Aging Successfully Fall2011

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Aging SuccessfullyFall 2011 Vol. XXI, No. 2 (continued on page 3) It’s a Winner! Treating Dementia with Baseball Memories SLU, St. Louis VA Hit Homerun with Special Therapy Group R eminiscence therapy has been developed for people with Alzheimer’s disease to stimulate them to talk about their memories. Therapists show older people with memory problems photographs, old programs and other familiar items, and patients eagerly share pleasant memories from their past experiences. The simple yet innovative treatment enhances mood and communication skills and may even improve intellectual ability. A Saint Louis University geriatrician and the act- ing director of the Geriatric Research, Education, and Clinical Center (GRECC) at the St. Louis Veterans Affairs Medical Center (VAMC) are convinced that

description

Newsletter for geriatrics at slusom

Transcript of Aging Successfully Fall2011

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1 Aging Successfully, Vol. XXI, No. 2 email: [email protected] Questions? FAX: 314-771-8575 Questions? FAX: 314-771-8575 email: [email protected] Aging Successfully, Vol. XXI, No. 2 1

Fall 2011Vol. XXI, No. 2

(continued on page 3)

It’s a Winner!Treating Dementia with Baseball Memories

SLU, St. Louis VA Hit Homerun with Special Therapy Group

Reminiscence therapy has been developed for people with Alzheimer’s disease to stimulate them to talk about their memories.

Therapists show older people with memory problems photographs, old programs and other familiar items, and patients eagerly share pleasant memories from their past experiences. The simple yet innovative

treatment enhances mood and communication skills and may even improve intellectual ability.

A Saint Louis University geriatrician and the act-ing director of the Geriatric Research, Education, and Clinical Center (GRECC) at the St. Louis Veterans Affairs Medical Center (VAMC) are convinced that

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1 It’s a Winner! Cardinals Reminiscence

League

2 News at SLU5 Morley Receives

Prestigious Award

6 SLU Listed in Best Hospitals

6 JAMDA Takes Lead in Impact Factor Ranking

7 Improving Care for Veterans

8 DVD Series Promotes Quality Care

8 Team Based Care for Older Veterans

10 Transitions and Medications

12 Immunosenes-cence

13 Sarcopenia

14 Editorial 15 Dementia with

Agitation17 PTSD in Older

Adults20 The Significance

of Red Flags21 Geriatric Syn-

dromes and Options for Interventions

23 Continuing Education Opportunities

“Golden Apple Award” This year, the Class of 2011 has chosen Andrew J. Lechner, PhD, (pre-clinical) and the Division of Ge-riatric’s own Miguel A. Paniagua, MD, (clinical) to honor for their teaching, mentoring and over-all posi-tive influence during the Class of 2011’s clinical years.

SLU Faculty Named Best DoctorsSeven Saint Louis University faculty were included in the list of Best Doctors in St. Louis. These were Dulce Cruz-Oliver, MD, Joseph H. Flaherty, MD, Julie K. Gammack, MD, Gerald Mahon, MD, John E. Morley, MB, BCh, Miguel A. Paniagua, MD, and David R. Thomas, MD. In addition, three physicians who completed fellowship training with SLU Geriatrics were also included. They were Lakshmi Bandi, MD, Hashim Raza, MD, and Mark Gunby, DO.

Nina Tumosa, PhD, has been named the new Section Editor in Education and Training for the Journal of the American Geriatrics Society (JAGS). Congratulations, Dr. Tumosa!

Dr. Tumosa Assumes New Role

Miguel A. Paniagua, MD, Appointed to the Na-tional Board of Medical Examiners

The National Board of Medical Examiners (NBME) is pleased to announce that Miguel A. Paniagua, MD, was appointed as a member of the National Board of Medical Examiners as a Test Committee Representative.

Dr. Paniagua serves as Associate Professor of Medicine and Director of the Internal Medicine Residency Program at Saint Louis University School of Medi-cine. He has been involved in test development activities at the National Board since 2008.

The NBME is an independent, not-for-profit organization that provides high-quality examinations for the health professions. Protection of the health of the public through state of the art assessment is the mission of the NBME, along with a major commitment to research and development in evaluation and measure-ment. The NBME develops the three-step USMLE®, which provides a common evaluation system for applicants seeking initial licensure to practice medicine in the United States. USMLE® is a joint program of the National Board of Medical Examiners and the Federation of State Medical Boards. Results of USMLE® are reported to individual licensing authorities in the United States and its territories for use in granting the initial license to practice medicine.

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(continued on page 4)

Cardinals Reminiscence League(continued from page 1)

if they build it, fans will come. The two have founded a new support group for Veterans who have dementia that uses baseball to trigger happy memories and engage par-ticipants in socializing. The idea has the backing of the St. Louis Cardinals and the Alzheimer’s Association. “This project provides social interactions for people with memory problems on a topic they can remember well- their love of baseball,” says Nina Tumosa, Ph.D., acting director of the St. Louis VAMC GRECC.

“We’re reaching a group of patients - typically older men - who have trouble so-cializing and maintaining friend-ships. We’ve gotten feedback from caregivers on how engaged and happy their loved ones have been after sessions,” says Tumosa, who also is a professor of geriatrics at Saint Louis University.

“Baseball is a universal lan-guage, particularly for St. Lou-isans,” says John Morley, M.D., a SLUCare geriatrician, Director of Geriatrics at Saint Louis Univer-sity and a dyed-in-the-wool Cardi-nals fan. In launching the therapy group, he borrowed the idea of us-ing sports to engage older adults with memory problems from Deb-bie Tolson, a Scottish nurse and professor at Glasgow Caledonian University who helped develop a similar program reflecting on soccer. Their project had the support of the Scottish Football Museum and Al-zheimer Scotland.

“Many other therapy groups that use happy memo-ries to spark discussions revolve around topics like cooking, movies and old music - subjects that many men may not be so passionate about. In St. Louis, the

Cardinals are such a prominent part of people’s lives and most of us have many fond memories about the Cardinals, making base-ball an ideal topic for reminisc-ing,” adds Dr. Morley.

The effort is embraced by all of the collaborators. Brian Finch, Manager of the Stadium Tours and Museum Outreach at the St. Louis Cardinals Hall of Fame Museum expressed his support of the Cardinals Reminiscence League, saying, “Baseball pro-vides a great narrative for the history of our city, country, and culture. I don’t think I’ve been a part of a more meaningful appli-cation of this concept, especially when you consider the positive benefits of the League to these

Veterans and its impact to them on a daily basis.” He added, “Clearly the League was established to share memories, but it is clearly creating new memories for these Veterans as well. It’s really special to see them respond with vigor to stories and recollections of their colleagues.” Carroll Rodriguez, Chief Operating Of-ficer of the St. Louis chapter of the Alzheimer’s As-sociation said, “The Cardinals Reminiscence League provides stimulation and socialization for people with early memory loss... a fun approach that helps keep people with dementia engaged and focused on a favor-ite pastime, the St. Louis Cardinals.”

SLU Faculty Named Best Doctors

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(continued from page 3)

About 10 Veterans from World War II and the Ko-rean and Vietnam conflicts and nearly as many volun-teers gather every other week for meetings that look as

much like happy hour at a sports bar (sans beer) as a therapy session. They shoot the breeze about Stan ‘the Man’ Musial, Sportsman’s Park, and sweet Lou Brock.

