Geriatric Research Education and Clinical Center (GRECC)
RECC Research News: July - September 2018 (FYQ4)
- Providing Comprehensive Care for Veterans with Amyotrophic Lateral Sclerosis (ALS) (Bronx GRECC)
- Clinical Video Telehealth for Continence Care: An Innovative Clinic Expansion in Birmingham and Atlanta (Birmingham/Atlanta GRECC)
- Falls Assessment of Medications in the Elderly (FAME) (Durham GRECC)
- Study of Factors that Affect Lifespan and Age-Related Diseases (Little Rock GRECC)
- Aging Well with Independence using Sensors in the Environment (AGING-WELL) (Minneapolis GRECC)
- Interdisciplinary Cognitive Assessment Clinic (Palo Alto GRECC)
- Moving Free-ly (Puget Sound GRECC)
- Innovative Clinical Programs That Impact Veterans and Caregivers (TVHS GRECC)
The James J. Peters VA SCI Interdisciplinary ALS Clinic provides comprehensive interdisciplinary care services for patients with ALS (also known as Lou Gehrig’s disease) with specialty in the unique needs of patients with severe functional disabilities. Housed in the VA Spinal Cord Injury Center and through collaboration and leadership by GRECC palliative care team expert Dr. Elizabeth Lindenberger, the clinic serves as the VISN 2 Center for ALS Care.
The clinic expanded its team to include a designated case manager in addition to neurology, social work, occupational and physical therapy, psychology, nutrition and speech and language therapy. All team members receive training in palliative care needs for patients, and all patients receive palliative care service. For patients with advanced disease, home hospice services are offered in combination with clinic care to maximize home care support, attention to symptoms and quality of life, and continuity of care for patients and their families.
Services to support patients and caregivers include:
- Addition of an ALS Association (ALSA) representative to the clinic team, offering ALSA resources such as support groups and home visits, and
- A monthly support group for Veterans with ALS and their caregivers.
The ALS Clinic also continues to serve as a clinical training site for the JJP Interprofessional Palliative Care Fellows.For more information, contact Dr. Elizabeth Lindenberger at 718-584-9000, ext. 3806.
Clinical Video Telehealth for Continence Care: An Innovative Clinic Expansion in Birmingham and Atlanta (Birmingham/Atlanta GRECC)
With an FY18 award from the national GRECC office, the Birmingham/Atlanta GRECC team adapted our clinic-based continence care services for clinical video telehealth visits. This project builds upon the infrastructure created by the GRECC Connect telehealth program in Geriatrics that is funded by the Office of Rural Health.
In Birmingham, we partnered with the Huntsville CBOC and our local telehealth office to launch these new clinics in May 2018. To date, we have seen a total of 15 Veterans during a half-day clinic per month. With this expansion, we now have the need to open an additional half-day clinic for a total of two half-days per month. This additional clinic will start in November 2018. In Atlanta, the first new patient continence telehealth consultation was completed with the Carrollton CBOC in September 2018. Telehealth visits are currently scheduled on Friday mornings. This new clinical video telehealth program involved training the telehealth staff in Huntsville and Carrollton to use a portable bladder ultrasound device that measures post void residual volume. Not only did we start a new clinic, we also now provide a new service and tool to measure bladder volume for Veterans at both CBOCs. This project meets key VA priority areas:
- Greater choice
- Modernize systems
- Focus resources
- Improve timeliness for our Veterans that we serve
Funding by the Patient Safety Center of Inquiry, the Durham GRECC is part of a new Patient Safety Center of Inquiry focused on medication safety in older adults with West Haven, Puget Sound, San Francisco, Palo Alto and coordinated through Bronx. Durham’s Team will pilot a new clinical program, Falls Assessment of Medications in the Elderly.
Rationale for the pilot: Falls are the most common and costly medication-related safety event in older adults, with a fall occurring in the U.S. every 17 seconds. In 2014, older Americans experienced 29 million falls causing seven million injuries and costing $31 billion to Medicare. A robust body of evidence supports medications as a major causal factor for falls in older adults. Psychoactive medications including benzodiazepines, antidepressants, anti-psychotics, and anticholinergic medications have been consistently associated with a two-fold or higher risk of falls and fractures in older populations.
