Fall 2012 Aging Successfully for Web

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

Fall 2012Vol. XXII, No. 1

(continued on page 4)

SLEEP Sleep quality plays an important role in

quality of life. Adequate sleep plays a key role in the body’s restorative functions. A variety of physiological changes in sleep occur with aging. Complaints concerning ability to fall asleep or maintain sleep occur in about half of the older population. In many older persons, medical and psychiatric disorders disrupt sleep. Primary sleep disorders, such as sleep apnea, tend to be more common in older persons. Table 1 (on page 4) provides the common sleep symptoms about which older persons complain. Persons in nursing homes have particu-larly poor sleep. The average nursing home resident tends to sleep in bouts of about 20 minutes, then awakens, and

and Aging

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

1 Sleep and Aging

2 News at SLU

3 Editorial

8 Aging and Sleep 2012

8 SLU Among Best in US News & World Report

9 Transfers are Dangerous

10 SLU Develops New Screening Tests

11 Got Delirium?

12 Geriatrics in a Page: Fall Prevention

13 Geriatrics in a Page: Leukemia

19 High Impact Factor for JAMDA

20 GRECCs: Trans-lating Aging Research into Clinical Practice

21 Mini-Falls Assess-ment and DVD set

22 SLU GEMS

22 Services

23 Continuing Education Opportunities

Milta Little Elected to AMDAMilta Little, D.O., was elected to the American Med-ical Directors Association (AMDA) at their spring meeting in San Antonio. Dr. Little is also the chair of the Communications Committee and Secretary of the Board. She also serves as an associate editor of the Journal of the American Medical Directors Association (JAMDA). Dr. John Morley serves on AMDA Foundation’s Board of Directors.

SLU Faculty Named Best DoctorsSeven members of the faculty of Saint Louis University’s Division of Geriatric Medicine were included among the Best Doctors in 2012. They are: Dulce Cruz-Oliver, Joseph H. Flaherty, Julie K. Gammack, Gerald Mahon, John E. Morley, Miguel A. Paniagua, and David R. Thomas. In addition, three of SLU’s previous fellows were honored by being included in the Best Doctor list. They are: Lakshmi Bandi, Mark Gunby, and Hashim Raza.

Malstrom Wins First PrizeTed Malstrom, Ph.D., Assistant Professor in Psychiatry, won first prize for his presentation at the International meeting of the Society of Sarcopenia, Cachexia, and Wasting Diseases in Milan, Italy. He presented a validation of the international definition of sarcopenia with limited mobility. His data showed that low muscle mass in persons with limited mobility was predic-tive of poor functional outcomes.

Saint Louis University, Veterans Administration present at Alzheimer’s Association’s International Conference

At the 2012 Alzheimer’s Association’s International Conference (AAIC), held in Vancouver, British Columbia, Dr. Lenise Cummings-Vaughn pre-sented a study demonstrating that the VA-SLUMS mental status examination performed slightly better than the Montreal Cognitive Assessment. Dr. Dulce Cruz-Oliver showed in a 7-year follow-up study in VA patients, that nearly half of the persons with mild cognitive impairment had returned to normal. She showed that the majority of these persons had treatable causes, such as anticholinergic drugs, poor vision, or poor hearing, of their cognitive impairment. A medical student, Katy Dun-can, showed that the Dr. Oz online mental status exam, which was developed based on the VA-SLUMS exam, was a reasonable screening test. Dr. Sue Farr showed that an antisense to amyloid precursor protein improved memory in a transgenic mouse model. Dr. John Morley showed that, while alpha-lipoic acid improved memory in a mouse model of Alzheimer’s disease (SAMP8 mouse), it also produced earlier death for the majority of animals.


Editorial

John E. Morley, MB, BCh

It is now clear that persons who are either pre-frail or frail are more likely to develop disability,

be institutionalized, and have excess mortality. The concept that frailty could be objectively measured was first shown by Dr. Linda Fried and her colleagues in the Cardiovascular Health Study. Their methodology for measuring frailty has proved too complex to be utilized by the average primary care physician. The Study of Osteoporotic Fractures (SOF) had a simpler screen of fatigue, weight loss, and 5-chair stands.