An animated group of Veterans and their caregiv-ers recently came together for the group’s first meeting. After a rousing rendition of “Take Me out to the Ball-game,” where it seemed only a few words got lost, the meeting was underway.

Veterans talked about their war experiences and some baseball connections. One Veteran, who lived next to Sportsman’s Park, reminisced that when the game was over, the players would come over and drink his beer. Another talked about meeting Jack Buck at the race track.

The volunteer coordinators then opened a book of baseball pictures that the Cardinals

have created. Sparked by a pho-to of Stan the Man in his navy uniform, the conversation then focused on one of baseball’s greatest all-time hitters.

“The idea is so simple,” Morley says. “When you get people talking about something they care about, their mood and ability to communicate im-

proves. Mental stimulation is a significant part of therapy for dementia.”

The group took a field trip to Busch Stadium to see sports memorabilia from the St. Louis Cardinals Hall of Fame collection. They talked about an enlarged photo from the 1934 World Champion Gashouse Gang. They then donned white gloves so as to be able to hold the bat used by Stan Musial, a recent Medal of Freedom recipi-ent and himself suffering from Alzheimer’s disease.

The impact of the program is shown by the quote from one of the patient’s sons. “My dad really enjoys the Cardinals Reminiscence League. It is one of the big highlights in his life. I know he would hate to miss this special event.”

The whole program is beautifully summed up by this quote from one of the volunteers: “As a life-long, die-hard Cardinals fan, I was happy to volunteer for the Cardinals Reminiscence League. I knew I could contrib-ute some personal stories and baseball memories. What I didn’t know was the impact I could have on our Veterans in such a short time. Most of them came into the League quietly and a little sad. By the end of the first meeting and throughout the season... they come in earlier and ear-lier each week, with so much anticipation and infectious enthusiasm, and I find not only a dramatic change in the Veterans, but in myself as well.” - Kathy Leonard

Reflecting on sports often brings joy and happy memories for those who have Alzheimer’s disease and their friends and families. To participate or volunteer as a coordinator for the St. Louis’ Cardinals Reminiscence League, call 314-894-6570.

Cardinals Reminiscence League

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(continued on page 22)

Dedicated To Long Term Care Medicine

John Morley, MB, BCh, Receives Award for Educational Excellence

John Morley, MB, BCh, Editor-in-Chief of the Journal of the Amer-ican Medical Directors Association (JAMDA), is the 2011 recipient of the James Pattee Award for Excel-lence in Education from the American Medical Directors Association (AMDA). The Pattee Award recognizes sig-nificant contributions to the educational goals of AMDA and efforts to enhance the associa-tion’s educational struc-ture and framework, It is named after the phy-sician who is considered the father of AMDA’s Core Curriculum in Medical Direction, In 2006, Dr. Morley became JAMDA’s edi-tor. Within a year, the journal was included in Index Medicus, the pres-tigious index of scientif-ic literature. Last year, JAMDA was rated as the 7th most-cited journal in a field of nearly 40 geriatric titles. “Dr. Morley has filled JAMDA’s pages with a sheer determination and the ability to express what long term care practice should be,” said AMDA’s 2010-2011 President Paul Katz, MD, CMD. In presenting the award, he added, “Dr. Morley has talked about JAMDA across the globe and spread AMDA’s message of the beauty of caring for the aged. For many, hearing him speak has been a turning point in their career choice. He has affected many, many people

and singlehandedly elevated the stat-ure of long term care physicians with every page and every word,”

Since 1989, Dr. Morley has been the Dammert Professor of Geron-

tology and Director, Division of Geriatric Medicine at Saint Louis University Medical Center. In addi-tion, he is medical director of three nursing facilities.

“Any award comes to you be-cause those around you have given you the opportunity to do things for others,” said Dr. Morley in ac-cepting the award. He talked about how Dr. Pattee first introduced him to geriatrics and got him involved in teaching for AMDA’s Core Cur-riculum in Medical Direction. He thanked many of his colleagues, including Charles Marshall, MD, of

whom he said, “Someday I hope I have a physician who cares for me as much as he does about his patients.” Dr. Morley spoke of his experiences attending AMDA’s annual conven-

tion, Long Term Care Medicine, saying, “I have been coming here for 21 years. It teaches about caring for our elder patients more than any other organization or meeting.”

Board certified in inter-nal medicine, endocrinol-ogy, and geriatric medicine. Dr, Morley has edited 16 books, including Medical Care in the Nursing Home, Geriatric Nutrition, and Endocrinology of Aging. He has published more than 800 papers, with a major

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The Journal of the American Medi-cal Directors Association (JAMDA) had a marked increase in its Impact Factor to 4.49 for 2010. This gives it the highest impact factor for a clinical geriatric journal (see box). The Journal is edited out of Saint Louis University with John Morley as the editor. Julie Gammack and David Thomas serve as associate editors, and Valerie Tanner is the managing editor.

Impact Factors of Clinical Geriatric JournalsJAMDA 4.492J Gerontol Biol Med Sci 3.988JAGS 3.913Am J Geriatr Psychiat 3.566Age Aging 2.719Drug Aging 2.656J Nutr Health Aging 2.393

JAMDA Leads Impact Factor

Services of the Division of Geriatric Medicine at Saint Louis University

Medical Center include clinics

in the following areas:

Aging and Developmental Disabilities

Bone Metabolism

Falls: Assessment and Prevention

General Geriatric Assessment

Geriatric Diabetes

Medication Reduction

Menopause

Nutrition

Podiatry

Rheumatology

Sexual Dysfunction

Urinary Incontinence

Call for an appointment

314-977-6055(at Saint Louis University)

or314-966-9313

(at Des Peres Hospital)

SERVICES

Saint Louis University Hospital Again in US News & World Report List of Best Geriatric Hospitals

Once again, US News & World Report ranked Saint Louis University Hospital as one of the best geriatric hospitals in the United States. This is the fourteenth year that Saint Louis University has been included in this ranking.

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Improving Care for Veterans in Rural Clinics Across the Nation By Josea Kramer, PhD

(continued on page 22)

A national VA in-service educa-tion program is leading the way to quality improvements in its rural community-based outpatient clinics (CBOC) across the United States. The “Geriatrics Scholars Program” offers state-of-the-art education in geriatrics to primary care providers, social workers, and pharmacists. The program culminates with each

Scholar initiating a quality im-provement project to improve care for the older Veterans in his or her clinic. Eleven of these quality im-provement projects were on display at the annual VA Geriatrics and Extended Care “Leads” conference this spring.

These innovative improvements were designed and implemented entirely in the rural clinics. The projects addressed seven common issues: medication reconcilia-tion, fall prevention, screening for age-related health problems, life planning, reducing morbidity and mortality related to poor dental hygiene, and improving process of care in home based primary care and in timely processing of labora-tory work. Each Scholar received personalized coaching in the qual-ity improvement process from the VA National Quality Scholars Pro-

gram and from the Tennessee Val-ley Geriatric Research Education and Clinical Center (GRECC). The GRECCs are centers of excellence dedicated to advancing knowledge and improving care for older Veter-ans.

