Geriatrics and Extended Care
Geriatric Research Education and Clinical Centers (GRECCs)
Geriatric Research Education and Clinical Centers (GRECCs) were developed in the 1970s when the Veterans Health Administration began focusing on the special needs of aging Veterans.
There are currently 20 GRECCs across the country. Each GRECC includes programs that address research, education and clinical aspects of aging. Research focuses on diseases associated with aging, as well as how care is delivered to older Veterans and the effects of rehabilitation.
Goals and Importance of GRECC
GRECCs were designed to attract scientists and health science students to the field of geriatrics, and to make sure that the care delivered to older Veterans continuously improved. With staff specially trained in the field of geriatrics, GRECCs have been able to increase basic knowledge in the field of aging, and transfer that knowledge to health care providers. In addition GRECCs train clinical staff in the field of geriatrics. This improves the quality of care delivered to older Veterans. More information about GRECC clinical and research programs: www.va.gov/GRECC
Improving Veteran’s Function and Community Mobility after Hospitalization using a Hospital Mobility Program
100 Veterans 65 years of age or older who were admitted to medical wards of the Birmingham VA Medical Center were randomized to usual care or a twice a day, 15-20 minute Mobility Program that began with assisted sitting, and progressed to standing, weight shifting, stepping in place, and then ambulation as tolerated. The program also included a behavioral intervention focused on goal setting and addressing mobility barriers.
The Veterans were 97% male, 19% African American, with a mean age of 74 years. Median length of stay was 3 days. Outcome was measured with the Life-Space Assessment (LSA), which measures community mobility ranging from one’s bedroom to beyond one’s town, with scores ranging from 0-120. Higher scores represent greater mobility. One month after hospitalization, the Mobility Program group had maintained community mobility. In the usual care group, LSA scores had decreased 10 points, which is a clinically significant decrease. Since lower LSA scores are associated with increased risk of death, nursing home placement, and functional decline, preserving the LSA with an easy-to-implement in-hospital Mobility Program should be of great clinical significance for hospitalized older Veterans. JAMA Internal Medicine, 2016.
Local Contact: Cynthia Brown,, MD, MSPH
VA Health Care Upstate New York (VISN 2) GRECC
VA Research on Older Adults with Sleep Problems
Sleep complaints from older adults are very common, and for many daytime sleepiness interferes with their activities of daily living. Like other syndromes and symptoms in older adults, sleep problems are often caused by multiple precipitating causes and risk factors, including health conditions, treatments, environmental conditions, and psychological or behavioral issues. In the November 2016 issue of the journal Clinical Therapeutics, Dr. Boockvar, AD-R of VISN 2 GRECC, guest edited a series of articles on sleep problems in older adults that featured VA investigators’ work nationwide [Clinical Therapeutics 2016; 38: 2330-2415]. First, a narrative review of sleep medicines in older adults supported the general recommendation that drugs be avoided for sleep problems in older adults. A second article reported results of a national survey of Veterans’ treatment preferences in which respondents chose non-pharmacological treatment for insomnia as more acceptable than pharmacological
treatment. A third article showed that in a national sample of surveyed adults, nocturia was associated with worse functional outcomes of sleep among adults older than 65 years, even with just two interruptions in sleep each night to urinate. Four additional articles underscore the high prevalence of sleep problems in older adults and their complications.
Local Contact: Annette Hintenach
Phone: 718-584-9000, ext. 3853
Problem-Solving Interventions for Caregivers of Veterans with Stroke
Caregiver depression and burden are common following a family member’s stroke and are major contributors to stroke survivors’ functional recovery, resource use, and institutionalization. Dr. Connie Uphold and her team conducted a VA RR&D funded pilot study titled “Internet and Telephone Support Intervention for Stroke Caregivers” to test a problem solving intervention that used telephone support and the RESCUE stroke caregiver website to improve the quality of caregiving and the rehabilitation of Veterans.
The study explored the impact of a nurse-led 4-session and 8-session internet and telephone support intervention on stroke caregiver and Veteran outcomes when compared to an attention-control condition and standard care. The study enrolled 53 caregivers of Veterans who had a stroke. Two follow-up assessments were conducted: one short-term (1 week) and one long-term (4 months) assessment as well as qualitative interviews to obtain feedback on the intervention.
Results of the short-term follow-up data did not find any statistically significant differences in pre-post changes by treatment group. Qualitative interviews revealed overwhelmingly positive responses to both the intervention and the registered nurses. Results from the 4-month follow up are currently being analyzed.
Local Contact: Connie Uphold
Phone: 352-376-1611 x6912 or 6893
Little Rock GRECC
VA Research on Alzheimer’s disease and related disorders.
Dr. Sue Griffin leads a research team including Dr. Steve Barger and Dr. Robert Reis that has received a $10.2 million NIH Program Project Grant on Alzheimer’s disease and related disorders. The proposal incorporates a multi-discipline approach that integrates three different projects: one devoted to the analysis of the characteristics of human aging-related brain disorders, one that will elucidate connections between Alzheimer’s and type-2 diabetes, and one that will use roundworms to discover the molecular triggers for the abnormal protein clumping in neurodegenerative diseases. All of these projects will be supported by four Core facilities, including one that will execute state-of-the art drug-discovery efforts. Together, this Program aims to achieve a novel and powerful advancement toward not only the understanding of brain diseases of the elderly, but also their successful treatment.
