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| ### GERIATRIC RESEARCH, EDUCATION AND CLINICAL CENTER    |   |   |   |   |
|                                                          |   |   |   |   |
| ### *Annual Report: Fiscal Year [2006]{.underline}*      |   |   |   |   |
|                                                          |   |   |   |   |
| ######## Part II: Accomplishments                        |   |   |   |   |
+----------------------------------------------------------+---+---+---+---+
| This GRECC Annual Report covers October 1, 2005 -        |   |   |   |   |
| September 30, 2006 and reflects status and               |   |   |   |   |
| accomplishments of GRECC Core staff.                     |   |   |   |   |
+----------------------------------------------------------+---+---+---+---+
| **1. GRECC NAME/LOCATION**                               |   |   |   |   |
+----------------------------------------------------------+---+---+---+---+
| a.  **GRECC Name: New England GRECC**                    |   |   |   |   |
|                                                          |   |   |   |   |
| b.  **Location: VISN 1: Two sites, Bedford VA Hospital   |   |   |   |   |
|     and Boston Health Care System (BHCS)**               |   |   |   |   |
+----------------------------------------------------------+---+---+---+---+
| **2. CONTACT PERSON**                                    |   |   |   |   |
+----------------------------------------------------------+---+---+---+---+
| **BOSTON: Elizabeth Grant, Administrative Officer (857)  |   |   |   |   |
| 364-2564, <elizabeth.grant@med.va.gov>**                 |   |   |   |   |
|                                                          |   |   |   |   |
| **BEDFORD: Linda Danner, Program Assistant (781)         |   |   |   |   |
| 687-3167, linda.danner@med.va.gov**                      |   |   |   |   |
+----------------------------------------------------------+---+---+---+---+
| **3. GRECC FOCUS AREA(S)**                               |   |   |   |   |
+----------------------------------------------------------+---+---+---+---+
| **GRECC Focus Area**                                     | * |   |   |   |
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|                                                          | > | > | > | > |
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|                                                          | B | A | H | R |
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+----------------------------------------------------------+---+---+---+---+
| Neuroscience/cognitive disorders, cardiovascular         | X |   |   |   |
| physiology and pharmacology, and metabolism.             |   |   |   |   |
+----------------------------------------------------------+---+---+---+---+
| Management of advanced Alzheimer's disease and other     |   | X |   |   |
| dementias, and aging with a long-term disability.        |   |   |   |   |
+----------------------------------------------------------+---+---+---+---+
| Ethics, advance directives, outcomes research, and       |   |   | X |   |
| decision support technology                              |   |   |   |   |
+----------------------------------------------------------+---+---+---+---+

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| **4. ADMINISTRATION**                                                 |
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| a.  **GRECC Impact on Host VAMC in Report Year**                      |
|                                                                       |
| -   The GRECC is responsible for a comprehensive model Alzheimer      |
|     Disease Program at the Bedford Division, including a 100-bed      |
|     Dementia Special Care Unit, Adult Day Health Center, and          |
|     Outpatient Clinics.                                               |
|                                                                       |
| -   The GRECC training program is the largest                         |
|     multidisciplinary/allied health training program at the Boston    |
|     Healthcare System, including geriatric medicine, psychology,      |
|     social work, pharmacy, nursing, and optometry trainees.           |
|     Interdisciplinary curriculum geared at training future geriatric  |
|     specialists in all disciplines.                                   |
|                                                                       |
| -   GRECC staff provide comprehensive interdisciplinary geriatric     |
|     assessment through Geriatric Intake Clinics at all three campuses |
|     of the Boston Healthcare System, providing services to growing    |
|     number of patients and training sites for geriatric fellows,      |
|     pharmacy residents, and neuropsychology trainees. The GRECC       |
|     provides leadership for the Acute Palliative Care Consult Team    |
|     which has provided consultative services to increasing numbers of |
|     patients as well as education in palliative care to residents and |