The director of the Geriatric Scholars Program, Dr. Josea Kram-er from the VA Greater Los Ange-les GRECC, explained that these presentations to thought-leaders demonstrate effective approaches to problems faced in many clinics and may stimulate similar improve-ments in other VA settings. While addressing common problems, each project took a unique approach. For instance, medication reconciliation was part of a strategy to improve adherence at Rutherford, NC, and was part of the discharge planning process for staff at Fallon, NV. The projects included the typical clinic setting as well as home-based pri-mary care. For example, staff at the clinic at Tulare, CA, initiated screening for cognitive impairment among all older patients, finding that this common syndrome had

been under-identified among clinic patients. Staff from home-based programs at Mt. Vernon, MO, and Montrose, NY, initiated fall assess-ments and interventions reducing falls among home-bound patients. Some projects streamlined VA pro-cesses to improve patient care such as timely processing of laboratory orders at Peru, IL, or improvements to home-based primary care at Mis-soula, Anaconda, and Bozeman, MT, and at Grand Island and North Platte, NE. Screening processes were improved for diabetes in Clarksville, TN, and for depression and dementia as part of life planning at Morehead City, NJ. Scholars in Grand Island, NE, created a referral system to streamline the process of connecting Veterans to local dental resources. That project was so suc-cessful that a local on-line newspa-per carried a story describing the happy life-changing experience on one Veteran.

Forty percent of Veterans live in rural areas. In these areas, older adults are particularly vulnerable to

40% of veterans live in

rural areas

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TEAM-BASED CARE FoR oLDER VETERANS

DVD Series Promotes Quality Care The Veterans Health Administration in cooperation with Saint Louis University has produced a series of five instructional DVDs to pro-mote quality care for Veterans. The titles of the DVDs are:

• Team-Based Care for Older Veterans • Agitated Behaviors • PTSD in Older Veterans • Discharge & Medications • Delirium: Quiet & Excited/Dementia with Agitation

An overview of the five topics covered in this series is included in this issue. These articles are designed to educate providers about why these training videos are important. To obtain a set of the DVD series, contact Dr. Nina Tumosa at [email protected].

Teams are the key to provid-ing high qual-

ity geriatric care(1,

2). Normally these healthcare teams consist of small groups of persons with complementary skills which allow the team to work synergistically to

solve problems that individuals could not solve alone. The goals of the team are listed in Table 1.

Good teams do not spring into perfect existence just because they are needed. It takes training to cre-ate a functional team and it takes even more training to keep a team functional. The American Geriat-rics Society Partnership for Health in Aging has recently posted a po-sition statement(3) that succinctly states why team based training is important in geriatrics. Table 2 lists training goals in the position statement for interdisciplinary team

TABLE 1: GOALS OF THE HEALTH- CArE TEAM • Improve patient function or main-tain maximum patient indepen-dence

• Enhance patient well-being • Increase patient satisfaction • reduce use of hospital services • Optimize the work satisfaction of all team members

training. Many factors are necessary for successful inter-

disciplinary training. They include acceptance of the necessity of interdisciplinary teams(9), enthusiastic participation of all disciplines(9), effective modeling and mentoring of interdisciplinary teamwork(3) and recognition that the teams differ across care settings(3).

Using adult learning principles which promote multi-faceted educational approaches, such as prac-tice-based tools, quality improvement data, and using opinion leaders to influence practice behaviors, have the most success in effecting practice changes(10, 11, 12,

13) such as the acceptance and adoption of the use of in-terdisciplinary team-based care. Teams need to show

that they make a difference to the bottom line, they need advocates to promote their use and they need constant vigilance to ensure that they remain effective. Sometimes teams need a good example to edu-cate newcomers and to encourage participants. Should your institu-tion require such an example, the Team Based Care for Older Veter-ans DVD provides a brief (22-min-ute) example of what can go wrong if care is not coordinated and how

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TABLE 2: TrAINING GOALS1. Understand their respec-

tive roles and responsibili-ties on the team

2. Establish common goals for the team

3. Agree on rules for conduct-ing team meetings

4. Communicate well with other members of the team

5. Identify and resolve con-flict

6. Share decision-making and execute defined tasks when consensus is reached

7. Provide support for one an-other, including the devel-opment of leadership roles

8. Be flexible in response to changing circumstances

9. Participate in periodic team performance reviews to ensure that the team is functioning well and that its goals are being met ( 4, 5,

6,7, 8).

a team approach can make a dif-ference. The Red Flags and Geriatric Syn-dromes that a good team looks for in anticipa-tion of a prob-lem and reacts quickly to avert a disaster are listed on pages 20-21.

RefeRences1. Boult C, Green AF,

Boult LB, et al. Suc-cessful models of comprehensive care for older adults with chronic conditions: evidence for the In-stitute of medicine’s “retooling for an ag-ing America” report. J Am Geriatr Soc. 57:2328-37; 2009.

2. Morley JE, Tumosa, N. Geriatrics is a Team Sport. Aging Successfully XVI (5), 1-6, 2005.

3. American Geriatrics Society Partnership for Health in Aging. Po-sition Statement on Interdisciplinary Team Training. http://www.americangeriatrics.org/pha/partnership_for_health_in_aging/interdisciplinary_team_training_statement/introduction.

4. Clark PG, Leinhaas MM, Filinson R. Developing and evaluat-ing an interdisciplinary clinical team training program: Lessons taught and lessons learned. Educ Gerontol 2002;28:491-510.

5. Medical Team Training: Strategies for Improving Patient Care and Communication. Joint Commission Resources. Oakbrook Terrace, IL. 2008:67-76. ISBN: 978-1-59940-092-1.

6. Katzenbach J, Smith D. The Wisdom of Teams: Creating the High Performance Organization. McKinsey & Co; 2003. HarperCollins Publishers, Inc. New York, NY.

7. West M. Effective Teamwork: Practical Lessons from Organiza-tional Research. 2nd ed. BPS Blackwell; 2004.

8. Mellor MJ, Hyer K, Howe JL. The geriatric interdisciplinary team approach: Challenges and opportunities in educating trainees to-gether from a variety of disciplines. Educ Gerontol 2002; 28:867-880.

9. Reuben DB, Levy-Storms L, Yee MN, et al. Disciplinary Split: A threat to geriatrics interdisciplinary team training. J AM Geriat Soc . 52: 1000-0; 2004,

10. Bradley EH, Holmboe ES, Mattera JA, et al. Data feed-back efforts in quality improvement: Lessons learned from U.S. hospitals. Quality and Safety in Health Care, 13, 26-31; 2004.

11. Gifford DR, Holloway RG, Frankel MR, et al. Improving adherence to dementia guidelines through education and opinion leaders: A randomized, controlled trial. Annals of Internal Medicine, 131, 237-246; 1999.

12. Grol, R, Grimshaw J. From best evidence to best prac-tice: Effective implementation of change in patients’ care. The Lancet, 362, 1225-1230; 2003.

13. Vickrey B. Effective strategies for changing physicians’ behavior: Insights from research on diffusion of innova-tions. Clinical Gerontologist, 29(2), 25-34; 2005.

