers of programs at Washington and      |
|     Martinsburg with systems, environment of care, and program        |
|     development.                                                      |
|                                                                       |
| -   Dr. Shaughnessy participates in a VISN organized external task    |
|     force reviewing patient care programs at the Baltimore            |
|     Rehabilitation and Extended Care Center. This task force is       |
|     charged with evaluating the patient care systems/environment and  |
|     making recommendations to improve care for at this facility.      |
|                                                                       |
| -   GRECC A/D Education-Evaluation developed a web-based educational  |
|     module for bedside nursing staff on early recognition of acute    |
|     illness in the older adult, with a corresponding database that    |
|     allows staff to document observations. The database automatically |
|     triggers notification of report to nursing administration and     |
|     medical providers, allowing tracking of outcomes.                 |
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| c.  **GRECC Trend-Setting Innovations since October 1,                |
|     [1999]{.underline}** *([list up to five]{.mark} most significant  |
|     GRECC research, education or clinical innovations in past five    |
|     years; for each item, provide date, GRECC staff responsible, and  |
|     [up to five line]{.mark} description)*:                           |
|                                                                       |
| -   There are no strategies proven to combat chronic disability of    |
|     stroke. We developed treadmill training as a model to promote     |
|     motor re-learning, while providing aerobic exercise to improve    |
|     fitness in chronic stroke. Treadmill training improved            |
|     cardiovascular fitness increases leg strength, gait and balance,  |
|     while reducing paretic hamstrings spasticity and energy cost of   |
|     hemiparetic gait. Findings suggest task-oriented training may     |
|     serve as a new model to improve function, cardiovascular fitness  |
|     and health in our aging chronic stroke population. 1998-2004.     |
|     Drs. Macko, Goldberg, Shaughnessy, Sorkin, Katzel, Hanley and UMB |
|     Claude D. Pepper Center.                                          |
|                                                                       |
| -   Rehabilitation research using bilateral arm training with         |
|     rhythmic auditory cueing (BATRAC) in chronic stroke patients with |
|     upper extremity hemiparesis correlate improved motor function     |
|     with new sites of brain activation using functional magnetic      |
|     resonance imaging. Training induced reorganization in motor       |
|     networks (contralesional cerebrum and ipsilesional cerebellum) in |
|     those individuals who also improved motor function.2001-2004.     |
|     Drs. Luft, Hanley, Goldberg, Macko, Sorkin, Forrester.            |
|                                                                       |
| ```{=html}                                                            |
| <!-- -->                                                              |
| ```                                                                   |
| -   GRECC investigators performed a series of single site clinical    |
|     trials that demonstrated that exercise rehabilitation can         |
|     significantly improve exercise capacity, time to onset of         |
|     claudication pain, quality of life and leisure time physical      |
|     activity in older individuals functionally limited by peripheral  |
|     arterial disease and intermittent claudication. 1995-2000. (Drs.  |
|     Gardner, Katzel, Sorkin, Bradham, Goldberg in collaboration with  |
|     investigators in the UMB Claude D. Pepper Center).                |
|                                                                       |
| -   The Biostatistics Core of the GRECC developed, GERI, a suite of   |
|     programs for running clinical trials. The programs are available  |
|     for use by other VA sites. The GERI system is used to store data  |
|     obtained from subjects participating in clinical trials at the    |
|     GRECC and University of Maryland Claude D. Pepper Older Americans |
|     Independence Center. In addition to storing research data, GERI   |
|     provides modules that assist in scheduling subject visits,        |
|     tracking subjects as they participate in GRECC and Pepper         |
|     studies, and keeps track of adverse events. 1999-2002. Dr.        |
|     Sorkin.                                                           |
|                                                                       |
| -   Used high throughput genotyping, SNP identification and genome    |
|     wide scans to identify several candidate genes in key regions     |
|     that may provide insights into the molecular mechanisms           |
|     underlying type 2 diabetes, obesity, hypertension, stroke and     |
|     osteoporosis. 2000-2004. Shuldiner, Mitchell, Kittner, Sorkin.    |
|                                                                       |
| -   Showed that APOE, PPAR, 2-AR, 3-AR, and ACE gene polymorphisms    |
|     affect the lipid and glucose metabolic, body composition and      |
|     blood pressure responses to weight loss, exercise and AHA dietary |
|     interventions. 1999-2004. Shuldiner, Nicklas, Goldberg, Hagberg,  |
|     Katzel, Ryan.                                                     |
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| **5. RESEARCH**                                                       |
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| a.  **Key Findings Published in Current Year -- GRECC Core Staff as   |