Recently, the FRAIL questionnaire, developed by the International Associa-tion of Nutrition and Aging, has been demonstrated to be validated in Aus-tralia, Hong Kong, and by our group in the United States. This is a very simple questionnaire which can be adminis-tered in under 30 seconds.

It has been shown that the FRAIL questionnaire performs as we l l a s the o t h e r t w o FRAIL screens and the Ca-nadian Health Care (Rock-w o o d) a p -proach which adds up the number of dis-eases and dis-abilities. FRAIL

is effective as a screener in middle-aged as well as older persons. Besides predicting a decline in Activities of Daily Living (ADLs) and Instru-mental Activities of Daily Liv-ing (IADLs), it also predicts gait speed. Slow gait speed has been shown to be highly predictive of increased mor-tality. Thus, we now have a simple, easy-to-administer, screening test for frailty.

Besides the previous complexity of the frailty questionnaires, physicians have questioned the utility of screening for frailty as they felt they did not know what to do if they found someone to be frail. The FRAIL question-naire actually points to the appropriate interventions in someone who is frail:FATIGUE – test for hypothyroidism,

hypotension, anemia, vitamin B12 deficiency, and depression and treat if present.RESISTANCE – Enroll person

in a resistance exercise program.

AEROBIC – Enroll person in a walking and balance exercise program.

ILLNESS – Consider if poly-pharmacy is a risk factor, and reduce medications whenever possible.

LOSS OF WEIGHT – Utilize the MEALS-ON-WHEELS mne-

monic (see page 7) to look for treatable cause of weight loss.

Having demon-strated that the FRAIL questionnaire is a sim-ple, effective screen, and that it also is a guidepost to treatment, I feel strongly that this screen should be used by all physicians seeing older persons. If they

do not feel comfortable treating the older person, the patient should be referred to a geriatrician.

The International Association of Ger-ontology and Geriatrics (IAGG) has called for this screening to be universally imple-mented. Professor Bruno Vellas, from Toulouse, France, is the President of the IAGG, and he has spearheaded this initia-tive. In the area around Toulouse, general practitioners have been trained to screen for frailty and offered the opportunity to refer frail persons to the geriatric center in Toulouse if they do not feel comfortable

F atigue (Are you tired?)R esistance (Can you

walk up a flight of stairs?)

A erobic (Can you walk a block?)

I llness (Do you have more than 5 illnesses?)

L oss of weight (Have you lost more than 5% of your weight in the last year?)

treating the older person them-selves.

The time for FRAIL has come. Using it will greatly im-prove the quality of life for all of us as we age!


SLEEP and Aging(continued from page 1)

then goes back to sleep. Of the eight hours nursing home residents spend in bed, they are awake for over two hours.

Physiologically with aging there is a decrease in slow wave sleep (SWS) and rapid eye movement (REM) sleep with a concomitant increase in stages 1 and 2 sleep. Sleep in older persons has more awakenings with total time awake being longer. Older persons also wake up more quickly than younger persons. The decline in the large amplitude, slow (delta) frequency EEG activ-ity (SWS) is considered to reflect a general decline in neuronal activity with aging. SWS decline is associated with poorer ability to learn and remember. In addition, older persons tend to have changes in their circadian rhythms such that they go to sleep earlier and awake ear-lier than do younger persons.

InsomniaInsomnia can occur in

as many as four out of ten older persons. Persons with insomnia function less well during the day. They have poor attention and react slower.

Insomnia can be due to various diseases (Table 2) or medications (Table 3). Insomnia is directly related to polypharmacy. Chronic pain is a major cause of sleep disturbances. Heart failure, chronic obstructive pulmo-nary disease, and neurologi-cal disorders are particularly common causes of sleep dis-

turbances. Persons with Parkinson’s disease tend to have fragmented sleep with frequent awakenings. Dopamine agonists increase neuronal activity lead-ing to sleep disruption. Persons with Alzheimer’s disease tend to have an increased sleep duration with more daytime naps. They have frequent awakenings and a decrease in slow wave and REM sleep. Some older persons have primary insomnia disorder which

often needs treatment by a sleep specialist.