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TRANSITIoNS AND MEDICATIoNS

On returning home, pa-tients often resume home medications in addition to

those prescribed in hospital or in place of those that were changed in hospital. Similarly, on entering a hospital, a patient is often restarted on the list of home medications, despite the fact that the patient has been non-compliant at home. This can lead to disasters such as when a physician has been increasing a patient’s hypertensive medicines but the patient has not been tak-ing the medicines. This failure of physician-patient communication can lead to a major hypotensive episode when medications are re-started in hospital.

Polypharmacy has become a way of life for senior citizens. This is despite excellent studies demonstrating that as the number of drugs increase, there is an ex-

good or bad indication for the medicine.

Drugs are one of the primary causes of falls. Antipsychotic medicines lead to increased mortality, hip fractures, and aspiration pneumonia, and rarely are useful in treating aggressive behaviors. The combination of anticholinergic medi-cines and cholinesterase inhibitors is nonsensical. In persons over 80 years of age, there is no evidence for the use of statins and in the younger elderly, benefit is only seen in persons with clear atherosclerotic dis-ease. Thus, a key to medi-cation reconciliation during transitions is to question whether the medicine is indicated.

To improve transitions, the fol-lowing are essential:

Hospital Physician and Health Professionals:

• Review medicines that the pa-tient was taking in hospital and discontinue any that are no lon-ger necessary.

• Check for medicines that negate one another’s effect or alter me-tabolism of one another.

• Provide the patient with a typed list of medications with clear indications of dose and the time to be taken. For example, make sure the patient understands that neither calcium nor iron can be taken with other medi-cines.

• Explain to the patient that he/she should not resume home medicines.

• Discourage the patient from taking over-the-counter medi-

(continued on next page)

ponential increase in the number of side effects. Stephen Fitzgerald2, using mathematical modeling has shown that more than five medications in older, frail individuals is associated with a marked increase in drug-induced side ef-fects. This is true no matter whether the patient has a

One in five persons discharged from the hos-pital to home has an adverse event1. The vast majority of these adverse events are due to medication problems.

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cines including vitamins, be-fore discussing this with his/her health provider.

• Make sure the patient has all questions answered.

• Make sure an adequate follow-up with a healthcare provider is in place and communicate the medicine list and hospital nurs-ing home course to the primary care provider.

Patient: • Make sure before leaving the hospital that there is under-standing about how medicines have been changed.

• Keep a list of your medicines and check when home that you are taking them. If you have cognitive problems or depres-sion, have someone else with

you when you are discharged and have them help you set up both new and old medicines in a pill box for each day.

• Do NOT resume home medi-cines unless they are on the list.

• Make sure you have all of the prescriptions necessary before leaving the hospital.

• Know who to contact if you have questions.

• Take a copy of your new medi-cation list when you go to see your health care provider. Ide-ally, bring all of the medicines you are taking, as well.

• Do not take over-the-counter medications or vitamins with-out discussing them with your health care provider.

• Ask the physician on discharge if any of the medicines can be

replaced by those costing $4 per month instead of the more expensive ones prescribed.

Transitions can be very dan-gerous3. It is incumbent on both the health care provider, patient, and carers to do everything they can to reduce medication-induced risks.

RefeRences

1. Forster AJ, Murff HJ, Peterson JF, et al. The incidence and severity of adverse events affecting patients after discharge from the hospital. Ann Intern Med 138:161-7; 2003.

2. Fitzgerald S, Bean NC. An analysis of the interactions between individual comor-bidities and their treatments – implica-tions for guidelines and polypharmacy. J Am Med Dir Assoc 11:475-84; 2010.

3. Morley JE. Transitions (editorial). J Am Med Dir Assoc 11: 607-11;2010.

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Physiology of Aging: immunosenescence

Cell-Mediated Immunity: ► Host defense against infection (virus, fungi, TB) ► Graft and Tumor rejection ► regulation of antibody response

Aging T Cells • Naïve T cells ► Decreased numbers (age related involution of

thymus) ► Shorter Telomeres ► restricted T cell receptor repertoire/decreased

diversity (decreased ability to respond to new antigen.)

► Impaired expansion and differentiation into effector cells:

Humoral Immunity ► Host defense against infection (op-

sonize bacteria, neutralize toxin and viruses)

► Autoimmunity

Adaptive Immunity: Specific

Innate Immunity: Non-Specific• Decreased function of epithelial barriers of the skin, lung or gastrointestinal tract enables pathogens

to invade mucosal tissues, presenting an increased challenge to the aging immune system…• Elevations of IL-6, IL-1B, TNF-A are seen in elderly patients, creating subclinical chronic

inflammation…Inflamm-aging! – possibly caused by partial inability of aging immune system to eliminate pathogens.

• Chronic inflammation is thought to contribute to age-related disorders: cancer, autoimmune disorders, neurodegeneration, and atherosclerosis.

CD4 T Helper(Inhibit intracellular bacteria/fungi)*Decreased regulatory control

& stimulation of B cells*reduced IL-2 production*Increased numbers memory

CD8 Cytotoxic T(Kill virus-infected cellsand tumor cells*Decreased proliferation*Produce cytokines*Increased #/clones*Loss of CD28

Aging B Cells (Neutralizes toxins and viruses; kills extracellular, encapsulated organisms)

► Peripheral B cell numbers do not decline with age. ► Increased number of antigen-experienced

memory B cells, with decreased apoptosis, accumulate in elderly

► Decreased naïve B cells ► Serum immunoglobulin levels are stable in aging ► Shift in antibody isotypes from IgG to IgM, with

lower affinity. ► Stimulated 70% less efficiently by dendritic

cells than B cells in young subjects ► Decreased B cell expansion and antibody

production.

12 Aging Successfully, Vol. XXI, No. 2 email: [email protected] Questions? FAX: 314-771-8575

Macrophages • Initiate inflammatory response

• Eliminate pathogens • regulate adaptive im-munity

• repair damaged tissue

Decreased: • Oxidative burst • Phagocytic capacity • Precursors in marrow • Macrophage derived chemokines (MIP, eotaxin)

Not affected:*Numbers

NK Cells • Play a major role in the MHC recognition of virally-infected cells and in rejection of tumor cells

Decreased: • Cytotoxicity • Proliferation

Increased: • Numbers

Not affected:*TNF production*Perforin synthesis

Neutrophils • Defense of bacterial and fungal infections in acute inflammation

Decreased: • Oxidative burst • Phagocytic activity • Bactericidal activity

Not affected:*Numbers*Chemotaxis*Adhesion

*phagocytosis of Unopsonized bacteria

Dendritic Cells • Link innate and adap-tive immune system; by initiating immune response, secreting cytokines, APC

Decreased: • Capacity to stimulate antigen specific T cells

• Lymph node homing • Update of antigen • Phagocytosis of apop-totic cells (contrib. to inflammaging)

• Migration

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12 Aging Successfully, Vol. XXI, No. 2 email: [email protected] Questions? FAX: 314-771-8575