|     PI or CO-PI** *([list up to five]{.mark}; for each item provide   |
|     GRECC Core Staff name(s), journal reference, and [up to five      |
|     line]{.mark} description of topic/method/ results/clinical        |
|     significance; use layperson language)*:                           |
|                                                                       |
| **(**NOTE: GRECC Core Investigators' names are in **bold**)           |
|                                                                       |
| -   **Andrew P. Goldberg M.D.**, Dora M. Berman Ph.D., Barbara J.     |
|     Nicklas Ph.D., **Alice S. Ryan, Ph.D.,** with Thomas Tittelbach,  |
|     Ph.D. Racial differences in adipocyte size and relationship to    |
|     the metabolic syndrome in obese women. Obesity Research, 2004;    |
|     12: 990-998.                                                      |
|                                                                       |
| Measurement of gluteal (GLT) and abdominal (ABD) fat cell size (FCS)  |
| in obese African-American women and Caucasian women with metabolic    |
| syndrome and obese normals showed that gluteal fat cell size was more |
| closely related to dyslipidemia, insulin resistance and glucose       |
| intolerance in African-American than Caucasian women. In contrast,    |
| abdominal fat cell size predicted metabolic risk in Caucasian women.  |
| This suggests that central obesity may be a less valid predictor of   |
| the metabolic syndrome in African-American women. Therapies targeted  |
| to reduce gluteal adiposity might lower risk for cardiovascular       |
| disease and diabetes in African American women.                       |
|                                                                       |
| -   **Alan R. Shuldiner, M.D.,** Nannette I. Steinle, M.D.,           |
|     Braxton D. Mitchell, Ph.D. Variation in Lamin                     |
|                                                                       |
| > A/C Gene: Associations with the metabolic syndrome.                 |
| > Arteriosclerosis, Thrombosis Vascular Biology,                      |
| >                                                                     |
| > 2004; 24:1708-1713.                                                 |
|                                                                       |
| Lamin A/C Gene *(LMNA)* gene mutations cause rare syndromes of        |
| insulin resistance and dyslipidemia; thus, they may influence         |
| susceptibility to the metabolic syndrome and its constituent          |
| components. Haplotype                                                 |
|                                                                       |
| analysis showed \>87% of 971 subjects in the Amish Family diabetes    |
| study carried one of two common                                       |
|                                                                       |
| *LMNA* haplotypes, and DNA sequence analysis showed that the H566H    |
| polymorphism was associated                                           |
|                                                                       |
| with metabolic syndrome. Thus, sequence variation in *LMNA* may       |
| confer modest susceptibility for                                      |
|                                                                       |
| development of metabolic syndrome in the Amish, but it is unlikely to |
| be the gene detected through linkage                                  |
|                                                                       |
| analysis contributing to risk of type 2 diabetes. Targeted screening  |
| for this polymorphism might identify                                  |
|                                                                       |
| susceptible individuals who might benefit from early preventive       |
| therapy to avoid the metabolic syndrome                               |
|                                                                       |
| and its cardiovascular sequella.                                      |
|                                                                       |
| -   **Alice S. Ryan Ph.D.,** Barbara J. Nicklas, Ph.D. Reductions in  |
|     Plasma Cytokine Levels of Weight loss improves insulin            |
|     sensitivity in over weight and obese postmenopausal women.        |
|     Diabetes Care, 2004;27:1699-1705.                                 |
|                                                                       |
| Elevated inflammatory markers are increased in obesity, and are       |
| associated the development of type 2 diabetes and the metabolic       |
| syndrome in older adults. Baseline measures of insulin sensitivity    |
| correlated with C-reactive protein (CRP) in obese sedentary           |
| post-menopausal women, and a low intensity exercise and weight loss   |
| program that reduced body fat by 13% also reduced CRP, IL-6 and       |
| soluble TNF receptor 1 concentrations and increased insulin           |
| sensitivity by 16%, with no change in TNF, soluble TNF receptor 2or   |
| IL-6 receptor. The improvements in glucose metabolism/insulin         |
| sensitivity correlated with reductions in IL- 6, CRP, soluble TNFR1,  |
| total and visceral fat mass, suggesting that one mechanism by which   |
| weight loss improves insulin sensitivity is by reducing inflammatory  |
| markers. This suggests that exercise and weight loss reduce           |
| inflammatory markers and improve glucose metabolism, potentially      |
| reducing risk for type 2 diabetes and cardiovascular disease in obese |
| postmenopausal women.                                                 |
|                                                                       |
| # Patrick G. De Deyne, Ph.                                            |
| D., Charlene E. Hafer-Macko, M.D., Frederick M. Ivey, Ph.D., Alice S. |
