A newsletter of the Division of Geriatric Medicine ...aging.slu.edu/newsletters/winter_2006.pdfgiven the low number of geriatri-cians now practicing medicine. Increase funding for

SUCCESSFULLYgingA

Winter 2006Vol. XVI, No. 1

(continued on page 6)

inside thisissue...

“We understand who we are- We know where we came from- We accept and understand our destiny Here on Mother Earth- We are spirit having a human experience.” Dianne M. Longboat*

(see complete citation at end of article)

Approaching one’s death re-mains one of the greatest emo-tional challenges for humanbeings. The Sioux people at-tempted to lighten the emotionalburden of death by their dailygreeting to one another: “Let thisbe a good day to die.” The impli-cation is that if one lives every-day to its full and embraces theenjoyment of living, death be-comes less of a terrifying experi-ence.

In modern Western Culturethe focus is different. The focusis on an internal locus of control

End-of-Life Care

where the individual is providedwith all information and expectedto be an active, and equal, part-ner in decision making. This con-crete approach tends to moveWesterners to a cure-orientatedapproach to the end of life as isstressed in the biomedical modelof medicine. However, this ap-proach often fails to accept thenotion that just as there is a timefor living, there is also a time fordying. This failure often createsmajor stresses in end-of-life carefor both the patient and thehealth care professional.

End-of-Life Care................................1

Editorial..............................................2

Palliative Care....................................3

Call to Action.....................................5

SLU Develops New Drug................7

Emergency Preparedness:Lessons Learned............................8

Health Care Hero............................11

End-of-Life Care: Moving Towardthe Ideal....................................12-13

The VA Focuses onEnd-of-Life Care............................18

SLU Organizes InternationalConferences....................................18

Aging Successfully on the Web...19

News at SLU...................................20

2006 Summer Institute..................21

CyberKnife.......................................22

Upcoming CME Conferences.......23

SUCCESSFULLYgingA

A newsletter of the Division of Geriatric Medicine, Department of Internal Medicine, Saint Louis University School of Medicine; Geriatric Research,Education and Clinical Center, St. Louis Veterans Administration Medical Center; and the Gateway Geriatric Education Center of Missouri and Illinois

Saint Louis

John E. Morley

E D I T O R I A L

“The test of a people is how it behaves toward the old. It iseasy to love children. Even tyrants and dictators make a pointof being fond of children. But affection and care for the old,the uncurable, the helpless are the true gold mines of aculture.”

- Abraham Joshua Heschel, The Insecurity of Freedom

In the year when Bill Clinton andI, together with the first wave BabyBoomers, reach our sixtieth yearand take our first tentative stepstowards our golden years, I see allaround me the ugly specter of age-ism. Congress defunded the Geri-atric Education Centers and cut thereimbursement for Medicare. Medi-care Part D arrived as an uncertainblessing for aging Americans. Ev-erywhere I look I hear the demo-graphic imperative of the age wavementioned but then ignored. In aca-demic medical centers I see littlemovement towards increasing theteaching of geriatrics as the strugglecontinues to fill the curriculum withesoteric high technology and newpharmaceuticals of uncertain benefit.While everywhere the angels sing ofthe need to concentrate on the futurecare of our aging population, I fail tosee a harkening of the public to themessage. Even the Baby Boomers

seem more inclined to look tomaintaining their immortalityrather than to providing an in-frastructure which will allowthem to maintain their functionlate into the twilight years.While none of us can write ourtrue autobiography until we die,it seems to me that we are writ-ing a future biography where

disaster awaits us at the end of ourjourney of life.

So what needs to be done toimprove the situation? In theUnited States, the flow of themighty dollar often appearsto be the only way to changethe situation. For this reason,I recommend that in 2007Congress gives up its ageistattitudes and passes the fol-lowing legislation:

Increase the Medicarerate by 20% for those persons withgeriatric certification. Because ofthe small number of certified geri-atricians and geropsychiatrists, thiswill have little effect on the nationalbudget but will increase the enthu-siasm for young physicians to gointo geriatrics.

Provide medical schools 50% ofthe salary of geriatricians on facultyto allow increased time for teaching.

Re-fund the Geriatric Educa-tion Centers at double their previ-ous level. These centers haveplayed the leading role in educat-ing health care providers in thecommunity and this remains a vitalneed for the foreseeable futuregiven the low number of geriatri-cians now practicing medicine.

Increase funding for the Na-tional Institute on Aging.

Continue to move rapidly to-wards a universal computerizedmedical record as so ably champi-

oned by the Secretary ofthe US Department ofHealth and Human Ser-vices, Mike Leavitt.

You may legitimatelyask me what I’ve beensmoking or have I justdeveloped prematuremild cognitive impair-ment. However I strongly

believe that it is time that America’saging population begins to advocatefor its own future by inundatingCongress with letters, e-mails andphone calls (contact informationcan be found h t tp : / /www.senate.gov and at http://www.house.gov). Only in this waywill our aging years be better thanit was for who went before us.

As Rabbi Heschel said “Man livesin a spiritual order. Moments of in-sight, moments of decision, momentsof prayer, may be insignificant in theworld of space, yet they put life intofocus.” It is time for decision andprayer, coupled with action, to re-verse the ageist tendencies we arecurrently experiencing in our society.

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

SUCCESSFULLYgingA


Palliative CareThe Saint Louis University ExperienceBy Nabil S Kamel, MD, Oscar Cepeda, MD, Maria Renna, MD, Rafi T.Kevorkian, MD, and Joseph H. Flaherty, MD

Ever increasing numbers of patientswith advanced illnesses are challeng-ing the health care system with in-creased demands for optimal medicalcare. Armed with medical informationthey or their family members have gar-nered from the Internet, these patientsare well-informed about their illnessesand the range of treatment optionsavailable to them. Today’s patientshave a more sophisticated under-standing of diseases and they havehigher expectations for pain andsymptom management than did pre-vious patients. It is with these grow-ing patient demands that palliative carehas started to flourish.

Palliative care is an interdisciplinaryapproach to medical care that focuseson patient-defined goals of care andworks to relieve distress experiencedby the patient and family. It also ex-tends into the bereavement period thatfollows the patient’s death. The goalof palliative care is torelieve suffering and topromote the best pos-sible quality of life forpatients and their fami-lies, regardless of thestage of the disease orthe need for other thera-pies. Such care requiresa unique approach thatdiffers from the standardmedical model of care.Palliative care assess-ment includes not only allthe standard elements ofa comprehensive medical history andphysical examination, but also extendsinto domains far beyond the traditionalmedical approach.

The word palliative comes from thelatin word, “palliare” which means“to cloak or to cover.” So in thebroadest sense, palliative care mustcover all aspects of a person’s life anddeath.