Two physIoLogIc EvENTs LEAD To DEcrEAsED muscLE mAss:1. increased catabolism

a. reduced activity of alkaline phosphatase indicates damage or disruption to the sarcolemma

b. Elevated levels of acid phosphatase indicate lysosome degradation

c. possibly from an increase in IL-1 and IL-62. Decreased anabolism

a. Largely from hormonal factorsb. reduced growth hormone, insulin-like growth factor,

estrogen and testosteronec. “Anorexia of aging” leads to a decrease in protein intake

sARcoPeniA of Aging

Aging changes the number and type of muscle fibers.Type I fibers: Red, oxidative fibers Slow-twitch, slow fatiguability Antigravity and tonic contraction Increased with aging

Type II fibers: White, glycolytic fibers Fast twitch, rapid fatigue Coordination-related and phasic contraction reduced with aging

Other factors associated with age-related muscle changes:

► Krebs cycle enzymes decline leading to a decrease in ATP and Creatine phosphate ► Changes in ion content, especially Ca2+

► Increase in oxidative damage

NutritionalHormonalMetabolicImmunologicFactors

↓ Motor Units ↓ Muscle Fibers

Muscle Fiber Atrophy

Physical Activity

↓ muscle mass ↓ muscle strength

Weakness Decreased Mobility

Adapted from Doherty TJ. Invited Review: Aging and Sarcopenia. J Appl Physiol 2003;95:1717-27.

sARcoPeniA

Disability and Loss of Independence

DefiniTion: Sarcopenia (Greek, literally means “poverty of flesh”) is the loss of skeletal muscle mass and function that occurs with aging. muscle weakness can lead to falls and loss of independence

ClINICAl PeArlS

Men have significantly greater muscle mass but have greater losses with aging than women. Physical inactivity is a significant contributor to sarcopenia. Resistance exercise increases strength and mass in

all age groups, even the frail elderly > 90 yrs old.

Fig. 1. General causes of muscle aging. Adapted from Carmeli E, et al. The biochemistry of aging muscle. Experimental Gerontology 2002, 37(4):477-489.

INTRINSIC FACTORSleading to sarcopenia of old age

Reduced metabolism, slowdown of protein synthesis and turnover

Reduction of enzymatic activities and energy reserves

Decreased mitrochondrial functionRole of oxidative stress

Changes in CNS functioning and neural stimulation

Changes in hormonal secretion and regulation. Reduction in blood supply and capillary beds.

EXTRINSIC FACTORSleading to sarcopenia of old age

MALNUTRITION

INADEQUATE EXERCISE

DISUSE ATROPHy, LIMB IMMOBILIzATION

TRAUMATIC INJURIES

DISEASES, DRUGS

{

Questions? FAX: 314-771-8575 email: [email protected] Aging Successfully, Vol. XXI, No. 2 13

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14 Aging Successfully, Vol. XXI, No. 2 email: [email protected] Questions? FAX: 314-771-8575

EditorialThe International Association

of Gerontology and Geriat-rics (IAGG) together with the

World Health Organization have recently released a position paper on the future of nursing homes world-wide and was written about in the Journal of the American Medi-cal Directors Association1. The main message was that with the rapid ag-ing of the population in both devel-oping and developed nations, there is a need to increase the quality of nursing homes and the individuals who work in them.

The paper stressed how im-portant nursing homes were for the care of the vulnerable elderly. It called for increased reimburse-ment for the primary caregivers who work in the nursing home. There was also a perceived need to increase research into how to deliver the highest quality care in nursing homes. It was strongly recommended that, before drugs were released on the market, they should be tested in nursing homes

to demonstrate their safety in the frail elderly.

A strong recommendation was to enhance the education available for health professionals working in the nursing home. To this end, the IAGG has developed a certificate course to provide state-of-the-art education on nursing homes. The first two of these certificate courses were held in Hong Kong and Cheng-du, China, in May this year. Both were highly successful2.

It is exciting that, at long last, major organizations are starting to recognize the impor-tance of nursing homes for the care of older persons. Professor Bruno Vellas, from Toulouse, France, needs to be especially congratulated for his leadership in this area.

John E. Morley, MB, BCh

RefeRences1 Morley JE. AMDA - A leader in

developing international long-term care. J Am Med Dir Assoc 12(5):319-20, 2011.

2 http://www.iagg.info/news-under-iagg-auspices

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14 Aging Successfully, Vol. XXI, No. 2 email: [email protected] Questions? FAX: 314-771-8575 Questions? FAX: 314-771-8575 email: [email protected] Aging Successfully, Vol. XXI, No. 2 15

DEMENTIA WITH AGITATIoN

Agitation can vary in its pre-sentation from excessive wandering and verbal ag-

gression to physical aggression. The first component to managing agita-tion is to understand its precedents. What caused the person to become agitated? For example, did a nurse approach the patient from behind or in a way that could be considered threatening? Does the patient have unresolved pain? Has the patient had a history of being easily an-gered or violent before becoming demented? Do the episodes occur at certain times of the day, e.g., sun-downing, or in relationship to the meal, e.g., hypoglycemia, hunger, or postprandial hypotension? Is there any evidence that the person has a condition that is triggering delirium? If the person is scream-ing, is s/he depressed or afraid? Are there environmental stimuli to trig-ger the agitation, e.g., poor lighting, shadows, pictures, television, or radio?

Just as in every day life, when you or your friends or family get angry, there is often a trigger from other persons that sets off the agi-tation. So the first approach to the management of agitation is to pro-vide caregiver education. Much of

agitation is precipitated unin-tentionally by carers. Helping

the carers to understand their be-haviors that are creating the agita-tion is key. The carer also needs to be taught to keep an appropriate distance and learn how to tolerate many behaviors that are annoying but not dangerous to anyone.

Social stimuli are associated with less agitated behaviors1. Task-orientated and reading stimuli are more calming than music stimuli. Manipulative stimuli are most likely to precipitate agitation. In general, many psychotherapeu-tics can calm the agitated person with dementia but evidence for lasting e f f e c t s is lim-ited. One study has sugge s t e d that, over the short term, Therapeu-tic touch may be calming2. In the CALM-AD trial, a brief psycho-social therapy for 4 weeks reduced agitation3. Multisensory stimulation (Snoezelen) has its advocates but limited evidence of effectiveness. The existence of a psychosocial intervention program may be of

more importance than the specific program. These programs may be more useful in improving staff sat-isfaction and therefore tolerance of agitated behaviors.

The more physically active de-mented persons are, the less likely they are to become agitated4. A number of exercise trials, usually lasting for 30 minutes three times per week, have led to a decrease in agitation5.

There is amazingly little data to support the wide range of medi-

cations utilized to decrease agitation. Valproate is widely used to treat agitation, yet the Cochrane meta-analysis found that valproate was ineffec-

tive for agitation in persons with dementia6. Haloperidol was also

ineffective at reducing agi-tation7. High dos-

es (>2mg/

d a y ) may have reduced aggression but with the trade off of increased side effects. Resperidone and olanzapine modestly improved aggression but were associated with serious side effects including stroke and extra-

(continued on page 16)

Agitation in a demented person is a ma-jor problem to deal with for caregivers in hospitals, nursing homes, and at home. It often results in inappropriate knee-jerk responses from health care providers.

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16 Aging Successfully, Vol. XXI, No. 2 email: [email protected] Questions? FAX: 314-771-8575

Are you looking for a past issue of

Aging Successfully? Maybe an article

on a particular topic? Or a screening tool?