|  Ryan Ph.D., Richard F. Macko, M.D. Muscle Molecular Phenotype After  |
| Stroke Is Associated With Gait Speed. Muscle Nerve 30: 209-251, 2004. |
|                                                                       |
| Disability after stroke is widely attributed to brain injury, but     |
| there are changes in muscle that could worsen function. We analyzed   |
| muscle fibers in the thigh of 13 older hemiparetic (half-paralyzed)   |
| stroke patients and found increased "fast fibers" on the paralyzed    |
| side. The abnormal shift to fast fibers, termed fast myosin heavy     |
| chains, was directly related to stroke severity. These muscle         |
| abnormalities would be expected to increase fatigue and insulin       |
| resistance to propagate diabetes and worsen health while aging with   |
| the disability of stroke.                                             |
|                                                                       |
| # Steven J. K                                                         |
| ittner, M.D., John W. Cole, M.D., Richard F. Macko, M.D. Acquired Imm |
| unodeficiency Syndrome and the Risk of Stroke. Stroke 2004; 35:51-56. |
|                                                                       |
| Although acquired immunodeficiency syndrome (AIDS) is thought to      |
| increase stroke risk, no population- based studies have ever          |
| quantified risk. We identified all new ischemic strokes (IS) and      |
| intracerebral hemorrhages (ICH, bleeds) cases among young adults 15   |
| to 44 years of age in central Maryland and Washington, DC. AIDS       |
| conferred a 14-fold increased risk for IS and 26-fold for ICH. AIDS   |
| may be a far more robust risk factor for stroke than hypertension or  |
| diabetes.                                                             |
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| b.  **Key Findings Published in Current Year -- GRECC Core Staff as   |
|     Co-Investigators on Projects with Non-GRECC PI (***[list up to    |
|     five]{.mark}; for each item provide GRECC Core Staff name(s),     |
|     journal reference, [and up to five line]{.mark} description of    |
|     topic/method/ results/clinical significance; use layperson        |
|     language)*:                                                       |
|                                                                       |
| -   **Leslie I. Katzel, M.D., Ph.D.,** and **Eliot L. Siegel, M.D.,** |
|     with **Shari R. Waldstein, Ph.D.,** David Lefkowitz, M.D.,        |
|     Karl J. Maier, Ph.D., Jessica R. Pelletier Brown, BA, Abraham M.  |
|     Obuchowski, M.D. Stress-Induced Blood Pressure Reactivity and     |
|     Silent Cerebrovascular Disease. Stroke 2004; 35:1294-1298.        |
|                                                                       |
| -                                                                     |
|                                                                       |
| Exaggerated blood pressure (BP) response to mental stress has been    |
| related to increased stroke risk. We examined relationships between   |
| stress -induced BP response and silent stroke in healthy older adults |
| and found higher systolic BP reactivity was independently linked to   |
| higher overall ratings of injury to brain regions fed by small blood  |
| vessels. Exaggerated stress-induced BP response warrants further      |
| examination as a potential behavioral risk factor for stroke in       |
| aging.                                                                |
|                                                                       |
| -   **Andrew P. Goldberg M.D., Alan R. Shuldiner, M.D.,** with        |
|     **James M. Hagberg, Ph.D.,** Dana Phares,                         |
|                                                                       |
| > Ph.D. et al. Association between body fat response to exercise      |
| > training and multilocas ADR genotypes.                              |
| >                                                                     |
| > Obesity Research, 2004; 12: 807-815.                                |
|                                                                       |
| Adrenergic receptor (ADR) stimulation affects body fat metabolism by  |
| increasing lipolysis and energy                                       |
|                                                                       |
| expenditure to increase body fat mobilization. In 70 healthy          |
| sedentary men and postmenopausal women                                |
|                                                                       |
| multilocus ADR genotypes of the β~2~, β~3~ and α~2~ ADR genes were    |
| associated with the reductions in total,                              |
|                                                                       |
| percent trunk and fat mass observed with exercise training. This      |
| suggests that the interaction of various ADR genotypes with physical  |
| activity may mediate changes in total and trunkal body fat. Thus,     |
| multivariate gene associations may determine the effects of clinical  |
| interventions on complex phenotypes such as obesity and               |
| cardiovascular diseases (CVD) that involve multiple etiologies and    |
| associated metabolic abnormalities.                                   |
|                                                                       |
| This may have important clinical implications for identifying high    |
| CVD risk subjects in whom exercise                                    |
|                                                                       |
| therapy has the potential to reduce the metabolic risk factors        |
| associated with central obesity.                                      |
|                                                                       |