Symptom management in palliativecare encompasses the assessmentand treatment of physical symptoms(such as pain, dyspnea, constipation,

nausea and vomiting, delirium, fatigue,and anorexia), emotional and psycho-logical symptoms (such as depres-sion, anxiety, delirium, cognitiveimpairment, fear, and agitation or se-dation), as well as spiritual and exis-tential angst.

Predictable palliative care issuescan be remembered by the mnemonic“PAINS WISDOM.”

Palliative care also focuses on clo-sure for the patient and the family nearthe end of life. Even experienced phy-sicians often struggle when initiatingcomplex, emotionally laden discus-sions about palliative care with seri-ously ill patients and their families.Oftentimes, it is the physician who mustask the most difficult questions, suchas, “How long do you think you haveto live?” or “Are you ready to die?”

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For the last year and a half, Saint Louis University’s Geriatric team has runa Palliative Care Consult Service. As documented in the Fall 2004 AgingSuccessfully, Saint Louis University has been shown to have some of the

best palliative care outcomes in the United States.

Aging Successfully, Vol. XVI, No. 1 3Questions? FAX: (314) 771-8575 • email: [email protected] •

(instead of answering the patient’squestion, “Doc, how long do Ihave?”).

There are several levels of pallia-tive care. They include:

1. Active palliation: Active and ag-gressive treatments which are directedtowards symptom relief and may alsoprolong life (e.g., hormonal therapy,chemotherapy, aggressive antibiotictherapy, radiation therapy, and ste-roids);

2. Comfort palliation: Noninvasiveinterventions such as drug therapiesand other measures to relieve symp-toms instead of modifying the disease(e.g., opioids, anxiolytics, antidepres-sants, steroids, NSAIDS, short termpsychotherapy, grief counseling, andspiritual support); and

3. Urgent Palliation: Treatmentsthat are given when symptoms occurabruptly, when patients experiencemoderate to severe symptoms, orwhen sudden complications arise, inorder that the patient does not haveto endure uncontrolled symptoms forany significant time or die with un-controlled pain.

Palliative care is often providedto patients whose disease no longerresponds to curative treatment. Thismodel is well-defined for patientsdying with metastatic cancer. How-ever, the majority of patients die ofchronic diseases in which the prog-nosis is often uncertain, functionaldecline is nonlinear, and life-pro-longing therapies coexist with, or

are identical to, therapies directedat palliation and comfort.

Palliative care may be delivered ina variety of settings, including a hos-pital, nursing facility, or private home.

The level of carerequired, thepatient’s wishesand the level ofcommitment bythe family will of-ten dictate thechoice of setting.However, the suc-

cess of palliative care depends as muchon the attitude of the clinician as on thesetting.

Because so many people chooseto die in the hospital, there is a strongneed for hospital-based palliativecare programs. Despite this increas-ing recognition for the need for pal-liative care, about three-fourths ofhospitals lack such a program. As aresult, the dying process is usuallyunsatisfactory and inadequate in acutehospitals. Improving end-of-life carerequires both providing palliativecare services to the patients and fam-ily and teaching the health care per-sonnel how to best provide palliativecare.

For the past year and a half, theGeriatrics Division of Internal Medi-cine has been running a palliative careconsult service at the Saint Louis Uni-versity Hospital. Upon review of thefirst five months of palliative care con-sults, it was discovered that 81% ofthe patients receiving palliative careconsults had a non-cancer terminalillness, such as multi-organ failure andsepsis, stroke, or end-stage cardiacdisease. Half of the consults werefrom the intensive care unit. Also,over half of the patients were dis-charged from the hospital to eithertheir homes or to nursing facilities.

The three most common themes ofpalliative care concerns by patients andfamilies in these consults were:

1- Fear that pain/comfort willnot be adequately addressed whenthe patient is transitioned to comfortmeasures only (or therapeutic sup-port level III status).

2- Fear that patients will sufferwhen nutrition and/or hydration arewithheld at the end of life.

3- Belief that withholding furtheraggressive intervention/withdraw-ing support leads directly to death,rather than allowing natural pro-gression of illness to death.

Saint Louis University Hospital isworking to improve the level of un-derstanding of what palliative care isand when it should be offered to pa-tients in the hospital. The goal of theGeriatrics Palliative Care ConsultService is to offer families and pa-tients a positive palliative-care expe-rience that will allow the patientexcellent pain and symptom manage-ment as well as compassionate andcompetent medical care.

REFERENCESLo B, Ruston D, Kates LW, et al. Discussingreligious and spiritual issues at the end of life.A practical guide for physicians. JAMA 2002;287: 749-54.Steinhauser KE, Christakis NA, Clipp EC, etal. Factors considered important at the end oflife by patients, family, physicians, and othercare providers. JAMA 2000; 284: 2476-82.Lo B, Quill T, Tulsky J, for the ACP-ASIMEnd-of-Life Care Consensus Panel. Discuss-ing palliative care with patients. Ann InternMed 1999; 130: 744-9.Pan CX, Morrison RS, Meier DE, et al. Howprevalent are hospital-based palliative careprograms? Status report and future directions.J Palliat Med 2001; 4: 315-24.Billings JA, Panitlat S. Survey of palliativecare programs in United States teaching hos-pitals. J Palliat Med 2001; 4: 309-14.Weissman DE. The growth of hospital-basedpalliative care. J Palliat Med 2001; 4: 307-8.AAHPM. Pocket guide to hospice/palliativecare medicine 2003.

Palliative Care(continued from page 3)

palliative (pal e uh tiv)adj. relieving or soothing thesymptoms of a disease or disorderwithout effecting a cure


Call to Action as CongressEliminates Geriatric Training

On December 14, 2005, delegatesto the White House Conference onAging adopted 10 policy recommen-dations, including two that called formore training for health professionalswho care for the elderly. Those two rec-ommendations were:

Support geriatric education andtraining for all healthcare profession-als, paraprofessionals, health profes-sion students, and direct careworkers.

Attain adequate numbers ofhealthcare personnel in all professionswho are skilled, culturally competentand specialize in geriatrics.

Three days later, on December 17,Congress passed the Labor, Healthand Human Services, and Educationspending bill for 2006 which elimi-nated funding for the three federalprograms that support training ofhealthcare personnel who treat olderpatients.

One program supported 60 medicalschool fellowships to train physicians,

dentists and mental health profession-als in geriatrics; another supportedteaching opportunities for 103 geriatri-cians who are junior faculty membersat medical schools; and the third pro-gram supported the infrastructure of 50Geriatric Education Centers across thecountry that trained healthcare person-nel from over 20 professions to carefor elderly patients.