Ideas for living longer and living stronger? Upcoming continuing medical

education opportunities?

Visithttp://aging.slu.edu

orhttp://www.stlouis.va.gov/GrECC/education.asp

They have what you’re missing. Everything you need is right there.

View it onscreen. Download it.Use it. Go ahead.

Take advantage of it!

pyramidal side effects8. The Food and Drug Administration found that when atypical neuroleptics were used for treating behavioral symptoms in persons with dementia, there was a significant increase in mortality.

The best treatments for agitated behavior in dementia appear to be psychosocial and exercise therapy. On the whole, drugs should be avoided. Two studies have suggested that SSRIs may reduce agitation. There is inadequate data for the use of trazodone. While we occasionally use low-dose lorazepam, no studies are available to support its use. Two DVDs offer examples for managing behaviors in the nursing home and in hospital (Agitated Behaviors) and at home (Delirium: Quiet and Excited/Dementia with Agitation).RefeRences

1 Cohen-Mansfield J, Marx MS, Dakheel-Ali M, et al. Can agitated behavior of nursing home residents with dementia be prevented with the use of standardized stimuli? J Am Geriatr Soc 58(8):1459-64; 2010.

2 Woods DL, Beck C, Sinha K. The effect of therapeutic touch on behavioral symptoms and cortisol in persons with dementia. Forsch Komplementmed 16(3): 181-9; 2009.

3 Ballard C, Brown R, Fossey J, et al. Brief psy-chosocial therapy for the treatment of agitation in Alzheimer disease (the CALM-AD trial). Am J Geriatr Psychiatry 17(9): 726-33; 2009.

4 Scherder EJ, Bogen T, Eggemont LH, et al. The more physical inactivity, the more agitation in dementia. Int Psychogeriatr 22(8): 1203-8; 2010.

5 Aman E, Thomas DR. Supervised exercise to reduce agitation in severely cognitively impaired persons. J Am Med Dir Assoc 10(4):

Dementia with Agitation(continued from page 15)

271-6; 2009.6 Lonergan E, Luxenberg J. Valproate

preparations for agitation in demen-tia. Cochrane Database Syst Rev 8(3):CD003945; 2009.

7 Londergan E, Luxemberg J, Colford J. Haloperidol for agitation in de-mentia. Cochrane Database Syst Rev (4):CD002852; 2001.

8 Ballard C, Waite J. The effectiveness of atypical antipsychotics for the treat-ment of aggression and psychosis in Alzheimer’s disease. Cochrane Data-base Syst Rev 25(1); CD003476; 2006.

1 Aging Successfully, Vol. XXI, No. 2 email: [email protected] Questions? FAX: 314-771-8575 Questions? FAX: 314-771-8575 email: [email protected] Aging Successfully, Vol. XXI, No. 2 1

Fall 2011

Vol. XXI, No. 2

(continued on page 3)

It’s a Winner!Treating Dementia with Baseball Memories

SLU, St. Louis VA Hits a Homerun with Special Therapy Group

Reminiscence therapy has been developed

for people with Alzheimer’s disease to

stimulate them to talk about their memories.

Therapists show older people with memory problems

photographs, old programs and other familiar items,

and patients eagerly share pleasant memories from

their past experiences. The simple yet innovative

treatment enhances mood and communication skills

and may even improve intellectual ability.

A Saint Louis University geriatrician and the act-

ing director of a St. Louis Veterans Affairs Medical

Center geriatrics organization are convinced that if

they build it, fans will come. The two have founded a

1 Aging Successfully, Vol. XIX, No. 1 email: [email protected] Questions? FAX: 314-771-8575 Questions? FAX: 314-771-8575 email: [email protected] Aging Successfully, Vol. XIX, No. 1 1

Spring 2009Vol. XIX, No. 1

(continued on page 4)

The ABCD’s of End-Of-Life Care for People With DementiaBy John T. Chibnall Ph.D., Nina Tumosa Ph.D., and Abhilash K. Desai M.D. “Life in the shadows of death

can be immensely rewarding

and fulfilling.” — Myles N. Sheehan, S.J., M.D.

Death and dying are common issues in caring for per-sons with advanced dementia. Yet, end-of-life care is not a concept that immediately comes to mind as a priority with respect to dementia. There are a number of reasons for this observation. For example, the National Center for Health Statistics currently lists Alzheimer’s disease as the fifth leading cause of death in the U.S. in people older than 65, and seventh overall. As compelling as these statistics may ap-pear, new research data suggest that they may actu-ally be underestimated. This underestimation may be tied to the fact that health care professionals, as well as people in the community, often do not recognize

1 Aging Successfully, Vol. XX, No. 1 email: [email protected] Questions? FAX: 314-771-8575 Questions? FAX: 314-771-8575 email: [email protected] Aging Successfully, Vol. XX, No. 1 1

Spring 2010Vol. XX, No. 1

(continued on page 4)

“Fatigue makes cowards of us all.” - Vince Lombardi

1 Aging Successfully, Vol. XVIII, No. 1 email: [email protected] Questions? FAX: 314-771-8575 Questions? FAX: 314-771-8575 email: [email protected] Aging Successfully, Vol. XVIII, No. 1 1

Spring 2008Vol. XVIII, No. 1

(continued on page 4)

and aging

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16 Aging Successfully, Vol. XXI, No. 2 email: [email protected] Questions? FAX: 314-771-8575 Questions? FAX: 314-771-8575 email: [email protected] Aging Successfully, Vol. XXI, No. 2 17

Symptoms of PTSD MnemonicP aranoia (feeling cut off or super watchful)T houghts or images of stressful eventsS leep disturbances (nightmares, insomnia)D eath wishes

PTSD and 54% for past PTSD4. PTSD occurs in 12% of Veter-ans in nursing homes5.

Late onset stress symptom-atology (LOSS) in Veterans who have been exposed to combat is relatively rare, though oc-currence of nightmares about

war is not uncommon6. For most Veterans, symptoms are

h i g h e s t

i m m e d i a t e l y following dis-charge, then de-crease for several

decades only for symp-toms to increase in late life2,7. PTSD symptoms may increase in the last month of life8. Ac-cording to family members,

these symptoms are more dis-tressful than dyspnea but less stressful than pain.

PTSD has three major symptom areas. These are re-experiencing, avoidance, and hyperarousal. Re-experiencing focuses on intensive recall of traumatic experiences, sleep disturbances, and combat-relat-ed nightmares, often associated

with anxiety. Avoidance includes feelings of being

threatened in crowds, feelings of detachment from others, and a numbing feeling (decreased affect). Hyperarousal includes

Post-traumatic stress disorder (PTSD) has, in recent years, been widely recognized as a major problem in younger Veterans re-turning home from combat zones. Recent-ly, there has been an increased recognition that PTSD may persist throughout life and symptoms may worsen in late life.

(continued on page 18)

PTSD IN oLDER VETERANS

In a survey of over 17,000 Veterans aged 65 or older, 12% experienced symp-

toms of PTSD1. Rates of PTSD are higher in ethnic minorities. Among soldiers who had been prisoners of war, the rate of PTSD was 16.6%2. This higher rate was due to an extremely high rate of PTSD (34%) in those taken prisoner of war

in the Pacific theater. Women who have had a

military sexual trauma episode are particularly vulnerable to PTSD and it occurs at a higher rate than in those experiencing a civilian sexual trauma3. In the civilian population, women are more likely to experience PTSD (10.4%) than men (5%)3, but this sexual differ-ence is reversed in the Veteran population.