| -   Barbara J. Nicklas, Ph.D., Dora M. Berman, Ph.D., **Alice S.      |
|     Ryan, Ph.D., with** Tongjian You. Effects of hypocaloric and      |
|     exercise training on inflammation and adipocyte lipolysis in      |
|     obese post menopausal women. Journal of Clinical Endocrinology    |
|     and Metabolism, 2004; 89:1739-1746.                               |
|                                                                       |
| Chronic inflammation is an independent predictor of insulin           |
| resistance; type 2 diabetes, and coronary heart disease. Weight loss  |
| (WL) and exercise training (AEX) both reduce chronic inflammation and |
| increase invitro adipocyte lipolysis. We hypothesized that one        |
| mechanism by which WL+AEX may reduce inflammatory markers is by       |
| increasing adipocyte lipolysis. Although WL alone and WL +AEX         |
| decreased total and abdominal fat to the same degree, only WL +AEX    |
| decreased plasma inflammatory markers and increased lipolysis.        |
| Changes in lipolysis correlated with reductions in the inflammatory   |
| markers IL-6 and soluble TNF receptor1; this suggests that the        |
| combined intervention has greater potential for reducing the chronic  |
| inflammatory state and metabolic dysfunction associated with obesity  |
| in postmenopausal women. This has important clinical implications for |
| the design of lifestyle interventions to reduce CVD risk in obese     |
| postmenopausal women.                                                 |
|                                                                       |
| -   **Richard F. Macko, M.D., Frederick M. Ivey, Ph.D.** with         |
|     Andrew W. Gardner, Ph.D. et al. 2004. Unilateral Impairment of    |
|     Leg Blood Flow in Chronic Stroke Patients Cerebrovasc Dis; 18(4): |
|     283-289, 2004.                                                    |
|                                                                       |
| Vasomotor reactivity (VR) is a natural mechanism defining blood       |
| vessels ability to dilate and supply more blood to tissues. VR is     |
| reduced in advancing age, diabetes, and vascular disease. We measured |
| leg VR in older hemiparetic (half-paralyzed) stroke patients and      |
| found major reductions on the paralyzed side. This could impact       |
| aerobic fitness, muscle function and energy metabolism contributing   |
| to disability. We are now testing whether exercise improves VR after  |
| stroke.                                                               |
|                                                                       |
| -   **Alan R. Shuldiner, M.D.,** with Nir Barzilai, M.D., Gil Atzmon, |
|     Ph.D., et al. Unique Lipoprotein Phenotype and Genotype           |
|     Associated With Exceptional Longevity. JAMA 2003; 290:2030-2040.  |
|                                                                       |
| Individuals with exceptional longevity have lower incidence or delay  |
| in age-related disease, and family members may inherit biological     |
| factors that modulate aging and disease susceptibility. In 213        |
| Ashkenazi Jewish probands (related groups) with exceptional longevity |
| we found high-density lipoprotein (HDL) and low-density lipoprotein   |
| (LDL) particle sizes were higher in probands than controls, and this  |
| associated with lower hypertension, cardiovascular disease, and       |
| diabetic profiles.                                                    |
+-----------------------------------------------------------------------+
| **6. EDUCATION**                                                      |
+-----------------------------------------------------------------------+
| **NOTE**: Do not list trainee and conference data here. Those data    |
| are reported in the GRECC Electronic Database.                        |
+-----------------------------------------------------------------------+
| a.  **Innovations in Educational Activities Implemented During        |
|     Current Year** (*[list up to five]{.mark}; for each item, [up to  |
|     three lines]{.mark} on how it is innovative)*:                    |
|                                                                       |
| -   Dr. Shaughnessy was primary author of the training module for the |
|     Geriatric Extended Care (GEC) Referral Form. This new form        |
|     creates an assessment and tracking mechanism that for the first   |
|     time will facilitate the planning of extended care needs for      |
|     veterans nationwide.                                              |
|                                                                       |
| -   Early Recognition of Acute Illness in Older Adults is a uniquely  |
|     designed interactive web-based module for educating bedside staff |
|     that has a built in CPRS-based evaluation mechanism. A            |
|     corresponding CPRS database is designed to track reports          |
|     generated by staff with observations of behavioral, functional or |
|     cognitive changes and tracks outcomes.                            |
|                                                                       |
| -   Dr. Shaughnessy chairs a workgroup within the nationwide          |
|     Consortium of E-learning in the Geriatrics Instruction            |
|     organization that is comprised of VA and non-VA geriatrics        |
|     educators tasked with developing innovative standards and         |
|     specifications for evaluating online learning tools in            |
|     geriatrics.                                                       |
|                                                                       |
| -   Developed a web-based educational module for bedside nursing      |
|     staff on early recognition of acute illness in the older adult,   |