This elimination of the programs totrain gerontologists and geriatricians iscounterintuitive. For example, only 1%of the currently-practicing 650,000physicians in the United States aregeriatricians who specialize in treat-ing the medical needs of the 12% ofthe nation’s population (36.3 millionpeople) that is over the age of 65. Thatnumber does not include any of the 78million Baby Boomers, all of whom willbe 65 or older as of 2030. The Alliancefor Aging Research estimates the UnitedStates will need 36,000 geriatriciansby 2030. The 60 geriatric fellowships andthe 103 geriatric faculty academic ca-

reer awards that have now been elimi-nated were on track to help 11,000doctors earn certification in geriatrics by2030. The Geriatric Education Centerswere training physicians as well as pro-viders in many other healthcare profes-sions, such as nursing, therapy, casemanagement, and social work, in orderto provide coverage for the increasinggeriatric patient loads that are occur-ring for those professions as well.

Now, in one quick vote, Congresshas eliminated the safety net that ensuredthat the frailest of our elders would re-ceive the quality healthcare they de-serve. The lost federal dollars meaninferior medical care for someof our country’s most vulner-able populations. The NationalAssociation for Geriatric Educa-tion will lead the charge to con-vince Congress to reinstatefunding for geriatric education.Please consider joining in thatfight. Our nation’s elders de-serve no less.


On the other hand in non-Western cultures the focus is oninterdependence and acceptanceof the group’s needs and a beliefin traditional ways. This oftenmakes the dying process easier.However, cultural conflict ariseswhen a Western physician insists

on directly communicatingwith the dying person froma non-Western cul ture,rather than with the hierar-chically appropriate personwho should serve as the de-cision maker. Thus, in deal-ing with the end-of-life care,the health care professionalneeds to understand the cul-tural beliefs of the dying per-

son and work within this contextto help that person to a gooddeath.

A History of End-of-LifeCare

From the be-ginning of timepeople have de-veloped ritualsand sacredspaces to allowfor the care ofthe sick and dy-ing in order tofacilitate theirjourney beyondthis l i fe . Theconcept of aplace to care forpersons at theend of life was first establishedduring the time of the ByzantineEmpire (the era following theRoman Empire and one drivenby the ethics of Christian belief).The first of these infirmaries for

care of the dying was establishedin Constant inople (modernIstanbul) by Saint Helen, themother of the first Byzantine Em-

peror, Constantine the Great.These institutions were calledgenocomeia from the Greek wordsgenos meaning old age and comeinwhich is care. During the MiddleAges hospices proliferated as

places that pro-vided hospitalityfor pilgrims as wellas care for the des-titute and the dy-ing. During the 19th

century, a “Calvaire”was opened byMadame Garnier inLyon, France tocare for the dying,and the Irish Sis-te rs of Char i tystarted a hospicein Dublin. In 1905,the Irish Sisters ofChar i ty a lsoopened St .Joseph’s Hospicein London.

End of Life Care(continued from page 1)


What is PalliativeCare?Palliative care is anapproach that improvesquality of life for anyonedealing with a seriousillness. It not only providesappropriate care for thepatient, but also supportfor the families.

What is HospiceCare?Hospice care is a form ofpalliative care, specificallyfor individuals with a lifeexpectancy of six monthsor less (as determinedby their physicians),whose goals for care focuson palliation (comfortmeasures) rather thancure of the underlyingdisease.

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The founder of the first nursing home in Constantinople, SaintHelen, with her son, Constantine the Great

The Armatius Nursing Home in Constantinople (miniaturefrom the Code Vaticanus Grecus, 1613).


SLU Researchers Develop Drugfor Alzheimer’s Disease

SLU researchers have continued their research intoan antisense for amyloid precursor proteins.Antisense drugs block the ability of messenger RNAto be translated into the protein. In the SAMP8mouse, a spontaneous model of Alzheimers-like dis-ease, and in transgenic mice that overproduce thehuman beta amyloid, the antisense has been shownto reverse memory and learning deficits. Theantisense also reverses the overproduction of free-radical damaged proteins in the brain of the SAMP8mouse and has been shown to cross the blood brainbarrier. Recently it has been shown to be deliver-able through the intraneural route. The antisense re-turns the slowed transport of beta-amyloid from thebrain to the periphery. Overall these animal studies

Norse goddess, Idunn, pictured with Thiazi, who stole herand her apples from the gods

suggest that antisense is an excellent target drug forexamining its potential for treating humans sufferingfrom Alzheimer’s Disease. Saint Louis University haslicensed the technology to Idunn Biotechnical Com-pany for development in humans. Idunn was theNorse goddess who handed out apples to the godsto allow them to maintain their youth.

The Physiological Role of Beta-AmyloidJohn Morley, MB, BCh, and his colleagues Susan

Farr, PhD, and William Banks, MD, presented evi-dence at the Neuroscience Meeting in Washington,D.C., in November, 2005, that the physiological roleof beta-amyloid is to act as a memory enhancing neu-rotransmitter. First, they showed that blocking ac-cess to the beta-amyloid receptors with the shortpeptide DFFVG (Asp-Phe-Phe-Val-Gly), inhibitingthe effect of beta-amyloid with an antibody or low-ering beta-amyloid production with an antisenseto amyloid beta precursor protein (APP), allinhibited memory in young mice. They thenshowed that very low doses of beta-amyloidenhanced memory when injected into the brain.Scientists the world wide have been curiousabout the physiological role of beta-amyloid andquestioned why the brain would make a sub-stance toxic to its functions. These studies haveclearly elucidated for the first time the physi-ological role of beta-amyloid.

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EMERGENCY PREPAREDNESS

Nursing home residents are vul-nerable. We learned that lesson wellin the hurricane season of 2005. Anunofficial estimate is that 10% of the1,322 people whose deaths havebeen attributed to Hurricane Katrinawere nursing home patients. Althoughmany of those residents who remainedin their facilities initially survived thestorm, some did not survive the af-termath. The heat and the lack offood, water, andproper medicalcare that fol-lowed were toomuch for them.Ironically, the les-sons learned withH u r r i c a n eKatrina abouthow dangerous itis to protect pa-tients in place

were usedin Hurri-cane Rita in Texas, with disas-trous, and very public, results.Pictures of the infamous bus firethat killed 24 persons beingevacuated from a nursing homewill haunt us for years. Morenursing home residents diedduring the evacuation ahead ofHurricane Rita than died in

nursing homes in Texas during the hur-ricane. When Hurricane Wilmapounded Florida, the majority of vic-tims were still elderly but this time,most of them were living in mobilehome parks, not in nursing homes.What did Florida do differently toprotect their nursing home residents?What went wrong in Texas, Louisi-ana, and Mississippi?

Lesson #1: Experience is thebest teacher. Because Florida typi-cally has two or three hurricanes an-nually, Florida takes emergencypreparedness seriously. People therehave worked hard to make sure thatall nursing homes have multiple gen-erators and sufficient gas to run them,food stuffs that do not require refrig-

eration or cooking, alternate locationsof evacuation sites, multiple commu-nity partners to assist them in either anevacuation or at the residence, goodcommunication to allow family mem-bers to find loved ones during and af-ter the crisis, and room for the familiesof workers to stay on site during thecrisis.

