About the Institute for Aging Research

The vision of Hebrew SeniorLife’s Institute for Aging Research is to transform the human experience of aging by ensuring a life of health, dignity and productivity into advanced age. Our mission is to conduct research that:

Discovers the mechanisms of age-related disease and disability Leads to the prevention, treatment and cure of disease Advances the standard of care for older people Informs public decision-making Develops the next generation of leaders in aging research

With nearly 50 years of history, we are the largest gerontological research facility in the U.S. in a clinical setting, and a research affiliate of Harvard Medical School. The Institute for Aging Research is home to five professors of medicine at Harvard Medical School.

Institute researchers have access to some of the world’s largest databases, including the Framingham Heart Study. Because the Institute operates within Hebrew SeniorLife, researchers are in close proximity to more than 5,000 seniors each year who may be recruited to participate in Institute studies. In turn, Institute research informs the health care services and programs provided at Hebrew SeniorLife, so patients and residents benefit from best practices in the treatment of common conditions of aging.

The Institute’s research portfolio ranks it in the top 15% of institutions receiving funding from the National Institutes of Health and the number one among hospital-based geriatric research facilities. Despite the success with grants, private philanthropy is critical to advancing our mission, by providing seed money for young and established researchers to test new ideas, and in helping to disseminate research findings so they can impact seniors around the world.

In 2013, IFAR introduced a new strategic plan that outlines the future of research at Hebrew SeniorLife, and positions us to have an increasing impact on quality of life for seniors. Key initiatives include:

Translational research, including a clinical trials unit and health systems research conducted through the joint IFAR/Heller School Center to Inform Health Care Policy and Practice on Aging.

Geriomics, one of the only scientific programs in the U.S. dedicated to determining the genetic mechanisms of disease in old age.

Innovation and professional development to support pilot projects, sabbaticals so senior faculty can remain at the cutting edge of gerontologic research, and postdoctoral training and junior faculty positions to assure a pipeline of research talent.

Informatics, to provide investigators with an environment where clinical studies are designed, managed, and assessed with rigorous and relevant statistical methods. This team is overseen by Dr. Thomas Travison, an applied biostatistician with broad interest in the epidemiology of human aging

Facts at a GlanceNumber of employees: 74

Number of faculty: 20

Number of faculty with academic appointments at Harvard Medical School: 16

Number of post-doctoral fellows: 4

FY17 revenue: $11.4 million

Total Grant Portfolio: $47 million

Number of funded Grants: 92

(All numbers as of November 2017)

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Table of Contents

Falls………………………………………………………………………………………………………………… 3

Osteoporosis and Fractures………………………………………………………………………………………. 5

Spine Health and Aging ………………………………………………………………………………………….. 8

Nutrition and Musculoskeletal Health …………………………………………………………………………... 9

Foot Disorders and Foot Pain ……………........................................................................................................... 11

Genetic Epidemiology …………………………………………………………………………………………… 13

Dementia …………………………………………………………………………………………………………. 15

Delirium ………………………………………………………………………………………………………….. 17

Palliative Care …………………………………………………………………………………………………… 20

Health Care Quality Improvement …………………………………………………………………………….. 22

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Falls

The Situation

Falls are the leading cause of death from injury among seniors. Risk increases with age and even the fear of falling can reduce quality of life. 1 in 3 seniors falls each year, and 10-20% of those who fall suffer moderate to severe injuries, such as hip fractures. Even when falls do not result in a severe injury, a fall in an older adult can lead to depression, fear of falls, and future falls.

By 2020, the annual direct and indirect cost of fall injuries is expected to reach nearly $55 billion. The good news is that falls in seniors are largely preventable.

IFAR Key Findings

Falls have a huge impact on seniors’ quality of life. That’s why it’s a major area of focus for researchers at IFAR, who have discovered that: Creating exercise programs for elders of all abilities increases muscle strength, improves mobility and reduces falls. Preventing sudden drops in blood pressure, especially those that occur after meals or when standing, can reduce fainting and

falls. Increasing the recommended daily dose of Vitamin D to 800 IU reduces falls in elders. Imperceptible vibrations applied to the soles of the feet can improve gait and balance. Low blood flow to the brain can cause damage in areas that control walking speed and cognition. New or increased doses of common medications (such as diuretics or sleeping pills) can increase falls risk; increased

vigilance after a medication change may help prevent falls. Balance may be enhanced in older adults by using low-level electrical currents to safely stimulate the brain. Medications used to treat hypertension do not cause falls and may increase brain blood flow.

Studies Currently Underway

Tai Chi is being tested within numerous subsidized housing facilities throughout Boston for its effects on health and healthcare utilization.

We are testing a special shoe insole that delivers imperceptible vibrations in order to enhance mobility and prevent falls. Multiple studies are underway to discover the effects of age-related changes to brain structure and function and how these

changes influence balance, mobility and falls. Noninvasive brain stimulation is being studied for its potential to improve balance in older adults with and without

movement disorders. We are studying how changes in blood flow to the brain during cognitive tasks affect memory and mobility using

technology such as MRI scans and transcranial Doppler ultrasound. We are studying how changes in blood flow to the brain during cognitive tasks affect memory and mobility using

technology such as MRI scans and transcranial Doppler ultrasound. We are testing whether simultaneous visual, auditory, and tactile stimulation at a particular frequency can activate brain cells

to remove toxic proteins from the brain and improve cognitive function on older adults with memory problems.

Impact

IFAR’s Vitamin D dose recommendations have become the national standard, having been recently recommended by the American Geriatrics Society, the Endocrine Society, and the U.S. Preventive Services Task Force – an independent, expert panel that makes evidence-based recommendations about clinical preventive services.

The Beer’s Criteria, the standard for inappropriate drug prescription in older adults, was modified to reflect that the greatest risk of injurious falls occurs immediately after starting a sleeping pill.

HSL’s research-based exercise programs for residents across our continuum of care and community dwelling seniors have been emulated throughout the country and around the world.

Tai Chi is rapidly growing in popularity as a safe and cost-effective therapeutic activity within numerous populations of older adults.

The treatment of hypertension not only prevents heart attacks and stroke, but may also present loss of memory and mobility. Non-invasive brain stimulation using a very weak electrical current applied to the forehead can improve cognitive function and mobility in older adults and those with Parkinson’s Disease.

Walking ability can be measured outside of the laboratory in community-based settings anywhere in the world by using a smart-phone APP developed by IFAR investigators.

Loss of touch sensation in the feet can result in slowing of walking speed and falls.

Selected Media Coverage

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“The Point” NPR radio interview with Dr. Brad Manor, June 2, 2015, “Studying the Brain for Better Balance”The Boston Globe, April 23, 2014, “Balance Training Moves to High-End Gyms”The New York Times, May 9, 2012, “Fitness Regimens That Go Well Beyond Shuffleboard”The Boston Globe, October 1, 2012, “Why Do People Faint?”