The approach to insom-nia requires an aggressive sleep hygiene program.The components of a sleep hy-giene program are:• Increase daytime exercise• Increase daytime social-

ization• Avoid daytime naps• Increase daytime exposure

to sunlight or high lux (2000) light

• Avoid caffeine at night• Have a regular sleep rou-

tine• Use bed only for sleeping

(and sex), i.e., do not read or watch television in bed

• Do not drink f luids for three hours before bedtime

• Keep bedroom as dark and noise-free as possible

• Have a small glass of hot milk before going to bed

• Get up if after 15-30 min-utes you fail to fall asleep

• Treat nocturiaIf these fail, consider a

cognitive behavioral therapy program for sleep.

Numerous drugs have been used to treat insomnia. All of these, with the excep-tion of melatonin and its

TABLE 1. Common sleep complaints in older persons

• Difficulty falling asleep• Early waking• Disturbed sleep• Increased wakefulness at night• Decreased sleep time• Daytime sleepiness



SLEEP

synthetic form, Remelteon, have numerous side ef-fects. There is a particularly high incidence of falls associated with hypnotics. When drugs are used for insomnia, they should be used as occasionally as possible.

NocturiaNocturia is present in 90% of men and 70% of

women over 80 years of age. It is a major cause of sleep fragmentation, daytime fatigue, and falls. A physiological loss of increased arginine vasopres-sin (antidiuretic hormone) at night, together with an increase in atrionaturetic hormone with aging leads to increased nocturnal urination. Further aging is associated with a smaller bladder capacity, in-creased urge incontinence, and lower urinary tract symptomatology increasing the desire to void at night. Persons with Alzheimer’s disease also have a decrease in arginine vasopressin. Edema fluid is reabsorbed at night when the person becomes recumbent , increasing the urine volume at night. A number of medical conditions, e.g., diabetes mel-litus, hypercalcemia, and renal failure, and medica-tions, e.g., diuretics and lithium, lead to polyuria. Prostate hyper t rophy results in an increased blad-der volume. Other factors altering bladder storage

TABLE 2. Diseases Associated with Insomnia• COPD• Heart failure• Pain• Restless leg syndrome• Depression• Urinary incontinence• Pruritis• Gastric acid reflux disease• Hyperthyroidism• Parkinson’s disease• Nocturia

TABLE 3. Drugs associated with insomnia• Donapezil• Selective Serotonin Reuptake

Inhibitors (SSRIs)• Steroids• Theophylline• Caffeine• Beta agonists• Diuretics

are constipation and drugs, e.g., an-ticholinergic drugs and cholinesterase inhibitors.

The approach to treating nocturia includes:• A v o i d f l u i d ,

alcohol, or caf-feine for 3 hours before going to bed.

• If edema is pres-ent, use compres-sion s tock ings ,

SLEEP and Aging

(continued from page 4)


take an afternoon nap, and el-evate legs for one to two hours before going to sleep.

• Hypnotics can reduce nighttime urine volume.

• If the person has urge inconti-nence, use a short-acting anti-cholinergic at bedtime.

• Treat lower urinary tract symp-tomatology.

• In persons with a large postvoid residual, consider urinary cath-eterization before going to bed.

• Low-dose desmopressin (0.1 mg) may help, but it can lead to hypo-natremia.

