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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}.                         |
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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:** Miami GRECC                                       |
|                                                                       |
| b.  **Location** *(facility, VISN)*: VAMC, Miami, Florida, VISN 8     |
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| **2. CONTACT PERSON**                                                 |
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| a.  **Name:** Debbie Berngard                                         |
|                                                                       |
| b.  **Position:** Administrative Officer                              |
|                                                                       |
| c.  **Phone, e-mail:** 305-575-3388; debbie.berngard@med.va.gov       |
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| **3. GRECC FOCUS AREA(S)**                                            |
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| **NOTE:** Each problem area should ideally be approached from the     |
| basic biomedical, clinical [and]{.underline} health services research |
| perspectives, as well as from the rehabilitation research perspective |
| where that expertise exists. The number of problem areas should be    |
| limited to one or two. If the focus of research is different for      |
| basic biomedical, clinical, health services and/or rehabilitation     |
| research, there should be no more than a [total]{.underline} of 4     |
| major areas of investigation. Changes to GRECC focus area(s) must be  |
| approved by VACO (114).                                               |
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| a.  **Basic Biomedical**: Bone & cartilage metabolism;                |
|     neurodegeneration; prostate disease                               |
|                                                                       |
| b.  **Applied Clinical**: Osteoporosis & osteoarthritis; Paget's      |
|     disease; prostate disease                                         |
|                                                                       |
| c.  **Health Services**: Cost-effectiveness studies; preventive       |
|     services; rehabilitation (falls & injuries)                       |
|                                                                       |
| d.  **Rehabilitation**: None                                          |
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| **4. ADMINISTRATION**                                                 |
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| a.  **GRECC Impact on Host VAMC in Current Year** *(list up to five   |
|     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)*:                               |
|                                                                       |
| -   The GRECC has spearheaded the cooperative efforts of the Miami    |
|     VAMC and the UMSM to recruit and support preeminent health-care   |
|     professionals committed to a team effort for geriatrics care in   |
|     general and particularly in our foci. Each new GRECC member has   |
|     taken the lead in developing a core laboratory facility or in     |
|     implementing a clinical model that bolsters our medical center's  |
|     capabilities in gerontology and geriatric care.                   |
|                                                                       |
| -   A collaborative venture with UM, initiated through the funding of |
|     a DW Reynolds grant, focuses on education of medical students and |
|     housestaff at the VAMC and on the development of geriatrician     |
|     clinician faculty based at the VAMC. The GRECC's education        |
|     activity is integrated into virtually all of the VA geriatrics    |
|     and medicine venues and represents a major success of the VA and  |
|     UM partnership.                                                   |
|                                                                       |
| -   The development of a model exercise and restorative therapy       |
|     program at the VA NHCU solely focused on the resident veterans,   |
|     exemplifies an integrated project that produced an end product    |
|     with beneficial and practical clinical applications. This project |
|     is based on more than \$100,000 of preliminary work and special   |
|     donated equipment from Jackson Foundation, with no VA dollars     |
|     expended in establishing the program. The model, developed        |
|     through Teaching Nursing Home funding, will ultimately mainly     |
|     benefit the VA.                                                   |
|                                                                       |
| -   Partnership with the Teaching Nursing Home (TNH) continues to     |
|     produce strong statewide linkages and educational products.       |
|     Miami's very successful VA-funded telemedicine project (TLC for   |
|     Dementia Care) was derived directly from the VA's participation   |
|     in a collaboration on training nurses in dementia care conducted  |
|     through the TNH. The TLC project has resulted in an estimated     |
|     cost avoidance of nearly \$500,000 for the Medical Center and the |