Senior FacultyLewis A. Lipsitz, M.D.Director, and Senior Scientist, Institute for Aging Research Irving and Edyth S. Usen and Family Chair in Medical ResearchProfessor of Medicine, Harvard Medical SchoolChief, Gerontology Division, Beth Israel Deaconess Medical Center

Douglas P. Kiel, M.D., M.P.H.Co-Director, Musculoskeletal Research and Senior Scientist, Institute for Aging ResearchProfessor of Medicine, Harvard Medical School

Marian T. Hannan, D.Sc., M.P.H.Co-Director, Musculoskeletal Research and Senior Scientist, Institute for Aging ResearchProfessor of Medicine, Harvard Medical School

Thomas G. Travison, Ph.D.Director, Biostatistics and Senior Scientist, Institute for Aging ResearchAssistant Professor of Medicine, Harvard Medical School

Other Faculty Brad Manor, PhDDirector, Mobility and Brain Function Research Program, Assistant Scientist II, Institute for Aging ResearchAssistant Professor of Medicine, Harvard Medical School

Dae Kim, M.D., M.P.H.Adjunct Scientist, Institute for Aging ResearchStaff Geriatrician, Division of Gerontology, Beth Israel Deaconess Medical CenterAssistant Professor of Medicine, Harvard Medical School

Sarah D. Berry, M.D., M.P.H.Associate Scientist, Institute for Aging Research Associate Professor of Medicine, Harvard Medical School

Junhong Zhou, PhDAssistant Scientist I, Institute for Aging ResearchInstructor of Medicine, Harvard Medical School

Victoria Poole, PhDAssistant Scientist I, Institute for Aging ResearchInstructor of Medicine, Harvard Medical School

Robert R. McLean, D.Sc., M.P.H.Adjunct Scientist, Institute for Aging Research

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Osteoporosis and Fractures

The Situation

In a few years, approximately one in five US residents will be over 65 years old. In 2010, osteoporosis – which causes fractures, musculoskeletal decline and loss of independence – was one of the 10 chronic conditions most costly to Medicare.

Currently, 10.2 million Americans are estimated to have osteoporosis. Another 43.4 million more have low bone mass, increasing their risk of fragility fracture. Worldwide osteoporosis causes more than 8.9 million fractures/year. By 2050, the worldwide incidence of hip fracture is projected to increase by an astounding 310% in men and 240% in

women compared to rates from 1990. Leaving these patients untested and untreated frequently leads to debilitating fractures that cause disability, loss of

independence and even death. 300,000 people 65 and older are hospitalized in U.S. for hip fractures each year.1 Hip fractures lead to 24% excess mortality within 1 year 50% of hip fracture survivors are permanently incapacitated 20% of hip fracture survivors require long-term nursing home care Having a hip fracture is associated with a twofold increase in the probability of entering into low-income status within

one year Osteoporosis-related fractures were responsible for an estimated $19 billion in health care costs in 2005, with that

figure expected to increase to $25 billion by 2025.

IFAR Key Findings

IFAR research is focused on preventing the occurrence, progression and disabling outcomes of osteoporosis, bone fractures and musculoskeletal disease. The work includes that of the Framingham Osteoporosis Study, which is housed at IFAR and based on data culled from the landmark Framingham Heart Study. Discoveries include:

Nursing home residents receiving at least 800 IU of vitamin D daily had a decreased risk of falls compared to those receiving lower doses. Vitamin D deficiency has been associated with low bone mineral density.

Increased dietary protein intake was found to be associated with a decreased risk of hip fracture in older adults. A hip protector was not effective in reducing the risk for hip fracture. Tai Chi for nine months improved bone mineral density and tended to slow down the turnover of bone. Women with low bone mass have increased risk of cardiovascular disease than those with higher bone mass. Increased lipid levels throughout adulthood are not associated with reduced bone density at advanced age. Older adults with diabetes have alterations in cortical bone density and microarchitecture that may explain increased

fracture risk Diabetes has negative effects on the cortical bone that is the outside core of bones in the leg and arms Individuals with greater calcium intake (from supplements or diet or both) have similar prevalence and severity of

coronary artery calcification than those with lower intake. Low estrogen levels has a role in increasing the risk of hip fracture in men. Incidence of hip fracture is increasing for successive birth cohorts. Prevalent vertebral fracture is the major risk factor for incident vertebral fracture. Repeating bone density testing may not add much to the assessment of fracture risk from a single test. Older adults with recent height loss are at an increased risk for hip fracture within the next 2-4 years. Daily low magnitude whole body vibration does not significantly increase bone density or muscle mass. Obesity and Fractures: Larger amounts of fat surrounding the aorta is associated with greater risk of vertebral fractures. Osteoarthritis of the knee is related to the presence of abnormal cysts in the bones surrounding the knee joint and these

cysts are related to genetic factors The amount of lean mass in the body has genetic causes.

Studies Currently Underway

Continuation of a 20-year study seeking to better define risk factors for age-related bone loss and fractures, including lifestyle and genetic factors.

A study to determine if bone “microarchitecture” improves the prediction of fracture risk over standard bone density testing.

Examination of the effect of dietary protein on bone and fracture, as well as the role of B vitamins, vitamin D, antioxidants and fatty acids in maintaining a healthy musculoskeletal system.

Examination of whether the shape of one’s hip can contribute to our understanding of why some older adults have a hip fractures while others do not, even with low bone mineral density.

Sequencing the entire genome to find previously unknown genetic determinants of osteoporosis A clinical trial to determine if women recovering from hip fracture will do better if exercise is continued past the usual

rehabilitation period and if testosterone is given during the exercise period.

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Investigation of whether the fat and muscle tissue around the hip area may protect older women and men from hip fracture, and if so, whether in different ways or similar patterns

Impact

IFAR’s vitamin D recommendations have become the national standard, recommended by the U.S. Preventive Services Task Force, the American Geriatrics Society and the Endocrine Society.

IFAR’s development of a way to grade the severity of calcification of the aorta using a side view on standard bone density testing led to one of the manufacturers adding it to their equipment software.

The use of hip protectors has not been embraced because of doubts raised about their effectiveness in IFAR studies.

Selected Media CoverageWebMD, September 24, 2013, “Little Benefit Seen in Repeat Bone-Density Testing”Boston Globe, March 15, 2012, “Boston researchers receive $2.7m grant to study ‘Dowager’s Hump’”USA Today, May 13, 2011, “Bones: Experts rethink long-term use of drugs”European Calcified Tissue Society, May 22, 2013 ‘VIBES’ trial shows no benefit in bone vibration therapies for older people Journal of Bone & Mineral Research, January 2018 "Diabetes and Deficits in Cortical Bone Density, Microarchitecture, and Bone Size: Framingham HR ‐ pQCT Study" The Daily Sun, March 3, 2017 “Eat-dairy-foods-vitamin-D-supplements-to-prevent-bone-loss”MedicalXpress, August 31, 2017 “New Assessment predicts fracture risk for patients in long term care” TechnologyNetworks, July 27, 2017 “GWAS reveals Genes Associated with Lean Body Mass”MSN Lifestyle October 24, 2017 “Is it a Myth that Dairy Builds Strong Bones?”