|     with a corresponding database that allows staff to document       |
|     observations. The database automatically triggers notification of |
|     report to nursing administration and medical providers, allowing  |
|     tracking of outcomes. 2003. Dr. Shaughnessy.                      |
|                                                                       |
| -   Dr. Heuser established a VISN 5 wide, integrated monthly          |
|     Geriatric Medicine Grand Rounds at BVAMC as a new educational     |
|     forum for Geriatric faculty to present research and clinical      |
|     topics, and current advances in the care of the elderly.          |
|     Conferences are attended by third and fourth year medical         |
|     students and housestaff from the University of Maryland School of |
|     Medicine and simultaneously transmitted via two-way               |
|     videoconferencing with extended care staff at Martinsburg, West   |
|     Virginia, Washington DC, the BRECC and Perry Point VAMCs.         |
|                                                                       |
| -   The VA/GRECC Geriatrics Fellowship has developed a consortium     |
|     with two affiliated community hospitals to enrich fellowship      |
|     training in the care of older women and populations of broader    |
|     gender and socioeconomic status. These hospitals have provided an |
|     additional fellow for the program.                                |
+-----------------------------------------------------------------------+
| b.  **Exportable Educational Products First Available for             |
|     Distribution in Current Year** *([list up to five]{.mark} most    |
|     important products; for each item, [up to three lines]{.mark}     |
|     summarizing content, target audience, format, product evaluation  |
|     results. Include educational products developed in previous years |
|     ONLY if this is the [first year]{.underline} they have been       |
|     available for distribution)*:                                     |
|                                                                       |
| -   Dr. Shaughnessy was the author of the training module for the     |
|     Geriatric Extended Care (GEC) Referral Form, a new referral       |
|     instrument designed to assist with national planning for          |
|     long-term care needs. The GEC is scheduled for nationwide rollout |
|     10/04.                                                            |
|                                                                       |
| -   Delirium educational module and/or database -- This web-based     |
|     educational module is designed to educate bedside care staff to   |
|     recognize acute illness early. A corresponding CPRS database      |
|     allows for tracking of reports generated by staff of observations |
|     of behavioral, functional or cognitive changes and tracks         |
|     outcomes.                                                         |
|                                                                       |
| -   GERI, a suite of programs designed to help run multiple clinical  |
|     trials is available for use by other VA researchers. GERI is      |
|     currently used by the Baltimore GRECC and the University of       |
|     Maryland Claude D. Pepper Older Americans Independence Center.    |
|                                                                       |
| -   Translational research project exporting successful GRECC         |
|     exercise and weight loss programs to a high-risk west Baltimore   |
|     Faith Community. PRAISED (People Reducing Risk and Improving      |
|     Strength through Exercise and Diet) is a 6-month program held in  |
|     the participant's church, which utilizes prayer and social        |
|     support to maintain motivation and achieve goals.                 |
+-----------------------------------------------------------------------+
| **7. NEW CLINICAL MODELS**                                            |
+-----------------------------------------------------------------------+
| **NOTE:** These are new models of care for elderly veterans that the  |
| GRECC is developing and evaluating, in relation to its area(s) of     |
| focus. This is NOT a list of all Geriatrics & Extended Care clinical  |
| programs at the host VAMC.                                            |
+-----------------------------------------------------------------------+
| a.  **New Clinical Models Implemented in Current Year** *(list all    |
|     new clinical models or significant modifications of existing      |
|     models that the GRECC is developing and evaluating. For each      |
|     item, indicate whether [N]{.underline}ew or [O]{.underline}ngoing |
|     in current year; provide [up to five line]{.mark} description)*:  |
|                                                                       |
| -   MOVE! (Managing Overweight and Obesity for Veterans Everywhere).  |
|     This program developed by the VA National Center for Health       |
|     Promotion and Disease Prevention (NCP) is being pilot tested at   |
|     the Baltimore GRECC and at other sites. Ultimately the program    |
|     will incorporate 5 treatment levels of increasing intensity of    |
|     intervention: 1) self-assessment and counseling; 2) nutrition     |
|     classes; 3) addition of weight control pharmacological agents; 4) |
|     admission to an inpatient or residential weight control program;  |
|     and 5) bariatric surgery.                                         |
|                                                                       |
| -   PRAISED. GRECC translational research project exporting           |
|     successful GRECC exercise and weight loss clinical demonstration  |
|     projects to a high-risk west Baltimore African American church    |
|     congregation with funding support from the Maryland Tobacco       |