Deprescribing fall-related medications, defined as intentionally stopping or reducing the dose of a medication to improve health or reduce the risk of adverse effects, is therefore a key step in reducing the burden of falls in older Veterans.Process:
- Identify Veterans 65 years of age and older at high risk of falls who are on one or more target medications.
- Provide a Fall Medication E-Consult with recommendations to the PCP.
- Contact the Veteran regarding recommendations
- Provide falls/medication education and follow-up
- Monitor compliance to the prescribed plan
- Communication with PCP
For more information, contact Cathleen Colon-Emeric, MD. at (919) 286-0411 ext: 7-1-6777.
Dr. Robert J. S. Reis leads a research group that studies the factors (genes, diet, etc.) that affect lifespan and the risk of age-related diseases. His group is supported by a VA Merit award (2018 – 2022) to study how failure to maintain correctly-folded proteins contributes to dementias such as Alzheimer’s Disease (AD). By defining the protein-protein contacts that bind damaged and misfolded proteins together as clumps or aggregates and by computer-model screening of molecular libraries for the ability to disrupt those interfaces, they hope to find novel drugs that prevent or reverse AD. They are also funded through a Program Project Grant headed by Dr. Sue Griffin to study early events in Alzheimer’s, and through a just-funded R01 award (2018 – 2023) to Drs. Reis and Ayyadevara from the National Institute on Aging, to analyze aggregates that form and grow with age in a variety of mouse tissues. Their goal in this new work is to discover and test common features that might underlie a wide variety of diseases and debilities associated with aging.
Little Rock Webinars:
Smoking Cessation for Older Veterans: Practical Care of Mature Adults
Presented by Lana Brown, PhD, RN, NEA-BC, VHA-CM
November 13, 2018 at 11:30 am – 12:00 pm
Ask the Expert on Smoking Cessation for Older Veterans
November 14, 2018 at 11:30 am – 12:00 pm
We are pleased to announce the recent addition of Adriana Seely, PhD, to the Minneapolis GRECC. She currently leads two exciting and innovative research projects. Promote Independent Aging (PRIA) is a VA Clinical Science Research and Development (CSR&D) funded pilot project that uses technology to measure activity in the home with the hope of helping veterans remain independent as they age. This project builds infrastructure for and demonstrates the ease of in-home sensor data collection approaches to detect early signs of cognitive decline in veterans at the Minneapolis VA Health Care System (HCS). Aging Well with Independence using Sensors in the Environment (AGING-WELL) is a larger National Institutes on Aging (NIA)-funded R01 project. Both studies involve measuring daily activity patterns by devices like a digital watch, home computer, instrumented pillbox, and a vehicle driving sensor. Machine learning approaches will determine which daily activity changes are the earliest signals of mild cognitive decline. Early detection of dementia is important and will allow for early implementation of preventative interventions and assistive technologies, which will prolong “aging in place” and maintain quality of life in our aging veterans.
For more information, contact Ann Bolan, Administrative Officer at 612-467-2785.
Moving Free-ly is a medical-center-based fall prevention education class which provides a multidisciplinary approach to fall prevention through awareness of risk factors and risk reducing interventions as well as promotion of independence and safety. Over the course of six sessions, patients learn about the intrinsic/extrinsic risk factors for falling, practice evidence-based exercises and learn to incorporate other fall reduction behaviors into their daily lives.
The class curriculum was developed and is facilitated by a Geriatrician with clinical research experience in fall prevention and osteoporosis, geriatric physical, and occupational therapists and a geriatric pharmacist. Each class begins with lower extremity strength and balance exercises and then involves a didactic component mixed with group discussion or individual activities based on the content focus for that week. Outside of class, participants are encouraged to perform exercises daily, work on an activity, or complete ‘homework’ pertaining to the content focus of the week, and modify behaviors which may place them at risk of falling. The class is offered in person at the Seattle division and is now telecast remotely (at the same time via VA Connect) to the American Lake division (thanks to the generous support of the Office of Geriatrics & Extended Care!).