|     staff. GRECC staff also lead the Palliative Care Outpatient       |
|     Clinic, the Pharmacologic Intervention in Late Live (PILL)        |
|     Clinic, and a new Memory Disorder Clinic.                         |
|                                                                       |
| -   GRECC provides care to homebound chronically ill veterans with a  |
|     goal of improving care through effective case management. GRECC   |
|     staff have developed a tool for measuring the outcomes of         |
|     Home-Based Primary Care interventions.                            |
|                                                                       |
| ```{=html}                                                            |
| <!-- -->                                                              |
| ```                                                                   |
| -   GRECC staff developed and lead a national VA ALS Consortium       |
|     including 8 VAMCs nationwide, as well as 2 non-VA sites:          |
|     Massachusetts General Hospital and Johns Hopkins University.      |
|     Phase I trial "Safety and Dose Escalating Study of Oral Sodium    |
|     Phenyl butyrate in subjects with Amyotrophic Lateral Sclerosis    |
|     (ALS)" initiated April 2005 and is ongoing.                       |
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| b.  **GRECC Impact on VISN in the Report Year:**                      |
|                                                                       |
| -   GRECC staff provide expert clinical consultation to the VISN      |
|     FALLS committee regarding state of the art and science to prevent |
|     falls in nursing home care units. GRECC staff provide expertise   |
|     to the Primary Care Service Line regarding use of Beers criteria  |
|     for medication use in the elderly and to the Community            |
|     Stabilization Program on health literacy and good medicine        |
|     practices. In addition, GRECC staff provided guidance and         |
|     feedback on patient education materials for medication            |
|     self-administration.                                              |
|                                                                       |
| -   VISN-wide training programs under the auspices of GRECC include   |
|     two newly funded post-doctoral level training grants: 1) MREP     |
|     focusing on associative learning ability in alcoholics with       |
|     hypertension; and 2) NRSA focusing on memory disorders in         |
|     individuals at risk for cerebrovascular disease. GRECC staff at   |
|     the Boston Division lead the Harvard/VA Geriatric Neuropsychology |
|     Training Program, one of the largest programs of its kind in the  |
|     country. The New England GRECC was approved as a new training     |
|     site for the Special Fellowship Program in Advanced Geriatrics.   |
|                                                                       |
| -   VISN educational conferences sponsored by GRECC include Good      |
|     Medicine Practices for Older Adults: A Patient /Team Approach,    |
|     which addressed the problems of polypharmacy, side effects,       |
|     research-practice gap, and under use of therapeutic drugs in the  |
|     elderly, and the VISN1 Culture Change Conference titled           |
|     "Medications and the Elderly" which reinforced the principles of  |
|     reducing the number of medications where possible; using          |
|     nonpharmacological approaches to manage behavioral issues in      |
|     dementia; and suspecting adverse drug event as most likely cause  |
|     of sudden behavioral changes in older patients.                   |
|                                                                       |
| -   GRECC has taken the lead in helping the Boston Healthcare System  |
|     meet VISN Geriatric Service Line goals in community-based         |
|     programs, including home telehealth and Home-Based Primary Care.  |
|                                                                       |
| -   Senior GRECC staff serve as advisors to the VISN Geriatrics       |
|     Service Line and the VISN Geriatrics Council.                     |
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| c.  **GRECC Trend-Setting Innovations since October 1,                |
|     [2001]{.underline}**                                              |
|                                                                       |
| -   An innovative series of programs to improve quality of life for   |
|     veterans with moderate to severe dementia include an off-ward     |
|     Therapeutic Activity Center, Snoezlen Room and inpatient          |
|     Veteran's Club that provide meaningful activities and reduce the  |
|     need for drugs to control behavioral disturbances. Program        |
|     guidelines available distributed widely to VA Medical Centers.    |
|     Drs. Kowall, Morin and GRECC staff (2003 to present)              |