Sleep ApneaSleep apnea occurs when a

person has multiple episodes of apnea during sleep, leading to hy-poxia. It is commonly associated

SLEEP and Aging(continued from page 5)

with excessive snoring. The most common type is obstructive sleep apnea which is seen in obese per-sons with a short neck. Central sleep apnea is rare in communi-

ty-dwelling older persons, but it is the most common cause of sleep apnea in the nursing home. Cheyne-Stokes breathing, which occurs in persons with heart fail-

TABLE 4. Saint Louis University Screen for Sleep Apnea If 3 or more points, person should be referred for sleep testing Excessive daytime sleepiness Excessive snoringAbnormal breathing pattern at night Person has more than 3 apneic episodes at night Person falls asleep while driving Person falls asleep while reading Person has BMI > 32 Person has a short neck

POINTS111

3

2111


SLEEP SLEEP and Aging

(continued from page 6)

ure, is a form of central sleep dis-ordered breathing.

Sleep apnea is associated with excessive daytime sleepi-ness, nighttime sweating, and morning headaches. Persons with sleep apnea tend to develop high blood pressure, hyperglycemia, memory disturbances, stroke, ar-rhythm i a s , a n d h e a r t f a i l u r e . A simple screen for sleep ap-nea is given in Table 4.

W h e n sleep apnea is suspected, a p e r s o n s h o u l d b e r e f e r r e d t o a s l e e p s p e c i a l i s t for nocturnal polysomnography testing. Treatment is using Con-tinuous Positive Airway Pressure (CPAP). Many persons struggle to use this and require reinforcement of the importance of its use and help from a respiratory therapist to teach methods to make CPAP more acceptable. In some cases, low level CPAP settings provide better outcomes. Other treatment strategies include dental appli-ances and surgery.

Other sleep disordersPeriodic limb movements dur-

ing sleep result in difficulty in falling asleep, nocturnal awaken-ings, and non-restful sleep. When

the definition of more than 5 leg movements per hour is used, 45% of community-dwelling persons over 65 years of age have this condition. Restless legs syndrome is the need to move one’s legs due to tingling or unpleasant feel-ings in the leg. The treatment of choice is the dopamine agonist

ropinirole. A ferritin level should be obtained in all these patients because if it is low, intravenous iron may decrease abnormal leg movements.

Rapid eye movement sleep behavior disorder occurs in about 1 in 200 persons older than 70 years. These persons have elabo-rate movements during sleep such as shouting out, kicking, hitting, or singing. Both clonazepam and melatonin have been used to treat this disorder.

Other sleep disorders include tooth grinding (bruxism), arousal disorders (sleep walking), sleep onset paralysis, and hypnagogic hallucinations.

Meals on Wheelsmnemonic for treatable

causes of weight loss(as mentioned in the editorial)

edications

motional (depression)

lcoholism, elder abuse

ate-life paranoia

wallowing problems

ral problems

osocomial infections (H pylori, tuberculosis)

andering and other dementia-related behaviors

yperthyroidism, hyperglycemia, hypoadrenalism, hypercalcemia, hypertension (pheochromocytoma)

nteral problems (Celiac disease, pancreatic disease)

ating problems

ow-salt, low-cholesterol (therapeutic) diets

tones (cholecystitis), shopping/meal preparation problems

MEALSON

W

H

E

EL

S


Saint Louis University Highly Ranked in US News & World Report

Once again, Saint Louis University remains highly ranked in US News & World Report’s academic geriatric rankings.

New Edition of Pathy Textbook of Geriatrics published

Aging and Sleep 2012The 2012 International Aging and Sleep meeting was held in Paris,

France, in June. Both of the keynote addresses were given by geriatricians from Saint Louis University. On the first day, Dr. John Morley set the tone by stressing the importance of sleep in allowing older persons to age success-fully. On the second day, Professor Joseph Flaherty introduced the problems of delirium and its relationship to anesthesia.

Drs, Joseph H. Flaherty (l) and John E. Morley (r) pose for this picture outside the Pasteur Institute in Paris. The Pasteur Institute is a private foundation dedicated to the study of biology, micro-organisms, diseases, and vaccines. It is named after Louis Pasteur. For over a century, the Institut Pasteur has been at the forefront of the battle against infectious disease.