|     decision has been made to continue funding the project beyond its |
|     initial trial period.                                             |
|                                                                       |
| -   We have involved other non-GRECC VA investigators as active       |
|     collaborators in our ongoing studies on a unique population of    |
|     marrow-isolated adult multilineage inducible (MIAMI) cells. Our   |
|     initial interest was the potential use of these unique cells for  |
|     regenerative medicine / repair of bone and cartilage in           |
|     conditions such as osteoporosis and osteoarthritis.               |
|     Collaborations have extended these studies to examine the         |
|     potential of the MIAMI cells for cancer therapy as well as repair |
|     of neuronal defects (e.g., spinal cord injury).                   |
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| b.  **GRECC Impact on VISN in Current Year** *(list up to five 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.* NOTE: |
|     GRECCs are intended and expected to serve as a                    |
|     [regional]{.underline}, and not merely local resource*)*:         |
|                                                                       |
| -   The Teaching Nursing Home Program has used the "Pain Assessment   |
|     in Advanced Dementia (PAIN-AD)" tool, developed by the VA, in a   |
|     teaching module on pain in residents with dementia for use by all |
|     the nursing homes in Florida.                                     |
|                                                                       |
| -   The technology developed for isolation of a unique population of  |
|     marrow-isolated adult multilineage inducible (MIAMI) cells, as    |
|     well as the cells, have been disseminated to investigators at our |
|     academic partner institution (University of Miami School of       |
|     Medicine), as well as to other academic institutions, both        |
|     locally (Florida International University) and nationally         |
|     (Harvard University). This expanded involvement has enhanced the  |
|     understanding and potential cell therapy use of these cells.      |
|                                                                       |
| -   Our work in the area of prescriptive exercise as an improvement   |
|     over standard low-speed progressive-resistance training protocols |
|     has demonstrated significantly improved mobility and balance and  |
|     reduced probability of falls, thereby increased quality of life   |
|     for the frail elderly. This information and the prescriptive      |
|     exercise protocols are being shared with other VA medical centers |
|     in the VISN, as well as with other nursing home facilities and    |
|     academic institutions within our VISN.                            |
|                                                                       |
| -   The Florida Consortium for Geriatric Medical Education (FCGME)    |
|     continues, chaired by Dr. Bernard A. Roos. The consortium was     |
|     formed to improve geriatric care in Florida through medical       |
|     education that benefits from synergies among the state's medical  |
|     schools and produces physicians who are competent to assess,      |
|     manage, and promote older persons' health and well-being. During  |
|     the year the group completed the dementia learning objectives and |
|     revised the FCGME's initial draft formulation of core             |
|     competencies for pressure ulcers.                                 |
|                                                                       |
| -   By coordinating our education programs with the Miami Area        |
|     Geriatric Education Center (MAGEC), we continue to offer numerous |
|     conferences, promoted to all VISN facilities, on a wide range of  |
|     topics in aging and geriatrics. Geriatric information related to  |
|     education and training, as well as conference topics and dates,   |
|     are available on the Web site (www.miami.edu/magec).              |
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| c.  **GRECC Trend-Setting Innovations since October 1,                |
|     [1999]{.underline}** *(list up to five 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 description)*:                                          |
|                                                                       |
| -   [The Osteoporosis Center]{.underline}; 2001; responsible staff: S |
|     Levis, B Troen                                                    |
|                                                                       |
| > The GRECC has contributed critically to the superior range and      |
| > depth of service, training, and research for older veterans with    |
| > osteoporosis. This center has been a principal site in all phases   |
| > of clinical testing for bisphosphonates and more recently for an    |
| > NIH trial on soy protein as replacement estrogen.                   |
|                                                                       |
| -   [Establishment of The Geriatrics Institute, based within the      |
|     Miami GRECC]{.underline}; 2003; responsible staff: B Roos, J      |
|     Ruiz, M Mintzer, G Howard                                         |
|                                                                       |
| > The mission of the institute is the discovery of a model of care    |