|                                                                       |
| -   Focus on safety for patients with dementia including home safety  |
|     programs and education materials. The booklet "Keep Your Home     |
|     Safe for the Person with Memory Loss" is available in PDF format  |
|     for families and persons with memory loss. Developed with clear   |
|     language and health literacy principles based on research with 62 |
|     families and 6 focus groups. These guidelines help keep patients  |
|     at home and delay the need for institutional care. Dr. Horvath.   |
|     Dates: 2003 -- present.                                           |
|                                                                       |
| -   The development and testing of improved assessment instruments    |
|     for patients with dementia, including the PAINAD (Pain Assessment |
|     in Advanced Dementia) tool fills a gap in the assessment of pain  |
|     in elderly, cognitively impaired adults. Use of the PAINAD meets  |
|     JCAHO criteria for an adequate pain assessment tool by using a 10 |
|     point scale that can be taught easily to all levels of staff and  |
|     family members. This innovative scale improves the recognition of |
|     pain in demented patients who are unable to communicate and helps |
|     monitor their response to pain treatment to ensure that pain is   |
|     adequately managed. Other scales developed by the GRECC include   |
|     SOAPD (Scale for Observing Agitation in Persons with Dementia)    |
|     agitation scale and the BANS (Bedford Alzheimer Nursing Scale)    |
|     which measures disease severity in late stage Alzheimer's         |
|     disease. Drs. Horvath, Kowall, Budson, and GRECC staff Bedford    |
|     division. Dates: 2004- present                                    |
|                                                                       |
| -   New approaches to improve the recovery of brain-damaged patients  |
|     have been developed and tested such as galvanic vestibular        |
|     stimulation (GVS). Preliminary studies on individual patients     |
|     show that this procedure may help improve visual perception in    |
|     patients and improve functional capacity after serious brain      |
|     damage caused by injury or strokes. Drs. Milberg and GRECC staff. |
|     Dates: 2005- present                                              |
|                                                                       |
| -   The Pharmacologic Intervention in Late Life (PILL) Clinic is a    |
|     multi-disciplinary approach to reduce polypharmacy and drug       |
|     interactions, provide patient and PCP education, and conduct      |
|     medication reconciliation. It addresses gaps in the current       |
|     health care system that can result in inappropriate medication    |
|     use. Drs. Nelson, Milan, and Salow. 2005-present                  |
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| **5. RESEARCH**                                                       |
+-----------------------------------------------------------------------+
| **a. Key Findings Published in the Report Year on projects for which  |
| GRECC Core Staff was PI or Co-PI:\                                    |
| **                                                                    |
|                                                                       |
| -   McKee AC, Au R, Cabral HJ, Kowall NW, Seshadri S, Kubilus CA,     |
|     Drake J, Wolf PA. Visual association pathology in preclinical     |
|     Alzheimer disease. J Neuropathol Exp Neurol. 2006                 |
|     Jun;65(6):621-30. This paper reports an important new finding     |
|     concerning brain areas that are damaged prior to the development  |
|     of clinical Alzheimer's disease. The brains of 41 elderly         |
|     subjects enrolled in the Framingham Heart Study were studied.     |
|     About 50% of the cognitively intact subjects and all subjects     |
|     with mild cognitive impairment or dementia, had significant       |
|     pathological change localized to the visual association cortex.   |
|     The unique metabolic, connectional, and vascular features of this |
|     region may confer enhanced vulnerability to neurodegeneration.    |
|                                                                       |
| -   [Smith KM, Matson S, Matson WR, Cormier K, Del Signore SJ,        |
|     Hagerty SW, Stack EC, Ryu H, Ferrante                             |
|     RJ.]                                                              |
| (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve |
| &dopt=AbstractPlus&list_uids=16647250&query_hl=1&itool=pubmed_docsum) |
|     "Dose ranging and efficacy study of high-dose coenzyme Q~10~      |
|     formulations in Huntington\'s disease mice." Biochem Biophys      |
|     Acta. , Jun 2006. During the past year our greatest success has   |
|     been the implementation of five phase l clinical trials in        |