A new edition of the Pathy geriatric textbook was recently published. Now in its fifth edition, this comprehensive textbook of geriatric medical practice provides up-to-date, evidence-based, and practical information about all the major medical problems of aging citizens. Containing 41 new chapters covering new infections, treatments, approaches to care, and end of life care, Pathy’s Principles and Practice of Geriatric Medicine includes expanded sections on acute stroke, dementia, cardiovascular disease and health, respiratory diseases, and training. To capture an international perspective this new text has contributions from a global editorial team.The text is edited by our own Dr. John Morley along with Drs. Alan Sinclair from England, and Bruno Vellas from France.


STOP AND WATCH TOOL

Transfers are DangerousNumerous studies

have demonstrated that transfers be-

tween hospitals and nursing homes are associated with numerous miscommunica-tions and medication er-rors. One in four persons admitted from a hospital to a nursing home is liable to be readmitted to the hospi-tal within 30 days. There is increasing awareness that we all need to do better to reduce these problems.

One program that has shown some success is the INTERACT (Interventions to Reduce Acute Care) pro-gram, developed by Joseph Ouslander, MD, and his

colleagues. This program provides a variety of tools to help reduce transfers and improve the transfer pro-cess when it occurs. The process begins by ensuring that appropriate advance directives are in place at the time of nursing home admission. A major inno-vation was to develop the STOP AND WATCH tool for nurses aides to allow early detection of condi-tion changes. Other tools include care paths, transfer forms, and a form to help develop a quality improve-ment program. These forms are available at www.inter-act2.net.

STOP

AND

WATCH

eems different from usualalks or communicates less than usualverall needs more help than usualarticipated in activities less than usual

te less than usual

rank less than usual

eight change

gitated or nervous more than usual

ired, weak, confused or drowsy

hange in skin color or conditionelp with walking, transferring, toileting more than usual


SLU Develops Two New Screening TestsSt. Louis University has developed two new screening

tests in response to needs identified by the clinical and medical research communities.

The SOCIAL mnemonic was developed to examine the effects of psychosocial frailty. Preliminary data using SOCIAL suggests that psychosocial frailty has equally bad outcomes to physical frailty. While there is some overlap, the two scales mostly identify different persons. Preliminary validation data was presented by Dr. Ted Malstrom at the IANA meeting in Albuquerque in July, 2012.

The FRAX® tool was developed by WHO (World Health Organization) to evaluate fracture risk in patients. The development of the FRAX® for osteoporosis and the recognition by clinicians that the questions are as effec-tive as the Bone Mineral Density test in identifying those needing treatment for osteoporosis opened the question if this could not be secondarily done for sarcopenia (age-related muscle mass).

Dr. John Morley presented a simple screening tool for sarcopenia, the SARC-F, at the National Institutes of Health conference on Sarcopenia in May. Previously, SLU has developed three highly utilized clinical screen-ing tests – The St. Louis University ADAM for late onset hypogonadism, the VA St. Louis University Mental Sta-tus Exam (SLUMS Exam), and the Simplified Nutritional Assessment Questionnaire (SNAQ).

sluggishness

sadness

outside activity

cognition

income adequacy

adaptation to neighborhood

lethargy

SOCIAL

S A R C Fassistance walking

rising from chair

climbing one flight stairs

falls


got delirium?

whose wife describes him as a “brilliant man, a scientist who can explain complex chemistry and physics.” But when he was sick in the hospital, he developed delirium, “he was talking wild nonsense and taking his clothes off.”1

The website of the American Delirium Society states that de-lirium is very common among older patients in the hospital, is often missed or misdiagnosed (as demen-tia or “just confusion” because the patient is older and in the hospital), and has serious consequences.2 (See

Table 1 on page 14.) Although the type of delirium discussed on NPR (often called “agitated delirium” or “hyperalert delirium”) gets the attention of doctors, nurses, and families, it is perhaps more impor-tant to recognize the “hypoalert” or “somnolent” type of delirium. These patients are often just con-sidered “sleepy” or “sedated,” but in fact, some underlying medical illness could be smoldering. Even if the cause is medication (e.g., overse-dation in the intensive care unit, or use of medication for patients who

are agitated), this is still de-lirium, and is associated with the negative consequences noted in Table 1 (see page 14).