|     settlement. This collaboration with the church leadership is      |
|     examining the feasibility of church based lifestyle interventions |
|     to decrease obesity, increase physical activity and improve       |
|     cardiac risk factors.                                             |
|                                                                       |
| -   GETFIT: There are a growing number of HIV-infected older          |
|     veterans. Medical comorbidities are frequent in older adults with |
|     HIV infection, further contributing to the complexity and cost of |
|     their medical care. With new advances in antiretroviral therapy,  |
|     and the graying of the population, the number of older veterans   |
|     with HIV will increase even further, clearly defining a need for  |
|     age-related interventions. This demonstration project examines    |
|     the effect of an aerobic exercise-training program on physical    |
|     functioning in older (\>55 years) HIV-infected veterans.          |
|                                                                       |
| ```{=html}                                                            |
| <!-- -->                                                              |
| ```                                                                   |
| -   Palliative Care consult service and the hospice programs include  |
|     partnership with Maryland Hospice Network, new Hospice Unit at    |
|     Perry Point, and home hospice program. An in home respite program |
|     was established for VAMHCS.                                       |
|                                                                       |
| ```{=html}                                                            |
| <!-- -->                                                              |
| ```                                                                   |
| -   Stroke - Lipid Clinic is a joint VA GRECC and Pharmacy            |
|     intervention using computerized surveillance and "stroke event"   |
|     triggered direct referral for expedited screening and care of     |
|     dyslipidemia in high risk Veterans with cerebrovascular disease.  |
|     It employs computerized lipid screening algorithms and            |
|     evidence-based treatments to treat dyslipidemia in veterans with  |
|     stroke and cardiovascular disease. We find less than 25% of 600   |
|     referrals get optimal screening and treatment with conventional   |
|     care, but 75% are brought to national target lipid goals in our   |
|     dedicated clinic. The program has also expanded tremendously to   |
|     the VA Cardiac Service this year.                                 |
+-----------------------------------------------------------------------+
| b.  **Current Year Evaluation Results of New Clinical Models** *([for |
|     each clinical model listed in 7-a above]{.mark}, indicate whether |
|     evaluated by [R]{.underline}esearch or [Q]{.underline}uality      |
|     [I]{.underline}mprovement project; [up to five lines]{.mark}      |
|     summarizing evaluation outcomes, such as changes in access to     |
|     care, patient functioning, satisfaction, cost-effectiveness,      |
|     organizational changes, etc. Note if no evaluation results in     |
|     current year for a particular model)*:                            |
|                                                                       |
| **NOTE:** Do not list patient service utilization data here. Those    |
| data are reported in the GRECC Electronic Database.                   |
|                                                                       |
| -   Participants in GRECC clinical studies (7-a above) undergo a      |
|     history and physical evaluation. As a result of these             |
|     evaluations, subjects are identified who have lipid               |
|     abnormalities, hypertension, diabetes and other metabolic         |
|     abnormalities. These subjects are refereed back to their          |
|     physician to have previously unidentified medical problems        |
|     revaluated. Over the last 12 months 416 distinct blood pressure   |
|     measurements and 659 distinct lipid assays have been performed as |
|     part of the GAC Clinic. More than forty one percent of the blood  |
|     pressure measurements and thirteen percent of the lipid assays    |
|     have been outside recommended ranges. In response to the large    |
|     number of subjects with sub-optimal risk profiles, we have        |
|     established the Stroke Lipid Clinic as a demonstration project to |
|     see if we can efficiently and economically reduce the risk        |
|     profile in subjects at high risk for recurrent cardiovascular     |
|     disease.                                                          |
|                                                                       |
| -   MOVE! (Managing Overweight and Obesity for Veterans Everywhere)   |
|     (Research). Twenty patients are currently enrolled in this pilot  |
|     program. We anticipate reaching our target enrollment goal of 30  |
|     by November 1, 2004. Feasibility data and other research outcome  |
|     measures will be analyzed nationally. Patient satisfaction with   |
|     the program is high.                                              |
|                                                                       |
| -   PRAISED (Research). The first cohort of 34 patients is enrolled   |
|     in this pilot program. The prevalence of obesity and other        |
|     manifestations of the metabolic syndrome is very high this        |
|     minority population. Attendance and compliance to the             |
|     intervention has been excellent. The patients are currently in    |
|     the intervention phase. Post-intervention metabolic assessments   |
|     have not yet been performed in this cohort. Therefore there are   |