In patients admit-ted for another mental health problem to a psy-chogeriatric ward, 27% met criteria for current

general hyperalertness, irritability, anger, ag-

gression, and an exaggerated startle response. In nursing home residents with PTSD, anger, i r r i t a b i l i t y , and aggressive

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18 Aging Successfully, Vol. XXI, No. 2 email: [email protected] Questions? FAX: 314-771-8575

disorders have been reported in 47% of patients9. Symptoms increase with the number of traumatic episodes. Depression is not necessarily more com-mon in persons with PTSD10. In a large Veterans Administra-tion study1, persons wth PTSD reported more poor health, were more likely to smoke and drink excessively, and to be divorced, reported limited social support, and had a high prevalence of mental distress, death wishes, and suicidal ideation.

Table 1. Veterans Administration Screening Test for PTSD

1. Some people have had terrible experiences that others never go through such as

• Being attacked • Being sexually assaulted or raped • Being in a fire or flood or natural disaster • Being in combat • Being in a bad accident • Being threatened with a weapon • Seeing someone being badly injured or killed

Did any of these things happen to you? YES (continue) NO (stop)

2. In the past month, have you been bothered by repeated, disturbing memories, thoughts, or images of one or more of the stressful events you experienced above? YES NO

3. In the past month, have you felt distant or cut off from other people? YES NO

4. In the past month, have you been super alert, or watchful, or on guard? YES NO

PTSD IN oLDER VETERANS(continued from page 17)

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18 Aging Successfully, Vol. XXI, No. 2 email: [email protected] Questions? FAX: 314-771-8575 Questions? FAX: 314-771-8575 email: [email protected] Aging Successfully, Vol. XXI, No. 2 19

Table 1 provides a Veterans Administration screening test for PTSD. A simple mnemonic for remembering the symptoms of PTSD is shown on page 16.

The treatment of choice for PTSD is Cognitive Behavioral Therapy (CBT)11. This requires learning to recognize distress-ful thoughts and replacing them with more pleasant thoughts. Exposure therapy is a form of CBT that includes allowing PTSD victims to re-experience distressing trauma related memories. Eye movement de-sensitization and reprocessing is a specific, successful therapy for PTSD. In general, it is CBT with the addition of and focus on eye movements.

Diverse psychotropic medi-cations have been used to treat PTSD in Veterans12, 13. Selective serotonin reuptake inhibitors have been most used for PTSD. Bupropion and Venlafaxine have been reported to have the

lowest drop-out rates. Trazo-done helps with sleep and anger and agitation. Prazosin reduced nightmares in combat Veter-ans, but its hypotensive effect should limit its use in older persons. Topiramate may have a role in reducing f lashbacks and nightmares. Beta blockers, e.g., atenolol or propanolol, possibly reduce hyperarousal symptoms. Zolpidem can be used for sleep disturbances. Lorazepam can be utilized to treat anxiety. In older persons, medication use should be limited to avoid poly-pharmacy.

Finally, engagement in exer-cise therapy has multiple bene-fits in older persons with PTSD, including socialization, reduc-tion of dysphoria, and improve-ment in physical condition.

RefeRences1 Durai UNB, Chopra MP, Coakley E, et al. Exposure to trauma and posttraumatic stress disorder symptoms in older Vet-erans attending primary care: Comorbid

PTSD IN oLDER VETERANS(continued from page 18)

conditions and self-rated health status. J Am Geriatr Soc 59:1087-92; 2011.2 Rintamaki LS, Weaver FM, Elbaum PL, et al. Persistence of traumatic memories in World War II prisoners of war. J Am Geriatr Soc 57:2257-62; 2009.3 Himmelfarb N, Yaeger D, Mintz J. Posttraumatic stress disorder in female veterans with military and civilian sexual trauma. J Trauma Stress 19:837-46; 2006. 4 Rosen J, Fields RB, Hand AM, et al. Concurrent posttraumatic stress disorder in psychogeriatric patients. J Geriatr Psy-chiatry Neurol 2:65-9; 1989.5 Lemke SP, Schaefer JA. Recent changes in the prevalence of psychiatric disorders among VA nursing home residents. Psy-chiatr Serv 61(4);356-64; 2010.6 King LA, King DW, Vickers K, et al. Assessing late-onset stress symptomatol-ogy among aging male combat veterans. Aging Ment Health 11:175-91; 2007.7 Port CL, Engdahl B, Frazier P. A lon-gitudinal and retrospective study of PTSD among older prisoners of war. Am J Psy-chiatry 158:1474-9; 2001.8 Alici Y, Smith D, Lu HL, et al. Families’perceptions of veterans’ distress due to post-traumatic stress disorder-related symptoms at the end of life. J Pain Symptom Manage 39:507-14; 2010.9 Hart J Jr, Kimbrell T, Fauver P, et al. Cognitive dysfunctions associated with PTSD: evidence from World War II pris-oners of war. J Neurospychiatry Clin Neu-rosci 20:309-16. 2008.10 Schnurr PP, Spiro A 3rd, Aldwin CM, et al. Physical symptom trajectories fol-lowing trauma exposure; longitudinal f indings from the normative aging study. J Nerv Ment Dis 186:522-8; 1998.11 Kar N. Cognitive behavioral therapy for the treatment of post-traumatic stress disorder: a review. Neuropsychiatr Dis Treat 7:167-81; 2011.12 Mohamed S, Rosenheck R. Pharmaco-therapy for older veterans diagnoses with posttraumatic stress disorder in Veterans Administration. Am J Geriatr Psychiatry 16:804-12; 2008.13 Alderman CP, McCarthy LC, Condon JY, et al. Topiramate in combat-related posttraumatic stress disorder. Ann Phar-macother 43:635-41; 2009.14 Rosenbaum S, Nguyen D, Lenehan T, et al. Exercise augmentation compared to usual care for Post-Traumatic Stress Disorder: A Randomised Controlled Trial (The REAP study: Randomised Exercise Augmentation for PTSD). BMC Psychia-try 11: 115; 2011. doi: 10.1186/1471-244X-11-115.