Senior Faculty

Douglas P. Kiel, M.D., M.P.H.Co-Director, Musculoskeletal Research and Senior Scientist, Institute for Aging ResearchProfessor of Medicine, Harvard Medical SchoolAssociate member, The BROAD Institute of MIT and Harvard

Marian T. Hannan, D.Sc., M.P.H.Co-Director, Musculoskeletal Research and Senior Scientist, Institute for Aging ResearchProfessor of Medicine, Harvard Medical School

Other FacultySarah D. Berry, M.D., M.P.H. Associate Scientist, Institute for Aging ResearchAssociate Professor of Medicine, Harvard Medical School

Alyssa B. Dufour, Ph.D.Assistant Scientist II, Institute for Aging ResearchInstructor of Medicine, Harvard Medical School

Shivani Sahni, Ph.D. Associate Scientist, Institute for Aging Research Assistant Professor of Medicine, Harvard Medical School

Elizabeth J. Samelson, Ph.D.Associate Scientist, Institute for Aging Research Assistant Professor of Medicine, Harvard Medical School

Yi-Hsiang Hsu, MD, ScDAssociate Scientist, Institute for Aging ResearchAssociate member, The BROAD Institute of MIT and Harvard UniversityAssistant Professor of Medicine, Harvard Medical School Assistant Professor, Program for Quantitative Genomics, Harvard School of Public Health

David Karasik, PhDAssistant Scientist II, Institute for Aging Research

Robert R. McLean, D.Sc., M.P.H. Adjunct Scientist, Institute for Aging Research 

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Spine Health and Aging

The Situation

Hyperkyphosis is a common condition characterized by excessive forward curvature of the upper (thoracic) spine. It is also known as “Dowager’s Hump” or “hunchback”. Dr. Elizabeth (Lisa) Samelson is leading a team of scientists at IFAR, BIDMC, BUMC, and the Framingham Heart Study to study 2,000 men and women between the ages of 50 and 85. The team will use the results to identify the causes and clinical consequences of hyperkyphosis. • As many as 20-40% of older adults are affected by hyperkyphosis. • In addition to disfigurement, hyperkyphosis poses serious health problems including difficulties in sitting, walking, reaching,

and even breathing. • As a result, older adults with hyperkyphosis have increased risk of falls and fractures as well as declines in physical function. • Individuals with severe hyperkyphosis can suffer from pain and disfigurement and become socially isolated and depressed. • Thus, it is critically important to identify the causes for hyperkyphosis and better understand the clinical consequences.

IFAR Key Findings

• Hyperkyphosis is an important spinal condition that can threaten independence and quality of life in older adults. Yet, little is known about the causes and consequences of this common, disabling condition.

• Individuals with the most severe kyphosis had an excess decline in lung function comparable to the average excess loss in lung function associated with light smoking (less than 15 cigarettes per day).

• Severity of thoracic curvature is highly heritable (runs in families and has a genetic component).• We found a genetic correlation between kyphosis severity and decreased muscle density and size, suggesting that thoracic

curvature and muscle strength may share genetic risk factors.• Prevalence of moderate to severe disc degeneration was as high as 70% in women and men.• Prevalence of moderate to severe osteoarthritis in the spine was higher in women (90%) than men (84%).• High physical activity levels do not significantly increase risk of vertebral fracture or spinal degeneration.• People with larger back muscle size and density (stronger spine muscles) have lower risk of hunched posture

(hyperkyphosis).• Measurements of spinal curvature on CT scans in healthy women and men do not predict subsequent declines in physical

function.

Studies Currently Underway

• The role of vertebral fracture, disc degeneration, and spine osteoarthritis and risk of hyperkyphosis. • Determine whether individuals with greater muscle density and size, measured by CT, have less risk of hyperkyphosis.• The impact of hyperkyphosis on physical function decline.

Impact

• The importance of hyperkyphosis in older adults is receiving a much needed focus. • The assessments completed by this project have led to additional investigations of spinal degeneration. • Individuals with a family history of hyperkyphosis can be targeted for interventions for preventing or delaying excessive

spinal curvature with aging.• Evaluation of muscle strength parameters using CTs may help to monitor progression of forward curvature in the upper spine • Strengthening back muscles may prevent hyperkyphosis

Selected Media Coverage

• The Boston Globe, December 5, 2011, “How Can I Keep from Getting Bad Posture?” • EurekAlert, February 2, 2012, “Institute for Aging research awarded $2.7 million grant to investigate 'dowager's hump'”

FacultyElizabeth (Lisa) J. Samelson, PhD Associate Scientist, Institute for Aging ResearchAssistant Professor, Harvard Medical School

Douglas P. Kiel, MD, MPHSenior Scientist, Institute for Aging ResearchProfessor of Medicine, Harvard Medical SchoolAssociate member, The BROAD Institute of MIT and Harvard University

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Thomas Travison, PhDDirector, Biostatistics and Senior Scientist, Institute for Aging ResearchAssistant Professor of Medicine, Harvard Medical School

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Nutrition and Musculoskeletal Health

The Situation

Poor diet and nutritional deficiencies are associated with major causes of morbidity and mortality including, but not limited to, osteoporosis, sarcopenia (age-related muscle loss), cardiovascular disease, hypertension, type 2 diabetes and some types of cancer.

Osteoporosis and sarcopenia are major public health problems in the United States with direct medical costs of approximately $17 billion and $18.5 billion per year respectively.

These diseases of the musculoskeletal system lead to falls, related fractures, disability, loss of independence and even death.

Diet and nutrition are highly modifiable and may be subject to population changes (i.e., adding vitamins to foods) as well as individual changes (adopting a Mediterranean diet)

Adequate nutrition is important in achieving and maintaining optimal bone mass as well as muscle mass. Evaluating the relation between nutrition and musculoskeletal health is of keen importance as it may lead to dietary recommendations that will help prevent these debilitating diseases.

IFAR Key Findings

The Nutrition Program at the Musculoskeletal Research Center led by Dr. Shivani Sahni uses an epidemiological approach to investigate the role of diet and nutrition status upon bone and muscle among middle-aged and older adults. Our research focuses on identifying the nutritional risk factors for osteoporosis, relating nutrition status and dietary intakes to measures of bone density, muscle mass, muscle strength, falls and fractures. Discoveries from the Framingham Osteoporosis Study include:

Older men and women with higher protein intake had reduced bone loss and lower risk of hip fracture. Among men and women with adequate dietary calcium, those with high protein intake from animal food sources had an

85% reduced hip fracture risk compared to those with low protein intake from animal food sources. Greater protein intake is associated with 54% lower rates of falls among older men and women who had ≥ 5% decrease

in weight. Greater dietary acid load (common to Western diets) was associated with lower hip bone density among older men (but

not in women or middle-aged men). Alkaline-producing dietary components, specifically potassium and magnesium that are obtained from fruit and

vegetables, contribute to the maintenance of bone health. Increase in homocysteine concentration (an amino acid that can be lowered by dietary intake of folic acid and vitamins

B6 and B12) was linked with higher risk of hip fracture (59% in men and 26% in women). Older men and women with higher vitamin C intake had 44% lower risk of hip fracture. Total carotenoid intake (obtained from brightly colored fruit and vegetables) as well as lycopene intake (obtained

primarily from tomatoes) were protective against hip fracture. Greater protein intake, particularly from animal sources is related to muscle mass in older adults. Higher protein intake,

regardless of source, was further protective against loss of muscle strength in older men and women.