So what exactly is delir-ium? References to patients with delirium date as far back as the time of Hippocrates. The first textbook dedicated solely to this topic (pub-lished in 1980), described delirium as “a clinically important sign of cerebral functional decompensation

The “got delirium” slogan may never catch on like the “got milk” slogan did. However, public awareness of delirium is gaining momentum. In August 2009, a story on National Public Radio (NPR) described delirium as a “sudden and frightening onset of confusion.” The story was about an active 79-year old man



Falls in Older Adults: Prevention is the Key

Facts On Falls

1/3 of community dwellers > 65 fall each year

Of those who have fallen will fall again

1/6 of nursing home residents will fall

Reducing RisksCan Make a Difference! Outcomes of falls:

Hip fracture Head injury Soft tissue injury Lacerations Other (i.e. vertebral or

Colles fractures) Pain Fear of falling Decreased activity and

functional decline Cost may be up to $55

billion annually by 2020

What You Can Do to Prevent Falls

In the Office

Patients don’t tell. AGS 2010 Guidelines for falls include annual screening for falls: Ask about falls annually Ask about frequency and

circumstances of falls

Those with a fall need a multi-factorial fall risk assessment: Focused history Medication review Physical exam including

strength, balance, mobility, neurological function, muscle strength, vision, feet and footwear, orthostasis

Functional Assessment activity/fear of falling/ curtailing activity

Home safety assessment

In the hospital or Long-term Care

Assess patients for fall risks Individualize a plan of care to address

risks + communicate to team Encourage activity levels and exercise

as to prevent decline Make sure the older adult has their

glasses, hearing aids, and walking aids Refer to therapy if needed to evaluate

walking, balance and activities of daily living

Identify dementia and delirium and monitor frequently

Make regular bathroom rounds Check environment and bathroom for

fall risks

General Fall Prevention

Exercise – should include muscle strengthining, flexibility and balance training

Physical therapy for those with a gait/balance problem

Learn to use assistive devices – walker or cane

Annual vision checks and correction as needed

Blood pressure checks for postural hypotension

Vitamin D supplementation as needed

Use a Home Safety Checklist to assess your home for risks

Get Up and Go Test : Timed test of mobility. Have patient rise from a chair, walk to a line or cone 8 feet away, turn and return to the chair, sit down again. Use a standard chair with arms if available, use customary walking aids. See normal times by age below (Rikkli & Jones, 1996).

Average Score for Women (Seconds) 60-64 65-69 70-74 785-79 80-84 85-89 90-94 4.4-6.0 4.8-6.4 4.9-7.1 5.2-7.4 5.2-7.4 6.2-9.6 7.3-11.5

Average Scores for Men (Seconds) 60-64 65-69 70-74 785-79 80-84 85-89 90-94 3.8-5.6 4.3-5.9 4.4-6.2 4.6-7.2 5.2-7.6 5.5-8.9 6.2-10.0

GERIATRICS PAGEin a

Falls in Older Adults: Prevention is the KeyReducing Risks Can Make a Difference!Risk factors for falls include difficulty walking, 4 or more medications, foot problems, unsafe footwear, dizziness or orthostasis, visual prob-lems, and an unsafe home environment.

In the Hospital or Long Term Care ► Assess patients for fall risks ► Individualize a plan of care to address risks + communicate to team

► Encourage activity levels and exercise so as to prevent decline

► Make sure the older adult has his/her glasses, hearing aids, and walking aids

► Refer to therapy if needed to evaluate walking, balance, and activities of daily living

► Identify dementia and delirium and monitor frequently

► Make regular bathroom rounds ► Check environment and bathroom for fall risks


Leukemia is cancer of the bone marrow and blood. It is the uncontrolled build-up of white blood cells, or leukocytes, that eventually crowd out normal cells.

Normal cells that get crowded-out include red blood cells (causing anemia), platelets (causing bleeding or bruising) and infection-fighting white blood cells.