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20 Aging Successfully, Vol. XXI, No. 2 email: [email protected] Questions? FAX: 314-771-8575

� Hospitalization

�Late for appointment

� Walks slowly to waiting room

�“I don’t know” or other short answers by patients

� “We haven’t been doing so well”

�Falls

� New medications

�Confusion in hospital

� Dizziness

• Loss of function (changes in Activities of Daily Living [ADLs]) • Delirium • Medication side-effects

• Loss of function (changes in ADLs) • Dementia, delirium, or depression • Travel/driving issues

• Loss of function (changes in ADLs) • Gait and balance disorder, falls • Fear of falling • Loss of muscle

• Depression • Possible delirium or dementia

• Caregiver burden

• Gait and balance disorder • Fear of falling • Medication side effects • Loss of function (changes in ADLs) • Dementia, delirium or depression • Orthostatic hypotension

• Polypharmacy

• Delirium • Possible underlying dementia • Possible underlying depression

• Orthostatic hypotension • Medication side-effects

RED flag Often Associated With:

The Significanceof FlagsRED

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20 Aging Successfully, Vol. XXI, No. 2 email: [email protected] Questions? FAX: 314-771-8575 Questions? FAX: 314-771-8575 email: [email protected] Aging Successfully, Vol. XXI, No. 2 21

Caregiver burden

Delirium

Dementia

Depression

Falls; Gait & balance disorders; Fear of falling

Incontinence: Urinary and/or fecal

Loss of function; Reduction in ADLs

Loss of strength/Loss of muscle mass

Polypharmacy

Transportation/driving issues

Weight loss

Geriatric Syndromes and Options for Interventions in the Outpatient Setting GERIATRIC SYNDROME POSSIBLE INTERVENTIONS

Social worker consultPsychologist consultIf patient has dementia, refer family members to the Alzheimer’s Associa-tion or a similar support group where availableScreen using the Confusion Assessment Method (CAM)Evaluate medications as possible causeRule out infection where appropriateRule out metabolic causes where appropriateScreen using the VA SLUMS examRefer family members to the Alzheimer’s Association or a similar group for education and supportRule out reversible causes (e.g., medications, depression)Screen using the Geriatric Depression Scale (GDS)Remember that depression is common, not normal, and should be treatedTreat as appropriate with medications and/or refer to a psychologistRule out orthostatic hypotension and/or low blood pressureRule out lower extremity weakness using 5-chair standsOutpatient or home care referral for PT/OTReview medications as possible causeRule out infection where appropriateDetermine the type of incontinence (urge, stress, or overflow)Frequent or scheduled toiletingMedications only when appropriate

Home care or outpatient referral for Occupational Therapy (OT)

Home care or outpatient referral for Physical Therapy (PT)

Home care referral for medication evaluation and managementConsultation with a pharmacistMedication reduction by the Nurse Practitioner (NP), Physician Assistant (PA), or PhysicianLook for medication side effects or errors

Social worker or other consult

Review medications for possible causesAvoid restricted diets

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22 Aging Successfully, Vol. XXI, No. 2 email: [email protected] Questions? FAX: 314-771-8575

research emphasis on the role of neuropeptides in the modulation of hormonal responses and behavior, as well as nutrition and hormones in older persons. He was among the 100 most-cited authors in the world from 1980 to 1988. He was Medi-cal Director of the Year for Life Care Centers of America in 1998. A year later, he received the IPSEN Foundation Longevity Prize, one of the most prestigious European awards for gerontology research. In addition to his work on JAMDA. Dr. Morley has served on the edi-torial boards of nine journals, and was the associate editor of the ge-riatrics section of the Yearbook of Endocrinology, In 2000, he became editor of the Journal of Gerontol-ogy: Medical Science.

AMDA - Dedicated to Long

Term Care (formerly the American Medical Directors Association) is the national professional associa-tion of medical directors, attending physicians, and other professionals

Morley Awarded for Educational Excellence(continued from page 5)

illness, disability, and mortality. The Geriatric Scholars Program is an example of the VA’s commitment to providing high-quality care to all Veterans. Sponsored by the VA Office of Rural Health in conjunction with the VA Office of Geriatrics and Extended Care, the program is a collaboration of the GRECCs at Bronx, Boston, Greater Los Angeles, Little Rock, Madison, Palo Alto, St. Louis, San Antonio, and Tennessee Valley. These GRECCs provide education, mentoring and coaching, and clinical practica to support intensive education in quality improvement and geriatric medicine.

Improving Care for Veterans(continued from page 7)

at a GEM of a price!The latest edition of this ever-useful pocket-sized book,

chock-full to the brim with screening tools and mnemonics, has just been reprinted! Order your copy now!

Only $1 per copy, plus s/h.Email [email protected] for your copy!

practicing long term care medicine committed to the continuous improvement of patient care. AMDA pro-vides education, advocacy, information, and profession-al development to enable its members to deliver quality long term care.

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22 Aging Successfully, Vol. XXI, No. 2 email: [email protected] Questions? FAX: 314-771-8575 Questions? FAX: 314-771-8575 email: [email protected] Aging Successfully, Vol. XXI, No. 2 23

Upcoming continUing EdUcation programs

ever building on the foundation

23rd Annual Saint Louis University

Summer Geriatric Institute

June 12-13, 2012St. Louis, Missouri

USAFor more information, call 314-894-6570.

Multi-disciplinary Certificate Program in Geriatrics for Non-PhysiciansWednesdaysSeptember 14, 28, October 12, 26, November 9, 30, 2011Bloomington, ILandFridaysSeptember 9, 23, October 7, 21, November 4, 18, 2011Palatine, IL

Regional Alzheimer’s ConferenceCHALLENGE, CHOICES, and OPPORTUNITIESFriday, October 14, 2011Mattoon, IL

Multi-Dimensional Func-tional Screening and As-sessment of Older AdultsThursday, October 27, 2011Mt. Vernon, IL

Other prOgrams are available. please call 773-930-3200 fOr mOre infOrmatiOn.

Page 24: Aging Successfully Fall2011

24 Aging Successfully, Vol. XXI, No. 2 email: [email protected] Questions? FAX: 314-771-8575

Division of Geriatric MedicineSaint Louis University School of Medicine1402 South Grand BoulevardSt. Louis, Missouri 63104

This newsletter is a publication of:

Division of Geriatric Medicine

Department of Internal Medicine

Saint Louis University School of Medicine

Geriatric Research, Education, and Clinical Center (GRECC)

St. Louis Veterans Affairs Medical Center

Gateway Geriatric Education Center of Missouri and Illinois(Gateway GEC)

This project is supported by funds from the Division of State, Community and Public Health (DSCPH), Bureau of Health Professions (BPHr), Health Resources and Services Administration (HRSA), Department of Health and Human Services (DHHS) under grant number UB4HP19060; Gateway Geriatric Education Center for $1.2 million. This information or content and conclusions are those of the authors and should not be construed as the official position or policy of, nor should any endorsements be inferred by the DSCPH, BHPr, HRSA, DHHS, or the U.S. Government.

John E. Morley, M.B., B.Ch.Dammert Professor of Gerontology; Director, Division of Geriatric Medicine; Department of Internal Medicine, Saint Louis University School of Medicine.

Nina Tumosa, Ph.D.Editor; Acting Director and Associate Director of Education, GRECC, St. Louis VA Medical Center - Jefferson Barracks; Ex-ecutive Director, Gateway GEC; Professor, Division of Geriatric Medicine, Department of Internal Medicine, Saint Louis Univer-sity School of Medicine.

Please direct inquiries to:Saint Louis University School of MedicineDivision of Geriatric Medicine1402 South Grand Boulevard, Room M238St. Louis, Missouri 63104e-mail: [email protected]

Previous issues of Aging Successfully may be viewed at http://aging.slu.edu/agingsuccessfully.Some of the photos used in this issue are from www.istockphoto.com.

Please fax the mailing label below along with your new address to 314-771-8575 so you won’t miss an issue! If you prefer, you may email us at [email protected]. Be sure to type your address exactly as it ap-pears on this label.

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