Studies Currently Underway

A study to determine whether the effect of dairy food intake on bone health varies with the type of dairy food consumed.

Determining whether certain protein rich foods (examined as protein food clusters) are associated with bone as well as muscle strength in men and women specifically examining both older adults as well as middle-aged adults.

Examination of the effects of specific antioxidants on loss of muscle mass and muscle strength in older men and women.

Determining whether certain protein rich foods (examined as protein food clusters) are associated with bone as well as muscle strength in men and women specifically examining both older adults as well as middle-aged adults.

Impact

Based on the protein and bone research at IFAR, the American Geriatrics Society has updated the recommendations for protein intake as related to bone health in older adults.

IFAR researchers were the first to publish findings suggesting that greater dietary acid load is bad for bone health in older men.

IFAR’s nutrition studies on vitamins B, C, D, E, and K, fatty acids, carotenoids, magnesium, and potassium, have made valuable contributions to the scientific literature and contribute towards the nutrition policy debates on optimal dietary recommendations for healthy aging in older Americans.

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The Nutrition Program hosts quarterly Nutrition Education & Research Seminars presenting cutting-edge research to local scientists, nutritionist, clinical dieticians and other clinical and research staff in the greater Boston area.

Each year, the Nutrition Program at IFAR has hosted visiting international scientists to work collaboratively on dietary risk factors for osteoporosis, diabetes and other chronic disease outcomes.

Selected Media Coverage

CBSBoston.com, March 14, 2011, “Seniors can prevent bone loss, fractures”Livestrong.com, Feb. 7, 2011, “Vitamin C & Bone Health” Boston.com, May 17, 2010, “Higher protein intake linked to fewer hip fractures”Time, May 24, 2004, “Health: Old Bones, New Hope”Time, December 4, 2014, “Should I eat yogurt?”CBSBoston.com, December 10, 2014, “Top 10 Foods That May Help You Live a Longer, Healthier   Life ”

Nutrition Program DirectorShivani Sahni, Ph.D.Director, Nutrition ProgramAssociate Scientist, Institute for Aging Research Associate Professor of Medicine, Harvard Medical School

Senior FacultyMarian T. Hannan, D.Sc., M.P.H.Co-Director, Musculoskeletal Research and Senior Scientist, Institute for Aging ResearchProfessor of Medicine, Harvard Medical School

Douglas P. Kiel, M.D., M.P.H.Co-Director, Musculoskeletal Research and Senior Scientist, Institute for Aging ResearchProfessor of Medicine, Harvard Medical SchoolAssociate Member, The BROAD Institute of MIT and Harvard University

Other Faculty Alyssa Dufour, Ph.D.Assistant Scientist II, Institute for Aging ResearchInstructor in Medicine, Harvard Medical School

Kelsey M. Mangano, Ph.D., R.D.Adjunct Scientist, Institute for Aging ResearchAssistant Professor, University of Massachusetts at Lowell

Robert R. McLean, D.Sc., M.P.H.Adjunct Scientist, Institute for Aging Research 

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Foot Disorders and Foot Pain

The Situation

Foot pain and certain foot disorders are very common in the general population, with physical limitations related to these foot problems also a frequent occurrence in the community. Population-based studies indicate that of the 25% of men and women with foot pain, approximately two-thirds report at least moderate functional limitation. Surprisingly, these aspects of musculoskeletal health, along with foot biomechanics, are rarely studied despite their common occurrence in everyday life.

1 out of 4 people over the age of 45 report frequent foot pain. Foot disorders have been shown to have a detrimental impact on health-related quality of life across a spectrum of age-

groups. Risk factors include increased age, being female, improperly fitting shoes, obesity and chronic medical conditions such

as osteoarthritis and diabetes. Despite the high prevalence and significant impact of foot pain, relatively little is known about the underlying risk

factors for its development. Similarly, the pattern is also true for many foot disorders, where the occurrence is well appreciated but the causes and risk factors remain largely unknown.

How foot biomechanics are affected by foot pain and the onset of foot disorders remains under-studied and yet could be highly modifiable via shoe wear.

IFAR Key Findings

IFAR has conducted studies of the foot in three different population-based cohorts of men and women, with the aim of examining effects as well as risk factors for common foot disorders and foot biomechanics, as well as possible related functional limitations. First, the Framingham Foot Study included more than 3,400 participants from the Framingham original and offspring cohorts and an additional community sample who were invited to participate between 2002 and 2008. A similar foot study was carried out in 765 seniors from the population-based Mobilize Boston Study conducted by IFAR, which aimed to examine the association between foot disorders and falls. And thirdly, this same information was collected in the Johnston County Osteoarthritis Project, a community-based study of both Caucasian and African Americans. Research to date has found:

Foot pain is associated with problems with balance and gait and an increased risk of falls. Specific foot disorders are also linked to these problems and falls.

Foot pain is associated with mobility limitations in both men and women. Foot pain is important in evaluating the relation between structural foot disorders and lower extremity physical

limitations in older adults and its role is different for men and women. Hallux valgus (a foot disorder commonly known as bunions) has differing associations with important outcomes

depending on whether or not the disorder is accompanied by pain. This disorder has been shown by our research group to run in families with a high heritability, both for men as well as women.

Compared to women who wore shoes that were structurally sound over their adult years, those women who wore shoes with average support and structure were at higher risk for pain in the forefoot region of the foot.

As men and women age, they tend to make smarter choices with their footwear (regarding structure and foot support). Foot pain commonly occurs along with knee pain, and also with low back pain in older adults.

Studies Currently Underway

The role of foot biomechanics (how the foot helps us stand and walk) is examined in the NIH funded study, Foot Disorders, Pain and Physical Disability in Older Persons, for effects upon difficulty in mobility and physical limitations in men and women from population-based studies. Factors for new foot pain are being evaluated as well as those factors contributing to persistent foot pain that occurs in older adults.

Another NIH funded study, The Genetics of Foot Disorders, is evaluating whether specific foot biomechanics (or how we walk) are inherited across families and from one’s parents. This study is also evaluating specific gene components (using GWAS methods) across two large cohorts, the Framingham Foot Study and Johnston County OA Project.

Impact

The long-ignored role of feet, in the well-established increased risk of falls, mobility limitations and physical disability with age, is at last receiving a much needed focus, especially in population studies, not solely patient-based research.

This work at IFAR has attracted international attention leading to collaborations with researchers in the UK, Australia and elsewhere; also, a Senior Fulbright Scholar collaborated on these topics with Dr. Hannan, leading to in-depth studies and harmonization of international data collection efforts.