|     amyotrophic lateral sclerosis using high-dose creatine and sodium |
|     phenylbutyrate and in Huntington's disease patients using         |
|     high-dose creatine, sodium phenylbutyrate, minocycline, and       |
|     high-dose coenzyme Q10. Each of these trials were successful in   |
|     showing safety and tolerability of the drug agents and are now in |
|     review for the support phase ll-lll clinical trials.              |
|                                                                       |
| -   Budson AE, Mather M, Chong H. Memory for choices in Alzheimer's   |
|     disease. *Dementia and Geriatric Cognitive Disorders* 2006 22     |
|     150-158. In this article we found that patients with mild         |
|     Alzheimer's disease have tremendous difficulty remembering enough |
|     information to make the kind of decisions they are frequently     |
|     faced with making, including basic decisions regarding where to   |
|     live and what health care plan to choose.                         |
|                                                                       |
| -   Munshi, M.; *Grande, L*.; Hayes, M.; Ayres, D.; Suhl, E.;         |
|     Capelson, R.; Lin, S.; *Milberg,W*.; & Weinger, K. (2006).        |
|     "Cognitive dysfunction is associated with poor diabetes control   |
|     in older adults," ­[Diabetes Care, 29]{.underline}: 1794-1799.     |
|     Research program at Boston Division geriatric neuropsychology     |
|     laboratory has focused on distinction between Alzheimer's type    |
|     dementia and vascular dementia, and diagnostic problems with the  |
|     latter. In order to identify early, non-memory loss cognitive     |
|     impairment, the team has developed a new screening tool called    |
|     "Clock in a Box".                                                 |
|                                                                       |
| -   Hurley AC, Harvey FR, Roberts JS, Wilson-Chase C, Lloyd S, Prest  |
|     J, Lock M, Horvath KJ, Green RC. Genetic susceptibility for       |
|     Alzheimer's disease: Why did adult offspring seek testing? Am J   |
|     Alzheimer's Dis Other Demen. 2005 Nov-Dec;20(6):374-81. The study |
|     explored why adult offspring in individuals with Alzheimer's      |
|     disease (AD) sought genetic susceptibility testing for AD.        |
|     Participants were a subset of subjects from the first randomized  |
|     controlled clinical trial to offer such testing. Qualitative      |
|     analysis revealed two central constructs: altruism and learning.  |
|     Planning for the future, hoping to prevent AD, and need to know   |
|     were concepts that explained the value of learning. These results |
|     add important contextual information into why people might seek   |
|     information on their genetic risk for a severe neurodegenerative  |
|     disease for which there are, as yet, no preventative treatments.  |
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| **b. Key Findings Published in the Report Year on work in which GRECC |
| Core Staff served as Co-Investigators to a Non-GRECC PI:**            |
|                                                                       |
| -   Kraytsberg Y, Kudryavtseva E, McKee AC, Geula C, Kowall NW,       |
|     Khrapko K. Mitochondrial DNA deletions are abundant and cause     |
|     functional impairment in aged human substantia nigra neurons. Nat |
|     Genet. 2006 May;38(5):518-20. This is an important new study      |
|     linking aging, mitochondrial DNA damage and functional impairment |
|     of brain cells. Using a novel single-molecule PCR approach to     |
|     quantify the total burden of mitochondrial DNA (mtDNA) molecules  |
|     with deletions, we show that a high proportion of individual      |
|     pigmented neurons in the aged human substantia nigra contain very |
|     high levels of mtDNA deletions.                                   |
|                                                                       |
| -   Barrett, A, Buxbaum, L. Coslett B, Heilman K., Hillis, A.,        |
|     Milberg, W., Robertson, I.  Cognitive rehabilitation              |
|     interventions for neglect and related disorders: Moving from      |
|     bench to bedside in stroke patients. J. Cognitive Neuroscience.   |
|     2006 18, 1223-1236. In this review we consider the challenges and |
|     obstacles facing scientific researches wishing to evaluate the    |
|     mechanisms and effectiveness of rehabilitation interventions. We  |
|     review current opinion about methods of assessment, suggest a     |
|     rational approach to selecting therapies, which requires further  |
|     study, and make systems-level and theoretical recommendations for |
|     building theory. We lastly review some creative questions for     |
|     consideration in future research.                                 |
|                                                                       |