| > for the frail elderly that is scientifically informed, culturally   |
| > sensitive, and ethically appropriate. Under this umbrella we have   |
| > been awarded a multi-million dollar grant from the Donald W.        |
| > Reynolds Foundation to develop a competency-based curriculum in     |
| > geriatrics with a focus on the effectiveness of learning by medical |
| > students and residents.                                             |
|                                                                       |
| -   [Isolation and characterization of a unique population of stem    |
|     cells, the MIAMI cells]{.underline}; 1^st^ detailed report        |
|     published in 2004; responsible staff: PC Schiller, GA Howard, G   |
|     D'Ippolito, HS Cheung, BA Roos                                    |
|                                                                       |
| > *Description:* The term MIAMI (marrow-isolated adult multilineage   |
| > inducible) cells acknowledges their source and their potential.     |
| > Patents have been filed on the procedure and the cells, which are   |
| > capable of differentiating/maturing into defined phenotypes (e.g.,  |
| > osteoblasts, chondrocytes, neuronal cells). These cells can         |
| > potentially provide a source of allogeneic cells for regeneration   |
| > and/or repair of tissues. .                                         |
|                                                                       |
| -   [Positive effects of specific exercise regimens (prescriptive     |
|     exercise) on mobility, balance, and sense of well-being in the    |
|     frail elderly]{.underline}; report published in 2002; responsible |
|     staff: JF Signorile, BA Roos                                      |
|                                                                       |
| > These studies found that a high-speed resistance training protocol  |
| > (compared to a standard low-speed progressive resistance training   |
| > protocol) produces superior increases in functional factors that    |
| > affect mobility and balance and thereby reduce the probability of   |
| > falls and improve the individual's quality of life.                 |
|                                                                       |
| -   [Establishment of *GeriU*, The Online Geriatrics University, in   |
|     collaboration with the Teaching Nursing Home Program              |
|     (TNH);]{.underline} 2001; responsible staff: J Ruiz, M Mintzer    |
|                                                                       |
| > Statewide we are making a substantial impact in geriatrics          |
| > education, working with Florida's TNH program, on creating and      |
| > implementing training. *GeriU* 's highly effective pedagogical and  |
| > communication platform enables nurses, medical students, residents, |
| > faculty, and community physicians to learn, seek information, and   |
| > discuss experiences and concerns related to gerontology and         |
| > geriatric medicine. *GeriU* personalizes content and access at all  |
| > levels, taking formal requirements into account, as well as         |
| > individual needs and preferences.                                   |
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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; for each item provide GRECC Core |
|     Staff name(s), journal reference, and up to five line description |
|     of topic/method/ results/clinical significance; use layperson     |
|     language)*:                                                       |
|                                                                       |
| -   D'Ippolito G, et al. Marrow-isolated adult multilineage inducible |
|     (MIAMI) cells, a unique population of postnatal young and old     |
|     human cells with extensive expansion and differentiation          |
|     potential. *J Cell Sci* 117:2971-2981, 2004. GRECC Core Staff: GA |
|     Howard, BA Roos, PC Schiller                                      |
|                                                                       |
| > This report describes the isolation of a population of              |
| > nontransformed pluripotent human cells from bone marrow after a     |
| > unique selection/expansion procedure. Cells, obtained from males    |
| > and females 3 to 72 years old, were expanded in culture for more    |
| > than 50 doublings. MIAMI cells can become bone, fat, cartilage, or  |
| > neural cells and can proliferate extensively without evidence of    |
| > senescence or loss of differentiation potential, thus offering      |
| > great potential for cell therapy of inherited or degenerative       |
| > diseases.                                                           |
|                                                                       |
| -   Huang CY, et al. Chondrogenesis of human bone marrow-derived      |
|     mesenchymal stem cells in agarose culture. *Anat Rec*             |
|     278A:428-436, 2004. GRECC Core Staff: PC Schiller, HS Cheung      |
|                                                                       |
| > Mesenchymal stem cells (MSC) derived from human bone marrow         |
| > differentiate into chondrogenic cells for the potential treatment   |
| > of injured articular cartilage. These studies evaluated agarose     |
| > gels as a supportive material for the MSC. Formation of             |
| > cartilage-specific macromolecules in the agarose/MSC cultures       |