The Framingham Foot Study has been the model for three other funded studies now using Dr. Hannan’s foot research protocol. There are also related proposed studies in Australia and within the VA population in the United States bringing this long under-studied topic into focus along with efforts to increase physical activity (feet required!).

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Selected Media Coverage

Huffington Post, May 20, 2013, “Bunions May Be Hereditary, Study Finds”WBUR, Oct. 18, 2010, “If the Shoe Hurts, There May Be A Remedy”New York Times, Sept. 29, 2008, “High Heels and Pumps Now, Foot Pain Later”Science Newsline, May 10, 2017, “Severe Foot Pain Linked to Recurrent Falls”

Senior FacultyMarian T. Hannan, D.Sc., M.P.H.Co-Director, Musculoskeletal Research and Senior Scientist, Institute for Aging ResearchProfessor of Medicine, Harvard Medical School

Other FacultyAlyssa Dufour, Ph.D.Assistant Scientist II, Institute for Aging ResearchInstructor of Medicine, Harvard Medical School

Yi-Hsiang Hsu, MD, ScDAssociate Scientist, Institute for Aging ResearchAssociate member, The BROAD Institute of MIT and Harvard University Assistant Professor of Medicine, Harvard Medical School Assistant Professor, Program for Quantitative Genomics, Harvard School of Public Health

Yvonne Golightly, Ph.D., P.T.Associate Professor, University of North Carolina

Hylton B. Menz, Ph.D., D.P.M.Professor, Latrobe UniversitySenior Fulbright Scholar

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Genetic Epidemiology of Aging-Related Disorders

The Situation

Age-related musculoskeletal conditions that are inherited, such as osteoporosis (bone loss), sarcopenia (loss of muscle), muscle weakness and metabolic syndrome (insulin-related obesity), are very common in older individuals and result in disability and frailty. These conditions are related directly and indirectly to the devastating fragility fractures that reduce life expectancy and take a heavy toll on the health care system. Since these conditions are genetically determined, knowledge about their molecular underpinnings may yield important discoveries related to prevention and treatment.

Musculoskeletal disorders have been shown to have a detrimental impact on health-related quality of life across a spectrum of age-groups.

Non-genetic risk factors include increased age, being female, consuming a Western diet, and lack of exercise. Despite the high prevalence and significant impact of musculoskeletal disorders, relatively little is known about the

interaction between genetic and environmental risk factors for their development.

IFAR Key Findings

The Genetic Epidemiology program has conducted studies of musculoskeletal disorders in population-based cohorts of men and women, most prominently three generations of the Framingham Study. One of the aims of these studies is to find and validate new genes and genetic variants important for maintenance of bone and muscle mass and strength. Genome-wide association studies (GWAS) have become a driver of genomic revolution as a tool to discover new genes that potentially regulate novel biochemical/molecular pathways underlying fracture risk. Our group conducted the first GWAS for osteoporosis traits in the Framingham Heart Study. We also focused on the interaction between genetic predisposition and modifiable environmental factors, which might inform personalized healthy choices. Our research to date has found:

Novel genetic variants and unexpected genes that affect bone density and fracture risk. The results provide insights into the genetics underlying osteoporosis and may lead to new ways to prevent bone loss and fractures.

With the largest samples of volunteers, more than 80 genomic loci have been identified, contributing to bone mineral density (BMD), bone geometry, muscle mass and osteoporotic fractures.

Fractures of the spine are inherited, as well as thoracic spinal curvatures. Novel genetic variants are associated with the amount of lean mass in the body Changes to the “epigenetics” of an individual may be a marker of the biological clock.

Studies Currently Underway

The role of genetics and its interaction with the environment on older adults is examined in the NIH funded study, Risk Factors for Age Related Bone Loss, using data from men and women from the population-based Framingham Study.

Another NIH funded study, Genetics of Foot Disorders, examines the genes that influence the risk for developing foot disorders such as bunions.

Whole genome sequencing to discover less common genetic variants associated with bone density and fracture. Use of the Exome chip to discover rare variants associated with bone density and fracture. Discovery of novel genetic variants associated with longevity, grip strength, lean body mass, hip geometry, and

fractures. Whole genome sequencing to discover novel new genetic factors related to osteoporosis. With the advent of sophisticated skeletal imaging modalities, such as high resolution peripheral quantitative computed

tomography (HR-pQCT), it is now possible to determine the contribution of bone microarchitecture and strength, to the risk of fracture, in the Framingham Osteoporosis Study.

Targeted Sequencing of Three Loci Associated with BMD in the Framingham Osteoporosis Study is a study of several promising regions in the genome that might be important for osteoporosis. We are performing sequencing of these regions to determine if we can identify the variants that are directly affecting an individual’s BMD.

We are engaged in genome-wide and gene-wide interaction studies to examine the genetic and environmental determinants (such as vitamin D intake, vitamin D supplement, fat intake, physical activity and even gender) of bone mineral density.

New statistical methods, such as multiple-phenotypes association analytical approaches, are being developed to study the effects of the same genes on multiple diseases and co-morbidities. Mechanisms underlying the relation between skeletal (bone mineral density and bone structure) and energy metabolism (fat, insulin resistance, insulin secretion) using GWAS data as well as pleiotropic genetic effects underlying the relation between skeletal and vascular calcification.

The presence of “bone marrow lesions” in the knee, which are associated with osteoarthritis, have genetic origins and may pave the way to identify new drug targets for this disabling condition.

Impact

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With the development of genome science in the last decade and due to our efforts, the role of genetic factors in musculoskeletal aging has received a much needed focus and recognition.

Bioinformatic approaches are being developed to integrate genomics, transcriptomics, proteomics and metabolomics resources for better understanding relationships between the biological components that work together to drive complex pathophysiological processes underlying common musculoskeletal diseases.

This work at IFAR has attracted international acclaim leading to collaborations with researchers all over the world. For the past several years, with the rapid progress in genome-wide association studies (GWAS), the Consortium for Heart and Aging Research in Genomic Epidemiology (CHARGE) and the Genetic Factors for Osteoporosis (GEFOS) consortiums have been established to provide an international collaboration framework.

Investigators at IFAR are leading the Musculoskeletal group that is part of the NIH project called Trans-Omics for Precision Medicine, which will identify novel pathways leading to osteoporosis, and this may identify future therapies for this disease.

We discovered multiple genes for measures of musculoskeletal health, besides bone and muscle, including levels of anabolic hormones, serum vitamins and a variety of musculoskeletal protein biomarkers.

We envision our continuous efforts to be dedicated to the translation of basic research into medical practice, by building a much needed bridge of communication between research scientists and physicians that will lead to novel treatments and prevention strategies for devastating diseases of the musculoskeletal system.