| -   Jenkins BG, Andreassen OA, Dedeoglu A, Leavitt B, Hayden M,       |
|     Borchelt D, Ross CA, Ferrante RJ, Beal MF. Effects of CAG repeat  |
|     length, HTT protein length and protein context on cerebral        |
|     metabolism measured using magnetic resonance spectroscopy in      |
|     transgenic mouse models of Huntington's disease. J Neurochem.     |
|     2005 Oct; 95 (2): 553-62. This collaborative investigative team   |
|     of GRECC investigators partnering with scientists at Cornell and  |
|     Harvard, used state of the art in vivo magnetic resonance         |
|     spectroscopy techniques to define neurochemical profiles in a     |
|     series of five living animal models of Huntington's disease. They |
|     identified profound metabolic defects that were strongly          |
|     associated with CAG repeat length, gene expression levels and     |
|     protein context.                                                  |
|                                                                       |
| -   Lee J, Kim CH, Simon DK, Aminova LR, Andreyev AY, Kushnareva YE,  |
|     Murphy AN, Lonze BE, Kim KS, Ginty DD, Ferrante RJ, Ryu H, Ratan  |
|     RR. Mitochondrial cyclic AMP response element-binding protein     |
|     (CREB) mediates mitochondrial gene expression and neuronal        |
|     survival. J Biol Chem. 2005 Dec 9;280(49):40398-401. This novel   |
|     study demonstrates that altered regulation of mitochondrial gene  |
|     expression may directly contribute to the mitochondrial           |
|     dysfunction and neuronal loss associated with neurodegenerative   |
|     disorders. This may have major impact on future drug development. |
|                                                                       |
| -   Daffner KR, Ryan KK, Williams DM, Budson AE, Rentz DM, Scinto LF, |
|     Holcomb PJ. Age-related differences in novelty and target         |
|     processing among cognitively high performing adults. Neurobiol    |
|     Aging. 2005 Oct;26(9):1283-95. The electrophysiological study     |
|     comparing cognitively high performing shows that brain activity   |
|     was comparable across old, middle-aged, and young adults matched  |
|     for IQ, education, and gender, indicating that for cognitively    |
|     high functioning elders there may be no age-related differences   |
|     specific to the processing of novel and target events measured    |
|     during this series of neuropsychological tasks                    |
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| **6. EDUCATION**                                                      |
+-----------------------------------------------------------------------+
| a.  **Innovations in Educational Activities Implemented during the    |
|     Report Year**                                                     |
|                                                                       |
| -   Co-sponsored program on "Wellness for Persons with Dementia"      |
|     which included a pre-conference expert consensus summit. Forty    |
|     participants from community agencies, state and federal           |
|     government, and international academic and health agencies        |
|     developed recommendations for nutrition, exercise, cognitive      |
|     stimulation and non-pharmacologic treatments for Alzheimer's      |
|     disease. A position paper is in preparation. Abstracts from the   |
|     conference were published in Emerson Lombardo, N.B. "Selected     |
|     abstracts from the Wellness for Persons with Dementia symposium." |
|     [J. of Alzheimer's Disease, 9]{.underline}: 445-448.              |
|                                                                       |
| -   New health literacy verified patient education materials are      |
|     incorporated into both professional and lay presentations         |
|     ("Understanding Memory Loss" and "Understanding Alzheimer's       |
|     Disease"                                                          |
|                                                                       |
|    [www.alzheimers.nia.nih.gov](http://www.alzheimers.nia.nih.gov/)). |
|     Recent research has shown that giving providers patient education |
|     tools as part of a lecture increases the likelihood of change in  |
|     provider behavior. Additionally, providers do more patient        |
|     teaching if patients ask them specific questions. GRECC staff     |
|     have been invited to return to community groups and hospitals to  |
|     talk more about early identification of serious memory problems.  |
|                                                                       |
| -   Boston GRECC site director organized and provided leadership for  |
|     workshops in study design, grant writing, and manuscript writing  |
|     for VA fellows and trainees.                                      |
|                                                                       |
| -   New program for "Care of the Cognitively Impaired Person in the   |