|     no research outcomes to report at this time.                      |
|                                                                       |
| -   Stroke and cardiovascular disease lipid clinic (QI).              |
|     Retrospectively examination of adherence to evidence-based        |
|     guidelines in 320 consecutive patients admitted to the Baltimore  |
|     VAMC with a diagnosis of stroke indicates that LDL-C was assessed |
|     acutely in only 38% of the patients. During the 6-month follow-up |
|     post-stroke, when stroke recurrence is highest, only 35% were     |
|     evaluated. Of these, only 42% were at target with LDL-C\<         |
|     100mg/dl. In the first 41 stroke patients treated in the          |
|     demonstration research clinic, we reduced LDL-C by 27%.           |
|                                                                       |
| -   GETFIT (Research): A cross-sectional examination indicates that   |
|     physical functional performance as indexed by the peak aerobic    |
|     capacity is markedly reduced (18 ml/kg/min versus 30 ml/kg/min    |
|     for age-matched non-infected) in the older HIV infected veterans. |
|     We are currently enrolling the first cohort into the exercise     |
|     intervention. Therefore there are no research outcomes on the     |
|     effect of the intervention on functional performance to report at |
|     this time.                                                        |
|                                                                       |
| -   As part of the Palliative Care initiative at BVAMC, we            |
|     established an Advanced Care Planning template in CPRS that is    |
|     linked to educational materials to assist a clinician in          |
|     discussing and obtaining meaningful advanced directives from      |
|     elderly veterans. When the template is completed a "flag" is      |
|     automatically created to alert future providers that Advanced     |
|     Care Planning directives exists and are documented.               |
+-----------------------------------------------------------------------+
| c.  **New Clinical Models Exported in Current Year** *([list up to    |
|     five examples, up to two lines each]{.mark}; provide name of new  |
|     clinical model, name of VA or non-VA facility to which it was     |
|     exported, and method of export, such as "Falls Clinic protocol    |
|     sent to [X]{.underline} VAMC")*:                                  |
|                                                                       |
| -   PRAISED. The GRECC nutrition and exercise clinical demonstration  |
|     clinic have implemented a pilot weight loss and exercise          |
|     intervention at a large, predominantly African American church in |
|     West Baltimore.                                                   |
|                                                                       |
| ```{=html}                                                            |
| <!-- -->                                                              |
| ```                                                                   |
| -   Bilateral Arm Training with Rhythmic Auditory Cueing was exported |
|     to a rehabilitation facility in Cleveland, Ohio to train a stroke |
|     patient who had traveled to Baltimore for evaluation. Although    |
|     there was minimal upper extremity improvement, the patient became |
|     more motivated and began the treadmill-training program. He       |
|     reports an increase in ambulatory function, and is due to return  |
|     to the GRECC/Pepper Center for reevaluation in December.          |
|                                                                       |
| -   GRECC staff are developing an instrument, based on the            |
|     Geriatrics/Dementia Clinic that will be exported to the other     |
|     facilities in the VISN.                                           |
+-----------------------------------------------------------------------+
| **8. CONSULTATION AND OUTREACH**                                      |
+-----------------------------------------------------------------------+
| NOTE: **Consultation** = GRECC staff going to sites **[within host    |
| VAMC]{.underline}** or having those staff come to the GRECC, to       |
| assist in development of research, education or clinical programs at  |
| those sites. **Outreach** = GRECC staff going to **[non-host VAMC     |
| facilities]{.underline}** or having those staff come to the GRECC (in |
| person or by video or other technology) to assist in development of   |
| research, education or clinical programs at those sites.              |
+-----------------------------------------------------------------------+
| **a. Current Year Activity Outcomes** *([list up to five              |
| examples]{.mark}, [up to two lines each]{.mark}; summarize specific   |
| outcomes realized from current year **consultation**, e.g., "Host     |
| VAMC instituted a Falls Clinic after consultation from GRECC staff;"  |
| or **outreach**, e.g., [X]{.underline} VAMC instituted a Falls Clinic |
| after GRECC outreach via series of videoconferences)*:                |
|                                                                       |
| -   The Baltimore VAMC GRECC and MIRECC are establishing obesity      |
|     interventions for veterans with serious mental illness based on   |
|     the MOVE! Protocol for obese veterans.                            |
|                                                                       |
| -   In collaboration with VISN 5 Geriatrics and Long-term Care, and   |
|     Johns Hopkins University School of Medicine, the GRECC initiated  |
|     a new clinical geriatrics education series at the Baltimore VAMC. |
|                                                                       |