Selected Media Coverage

NIH Research Matters, September 28, 2015, “Bone Risks Linked to Genetic Variants”Boston.com, July 21, 2014, “Researchers Find Genes That Time Girls’ First Periods”Men’s Health, June 29, 2011 “Why Skinny Guys Have Fat Hearts” Boston Magazine, June 9, 2015 “Eating a Protein-Rich Diet May Helps Older Adults Preserve Muscle Mass, Study Says”EurekAlert, July 24, 2017, “Scientist gain clearer picture of how genes affect lean body mass”

Senior FacultyDouglas P. Kiel, M.D., M.P.H.Co-Director, Musculoskeletal Research and Senior Scientist, Program Director, Geriomics Program, Institute for Aging ResearchProfessor of Medicine, Harvard Medical SchoolAssociate member, The BROAD Institute of MIT and Harvard University

Marian T. Hannan, D.Sc., MPHCo-Director, Musculoskeletal Research and Senior ScientistProfessor of Medicine, Harvard Medical School

Other FacultyYi-Hsiang Hsu, MD, ScDAssociate Director, Geriomics Program , Institute for Aging ResearchAssociate Scientist, Institute for Aging ResearchAssociate member, The BROAD Institute of MIT and Harvard UniversityAssistant Professor of Medicine, Harvard Medical SchoolAssistant Professor, Program for Quantitative Genomics, Harvard School of Public Health

David Karasik, PhD Associate Scientist, Institute for Aging Research

Michelle Yau, PhDPost-Doctoral Research Fellow, Institute for Aging Research and Harvard Medical School

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Dementia

The Situation

Dementia, including Alzheimer’s disease, affects nearly 7 million Americans and 24 million people worldwide. Alzheimer’s, the most common form of dementia, is the 5th leading cause of death among Americans over age 65. Cognitive decline, an early stage on the continuum that can lead to dementia, can begin as early as age 45.

One in eight Americans age 65 and older, including nearly half of those age 85 and older, have Alzheimer’s disease. Nearly 15 million non-professional caregivers are helping to care for an estimated 5.4 million people with Alzheimer’s. In 2012, the direct costs of caring for those with dementia will total $200 billion in the U.S. alone, including $140

billion in costs to Medicare and Medicaid. Among the top 10 causes of death, Alzheimer’s is the only one that currently cannot be prevented or cured.

IFAR Key Findings

Although there is no cure for Alzheimer’s and other dementias, IFAR research has improved quality of life for those living with the diagnosis, and increased understanding of existing treatment guidelines. Discoveries include:

The use of memory training strategies is associated with less decline in memory and everyday functioning, as well as higher quality of life.

Hospice eligibility guidelines for those with advanced dementia should be guided by patient and family preference for comfort, not by estimated life expectancy.

30% of Medicare expenditures for nursing home patients with dementia were for aggressive treatments that may be of limited clinical benefit.

Tube-fed patients with advanced dementia don’t live any longer than those who are hand-fed, though their quality of life may be compromised.

Deaths due to dementia and Alzheimer’s are underreported on death certificates, raising concerns about the accuracy of mortality statistics based on these documents.

Studies Currently Underway

The Successful AGing after Elective Surgery (SAGES) study is examining risk factors, causes, and duration of changes in thinking and functioning following surgery and hospitalization.

The Role of Inflammation after Surgery Elders (RISE) seeks to understand the role of inflammation in delirium and long-term cognitive decline around surgery and hospitalization.

The Marcus Applebaum grant focuses on the identification of Cerebrospinal Fluid Biomarkers of Cognitive Decline Following Surgery and Delirium;

The Alzheimer and Related Dementia (ADRD) study assesses the association of neuroimaging biomarkers for preclinical Alzheimer’s disease with postoperative delirium and long-term cognitive decline

The EVINCE (Educational Video to Improve Nursing Home Care in End-stage Dementia) study is testing whether a video can help families of patients with advanced dementia conduct advanced care planning. If successful, this video could be one of the first rigorously tested interventions shown to improve outcomes in advanced dementia.

A large national trial studying cognitive training to promote independence and healthy cognitive aging. Examining whether delirium leads to permanent cognitive impairment, as a potentially reversible cause of dementia

and Alzheimer’s. Evaluating the role of cognitive reserve – an individual’s ability to cope with damage to the pathways in the brain – in

delirium and cognitive decline. Developing a prognostic tool for advanced dementia using nationwide data for federally mandated clinical assessment

of nursing home patients and validating the tool at the bedside. Examining the frequency, risk factors, and outcomes of hospitalization of Alzheimer’s patients. Looking at whether early life IQ has an impact on development of Alzheimer’s. Developing a scale to measure family distress while taking care of a loved one with advanced dementia.

Impact

IFAR researchers were the first to liken advanced dementia to cancer and other terminal illnesses, prompting the medical community and families of patients to focus on comfort care and enhanced quality of life in the last days of life.

IFAR researchers have demonstrated that delirium can worsen clinical outcomes and the progression of dementia. IFAR researchers have shown that cognitive reserve may protect against cognitive decline in older persons.

Selected Media Coverage

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Associated Press, June 18, 2012, “With Alzheimer’s, hospital stays can be a hazard” Time, October 14, 2009, “Redefining dementia as a terminal illness”

Senior FacultySharon K. Inouye, M.D., M.P.H.Director, Aging Brain Center and Senior Scientist, Institute of Aging ResearchMilton & Shirley F. Levy Family Chair in Alzheimer's DiseaseProfessor of Medicine, Harvard Medical School

Susan L. Mitchell, M.D., M.P.H. Director, Palliative Care Research and Senior Scientist, Institute of Aging ResearchProfessor of Medicine, Harvard Medical School

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Delirium

The Situation

Delirium is an acute confusional state that often follows surgery or serious illness, complicating hospital stays for at least 20% of the 12.5 million patients age 65 or older who are hospitalized each year.

Delirium occurs in 15 to 53% of patients age 70 or older following surgery, and 70 to 87% of patients age 70 or older in intensive care.

In one study, about one-fifth of patients age 65 and older who were admitted to post-acute skilled nursing facilities suffered from symptoms of delirium at the time of admission.

About a fifth of admissions to post-acute skilled nursing facilities have prevalent delirium. Delirium costs more than $13 billion per year in hospital expenses and more than $160 billion per year when all post-

hospital healthcare costs are included, such as rehabilitation, institutionalization and home care.

IFAR Key Findings

IFAR researchers were among the first to look at the delirium experienced by many hospitalized seniors as a preventable condition. Findings include:

For patients with Alzheimer’s disease, hospitalization and delirium can lead to adverse outcomes like accelerated cognitive decline, institutionalization, and death.

Older hospitalized patients with lower levels of education may have an increased risk for delirium compared to patients with more education.

Cognitive decline can be delayed by at least six months when delirium is prevented in Alzheimer’s patients. Patients with Alzheimer’s disease who suffered episodes of delirium while hospitalized had a sharply increased rate of

cognitive decline for up to five years after their hospitalization compared to those who did not have any such episodes. Older adults who experience pain and depressive symptoms prior to surgery are more likely to have delirium following

surgery.

Studies Currently Underway

The Successful AGing after Elective Surgery (SAGES) study is examining risk factors, causes, and duration of changes in thinking and functioning following surgery and hospitalization. The SAGES study is truly unique as it is one of the largest studies of its kind, having examined more than 566 older adults after surgery since the study began. Ultimately, the results of the study may contribute to finding ways of helping older adults successfully recover after surgery, avoid complications from hospitalization and surgery, and maintain their cognitive abilities.