|     Acute Care Hospital" includes a "tool kit" of assessment tools.   |
|     Examples of their use and scoring are used to increase provider   |
|     self-efficacy in cognitive assessment. People with increased      |
|     self-efficacy are more likely to implement new practice           |
|     behaviors.                                                        |
+-----------------------------------------------------------------------+
| b.  **Exportable Educational Products First Available for             |
|     Distribution in Report Year**                                     |
|                                                                       |
| -   "The Elderly Driver," assessment, legal and ethical issues, and   |
|     rehabilitation, is a 3-part video taped satellite conference      |
|     produced in collaboration with EES and Consortia of Geriatric     |
|     Education Centers. Program includes power point slides, reference |
|     tools, and support documents to reinforce the content and         |
|     transfer to clinical practice.                                    |
|                                                                       |
| -   Audiotape and power point presentation on "Executive Dysfunction  |
|     in Patients with Cerebrovascular Risk Factors" teaches primary    |
|     care providers to distinguish between vascular dementia and       |
|     dementia of the Alzheimer type, and to conduct a clock drawing    |
|     task for cognitive screening.                                     |
|                                                                       |
| -   "Medicare Part D: 4 Easy Steps" (Jan-May 2006; Time Limited), a   |
|     simple, easy to understand guide that was developed in response   |
|     to clinical providers' needs to give direction to patients who    |
|     didn't know how to begin. Widely distributed to community groups, |
|     non-VA providers, and VAMCs. Even if a veteran did not enroll     |
|     because they had comparable prescription coverage from the VA,    |
|     their caregivers needed guidance to ensure their health and       |
|     continued support of the veteran.                                 |
|                                                                       |
| -   "Tool kit" for Care of the Cognitively Impaired Person in the     |
|     Acute Care Setting, includes samples of assessment and treatment  |
|     planning tools, supportive references, and associated web sites.  |
+-----------------------------------------------------------------------+
| **7. CLINICAL DEMONSTRATION PROJECTS**                                |
+-----------------------------------------------------------------------+
| a.  **Clinical Demonstration Projects Underway in Report Year:**      |
|                                                                       |
| -   The Boston division GRECC has established a post-operative        |
|     delirium consult service to investigate delirium assessments and  |
|     provide inpatient education to nursing staff, staff physicians    |
|     and residents on the detection and management of delirium.        |
|                                                                       |
| -   The Boston division GRECC has established a new GRECC/Memory      |
|     Disorder Clinic.                                                  |
|                                                                       |
| -   The Boston division GRECC has established Geriatric Intake        |
|     Clinics at three sites in the Boston Healthcare System (Jamaica   |
|     Plain, West Roxbury, and Brockton).                               |
|                                                                       |
| -   Pharmacologic Intervention in Late Life (PILL) Clinic is staffed  |
|     by a geriatrician, pharmacist and trainees in geriatric medicine  |
|     and pharmacy that reviews medication lists and makes              |
|     recommendations to primary care providers how to reduce           |
|     polypharmacy. (New - Boston)                                      |
|                                                                       |
| -   "*The Club*" is a novel ward-based quality of life program        |
|     developed at the Bedford division GRECC to enhance activities of  |
|     daily living and provide therapeutic activities for inpatients    |
|     with advanced dementia in the framework of a social model.        |
|     Participants engage in a range of directed activities that are    |
|     integrated with family visits. The roles of the multidisciplinary |
|     staff that includes nurses, therapists, social workers, and other |
|     ward-based staff are designed to enhance creativity and ensure    |
|     the efficient use resources.                                      |
|                                                                       |
| -   *Convivium* is a new approach to the dining experience for        |