| > increased with the initial placement of more cells in the gels.     |
| > This study establishes a basic model for future studies on          |
| > chondrogenesis of the MSCs as a potential therapy for cartilage     |
| > defects.                                                            |
|                                                                       |
| -   Huang CY, et al. Effects of cyclic compressive loading on         |
|     chondrogenesis of rabbit bone-marrow derived mesenchymal stem     |
|     cells. *Stem Cells* 22:313-323, 2004. GRECC Core Staff: HS Cheung |
|                                                                       |
| > This study examined the effects of cyclic compressive loading on    |
| > the ability of mesenchymal stem cells (MSC) in agarose cultures to  |
| > become cartilage-forming cells (chondrocytes). The findings suggest |
| > that cyclic compressive loading can promote chondrogenesis of bone  |
| > marrow MSCs by inducing the synthesis of a specific growth factor   |
| > (TGF-bets1) which in turn stimulates the cells to differentiate     |
| > into chondrocytes. These studies hold promise for the potential     |
| > development of artificial cartilage and regenerative medicine.      |
|                                                                       |
| -   Sipski ML, et al. Lack of justification for routine abdominal     |
|     ultrasonography in patients with chronic spinal cord injury. *J   |
|     Rehabil Res Dev* 41:101-108, 2004. GRECC Core Staff: ML Sipski    |
|                                                                       |
| > Although annual abdominal ultrasonography was routinely used for    |
| > patients with spinal cord injury (SCI) at our medical center,       |
| > little evidence-based research supported this procedure. The        |
| > results of the study showed no added benefits through repetitive    |
| > exams, and no specific interventions were noted solely on the basis |
| > of the ultrasound findings. The recommendation from these           |
| > investigators is that further evidence-based studies be performed   |
| > to ascertain the benefits of performing certain routine procedures  |
| > in patients with SCI.                                               |
|                                                                       |
| -   Troen BR. Molecular mechanisms underlying osteoclast formation    |
|     and activation. *Exp Gerontol* 38:605-614, 2003. GRECC Core       |
|     Staff: BR Troen                                                   |
|                                                                       |
| > Osteoporosis, a leading cause of morbidity in the elderly, is       |
| > characterized by progressive loss of total bone mass and density.   |
| > The relative balance between bone formation and bone loss depends   |
| > on the coupling of the 2 types of bone cells (bone-forming =        |
| > osteoblasts, bone-resorbing = osteoclasts) and the various factors  |
| > they produce or respond to. Better understanding of the factors     |
| > (e.g., cathepsin K) required for normal bone resorption may lead to |
| > therapeutic intervention to prevent or ameliorate osteoporosis in   |
| > the elderly.                                                        |
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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; for each item provide GRECC Core Staff name(s), journal     |
|     reference, and up to five line description of topic/method/       |
|     results/clinical significance; use layperson language)*:          |
|                                                                       |
| -   Dahn JR, et al. Sexual functioning and quality of life after      |
|     prostate cancer treatment: considering sexual desire. *Urology*   |
|     63:273-277, 2004. GRECC Core Staff: BA Roos                       |
|                                                                       |
| > The objective of this study was to evaluate whether the             |
| > relationship between sexual desire and quality of life (QOL) is     |
| > moderated in men who had received treatment for prostate cancer     |
| > within the past 18 months. Results of the study suggest that both   |
| > sexual desire and sexual functioning are necessary for optimal QOL. |
|                                                                       |
| -   Peneda FJ, et al. Cognitive-behavioral stress management improves |
|     stress-management skills and quality of life in men recovering    |
|     from treatment of prostate cancer. *Cancer* 100:192-200, 2004.    |
|     GRECC Core Staff: BA Roos                                         |
|                                                                       |
| > This study evaluated the efficacy of a 10-week cognitive            |
| > stress-management intervention seminar in improving quality of life |
| > (QOL) among men who had been treated for prostate cancer by either  |
| > radiation therapy or radical prostatectomy. Individuals were shown  |
| > to have significant improvement in QOL after the 10-week seminars   |
| > relative to men attending a 1-day control seminar. The improved QOL |
| > was associated with increases in perceived stress-management skills |
| > by the individuals.                                                 |
|                                                                       |