Lesson # 2: Sometimes one can-not win, no matter what one does.For Hurricane Katrina, it would havebeen best to evacuate everyone. WithHurricane Rita, evacuation causedmore deaths than protecting patientsin place. All nursing homes, regard-less of which state they are in, haveemergency evacuation plans and allhave plans that allow them to protectpatients in place. Nursing home ad-ministrators are trained to make deci-sions about who can survive the rigors

by Nina Tumosa, PhD

HURRICANE KATRINA

LESSONS LEARNED IN 2005

of evacuation and who cannot. Theyalso make decisions about how manypersonnel to leave behind to care forthose who are not evacuated and howmany to send with those who are.These decisions are made in consul-tation with nursing staff, patients,family members, government em-ployees, and public health officials.Some, as in the very public case of St.



Rita’s in New Orleans, are made inconsultation with a Higher Power. InLouisiana, Mississippi and Texas, al-though these methods all resulted insaving many lives, they also resultedin the loss of other lives. No solutionis perfect all the time.

Lesson # 3: We need to in-crease education to the generalpublic about emergency pre-paredness for the elderly. Themore people you have who areaware of potential problems, themore people you have who can helpsolve those problems. Many elderscan help others, as well as them-selves, in an emergency; many needhelp. Those who need help are a di-

verse group with diverse problems.A well-educated workforce can of-fer appropriate assistance in a timelymanner.

Lesson # 4: There is aneed for special educa-tion about the physicaland mental health needsof elders under stress, in-cluding, but not limited to:

■ Dehydration■ Nutrition■ Frailty■ Gait and balance■ Sensory changes■ Chronic conditions■ Medications/

vaccinations■ Incontinence■ Skin breakdown■ Hypothermia/

hyperthermia

Lesson # 5: There is a needto educate healthcare and emer-gency workers about specialcommunication strategiesneeded to communicate with el-ders during emergencies. Suchcommunication should include meth-ods to assist people with any or allof the following impairments:

■ Vision■ Hearing■ Language/literacy■ Fear of authorities■ Level of cognition■ Physical limitations■ Fear of cost of

evacuation/assistance

Lesson # 6: Transportationof elders away from emer-gency zones is complicated.

Several important concerns in-clude the answers to the follow-ing questions:

■ Where do we evacuateto and what happens ifthat site is no longer safe?

■ When do we evacuate?■ Who runs the

evacuation?■ How can we safely

evacuate patientswho are bedriddenor who need oxygenor a feeding tube?

Lesson # 7: There arecurrently public policygaps in making coordi-nated preparednesstraining mandatory for

(continued from page 8)

Nita LaGarde, first reported to be age 105 and now knownto be 89, is pictured leaving the New Orleans ConventionCenter after Hurricane Katrina. The discrepancy in thereports of her age is typical of the incorrect informationoften gathered in emergency situations.

HURRICANE KATRINA


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agencies that deal with frail eld-erly. Many questions remain unan-swered and many opportunitiesremain unmet. For example, what roleshould fire and police have in plan-ning for the evacuation of a nursinghome; what priority do individualsin assisted living facilities have in re-ceiving limited transportation away

from an emergency site; what re-sponsibilities do visiting nurses havetowards home-bound elders in anemergency; and should we developand use tracking systems that allowthe authorities to know where an el-der is before, during and after anemergency?

Lesson # 8: A resource/train-ing center is needed to coordi-nate training and certificationof professionals in geriatricemergency preparedness.

This Center would need to de-velop minimum standards of train-ing, establish reasonableexpectations for families about thecare of a loved one, help determinethe role of family members inemergencies, and work to de-velop policies that will minimizesensationalism and the individualprofit that often comes with disas-ters. Public good is seldomserved when individuals prof itfrom honest mistakes made dur-ing a disaster. Good Samaritan rulesdo not commonly apply to thosewho help disaster victims who arebeing removed from the site of a di-saster. In the case of elders, remov-ing them from disaster sites is clearlybetter than leaving them there un-attended but if this is at the ex-pense of the rescuers,where is the greatergood in this?

Lesson # 9: Thereis a need to developcore competenciesin geriatric emer-gency prepared-ness. The role of suchcompetencies is to pro-vide a measure against whichtraining can be judged. Compe-tencies identify key issues, setstandards for training, and makeevaluation possible. With evalu-ation comes the ability to deter-mine which teaching strategieswork and whether learning hastaken place. Answers to the follow-

ing questions can be determinedwhen testing core competencies.

■ Are lives being saved as aresult of this training?

■ Is the training making adifference in efficiency orefficacy of care?

■ How can training beimproved?

Lesson # 10: Emergency Pre-paredness for the Aging trainingmust be regulated. In order to beevaluated properly, training must bestandardized by someone. Once thetraining is standardized, it must beprovided. Education is not cheap.Someone must pay for it. There-fore, questions such as who will payfor this training and who will cer-tify the training must be asked in

order to ensure thattraining in emer-gency preparednessfor the aging willmake a difference inthe lives of our elders.

It is our belief that,as Louis Pasteur oncenoted, “Chance fa-vors the prepared

mind.” Disasters are not predict-able, but by being prepared we canhope to minimize the damage andsurvive the crisis. If this essay hasencouraged you to become moreeducated about emergency pre-paredness, please let us knowhow we can help you attain thatgoal.


HURRICANE KATRINA


HEALTH CARE HEROJohn E. Morley was nominated as a Health

Care Hero by the St. Louis Business Jour-nal in November 2005 in response to hiswork with Hurricane Katrina evacuees. Dr.Morley oversaw the development of a pro-gram in which the faculty in Geriatrics in-

terviewedand exam-ined 250evacueesand pro-v i d e dthem withm e d i c a -tions andfollow-upcare. De-spite the

fact that the oldest person was only 59, theteam’s expertise in geriatrics offered a goodfit for the evacuees’ needs. “Geriatriciansspend more time talking to people. We tryto find out if they are depressed, then try tomake them comfortable and feel that theyare part of the process,” Morley says abouthis regular patients. This approach alsoworks well for people who are displaced.The geriatricians took all oftheir special skills they nor-mally use in treating frailand often demented elderlypatients and applied them toconfused and anxious evacu-ees. When people leave theirhomes in a hurry or a recaught up in a disaster likeHurricane Katrina, they arein shock. Many have healthproblems such as diabetes or

hypertension and many of them leave theirmedications behind. Special skills areneeded to help displaced people rememberwhat their medications are, as well as thedosages they had been taking.

In addition to volunteers from the Divisionof Geriatrics, Morley credits the NHC nurs-ing home and Interlock Pharmacy with pro-vid ing f ree medica t ions for newlydiscovered medical conditions, as well aswith also filling prescriptions for criticallyneeded medications over the weekend – some-thing thatthe Fed-eral Emer-g e n c yManage-m e n tA g e n c y( F E M A )has not yetd e t e r -m i n e dhow to dofor victims of a disaster.