| -   Extended Care Screening Committee that daily screens and          |
|     coordinates the admission of elderly veterans to appropriate      |
|     clinical programs was initially established at our host VAMC and  |
|     has been initiated at Washington and Martinsburg VAMCs after      |
|     consultation form GRECC staff (Dr. Heuser and Colvin).            |
|                                                                       |
| -   VA Home Hospice program was established based on the Medicare per |
|     diem model at our host VAMC and has been established at           |
|     Washington and Martinsburg VAMCs after consultation from GRECC    |
|     staff (Dr. Heuser). This model was distributed nationally through |
|     the Geriatric Consultant's office at VA Central Office.           |
|                                                                       |
| -   For the last two years Dr. Sorkin has helped lead Harbor          |
|     Hospital's Department of Medicine's Journal Club, Dr. Sorkin adds |
|     statistical, ethical, clinical research expertise and historical  |
|     insight to discussion of current journal articles.                |
|                                                                       |
| -   PRAISED exercise and weight loss program at West Baltimore church |
|     has resulted in extension of outreach services to include         |
|     screening health fairs and participation in other GRECC outreach  |
|     protocols to community organizations, e.g., TOPS, Kiwanis Club,   |
|     Brandeis Women's Alumni Society to reduce obesity-related CVD     |
|     risk.                                                             |
|                                                                       |
| -   Forty-four study participants attended "Heart Healthy" classes in |
|     FY04. Baseline food record analysis showed an average dietary     |
|     intake of 36% of calories from total fat, 12% of calories from    |
|     saturated fat, and 248 mg of dietary cholesterol. Analysis after  |
|     American heart Association (AHA) diet instruction showed a        |
|     reduction in average total fat intake to 29% of calories, 8% of   |
|     calories from saturated fat, and 186 mg dietary cholesterol.      |
|     Seventy study participants attended weight loss classes this      |
|     year, of which 26 participants completed the 6-mo program. The    |
|     average weight loss was 7.5 kg or 9%. Forty patients are in       |
|     active weight loss and have dropped out.                          |
|                                                                       |
| -   Mr. Woodcock worked with the Executive Chief of Staff and VA      |
|     Canteen Service Central Office on providing healthier food        |
|     choices in the Baltimore VAMC cafeteria. As a result of Mr.       |
|     Woodcock's efforts, the Baltimore VAMC cafeteria will be          |
|     renovated to add a salad bar in FY05.                             |
+-----------------------------------------------------------------------+
| b.  **Previous Years' Activities Outcomes** ([list up to five         |
|     examples]{.mark}, [up to two lines each]{.mark}; summarize        |
|     specific outcomes realized from previous years' [**consultation** |
|     to host VAMC]{.underline} or [**outreach** to non-host            |
|     facilities]{.underline}, where results were first realized in the |
|     current year.)                                                    |
|                                                                       |
| -   The PharmD/GRECC Faculty Stroke Lipid Clinic was implemented as a |
|     demonstration project to improve the management of dyslipidemia   |
|     in veterans with stroke and cardiovascular diseases.\" It now     |
|     averages 7 visits per session, and trains PharmD and nursing      |
|     students in the management of complex CVD risk in veterans. LDL-C |
|     was lowered by 27% in the first 41 patients treated in this       |
|     clinic.                                                           |
|                                                                       |
| -   GEMU Evaluation/Assessment at Perry Point is pilot testing        |
|     functional performance measures utilized in the GEMU trial and    |
|     Pepper Center Biomechanics and Neuromuscular Core for             |
|     incorporation into patient evaluation.                            |
|                                                                       |
| -   Functional Outcomes in the Baltimore Rehabilitation and Extended  |
|     Care Center at Loch Raven -GRECC and Pepper Center investigators  |
|     assist Dr. Colvin and Mary Grant, R.N. in their MERIT Review      |
|     Grant examining the physiological, psychological and functional   |
|     benefits of low intensity exercise in frail NH patients.          |
|                                                                       |
| -   Nutrition/weight loss and exercise outreach program- GRECC        |
|     investigators have implemented a health promotion program at a    |
|     predominantly African American church in West Baltimore in        |
|     collaboration with the Church ministers. Thirty-three subjects    |
|     are currently enrolled, and have lost an average of 2 kgs in 12   |
|     weeks.                                                            |
|                                                                       |
| -   Employee Wellness program at the BVAMC. Currently 577 employees   |
|     are enrolled. A needs assessment showed employees wanted to avail |
|     themselves of the program daily; however, despite this increased  |
|     availability only \~\<10% of the employees consistently use the   |
|     exercise facility 3x per/week.                                    |
+-----------------------------------------------------------------------+