Celebrating 25 years of Research, Education, & Clinical Discovery
Twenty-five years ago, the Miami VA was awarded a Geriatric Research, Education and Clinical Center – The GRECC. There are only 20 such centers of excellence in aging research in the entire VA system. Our GRECC has been valued and consistently supported by the medical center leadership: from Mr. Doherty and Dr. Perez-Stable through Mr. Russo and Dr. DeGennaro.
Dr. Bernard Roos, founding director, guided the GRECC from its infancy to adulthood. Dr. Hermes Florez, the current director, has charted a course into the future that continues to address the VA strategic priorities for our aging Veterans. Throughout the years many VA and affiliate university staff have collaborated with GRECC staff to produce discoveries that have achieved national recognition.
Over a quarter of a century, the Miami GRECC has obtained $92 million in competitive grant support to foster collaboration and innovation as evidenced by over 2300 peer-reviewed publications. Here is a short list of a few important achievements:
- Developed a line of adult stem cells used nationally to treat disease (MIAMI Cells)
- Prostate cancer research that helps clinicians select the best treatment for each Veteran
- Established an osteoporosis center that has made important contributions in understanding bone loss in aging women and men
- Collaborated with Dr. Andrew Schally, Nobel Laureate, to study the impact of small peptide molecules on a variety of cancers
- Designed and exported a competency-based curriculum that is used locally and nationally
- Developed a telehealth care system that has improved care and reduced outpatient costs
- Designed and studied the use of virtual reality (avatars) in medical and patient education
- Introduced and studied exercise interventions to improve the quality of life and disease complications in diabetes and obesity
Thank you for your many years of support!
Hermes J. Florez, MD, MPH, PhD, Miami GRECC, Director
Antoine J. “AJ” Garand, MBA, Miami GRECC, AO
Email: firstname.lastname@example.org ; email@example.com
VA Pittsburgh Healthcare System (VAPHS) GRECC
Improving Care of Older Veterans with Chronic Low Back Pain
Researchers at the VA Pittsburgh Healthcare System (VAPHS) GRECC are conducting research, funded by VA Rehabilitation Research & Development, to improve the care of older veterans with chronic low back pain. The Principal Investigator of the study, Dr. Debra K. Weiner, Staff Physician at the VA Pittsburgh GRECC and Professor of Medicine, Psychiatry, Anesthesiology and Clinical & Translational Science at the University of Pittsburgh, explains that “virtually all older adults have degenerative disease of the lumbar skeleton without any pain at all. Care for those with pain and difficulty functioning that focuses exclusively on the spine has failed to improve the function or quality of life of these vulnerable patients, often exposing them to undue harm.”
The study is being conducted at VAPHS and the Richmond VA and aims to compare outcomes in those > age 60 with chronic low back pain and who are recent recipients of a lumbar MRI, randomized to receive either patient-centered comprehensive evaluation and treatment (PCCET) guided by evidence and expert-informed algorithms versus usual care. The algorithms, focusing on common contributors to pain (e.g., hip arthritis, fibromyalgia, maladaptive coping) were developed by 42 interdisciplinary specialists and primary care providers in the context of a prior Merit Review and have been published as a 12-part series in Pain Medicine. Participants in the current study will be followed for 6 months. Results will inform the development of a future multi-site randomized trial. The ultimate goal of the study is to improve the quality of life of older adults with chronic low back pain and improve the quality and safety of chronic.
Local Contact: Kimberly Hayes
Puget Sound GRECC
Mild traumatic brain injury from blast trauma associated with cerebellar damage
Blasts from explosives have long been known to cause Mild traumatic brain injury (mTBI) in combat Veterans, but a new study by VA Puget Sound GRECC (& MIRECC) investigators sheds light on how and where lasting harm may occur. Using brain scans from dozens of former soldiers, plus similar research in mice, scientists have identified the cerebellum, the area of the brain critical for coordinating movement, balance and certain cognitive skills, as particularly vulnerable to repeated blasts. The findings could prompt studies into ways to prevent and treat mTBI which has been called the “signature injury” of recent wars in Iraq and Afghanistan. An estimated 250,000 and 500,000 members of the U.S. military have been diagnosed with mTBIs across the globe. More than 40 veterans who participated in the study experienced an average 21 mTBIs as a result of explosions, with some enduring more than 100 such injuries. The more blasts they were exposed to, the more they showed lower levels of glucose metabolism, a marker of brain activity, in the cerebellum. These types of brain injury are usually not on most clinicians’ radar. Damage from repeated blasts was also detected in the cerebellums of mice, which are broadly similar to those in humans. Researchers created “shock tubes” to test simulated blast effects in the rodents. In mice, the explosions ruptured parts of the blood-brain barrier and led to the loss of certain neurons in the cerebellum. They also revealed the buildup of proteins associated with dementia and Alzheimer’s disease. Further neuroimaging in both mice and humans showed additional structural changes in the cerebellum which suggests that scientists should pay more attention to how mTBI affects the cerebellum to understand the emotional difficulties many Veterans face; this in turn may eventually help Veterans to learn different strategies to cope.