According to Dr. Morley, “The saddestpart of it was that the people who evacuated

ahead of time were the

Photo courtesy Brandon Jennings

HURRICANE KATRINA’S

working poor. Theykept being movedfurther north, and bythe time they gotto St. Louis theywere out ofmoney, out of ev-erything. It was anextraordinary lossin their life.”


End-of-Life Care: Mov

Consider medication ef-fect. Provide help athome. Provide emo-tional support. Utilizeenergy conservationstrategies. Check sleep-ing patterns. Physical/occupational therapy.Exercise.

Non-Pharmacological Pharmacological

Treat depression. If ane-mic, use Erythropoietin orDarbopoietin X.Testosterone.Dexamethosone (4-6week benefit). Meth-ylphenidate.

Non-Pharmacological Pharmacological

Provide psychologicalsupport and regular visi-tors/outings.

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Trazodone if associatedwith poor sleep.Mirtazapine if associatedwith anorexia. De-sipramine/Nortriptyline.Selective SerotoninReuptake Inhibitors(SSRIs).

Provide emotional sup-port. Encourage small,frequent meals withcalorie supplements be-tween meals. Considermultivitamin. Considerglass of wine/beer.

Sit upright (may needarmchair). Reduce roomtemperature. Maintainhumidity. Avoid activitiesthat increase dyspnea.Avoid irritants, e.g.,smoke. Elevate head ofbed. Utilize oxygen whenwanted. (Remember, can-nula/mask can be irritating).Use a fan.

Megestrol acetate (ifanorexic use new formu-lation to enhance absorp-tion). Dronabinol(causes munchies, useonly when weight gain isnot a major concern).Testosterone (effective-ness uncertain).

Treat anxiety with benzo-diazepines (Lorazepam).Dronabinol for CO

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Consider drugs ascause. Increase fluid in-take. Exclude fecal im-paction. Toilet aftermeals with gastro-colicreflex.

Check to make sure itis not due to osmoticlaxative. Rehydrate.

Use mainly osmoticlaxatives:Sorbitol, Lactulose,Polyethylene glycol.

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Use Kaopectate,Loperamide, Prostag-landin inhibitors, orOctreotide (somatosta-tin analog)

AN

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AC

HEX

IAFA

TIG

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IPA

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Management of End

Medical Model


ving Towards The IdealIN

SOM

NIA

Supportive nursing. Con-sider drugs as possiblecause. Ensure ad-equately lighted room.Avoid illusional objects.Have someone in room(e.g., use delirium ICU).

Non-Pharmacological Pharmacological Non-Pharmacological Pharmacological

DEL

IRIU

MAvoid drugs. If essential:Trazodone (25-50mg 2-4times per day), for agitation.Haloperidol (0.5-1mg daily).Respiridol (1-2mg daily) forparanoia., hallucinations, andrarely for agitation. IVLorazepam (0.25-1mg) forsedation to allow for medicalprocedures.

Make use of massagetherapy. Try heat/cold,Transcutaneous Electri-cal Nerve Stimulation(TENS), lidocainepatch, and activity/dis-traction therapy.

PAIN

Use WHO Analgesic Ladder.Try acetominophen, NSAIDS,weak opioids, strong opioids,adjuvant drugs, e.g.,Neurontin®, (Gabapentin).All drugs scheduled by theclock and use PRNs forbreakthrough pain. DO NOTUSE MEPERIDINE due toseizure potential.

Provide psychologicalsupport, help with socialissues, and spiritual sup-port. Limit loneliness.Increase activitieswithin patient’s limita-tions. Keep out of bed.

GEN

ERA

L EN

D-O

F-LI

FEIS

SUES

Treat depression and anxi-ety. Consider dronabinol forgeneral end-of-life care (en-hances food intake andsleep, decreases nausea andpain, and improves generalwell-being). Use low dosesand introduce first dose atbedtime to limit delirium.

d-of-Life Symptoms

End-of-Life ModelA

NX

IETY

NA

USE

A/

VO

MIT

ING

Check to make sure it isnot due to drugs.

Avoid sleeping all day.Increase daytime activ-ity. Control pain. Indulgein warm milk beforesleeping. Get out of bedduring the daytime. Noreading or television inbed.

Try supportive therapyand/or relaxationtherapy. Consider vari-ous causes such as pul-monary embolus ormyocardial infarction.

Dopamine antagonist.H

2 blockers. Serotonin

antagonists. Prokineticagents. Low-doseDronabinol.

Treat depression.Treat anxiety.Treat pain.Ambien®. Sonata®.Lunesta®. Trazodone.

Lorazepam.Buspirone.Trazodone.


In 1948, while working as a nurseand social worker, the founder of themodern hospice movement, CicelySaunders, cared for David Tasma, a

Pole who had escaped from the War-saw ghetto and was dying of cancer.This taught her that end-of-life carewas extremely inadequate. Aftergraduating from medical school, shefounded St. Christopher’s Hospice inLondon in 1967 – a place whichwould help the dying to liveand die and their families tolive on. Dame CicelySaunders’ philosophy andtimeless evangelism led to thecreation of the medical spe-cialty of palliative care and hervision has resulted in alleviat-ing suffering and making deatha more humane process formillions of persons throughoutthe world. In 1965, the Deanof the Yale School of Nursinginvited Dame Saunders to visitand this eventually led to theestablishment of America’sfirst hospice, The Connecticut

Hospice, in New Haven, Connecti-cut, founded by Florence Wald. Lastsummer, Dame Cicely Saunders diedat age 87 of cancer at St.

Christopher’s Hos-pice, the hospice thatshe had created inLondon.

In 1969, Dr.Elisabeth Kubler-Ross published herbook “On Deathand Dying” whichidentified five stagesof dying and made aplea for allowing pa-tients to die at home.In 1972, during hertestimony to the U.S.Senate SpecialCommittee on Agingshe stated, “We livein a very particulardeath-denying soci-

ety. We isolate both the dying and theold.” This led eventually, after the Na-tional Cancer Institute and the HealthCare Financing Administration hadfunded several hospice demonstrationprojects, to the establishment of theMedicare Hospice Benefit by Con-

gress in 1982. In 1991, The Com-mission on the Future Structure ofVeterans Health Care recommendedthe inclusion of hospice care as partof the veterans benefit package. Be-tween 1984 and 1993, the numberof hospices funded by Medicare in-creased from 31 to 1,288. Studies bythe United States government havedemonstrated that hospice care is costeffective. While hospice care has clas-sically focused on care in the last sixmonths of life, it has recently been rec-ognized that quality of life for manypatients with chronic diseases can beimproved during their final two yearsof life if they are treated using the prin-ciples underlying palliative care. Inaddition to providing emotional andspiritual support, end-of-life care (beit palliative or hospice care) recog-nizes the importance of a team-ori-entated approach to pain and otherpsychological and physical symptomsmanagement. Support is also pro-vided to the patient’s family and con-tinues beyond death throughout thebereavement process.