|     inpatients with dementia that has been developed by the Bedford   |
|     division GRECC to improve quality of life and physical health for |
|     the patient with advanced dementia and their caregivers in a long |
|     term care setting.                                                |
|                                                                       |
| -   The Boston Division GRECC collaborated with the medical service   |
|     to start an Acute Palliative Care Consult Team. This              |
|     collaborative model provides multidisciplinary clinical           |
|     consultation and education in palliative care to acute services   |
|     including the intensive care units at the West Roxbury VA. An     |
|     Outpatient Palliative Care Clinic has also been established.      |
+-----------------------------------------------------------------------+
| b.  **Evaluation of Clinical Demonstration Projects:**                |
|                                                                       |
| -   Data collection for the Geriatric Intake Clinics, Memory Clinic,  |
|     and Delirium Consult Service is ongoing.                          |
|                                                                       |
| -   Pharmacologic Intervention in Late Life (PILL) clinic project     |
|     began with screening almost 1000 patients taking more than 14     |
|     medications, with discovery that about 60% are on at least one    |
|     Beers criteria drug. The clinic has seen 38 unique patient visits |
|     with 95 total interventions. The success of the PILL Clinic has   |
|     been disseminated through VISN and GRECC newsletters and in a     |
|     regional conference on Good Medicine Practices in Older Adults.   |
|     Data gathering started in August, 2005.                           |
|                                                                       |
| -   *The Club*: Using the nursing home minimum data set we evaluated  |
|     the effect of "*The Club*" on involvement in activities, use of   |
|     sedatives/hypnotics and falls and showed improvements in all      |
|     three measures.                                                   |
|                                                                       |
| -   *Convivium*: The first phase of evaluation demonstrated "buy in"  |
|     by all staff and showed that new individualized feeding plans     |
|     were developed. The program successfully maintained desired body  |
|     weights and was effective in dealing with feeding problems.       |
|     Future improvement will be focused on increasing patient comfort  |
|     and enhancing the mealtime experience as a meaningful activity.   |
|                                                                       |
| -   In the short term, our initiatives in palliative care have        |
|     improved patient care and promoted education in palliative care.  |
|     In the long term, as we evaluate the outcomes of this             |
|     collaboration, we hope to improve communication and planning      |
|     around chronic illness management,end-of-life care, and integrate |
|     palliative medicine into mainstream medical and geriatric         |
|     practice.                                                         |
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| c.  **New Clinical Models developed that were exported in the Report  |
|     Year**                                                            |
|                                                                       |
| -   The PAINAD (Pain Assessment in Advanced Dementia) and SOAPD       |
|     (Scale for Observing Agitation in Persons with Dementia) are      |
|     being used by Alexandria Hospital in Singapore. Scoring           |
|     categories and a training video were provided to them. Ongoing    |
|     advice and mentoring regarding baseline measures and screening    |
|     tools was communicated by e-mail.                                 |
|                                                                       |
| -   The *Convivium* dining experience was presented to VA and non-VA  |
|     facilities throughout Massachusetts through a multimedia          |
|     Alzheimer's Association educational program. The program was very |
|     well received and it is expected that facilities will begin       |
|     implementing the *Convivium* experience*.*                        |
|                                                                       |
| -   The home safety health literacy booklet was exported to the Tampa |
|     VAMC and is being translated into Spanish. The booklet was also   |
|     shared with nurse educators at the University of Michigan and was |
|     translated into Korean.                                           |
|                                                                       |
| -   Patient education interventions included counseling about         |
|     expiration dates, inhaler use, and use of nitroglycerine.         |