| -   Brown JW, et al. Extracts from two marine sponges lower cyclin B1 |
|     levels, cause a G2/M cell cycle block and trigger apoptosis in    |
|     SW-13 human adrenal carcinoma cells. *Toxicon* 43:841-846, 2004.  |
|     GRECC Core Staff: C Perez-Stable                                  |
|                                                                       |
| > Marine sponges have been shown to produce metabolites with cell     |
| > growth- and endocrine-altering activities. Extracts from 2 species, |
| > the "brown variable sponge" and the "West Indian bath sponge,"      |
| > caused a 70-90% reduction in cyclin B1 levels (a cell-cycle         |
| > regulatory protein) and a 10-16 fold increase in the number of      |
| > carcinoma cells showing signs of cell death, demonstrating that     |
| > these marine sponges are capable of producing metabolites that      |
| > interfere with the survival of human adrenal carcinoma cells.       |
|                                                                       |
| -   Price TB, et al. Comparison of MRI with EMG to study muscle       |
|     activity associated with dynamic plantar flexion. *Magn Reson     |
|     Imaging* 21:853-861, 2003. GRECC Core Staff: JF Signorile         |
|                                                                       |
| > MRI and surface electromyography (EMG) were compared to evaluate    |
| > the effect of knee angle on plantar flexion activity in 2 muscles.  |
| > Height- and weight-matched groups performed prescribed exercises    |
| > with the knee in various positions; then images were taken by the 2 |
| > methods. The results showed that MRI and EMG produce similar        |
| > results from different physiological sources and are therefore      |
| > complementary tools for evaluating muscle activity.                 |
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| **6. EDUCATION**                                                      |
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| **NOTE**: Do not list trainee and conference data here. Those data    |
| are reported in the GRECC Electronic Database.                        |
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| a.  **Innovations in Educational Activities Implemented During        |
|     Current Year** (*list up to five; for each item, up to three      |
|     lines on how it is innovative)*:                                  |
|                                                                       |
| -   The GRECC has installed training for LPNs in caring for nursing   |
|     home residents with dementia, developed in collaboration with     |
|     Florida's Teaching Nursing Home Program, on the training          |
|     computers at the Miami VAMC.                                      |
|                                                                       |
| -   We have designed and implemented a new 1-month mandatory          |
|     geriatrics rotation for internal medicine interns that provides   |
|     training in home, GEM, and palliative care and introduces the     |
|     geriatrics syndrome competencies.                                 |
|                                                                       |
| -   Our geriatricians serve as teaching attendings on the general     |
|     medicine wards 3 days each week, where they role-model for the    |
|     2^nd^- and 3rd-year residents how to reinforce medical students'  |
|     instruction in geriatrics syndromes, concentrating on the         |
|     assessment and management of the frail elderly.                   |
|                                                                       |
| -   3^rd^-year students complete a 1-week clerkship on the ACE unit.  |
|     Dr. A Juan, clerkship director, has developed 2 2-h               |
|     preceptor-assisted training activities for basic assessment       |
|     skills related to dementia and falls for this rotation, which are |
|     guiding the design of computer-based training modules.            |
|                                                                       |
| -   GRECC staff have worked with Family Medicine to formalize a       |
|     required longitudinal NHCU experience for their 3^rd^-year        |
|     residents to complement the ACE rotation, thus creating ample     |
|     opportunity to learn geriatric syndrome evaluation and management |
|     in a challenging frail population.                                |
|                                                                       |
| -   Dr. M Paniagua has added training related to incontinence and     |
|     pressure sores for 4^th^-year students. M Reyes-Yera, ARNP, an    |
|     expert on pressure sores, lectures on wound care and gives        |
|     bedside wound care rounds. Other activities address incontinence  |
|     and catheter care, medication management, and hands-on            |
|     experience.                                                       |
|                                                                       |
| -   The mission of the Consortium of E-Learning in Geriatrics         |
|     Instruction (CELGI), with geriatrics educators from 40 US and     |
|     Canadian medical schools, is to facilitate the development and    |
|     portability of e-learning materials for gerontology and           |
|     geriatrics professionals. Associate directors from 5 GRECCs are   |
|     CELGI members.                                                    |