Understanding the Principlesof End-of-Life Care

The first principleof end-of-life care isthat appropriate dis-ease-focused care(which may be life-prolonging) shouldcontinue throughoutthe process. Deci-sions to continue ordiscontinue certaint rea tments of tenneed to be individu-alized based on con-sidering the benefitsand burdens oftherapy. Treatment is


Elisabeth Kubler-Ross. For more information about her work, visitwww.elisabethkublerross.com.Photo courtesy and copyrighted by Ken Ross. (continued on page 15)

Dame Cicely Saunders, founder of St. Christopher’s Hospice.Photo courtesy St. Christopher’s Hospice.


The Five Stages of DyingDenial and isolation: “This is not happening to me.”

Anger: “How dare God do this to me.”

Bargaining: “Just let me live to see my son graduate.”

Depression: “I can’t bear to face going through this, putting my family through this.”

Acceptance: “I’m ready. I don’t want to struggle anymore.”

only withdrawn when it is futile –a simple, but not always obviousexample, is that lipid loweringtherapy has little utility but can doharm in a person at the end stageof cancer or Alzheimer’s Disease.Furthermore, cost should neverbe an issue and pursuing a poten-tially curable diagnosis is always ap-propriate.

Singer and colleagues (JAMA281:163, 1999) identified five com-ponents of quality end-of-life carebased on the patient’s perspective:

◆ Adequate control of pain andother symptoms

◆ Avoidance of inappropriateprolongation of the dyingprocess

◆ Maintenance of a sense ofcontrol

◆ Minimizing the burdenassociated with dying

◆ Strengthening of relationshipswith loved ones.

The overwhelming challenge toend-of-life care is that the processand the outcome are inherently bad.As appropriately phrased by MikeHarlos, Medical Director of the Pal-liative Care Sub Program of theUniversity of Manitoba, “How canyou tell when something inherentlyhorrible goes badly?”

Cicely Saunders formulated theconcept of “total pain,” which rec-ognizes that end-of-life care must

address not only physical symptomsbut social, psychological, and spiri-tual issues as well. The process ofdealing with the end stage of an ill-ness and dying has a tremendous im-pact on those close to the individual,the so-called “col-lateral suffering.”This is why end-of-life care requires asmuch focus on thefamily as on the in-dividual.

Care of patientsnearing the end oflife is moving awayfrom a medicalmodel with a pro-longed period of aggressive medi-cal management with patients beingreassured that the side effects areessential to care followed by a fewdays of comfort-focused care. It ismoving towards a more complexmodel where medical management

and disease modifying treatmentsare blended with symptom controland psychosocial and spiritual sup-port focusing on patients and theirloved ones, starting at the time ofdiagnosis and continuing through-out the bereavement process.

Symptom ManagementThe keys to appropriate symp-

tom management are: 1) that thehealth care professional needs to


recognize that it is the patient’s per-ception of how distressing thesymptom is that drives managementand 2) that help for symptom reliefneeds to be available around theclock. While fatigue and psycho-

social factorsmay worsens y m p t o m s ,that does notallow thehealth careprofessional toignore symp-toms. Patientsneed to betaught that dy-ing does not

equate to unavoidable suffering.They also must be provided witheducation about their disease pro-cesses and choices when this is cul-turally appropriate. Throughout theend-of-life care process, invasiveinvestigations (even as minor as

blood or urinetesting) should bekept to a minimumand used only whenthe result would al-ter management.During the dyingprocess, a diagno-sis is not neededfor the manage-ment of symp-

toms– whenever possible, treat thesymptom, not the cause.

Fatigue is the major symp-tom experienced by patientswith advanced cancer andother end-of-life conditions.Depression and anxiety areoften associated with fatigue,as are two other major symp-toms, anorexia/cachexia(wasting) and pain. An ap-

(continued on pages 16 and 17)


The Edmonton Symptom Assessment SystemBruera E, Kuehn N, Miller MJ, Selmser P, Macmillan K.

For more information about the Edmonton Symptom Assessment System, please seewww.palliative.org/PC/ClinicalInfo/AssessmentTools/esas.pdf




proach to management of variouscommon end-of-life symptoms isprovided in the Table at the bottomof pages 12-13.

The patient should be askedabout symptoms ateach contact with ahealth professional. TheEdmonton SymptomAssessment System(ESAS) questionnaire(see page 16) repre-sents a simple guide tofollow. This can also bedone by the patient orcaregiver at home ifthey are not seeing ahealthcare professional weekly.

ConclusionWhile many physicians are poorly

trained in end-of-life care, many pa-tients can benefit from having the

principle of palliative care used forthem during the last two years oftheir life. Patients who may particu-larly benefit include those with end-stage congestive heart failure, chronic

obstructive pulmo-nary disease,chronic renal fail-ure, strokes, amyo-trophic laterals c l e r o s i s ,Alzheimer’s Dis-ease, cancer, andAIDS. The inter-disciplinary teamapproach, withthe focus on

maintaining function and treatingsymptoms, makes geriatricians anideal group of physicians to be in-volved in palliative care. Good end-of-life care requires health careprofessionals to listen very carefully

to the patient and family and to helpthem make good decisions in a sup-portive psychosocial and spiritualenvironment. Finally, end-of-lifecare needs to continue beyonddeath as has been so well dem-onstrated by the Center for GriefCare and Education at the San Di-ego Hospice and Palliative Care(www.sdhospice.org/cgcefpc.htm).

End of Life Care

NEW! 2006 NEW!Major Geriatric Textbook Published

This fourth edition of Pathy’s textbookcombines both the American and Europeanapproaches to geriatrics. This two-volumeresource provides in-depth reviews of ge-riatric topics. There are a total of 170 chap-ters and 2076 pages. Each chapterhighlights four to five key points. The bookis divided into four parts, namely HumanAging: A Biological Perspective; Human Ag-ing: Social and Community Perspectives;Medicine in Old Age; and Health Care Sys-tems. Special introductory price (untilApril 30, 2006), is $634. To order, callWiley & Sons Publishing at 1-877-762-2974.


The quote at the beginning ofthis article is reprinted from“Indigenous Perspectives onDeath and Dying”Author: Dianne M. LongboatPublisher: Ian AndersonContinuing Education Programin End-of-Life Care, University ofTorontoYear: 2002


The VA Focuses on End-of-Life Care

In recent years, the Depart-ment of Veterans Affairs (VA) hasundergone a remarkable transfor-mation in care at the end of life.In 2001, fewer than 40% of VAmedical centers had a formal pal-liative care program. Now, bypolicy, all VA facilities have a Pal-liative Care Consult Team. And ev-ery VA Network, or regionalcluster of VA facilities, has hadan interdisciplinary team trainedin hospice & palliative careprogram development.