Local Contact: David Cook, PhD
Salt Lake City GRECC
The research activities of 21 investigators who are supported by approximately $5.8 million in annual grant funding span a wide spectrum of basic science, clinical translational and health services research. The common theme is to enhance knowledge of relevance to the health and health care of aging veterans. Two recent publications from among the more than 100 papers published in FY16 are highlighted below:
Evidence of a metabolic reserve in the skeletal muscle of elderly people
Layec, G. et al. Aging 10.18632/aging.101079. [Epub ahead of print]. The purpose of this study was to determine whether mitochondrial function is limited by O2 availability or the intrinsic capacity of mitochondria to synthesize ATP in elderly individuals. The results of this study reveal hemodynamic reserve in the contracting calf muscle of the elderly accessible by superimposing reactive hyperemia. Furthermore, this increase in O2 availability enhanced mitochondrial function thus indicating a skeletal muscle metabolic reserve despite advancing age and low level of physical activity.
Ascorbic acid improves brachial artery vasodilation during progressive handgrip exercise in the elderly through a nitric oxide-mediated mechanism
Trinity, J.D. et al. Am. J. Physiol. Heart Circ. Physiol. 2016, 310:H765-74. The proposed mechanistic link between the age-related attenuation in vascular function and free radicals is an attractive hypothesis; however, direct evidence of free radical attenuation and a concomitant improvement in vascular function in the elderly is lacking. The results of this study indicate that ascorbic acid improves vasodilation in the elderly during handgrip exercise through an nitric oxide-dependent mechanism; however, this improvement appears not to be the direct consequence of attenuated free radical outflow from the forearm.
San Antonio GRECC
Metformin for the Prevention of Frailty in High Risk Older Adults
Researchers at the South Texas Veterans Health Care System (STVHCS) GRECC and the Barshop Institute for Longevity & Aging Studies within the University of Texas Health Science Center at San Antonio are conducting a new study that focuses on the prevention of frailty.
The Principal Investigator of the study, Dr. Sara Espinoza, Associate Director of Clinical Programs at the GRECC, explains that “frailty is a clinical geriatric syndrome of progressive physical decline that is known to increase risk for multiple adverse outcomes with aging, such as falls, disability or nursing home placement, and death.”
The purpose of the study “Metformin for the Prevention of Frailty in High Risk Older Adults” is to find out if metformin, a drug commonly used to treat diabetes, helps prevent or slow down the development of frailty in older individuals who have pre-diabetes. Pre-diabetes, also known as impaired glucose tolerance is a term that refers to people who have blood glucose levels that are higher than normal, but are not high enough to be classified as diabetes. The researchers believe that pre-diabetes is a major risk factor for frailty and that metformin will prevent the onset of frailty.
Sponsored by the National Institute for Health (NIH) funded Claude D. Pepper Older Americans Independence Center in San Antonio, the study is currently recruiting pre-diabetic, community-dwelling participants of all ethnicities aged 65 and older who have impaired glucose tolerance. Participants will be randomly assigned to take either metformin or a placebo every day during the trial and will be followed for two years. Participants are expected to attend a total of 14 visits, some of which include tests and procedures to measure the body’s response to sugar and insulin and markers of inflammation.
Local Contact: Alice Conde
Tennessee Valley GRECC (VISN 9, TVHS)
National Veterans Health Administration inpatient risk stratification models for hospital-acquired acute kidney injury. (Speroff T, Matheny ME) This study of over 1.5 million patient hospitalizations from 116 VA hospitals determined multiple risk factors for development of sudden kidney failure, (which is particularly worrisome in the elderly), including NSAIDs, blood pressure medications, antibiotics, and intravenous fluids during the first 48h of admission. These are modifiable risk factors and further work can help prevent this life threatening and costly component of healthcare in the VA system. J Am Med Inform Assoc. 2015 Sep 22 (5):1054-71 NM for the SPRINT Research Group Intensive Blood Pressure Control in Adults 75 Years of Age and Older: The Systolic Blood Pressure Intervention Trial. (Roumie CL) This landmark investigation of patients aged 75 years or older showed that treating to a systolic blood pressure target of <120 mm Hg was better than a target of <140 mm Hg, yielding lower rates of fatal and nonfatal major cardiovascular events and death from any cause. Widespread modifications in care will hopefully result in fewer heart attacks and strokes. JAMA. 2016;315(24):2673-2682. Incidence and Risk Factors for Intensive Care Unit-related Post-traumatic Stress Disorder in Veterans and Civilians. (Girard TD, Dittus RS, Ely EW) This study found that 1 in 10 ICU survivors had PTSD and that preexisting PTSD and depression were strong predictors but that veteran status was not predictive. This study reinforces the need for aggressive monitoring of these two psychiatric issues even during critical illness in the ICU. Am J Respir Crit Care Med. 2016. Jun 15;193(12):1373-81.
Local Contact: Sumathi Misra
Phone: (615) 873-6063