The Role of Inflammation after Surgery Elders (RISE) study seeks to understand the role of inflammation in delirium and long-term cognitive decline around surgery and hospitalization. RISE will identify risk markers for delirium and cognitive decline and identify biomarkers of inflammation, using plasma, Cerebrospinal fluid (CSF), and innovative PET ligands in approximately 70 patients undergoing total joint replacement. This study holds great promise to accelerate treatments which may reduce neuro-inflammation with the ultimate goal of reducing delirium and long-term cognitive decline following surgery.

The Marcus Applebaum Grant focuses on the identification of Cerebrospinal Fluid Biomarkers of Cognitive Decline Following Surgery and Delirium; in a new sample (n=20) undergoing major orthopedic surgery under spinal anesthesia.

The Alzheimer and Related Dementia (ADRD) study assesses the association of neuroimaging biomarkers for preclinical Alzheimer’s disease with postoperative delirium and long-term cognitive decline.

The Better Assessment of Illness (BASIL) study aims to create a new way to measure the severity of delirium. Delirium is preventable and treatable, but good measures of delirium severity are needed to understand the clinical course and recovery, and to test the effectiveness of treatment on relevant clinical outcomes. The BASIL team is currently developing an instrument to assess the burden of delirium on patients, family members, and nurses. The results of the BASIL study may ultimately help to reduce healthcare utilization, and to minimize distress to patients and burden to family members and nurses.

Examining delirium prevention as a way to prevent or slow the progression of some dementias and Alzheimer’s. Evaluating the role of cognitive reserve – an individual’s ability to cope with damage to the pathways in the brain – in

delirium and cognitive decline. Identifying subtypes of delirium, based on their symptoms, to see if subtypes differ in response to interventions or

according to patient outcomes.

Other Projects

HELP Central: Designed to prevent delirium in hospitalized older patients, the Hospital Elder Life Program (HELP) focuses on orienting hospitalized patients to their surroundings and meeting their nutrition, sleep, and physical activity needs (http://www.hospitalelderlifeprogram.org/). While HELP programs are independent entities of individual hospitals, HELP Central is housed at ABC and is responsible to support education about and dissemination of the

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HELP program. Supported with a grant from the John A. Hartford Foundation HELP Central developed a stepped training program including web-based and in-person elements to support HELP programs during their different stages of implementation, maintenance, and quality assurance.

Network for Investigation of Delirium: Unifying Scientists (NIDUS), an interdisciplinary network of researchers united in focused, collaborative efforts to accelerate scientific discovery in delirium (https://deliriumnetwork.org/). Tools to advance delirium research include: a) A dynamic database of ongoing delirium studies to encourage multi-site collaboration, secondary analyses and pilot studies; b) Resources to help researchers choose and compare tools for assessing; c) Annual pilot grants to encourage innovative research into new areas of study; d) Annual Bootcamp for researchers new to the field of delirium and ongoing support; e) Annual scientific symposium; f) Outreach and dissemination to communicate information about delirium research broadly.

The Center of Excellence for Delirium in Aging: Research, Training and Educational Enhancement (CEDARTREE) is dedicated to serving as a focal point for improving healthcare for older adults through the recognition, evaluation, prevention, and management of delirium. CEDARTREE offers comprehensive interdisciplinary training and mentorship to attract interdisciplinary investigators to engage in collaborative, delirium-related, and patient-oriented research. CEDARTREE supports NIDUS activities including the annual Delirium Boot Camp and the Scientific Symposium.

Policy initiatives by Dr. Inouye: a) Leadership for Addressing Aging in America: The Health and Aging Policy Fellowship focused on working with Centers for Medicare and Medicaid Innovation (CMMI) on a mobility initiative designed to improve mobility in health care; b) National Hospital Mobility Initiative: working with CMMI to implement a hospital mobility initiative in 120 acute care hospitals to improve mobility and decrease usage of bed and chair alarms in the hospital; c) Grand Challenge in Aging Initiative in collaboration with experts at the National Academy of Medicine (NAM) focuses on the prevention of illness and disability across the life course and will create a Roadmap for Healthy Longevity.

Impact

The Confusion Assessment Method (CAM), developed by IFAR Aging Brain Center Director, Dr. Sharon Inouye, is the world’s most widely used method for detecting delirium. The CAM instrument has been used in over 5,000 original articles to date, and has been translated into over 19 languages. Dr. Inouye also developed the CAM-S, a new measure for assessing the severity of delirium.

Dr. Inouye designed the Hospital Elder Life Program (HELP), a model of hospital care that has been shown to reduce the incidence of delirium by 40%. It is being used in more than 200 hospitals worldwide.

IFAR’s studies of the impact of delirium on hospitalized patients may ultimately change the way Alzheimer’s patients are cared for in the future. The timely use of delirium prevention strategies has significant potential to prevent or delay cognitive decline, more than existing dementia treatments.

Delirium is increasingly recognized as an important geriatric syndrome that needs attention in clinical care and research.

Selected Media CoverageThe Wall Street Journal, September 2017, “Hospitals Increasingly Tell Patients to get up and Move”Science, June 2017, “Will surgery sap your brain power?”Kaiser Health News, October 2016, “Delirium: A surprising Side Effect of Hospital Stays”WBUR, November 20, 2015, “Sundowning’: Why Hospital Staffs Dread Nightfall, And How to Help Seniors Avoid It”Same-Day-Surgery, November 2015, “Growing number of elderly brings issues with LOS, readmissions”Same-Day-Surgery, December 2015, “4 steps to avoid hospital admissions that are unanticipated with elderly patients”American Medical Association, September 2015, “Delirium in Older Persons: Advances in Diagnosis and Treatment”US News & World Report, September 9, 2015, “Delirium in Older Surgical Patients Threatens Recovery”Annals of Internal Medicine, August 18, 2015, “Enhancing Cognitive Aging: Clinical Highlights of a Report from the Institute of Medicine”The Atlantic, June 7, 2015, “The Overlooked Danger of Delirium in Hospitals”PBS NEWSHOUR, June 2, 2015, “For many patients, delirium is a surprising side effect of being in the hospital”WBUR, February 6, 2015, “Delirious: Study Finds Simple, Humane Fixes for Aged, Disoriented Patients ”

Senior FacultySharon K. Inouye, M.D., M.P.H.Director, Aging Brain Center and Senior Scientist, Institute of Aging ResearchMilton & Shirley F. Levy Family Chair in Alzheimer's DiseaseProfessor of Medicine, Harvard Medical School

Other Faculty

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Tamara G. Fong, M.D., Ph.D.Assistant Scientist II, Aging Brain Center, Institute for Aging ResearchInstructor of Neurology, Harvard Medical School

Annie Racine Post-Doctoral Research Fellow, Institute for Aging Research and Harvard Medical School

Eva M. Schmitt, Ph.D.Assistant Scientist I, Institute for Aging ResearchAssociate Director, Aging Brain Center

Thomas Travison, Ph.D. Director, Biostatistics and Senior Scientist, Institute for Aging ResearchAssistant Professor of Medicine, Harvard Medical School

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Palliative Care

The Situation

Palliative care involves a team-oriented approach to care for patients with serious illnesses, and focuses on providing high-quality symptom control, communication and family support. Unlike hospice care, palliative care can be provided regardless of life expectancy and in addition to curative treatments. But, palliative care is often not adequately provided to older persons with advanced illness. Palliative care can improve quality of life for patients at the end of life and their families.