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| b.  **Exportable Educational Products First Available for             |
|     Distribution in Current Year** (list up to five most important    |
|     products; for each item, up to three lines 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):                                                    |
|                                                                       |
| -   The Consortium of E-Learning in Geriatrics Instruction (CELGI) is |
|     a group of geriatrics educators from 40 US and Canadian medical   |
|     schools. Its membership includes 5 GRECC education directors.     |
|     CELGI's mission is to facilitate the development and portability  |
|     of e-learning materials for gerontology and geriatrics            |
|     professionals.                                                    |
|                                                                       |
| -   *GeriU*, the Online Geriatrics University (www.geriu.org), is a   |
|     learning-management system for the geriatrics education of        |
|     nurses, medical students, and geriatrics fellows. 3 training      |
|     activities related to Alzheimer\'s and related disorders are now  |
|     available online and in CD-ROM, specifically for nursing home     |
|     LPNs and CNAs.                                                    |
|                                                                       |
| -   Dr. MJ Mintzer worked with Florida's Teaching Nursing Home        |
|     Program to produce an e-learning 4-h training module for LPNs on  |
|     caring for patients with dementia in the nursing home consisting  |
|     of 7 sections. This training has been reviewed and certified by   |
|     the Department of Elder Affairs for the State of Florida.         |
|                                                                       |
| -   Dr. MJ Mintzer worked with Florida's Teaching Nursing Home        |
|     Program to produce an e-learning advanced training module for     |
|     LPNs on pain assessment in nursing home patients with dementia.   |
|                                                                       |
| -   Dr. MJ Mintzer worked with Florida's Teaching Nursing Home        |
|     Program and the Alzheimer's Association of Central Florida to     |
|     produce an e-learning training module for CNAs on caring for      |
|     nursing home patients with dementia, which has been reviewed and  |
|     certified by the Department of Elder Affairs for the State of     |
|     Florida.                                                          |
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| **7. NEW CLINICAL MODELS**                                            |
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| **NOTE:** These are new models of care for elderly veterans that the  |
| GRECC is developing and evaluating, in relation to its area(s) of     |
| focus. This is NOT a list of all Geriatrics & Extended Care clinical  |
| programs at the host VAMC.                                            |
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| a.  **New Clinical Models Implemented in Current Year** *(list all    |
|     new clinical models or significant modifications of existing      |
|     models that the GRECC is developing and evaluating. For each      |
|     item, indicate whether [N]{.underline}ew or [O]{.underline}ngoing |
|     in current year; provide up to five line description)*:           |
|                                                                       |
| -   Ongoing: The [Geriatric Primary Care Clinic (GPCC)]{.underline}   |
|     serves as an education and research venue for fellows and other   |
|     health-care personnel. Each geriatric medicine fellow attends a   |
|     weekly 1-day clinic and is assigned a cohort of patients. Besides |
|     being the fellow's continuity clinic throughout the fellowship,   |
|     the GPCC is a venue for research by fellows and staff. The AHEAD  |
|     project screening instruments initiated in the GPCC last fiscal   |
|     year are now used regularly for the clinic's demented patients.   |
|                                                                       |
| -   Ongoing: The [Telephone-Linked Computer System (TLC) for Dementia |
|     Care]{.underline} began as a VISN-funded Miami VA initiative to   |
|     study the effect of care coordination combined with technology    |
|     for home-dwelling veterans with dementia. The goal is to increase |
|     caregiver competence and reduce caregiver burden, with the final  |
|     outcome of reducing health-care utilization. Having succeeding in |
|     reducing the medical center's dementia care costs by nearly       |
|     \$500,000 a year, the project has been approved by the medial     |
|     enter for continued funding.                                      |
|                                                                       |
| -   Ongoing: The [Home-Based Primary Care (HBPC)]{.underline} program |
|     serves homebound veterans in Miami-Dade and Broward counties,     |
|     providing intensive medical case management by an                 |
|     interdisciplinary team of health-care professionals including     |
|     geriatricians, physical therapists, nurses, dieticians, nurse     |
|     practitioners, and social workers. During this year, QI projects  |