|     Feedback was given to 11 primary care providers.                  |
+-----------------------------------------------------------------------+
| **8. CONSULTATION AND OUTREACH**                                      |
+-----------------------------------------------------------------------+
| **a. Current Year Activity Outcomes**                                 |
|                                                                       |
| -   The PILL (Pharmacologic Intervention in Late Life) Clinic has     |
|     seen 38 unique patient visits with 95 total interventions         |
|     including education, reconciliation, and medication changes.      |
|     Medication changes included reduction, discontinuation and        |
|     changing agents. Patient education included a medication chart,   |
|     expiration dating, and counseling on appropriate administration.  |
|     The success of the PILL Clinic has been disseminated through VISN |
|     and GRECC newsletters and in a regional conference on Good        |
|     Medicine Practices in Older Adults.                               |
|                                                                       |
| -   Consultation to Community Stabilization Program on health         |
|     literacy and patient education for self-management. Information   |
|     sheets were revised for literacy levels and readability.          |
|                                                                       |
| ```{=html}                                                            |
| <!-- -->                                                              |
| ```                                                                   |
| -   Consultation to FALLS Committee on latest research findings and   |
|     clinical applications. Developed power point presentation that    |
|     was used by chair of committee for grand rounds.                  |
|                                                                       |
| -   Outreach to Salt Lake City Health Care System for health trainee  |
|     education on Alzheimer's disease; power point presentation and    |
|     tools incorporated into the curriculum                            |
|                                                                       |
| -   Outreach to all Associate Directors for Education and Evaluation  |
|     in other VAMCs regarding education of non-veteran caregivers      |
|     regarding Medicare Part D. Template for educational materials was |
|     developed and disseminated.                                       |
|                                                                       |
| -   Outreach to Central Alabama Veteran's Healthcare System for use   |
|     and scoring of PAINAD. Outcomes include use of better tool to     |
|     assess and treat pain in patients with late stage dementia, and   |
|     therefore better pain management.                                 |
+-----------------------------------------------------------------------+
| **b. Previous Years' Activities Outcomes**                            |
|                                                                       |
| -   Educational program in 2004, "Building Effective                  |
|     Community/Academic Partnerships in Dementia Research" lead to     |
|     successful funding of a pilot grant on "Effects of nutrition and  |
|     exercise on cognitive function in older adults". Collaboration    |
|     between community leaders and Boston Division Geriatric           |
|     Neuropsychology Laboratory resulted in more sophisticated         |
|     physiological measures for the pilot grant and a new cohort of    |
|     subjects for an ongoing study at the Boston division on exercise  |
|     and cardiovascular status in African American older adults.       |
|                                                                       |
| -   Ongoing collaboration with the Patient Safety Center of Inquiry   |
|     at Tampa VAMC on wandering initiatives in veterans with dementia  |
|     has lead to a book in review for publication by the Springer      |
|     Publishing Company. Dr. Horvath's chapter in the book will        |
|     increase the dissemination of research-based interventions to     |
|     prevent wandering in the home environment. (Estimated publication |
|     date: Spring 2007)                                                |
|                                                                       |
| -   Previous educational program on "Giving Older Drivers' the Green  |
|     Light" in 2004 identified and developed faculty expertise in VISN |
|     1 on the assessment and legal/ethical issues for older drivers.   |
|     The clinical and legal experts were primary presenters this year  |
|     in a 3-part satellite conference on The Elderly Driver developed  |
|     in collaboration with the Consortia of Geriatric Education        |
|     Centers and EES.                                                  |
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