Approximately 68% of Medicare costs are related to people with four or more chronic conditions—the typical palliative care patient

Approximately 90 million Americans are living with serious illness, and this number is expected to more than double over the next 25 years with the aging of the baby boomers.

Dementia afflicts half of people over age 85 and is the 6th leading cause of death in the US.

IFAR Key Findings

Palliative care research at IFAR is focused on improving the quality of care provided to older adults with advanced and their families, particularly for patients in long-term care with dementia. Discoveries include:

Describing end-stage dementia for the first time and showing that nursing home residents dying of this condition often do not receive optimal palliative care.

While hospice improves the quality of care in advanced dementia, it is underutilized in dementia because of eligibility guidelines that are very hard to apply to these patients. 

Tube-feeding has no demonstrable benefits in advanced dementia. Tube-feeding rates have declined by 50% in the last decade in this population.

There is widespread misuse of antimicrobials in advanced dementia, which contributes to the emergence of antimicrobial resistant bacteria.

Older patients commonly receive implantable cardiac devices although it is unclear whether they will benefit from these devices.

Studies Currently Underway

The PROVEN (Pragmatic trial Of Video Education in Nursing homes) study is a pragmatic trial of an Advance Core planning video intervention in two large nursing home networks.

The TRAIN-AD (Trial to Reduce Antimicrobial Use in Nursing home residents with Alzheimer's isease and other Dementias) study is a cluster randomized clinical trial of a practice intervention to improve infection management among nursing home residents with advanced dementia.

DIGNITY: Prospective study of the quality of life and palliative care needs of older person with implantable cardiac devices.

Impact

IFAR’s work has had direct clinical impact on the care of patients with advanced dementia and their families by reducing the use of treatments with little benefit, such as feeding tubes and antibiotics, making their care more aligned with their wishes, and increasing educational tools for caregivers.

IFAR’s work has identified policy areas that need to be addressed to improve the care of patients with advanced dementia, including better access to hospice and nursing home reimbursement.

Researchers at IFAR have contributed to national guidelines on implantable defibrillator deactivation while highlighting persistent barriers to optimal patient-doctor communication surrounding cardiac devices.

Selected Media Coverage

Hebrew SeniorLife’s Susan Mitchell earns coveted NIH MERIT awardNew York Times New Old Age Blog, August 29, 2016, “The Decline of Tube Feeding for Dementia Patients”New York Times New Old Age Blog, June 7, 2012, “A Heart Quandary ” WBUR CommonHealth blog, June 13, 2011, “Loving our parents to death”New York Times New Old Age Blog, January 24, 2011, “When they cannot eat”

Senior Faculty

Susan L. Mitchell, M.D., M.P.H.Director, Palliative Care Research Center and Senior Scientist, Institute for Aging ResearchProfessor of Medicine, Harvard Medical SchoolOther Faculty

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Zara Cooper, MDAdjunct Scientist, Palliative Care Research Center, Institute for Aging ResearchAssociate Professor of Surgery, Brigham and Women’s Hospital Research Associate, Harvard T.H. Chan School of Public Health

Corey Fehnel, MDAssistant Scientist, Palliative Care Research Center, Institute for Aging ResearchAssociate Director, Neuroscience Intensive Care Unit, Department of Neurology, Beth Israel Deaconess Medical CenterAssistant Professor of Neurology, Harvard Medical School

Jane Givens, MD, M.S.C.E.Adjunct Scientist, Palliative Care Research Center, Institute for Aging ResearchStaff Physician, Hebrew SeniorLifeAssistant Professor of Medicine, Harvard Medical School

Daniel B. Kramer, M.D.Adjunct Scientist, Palliative Care Research Center, Institute for Aging ResearchCardiac Electrophysiologist, Beth Israel Deaconess Medical CenterAssistant Professor in Medicine, Harvard Medical School

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Health Care Quality Improvement

The Situation

Currently, seniors are cared for in a wide variety of settings and health care programs but there is a great disparity of outcomes across these settings. Higher quality care, in the right setting at the right time, will also lead to cost savings.

Health care costs per capita for those over age 65 are three- to five-times greater than that of younger people. Medicaid spends $100 billion annually – one-third of its total budget – on long-term care services. Public financing of long-term care is projected to increase by 20 percent by 2020 in the U.S.

IFAR Key Findings

IFAR is addressing these challenges by conducting research that leads to standards of care in a variety of settings. Findings include:

Developed the Minimum Data Set (MDS), a comprehensive documentation system that helps nursing home staff gather information on a resident’s health, needs and strengths in order to determine the best care giving plan.

With Kendal Corporation, IFAR developed COLLAGE, an evidence-based health and wellness assessment tool that helps senior housing and service organizations measure participants’ quality of life, evaluate program and service effectiveness, and emphasize health promotion.

Working with Medicare to profile facilities providing psychiatric care for their residents, develop an assessment tool for inpatient psych patients, collect data on costs of this care, and develop a new payment system based on how ill the patients are and how much care they need.

Studies Currently Underway

Helping Elders Activate Their Lives (HEAL) is looking at types of interventions that can be put into place in nursing homes to help the oldest and frailest residents perform activities of daily living.

Sustaining Achievable Vitality and Effectiveness (SAVE) is implementing and evaluating an intervention to increase the number of high quality nursing homes in Massachusetts. The program uses an organizational continuous quality improvement system that includes problem recognition, evidence-based care and evaluation.

Impact

All U.S. nursing homes are now required by law to use Minimum Data Set (MDS) documentation system developed at IFAR. It has also been adopted by 24 countries worldwide.

COLLAGE is being used by more than 60 organizations in 22 states to improve the health of seniors. HSL’s Vitality 360, a wellness program piloted for residents of Orchard Cove and now expanding across our sites, was

developed based on COLLAGE data. 90% of Orchard Cove residents participate in Vitality 360 and 80% of those residents exercise regularly as a result.

An IFAR study was among the first to demonstrate the role of supportive housing as an alternative to nursing homes for impaired elders. It led to HSL’s decision in the 1970s to building congregate housing rather than add more nursing home beds.

Selected Media Coverage

The Boston Globe, August 23, 2012, “Getting fit for adventures ahead”The New York Times, May 10, 2012, “Fitness regimens, well beyond shuffleboard”

Senior Faculty

John N. Morris, Ph.D.Director, Social and Health Policy Research, Senior Scientist, Institute of Aging ResearchAlfred A. and Gilda Slifka Chair in Social Gerontological Research

Other Faculty

Elizabeth P. Howard, PhD, MSN, BSNVisiting ScientistAssociate Professor, Director, PhD Program in Nursing

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