Although VA offers to provideor purchase needed hospice carefor all enrolled veterans, prior to2001 half of all VA facilities didnot purchase any hospice carebecause of inconsistent poli-

cies. VA now has a national policyand standardized practices for the pur-chase of comprehensive per diemhospice care, home hospice be-came a separate item in the 2004 VAbudget for the f irst time in VAhistory, and all VA facilities nowpurchase hospice care. To promotecollaboration between VA and thecommunity agencies that directlyprovide hospice care to veterans,VA began the Hospice-VeteranPartnership initiative workingwithin each state. VA also pio-neered an innovation in training, bystarting interdisciplinary fellowshipprograms in palliative care. (Seewww.hospice.va.gov for more infor-mation on fellowship sites).

As a result of these coordinated

changes that addressed policy,workload capture, budget, per-formance measures, training, andcommunity agency collaborations,VA has greatly increased access tohospice and palliative care for vet-erans. In the past two years, VA hastripled both the number of veteransreceiving VA-paid home hospicecare and the number of veteransreceiving inpatient hospice care inVA facilities. While this progressis encouraging, VA’s efforts areaccelerating. Keep an eye on VAcare at the end of life – for ad-vances in outcome measures,quality of care, staff competency,caregiver support, veteran andfamily satisfaction, and hospicecare in nursing homes.

SLU to Organize Two Major InternationalNutrition Meetingsin 2007

In May 2005, theInternational Academy of

Nutrition meeting was held in St. Louis. The next meeting will be held in Adelaide,

Australia on September 5-6, 2007. The meeting will beorganized by Ian Chapman, John Morley, and Bruno Vellas.

It will be held conjointly with the Australian Geriatrics Society Meeting.The Third International Cachexia Meeting was held in December, 2005, in Rome.Among participants from Saint Louis University were David Thomas, Matt Haren,

and John Morley. The Fourth Cachexia Congress will be held December 6-8, 2007,in Florida. It will be organized by Stefan Anker, Bill Evans, and John Morley.

photo courtesy www.clipart.com

By Thomas Edes, MD, and Scott T. Shreve, MD


AGING SUCCESSFULLY

IS ON THE WEB!

This issue and every issue is availableat our NEW website:

http://aging.slu.edu

While you’re there, check out thescreening tools, links to other use-ful sites, and information about ourupcoming conferences.

If you needadditional papercopies of aprevious issueof AgingSuccessfully,please [email protected].

SERVICESServices of the Division ofGeriatric Medicine, Saint LouisUniversity Health SciencesCenter include clinics at twolocations in the followingareas:

Aging and DevelopmentalDisabilities

Bone Metabolism

Falls: Assessment andPrevention

General GeriatricAssessment

Geriatric Diabetes

Medication Reduction

Menopause

Nutrition

Podiatry

Rheumatology

Sexual Dysfunction

Urinary Incontinence

For an appointment,call

314-977-6055(at Saint Louis University)

or 314-966-9313(at Des Peres Hospital)

PRODUCTS from the Gateway GECGEROPADY

ACE Unit VideoCrossword Puzzle BookChallenges and Choices

Aging Successfully NewsletterSLU GEMS

Emergency Preparedness CDBooks

Call 314-977-8848 for moreinformation about these products.

phot

o co

urte

sy w

ww

.cli

part

.com


News at SLUNews at SLU

Dr. Wilson Elected to Executive Committee

Doctors Receive Awards from AMDADrs. Julie K. Gammack and Zareen Syed have received a 2006 Pfizer Quality

Improvement award through the American Medical Directors Association. This$14,000 award is designed to encourage the develop-ment of innovative projects that will help to make a dis-tinct impact on the quality of patient care in the nursinghome setting. The quality improvment project is titled “OralHealth Care in the Elderly Demented Patient in the Long-Term Care Setting.” The study will begin in Summer, 2006and will continue until Spring, 2007. The purpose of thestudy is to improve oral care in older nursing home resi-dents by providing education to the staff who care forthese individuals.

Dr. Margaret Wilson has just been elected to athree-year term as a member of the Executive Com-mittee of the School of Medicine Faculty Assembly.

There is nothingthe matter with me

I’m as healthy as I can be.I have arthritis

in both my knees,And when I talk

I talk with a wheeze.My pulse is weak,

and my blood is thin,But I’m awfully well

for the shape I’m in.Arch supports

I have for my feet,Or I wouldn’t be able

to be on the street.Sleep is denied menight after night,

But every morningI find I’m all right.

My memory is failing,my head’s in a spinBut I’m awfully well

for the shape I’m in.How do I know

that my youth is all spent?Well, my “get up and go”

has got up and went!

But I really don’t mindwhen I think again

Of all the grand placesthat my “get up” has been.

Old age is golden,I’ve heard it said,

But sometimes I wonderas I get into bed,

With my ears in the drawer,my teeth in a cup,

My eyes on the tableuntil I wake up,

Ere sleep overtakes me,I say to myself,

“Is there anything elseI could lay on the shelf?”

I get up each morningand dust off my wits,

And pick up the paperand read the “Obits”.If my name is missing,I know I’m not dead,

So I have a good breakfastand go back to bed!

I’m Fine, Thank You!Author unknown

Dr. Margaret Wilson

Geriatric Medicine Fellows ReceiveScholarship

Drs. Chris Espana, Ahmed Ali, and Oscar Cepeda havebeen awarded a scholarship to attend the 2006 AmericanMedical Directors Association (AMDA) Future’s Pro-gram. Held during the AMDA Annual Symposium, this intensive learning experi-ence is designed to expose residents and fellows to the numerous careeropportunities available in long term care. Participants chosen for this programreceive admission to the AMDA Futures Program on March 16, 2006, registra-tion to the AMDA Annual Symposium, March 16-19, 2006 in Dallas, Texas,lodging and transportation to the meeting and a one-year membership to AMDA.

Dr. Ramzi Hajjar

Drs. Hajjar and Kamel AwardedDr. Ramzi Hajjar and Dr. Nabil Kamel earned the

American Academy of Hospice and Palliative Medicine(AAHPM) Award for Young Investigators for the posterthey submitted, entitled, “Delay in Seeking Hospice andPalliative Care Services in Terminally Ill Patients - A pi-lot study of determinants of use and potential points ofintervention.” This award recognizes a young investigatorwhose submission was considered outstanding by the pro-gram committee. The poster will be on display at theAAHPM/HPNA conference in Nashville, TN on February 8-10, 2006.

Dr. Julie K. Gammack


Caringfor the Vulnerable

The 17th Annual Saint Louis UniversitySummer Geriatric Institute

June 6-7, 2006

IMPORTANT INFORMATION:Due to increased postal rates and the loss of Federal funding, we will bemaking all of the conference details (including brochure and registrationform) for the 2006 SUMMER GERIATRIC INSTITUTE available on the Internet athttp://aging.slu.edu. Please visit this site for conference information and to register.If you want to be updated on conference details, send an email to: [email protected].