Out of 30 Veterans enrolled, 26 have completed the program. Nearly all participants reported that the class has reduced their fear of falling; most felt more comfortable talking to their health care provider about falling risks and medications, made changes to their environment to reduce the risk of falling, and would recommend the program to a friend; and few had falls during the class.
For more information regarding program implementation, etc., please email Dr. Ritchey, DO MPH or call her at 206-277-4515.
Palo Alto GRECC is participating in a pilot Cognitive Assessment Clinic (CAC), which is a collaborative effort with Medical Service, Neurology, and Neuropsychology to provide timely and patient-centered assessment of Veterans for whom there is a concern by Veteran, family member, or provider for cognitive impairment. Targeted for Veterans who do not have a diagnosis of dementia nor need capacity assessment, this clinic provides cognitive evaluation, probable diagnosis, and a suggested management plan within one consolidated half-day visit. The visit begins with neuropsychological testing, and concomitant physician interviews with spouse/family member(s) for collaborative information. During the time the neuropsychological testing is being scored, the physician interviews and examines the Veteran. Once evaluations are complete, the interdisciplinary team (neuropsychologists, geriatrician, and neurologist) meet to discuss each case, and formulate diagnosis and management plans. At completion of the visit, the physicians and neuropsychologists meet with each Veteran and spouse/family member to review and explain findings and to go over the suggested management plan, a typed summary of which is provided.
To date, 27% of assessed Veterans were given a new diagnosis of major neurocognitive disorder (dementia), 43% were classified as having mild cognitive impairment (MCI), 20% had age-related cognitive decline (although some were felt to have concomitant mood disorders), and 9% were felt to have normal cognition; only 1% were referred for more extensive neurocognitive testing. If appropriate, CAC faculty made referrals for cognitive rehabilitation, driving evaluation (or, if new diagnosis of dementia, reported to the DMV), head imaging, or other evaluations. If there were suggestions for medication management, these were transmitted to Veteran’s primary care physician for implementation. Veteran and family satisfaction with the CAC has been very high, particularly noting appreciation of having the entire evaluation done in just one visit and the immediate and thorough feedback provided.
For more information, contact Christine Gould, PhD, ABPP at 650-493-5000 ext. 68899.
THRIVE ICU Support Group: This is a program offered by our MICU and SICU to surviving patients and their families to help them rebuild their lives following critical illness episodes cared for at TN Valley Nashville VA ICUs. The program — the first of its kind across the entire VA healthcare system — is attended weekly by 5 to 10 people and run by the ICU nurses, Chaplain, and Social Worker along with a PhD nurse post-doc and consultation by GRECC faculty. Thirty-three ICU Recovery Group sessions were offered October 2016 – July 2017 with 82 ICU survivors and family members. Of those surveyed:
- 93% felt emotionally supported
- 91% learned from others
- 77% now understand common situations related to prolonged ICU stay
- 86% would strongly recommend group participation to a friend
- 42% expressed interest in volunteering to provide peer support to Veterans and support persons in need
ICU Diaries: The MICU and SICU developed a program to provide a diary that is filled out by family members and healthcare staff documenting the events experienced by our Veterans while on life support and under sedation. These diaries are reviewed by the patients and families in the months following the ICU and help all to cope with stress, consolidate memories, reduce depression and PTSD, and magnify the human side of ICU care as well as patient dignity. Diaries are given to the Veteran/family member at ICU discharge. Twenty-nine diaries were initiated in 2017.
- Diary knowledge increased from 38.8 to 71.85
- Belief that diaries are beneficial rose from 62.74 to 76
- Comfort level with educating family from 44.4 to 78.46
Enhancing Advance Directives Discussion in Geri-PACTs. Patients believe that their physicians should initiate advance directive discussions. A QI project underway encourages primary care physicians to have advance directive discussions with their patients. It also incorporates collaboration with Palliative care services for same day visits for complex scenarios. High Care Assessment Needs (CAN) scores and facility-based Veterans needs have been specifically addressed.
For more information, contact Sumathi Misra at 615-873-6063.