|     were completed on interventions for pain and falls.               |
|                                                                       |
| -   New: The [Nursing Home Care Unit (NHCU)]{.underline} was used as  |
|     a venue to conduct clinical research on bone mass index (BMI) and |
|     the frequency of osteopenia and osteoporosis in a male nursing    |
|     home population. The study was undertaken to examine the          |
|     characteristics of older men residing in our nursing home because |
|     of the paucity of research in osteoporosis in the long-term       |
|     setting, particularly in men. In this research study 57 male      |
|     nursing home patients were screened for osteoporosis using a      |
|     peripheral X-ray technique.                                       |
+-----------------------------------------------------------------------+
| b.  **Current Year Evaluation Results of New Clinical Models** *(for  |
|     each clinical model listed in 7-a above, indicate whether         |
|     evaluated by [R]{.underline}esearch or [Q]{.underline}uality      |
|     [I]{.underline}mprovement project; up to five lines 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.                   |
|                                                                       |
| -   [Geriatric Primary Care Clinic (GPCC)]{.underline}: Research      |
|                                                                       |
| > A research project, based in the GPCC, is evaluating the types of   |
| > complementary medicine used by VA patients and why, based on data   |
| > gathered in a questionnaire survey given to GPCC patients. A Merit  |
| > Review proposal has been submitted (not funded on the first         |
| > submission) on the use of acupuncture to treat dyspnea in COPD      |
| > patients. Dr. Cherniack, GPCC director, is preparing a research     |
| > proposal testing the effects of large doses of vitamin D and        |
| > calcium on improving strength and balance in the elderly.           |
|                                                                       |
| -   [Telephone-Linked Computer System (TLC) for Dementia              |
|     Care]{.underline}: Research                                       |
|                                                                       |
| > During the clinical demonstration period of this project nearly     |
| > \$500,000 annually was saved in the treatment of 81 patients, a     |
| > high satisfaction rate was found among the veterans and their       |
| > caregivers, and health-care utilization was reduced. Preliminary    |
| > data indicate clinically significant differences in                 |
| > caregiver-perceived burden and depressive symptoms among caregivers |
| > of different ethnic groups. Future analyses will examine other      |
| > factors affected by ethnic differences, including self-rated        |
| > health, coping style, and comorbid conditions.                      |
|                                                                       |
| -   [Home Based Primary Care (HBPC)]{.underline}: QI                  |
|                                                                       |
| > QI projects have been completed on interventions for pain and       |
| > falls. A review of nonpharmaceutical interventions for pain         |
| > revealed that 15 of the 246 patients were being managed             |
| > nonpharmaceutically and concluded that more patients should be      |
| > evaluated for the benefit of nonpharmaceutical intervention. A      |
| > review of falls in HBPC patients found that 18% of their patients   |
| > had fallen within a 6-month period. All f the patients who fell     |
| > were using 4 or more medications; further assessment led to         |
| > medication changes in some patients.                                |
|                                                                       |
| -   [Nursing Home Care Unit (NHCU)]{.underline}: Research             |
|                                                                       |
| > 57 nursing home patients in this study were compared by BMI rank,   |
| > T-score classification, and death since measurement. The cohort was |
| > found to be increasingly osteoporotic with increasing age and       |
| > greater (obese) weight, independent of ambulatory status and BMI.   |
| > Markers for frailty such as albumin level and dementia were common. |
| > The prevalence of frailty and susceptibility to other geriatric     |
| > syndromes (such as falls) merits more aggressive screening for      |
| > osteoporosis in the nursing home setting.                           |
+-----------------------------------------------------------------------+
| c.  **New Clinical Models Exported in Current Year** *(list up to     |
|     five examples, up to two lines each; provide name of new clinical |
|     model, name of VA or non-VA facility to which it was exported,    |
|     and method of export, such as "Falls Clinic protocol sent to      |
|     [X]{.underline} VAMC")*:                                          |
|                                                                       |
| -   The [TLC for Dementia Care]{.underline} program is being exported |
|     throughout the VISN. Dr. Dang is working with the Tampa VAMC and  |
|     Florida State University.                                         |
|                                                                       |