One of the workshops which will bepresented at the Summer Institute is“Breaking Bad News: Do’s and Dont’s.”This workshop will provide instructionon how to break bad news to patients,family members, and professionalcaregivers. The mnemonic on the left,created by the workshop presenter,Anupam Agarwal, MD, highlights majorpoints to consider when talking aboutdifficult medical diagnoses.


CyberKnife: Improving Care for theOlder Cancer Patient

The CyberKnife Stereotactic Radiosurgery System(CyberKnife) is now being used at Saint Louis UniversityHospital.

CyberKnife radiosurgery is a noninvasive radiation treat-ment that can be used as an alternative to open surgery incertain cases. It uses image-guided robotics designed todestroy tumors with pre-cisely directed beams of ra-diation. It may improvetreatment outcomes andquality of life for some pa-tients with malignant and be-nign lesions of the brain,spine and neck that mayhave been previously con-sidered inoperable or inac-cessible by radiation therapy.The CyberKnife uses highdoses of focused radiationbeams delivered from mul-tiple points outside the bodyto irradiate the tumor or le-sion. Each individual beamis not sufficient to causeharm, but the convergenceof all the beams at the target results in the tumor or lesionreceiving a very high dose of radiation while sparing nearbynormal tissue.

The CyberKnife’s targeting system may offer many pa-tients improved tumor control with few side effects and fewertreatments. In fact, treatment that may have required as manyas 30 sessions with conventional radiation therapy maybe reduced to one to five sessions for 60 to 90 minutes each.

How does the CyberKnife work?The CyberKnife, paired with other hospital imaging tech-

nology, allows specialists to customize a treatment plan foreach patient. Physicists use a complex program to determinea treatment plan for each patient based on the unique shapeand location of the tumor. The planning process determinesthe positions of the beams of radiation.

Through the use of technology, the CyberKnife systemlocates the position of the tumor and uses a robotic arm todeliver highly focused beams of radiation to the tumor. Therobotic arm’s range of motion allows for radiation to be de-

livered to tumor sites that are unreachable when using mostother stereotactic treatment procedures.

Potential Benefits of CyberKnife Treatmentinclude:

� better quality of life duringand after treatment� better access to hard-to-reach,larger or previously inoperable tu-mors� more accurate radiation target-ing for minimal radiation exposureto surrounding tissue� ability to treat multiple tumorsin different locations during a singlesession� treatment of lesions that havepreviously undergone the maxi-mum allowed dose of traditionalradiation therapy� improved comfort due to theelimination of an invasive headframe� no incision or scalpel� no blood loss

� no anesthesia required for treatment� no recovery time� immediate return to normal activities� fewer complications than traditional surgery such as infection,hemorrhage or nerve damage.

Conditions Treated With the CyberKnifeinclude:� Malignant brain tumors

� Benign brain tumors� Vascular malformations� Extracranial tumors and lesions.

For More InformationIf you are interested in the CyberKnife,you or your physician can contact us at

1-866-40cyber.


Been Here? Done This ?Offering regular updates on geriatrics, Cyberounds, an internet-basededucational program for physicians and other health providers, is editedby Dr. John E. Morley. The internet address for Cyberounds is:

www.cyberounds.comA cybersite for seniors has been developed in collaboration with SaintLouis University and the Gateway Geriatric Education Center. Besidesarticles written by geriatric experts, this site provides health updates andan interactive question and answer section. The address for this site iswww.thedoctorwillseeyounow. See you in cyberspace!

17th Annual SLUSummer Geriatric Institute


June 6-7, 2006

All of the conferences will be held at Saint Louis University, except as noted. For moreinformation about any of these conferences, please call

314-977-8848.

4th InternationalAcademy on

Nutrition and AgingSeptember 5-6, 2007In Adelaide, Australia

In Grayslake, Illinoison Thursdays,March 9, 23, April 6,20, May 4, and 18,2006.

The 17th Annual Saint Louis UniversitySummer Geriatric Institute


June 6-7, 2006

Upcoming CME Programs

15th Annual Multi-DisciplinaryCertificate Program inDementia Assessment,Care, and Management

In Lombard, Illinois onFridays, March 3, 17, 31, April 14,

28, and May 12, 2006.

4th Annual RushElder Rights ForumApril 7, 2006 at Rush University

Medical Center in Chicago, Illinois

In Effingham, Illinois onWednesdays, March 15,29, April 12, 26, May 10,and 24, 2006.

15th Annual Multi-Disciplinary CertificateProgram in Geriatrics forNon-Physicians

SLUGeriatricAcademy (SLUGA)July 10-14, 2006


Non-Profit Org.U. S. Postage

PAIDSt. Louis, MOPermit No. 6

This newsletter is a publication of:

Division of Geriatric Medicine

Department of Internal Medicine

Saint Louis University School of Medicine

Geriatric Research, Education, andClinical Center (GRECC)

St. Louis Veterans Affairs Medical Center

Gateway Geriatric Education Center of Missouri andIllinois (Gateway GEC)(supported by a grant from the Bureau of HealthProfessions, Health Resources and Services Administration)

With special thanks to Saint Louis UniversityHospital - TENET for providing funding for this issue.

John E. Morley, M.B., B.Ch.Dammert Professor of Gerontology andDirector, Division of Geriatric MedicineDirector, Gateway Geriatric Education CenterDepartment of Internal MedicineSaint Louis University School of Medicineand Director, GRECC, St. Louis VeteransAffairs Medical Center

Nina Tumosa, Ph.D.EditorHealth Education Specialist, GRECCSt. Louis VAMC-Jefferson Barracksand Executive Director, Gateway GECProfessorDivision of Geriatric MedicineDepartment of Internal MedicineSaint Louis University School of Medicine

Carolyn E. PhelpsAssistant Editor

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

Please fax the mailing label below alongPlease fax the mailing label below alongPlease fax the mailing label below alongPlease fax the mailing label below alongPlease fax the mailing label below alongwith your new address to 314-771-8575 sowith your new address to 314-771-8575 sowith your new address to 314-771-8575 sowith your new address to 314-771-8575 sowith your new address to 314-771-8575 soyou won’t miss an issue! If you prefer, youyou won’t miss an issue! If you prefer, youyou won’t miss an issue! If you prefer, youyou won’t miss an issue! If you prefer, youyou won’t miss an issue! If you prefer, youmay email us at may email us at may email us at may email us at may email us at [email protected]@[email protected]@[email protected]. Be sure to. Be sure to. Be sure to. Be sure to. Be sure totype your address exactly as it appears ontype your address exactly as it appears ontype your address exactly as it appears ontype your address exactly as it appears ontype your address exactly as it appears onthe label.the label.the label.the label.the label.

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

SUCCESSFULLYgingA

Documents

A newsletter of the Division of Geriatric Medicine ...aging.slu.edu/newsletters/winter_2006.pdfgiven the low number of geriatri-cians now practicing medicine. Increase funding for