| -   The Acute Geriatric Unit, exported to Jackson Memorial Hospital   |
|     and used as an educational resource for a 1-week 3^rd^-year       |
|     clerkship directed by Dr. A. Juan.                                |
+-----------------------------------------------------------------------+
| **8. CONSULTATION AND OUTREACH**                                      |
+-----------------------------------------------------------------------+
| NOTE: **Consultation** = GRECC staff going to sites **[within host    |
| VAMC]{.underline}** or having those staff come to the GRECC, to       |
| assist in development of research, education or clinical programs at  |
| those sites. **Outreach** = GRECC staff going to **[non-host VAMC     |
| facilities]{.underline}** or having those staff come to the GRECC (in |
| person or by video or other technology) to assist in development of   |
| research, education or clinical programs at those sites.              |
+-----------------------------------------------------------------------+
| b.  **Current Year Activity Outcomes** *(list up to five examples, up |
|     to two lines each; summarize specific outcomes realized from      |
|     current year **consultation**, e.g., "Host VAMC instituted a      |
|     Falls Clinic after consultation from GRECC staff;" or             |
|     **outreach**, e.g., [X]{.underline} VAMC instituted a Falls       |
|     Clinic after GRECC outreach via series of videoconferences)*:     |
|                                                                       |
| -   Dr. MJ Mintzer has been invited by Florida's Agency for Health    |
|     Care Administration to speak at the last 2 regulatory updates for |
|     nursing home staff on pain in demented residents and falls in     |
|     nursing home residents.                                           |
|                                                                       |
| -   Dr. MJ Mintzer spoke at the national meeting of the Assoc. of     |
|     Health Facility Survey Agencies (US health-care regulatory        |
|     agencies), on educational best practice in caring for residents   |
|     with dementia.                                                    |
|                                                                       |
| -   Dr. MJ Mintzer helped coordinate, through Florida's Teaching      |
|     Nursing Home Program, an expert advisory group in depression to   |
|     identify major curriculum elements required for training LPNs.    |
|                                                                       |
| -   Drs. J Ruiz (founder) and MJ Mintzer are working with CELGI, the  |
|     Consortium for E-Learning in Geriatrics Instruction, to           |
|     coordinate a national effort to develop e-learning guidelines,    |
|     evaluation, and funding.                                          |
|                                                                       |
| -   The Miami GRECC had 12 posters and 1 symposium at the 2004 annual |
|     meeting of the American Geriatrics Society and 1 poster and 5     |
|     symposia at the 2003 annual meeting of the Gerontological Society |
|     of America.                                                       |
+-----------------------------------------------------------------------+
| b.  **Previous Years' Activities Outcomes** (list up to five          |
|     examples, up to two lines each; summarize specific outcomes       |
|     realized from previous years' [**consultation** to host           |
|     VAMC]{.underline} or [**outreach** to non-host                    |
|     facilities]{.underline}, where results were first realized in the |
|     current year.)                                                    |
|                                                                       |
| -   [TLC for Dementia Care]{.underline} reduced the medical center's  |
|     dementia care costs by nearly \$500,000 a year and has now been   |
|     approved for continued funding by the medical center.             |
|                                                                       |
| -   Several [Teaching Nursing Home]{.underline} educational products  |
|     for nurses on Alzheimer's disease, developed in collaboration     |
|     with GRECC, are now available online                              |
|     ([www.geriu.org](http://www.geriu.org/)) and via CD-ROM.          |
|                                                                       |
| -   Preceptor-assisted training activities on dementia and falls      |
|     developed for the 3^rd^-year medical clerkship on the Acute Care  |
|     of the Elderly Unit are guiding the design of computer-based      |
|     training modules.                                                 |
|                                                                       |
| -   The Miami GRECC presented 12 posters and 1 symposium at the 2004  |
|     annual meeting of the AGS and 1 poster and 5 symposia at the 2003 |
|     annual meeting of the GSA.                                        |
|                                                                       |
| -   Speakers at the monthly Geriatrics Institute Grand Rounds         |
|     organized by the GRECC education director include local and       |
|     national experts on topics relevant to geriatrics practice and    |
|     theory.                                                           |
+-----------------------------------------------------------------------+