Leukemia is classified by the type of blood cell affected (lymphoblastic or myeloid) and by how quickly it

progresses (acute or chronic). Acute leukemia is primarily a disease of children and the elderly.

Table 1. Four main types of leukemia Cell Type Acute (rapid progression) Chronic (slow progression)

Lymphoblastic “Lymphocytic Leukemia”

Acute Lymphoblastic Leukemia (ALL) Chronic Lymphocytic Leukemia (CLL) Usually involves “B cells”, that are

infection-fighting cells Most common type in children, it also

tends to affect adults over 65

Also involves “B cells” Most common type of leukemia Usually occurs in adults > 55 and men Incurable, but treatable

Myeloid “Myelogenous Leukemia”

Acute Myelogenous Leukemia (AML) Chronic Myelogenous Leukemia (CML) Affects the marrow cell that has the

potential to become white blood cells, red blood cells or platelets (myelocyte)

More common in adults and men

Also affects the myelocyte Mostly affects young adults Very slow-growing (90% of people

with CML are alive after 10 years)

The cause of leukemia is usually unknown, but there are a few risk factors: Radiation (atomic bombs and x-rays)

Benzene exposure (an old solvent) Viruses Table 2. Treatment of Leukemia

Previous chemotherapy ALL Standard therapy is chemotherapy and radiation Chemotherapy is given in two phases:

1. To kill the cancer cells growing in the bone marrow. 2. To eliminate remaining cancer cells in the body.

Radiation is to prevent spread to the brain and spinal cord. Bone marrow transplant if the cancer is very aggressive or recurs.

Five-year survival rates vary by age: 85% in children, 50% in adults. AML High-dose chemotherapy is the main treatment option.

The aim of treatment is complete remission. Median survival is 1-2 years in the elderly.

CLL Stage A and B (5 or less sites involved, no blood suppression and no troubling symptoms), usually require NO treatment. Stage C patients (anemia, low platelets and/or symptoms) are treated with chemotherapy combined with steroids. The five-year survival rate in elderly patients is 60-70%. Many live 10 or more years.

CML The main treatment is imatinib. A rare leukemia in the elderly. The five-year survival rate is 90%.

Infection, kidney failure and bleeding are the most common complications of treatment.

Palliative (comfort) care and advanced care planning are vital parts of treatment.

GERIATRICS PAGE

Falls in Older Adults: Prevention is the KeyGERIATRICS PAGEin a

Leukemia


(continued on next page)

caused by physical illness.”3 The Diagnostic and Statistical Manual of Mental Disorders-V (DSM-V), due out in 2013, will likely define delirium as a disturbance in level of awareness or attention (rather than consciousness, as in the previous Manual), marked by the acute or subacute onset of cogni-

lirium comes from a psychiatric textbook, it is a medical diagnosis because it is caused by a medical illness (sometimes more than one) or a medication.

Delirium should not be con-fused with psychiatric disorders or diagnosis, such as bipolar af-fective disorder or schizophrenia,

both of which can have symptoms such as hallucinations or agitated behavior. Delirium should also not be confused with dementia, which can sometimes have agi-tated behavior.

Is it serious? ABSOLUTELY. As the saying goes, “It’s as serious as a heart attack.” The truth of the matter is that patients with delir-

ium, when compared to patients without delirium (but similar with respect to other illnesses such as pneumonia, stroke, heart attacks, etc.), are more likely to have prob-lems in the hospital (such as falls and difficulty completing tests and treatment), to stay longer in the hospital, to lose physical func-tion (ability to do self care) and to go to a nursing home. They are even more likely to die, not only during the hospital stay, but up to 12 months following hospitaliza-tion.

One consequence of delirium is Long Term Cognitive Impair-ment (LTCI). In the past, most people believed that delirium is re-versible. However, studies (mostly of ICU patients) have shown that patients who are seriously ill and have delirium are more likely to have some residual cognitive impairment many months after the illness.5,6 This research may explain one of the common com-plaints health care professionals hear from family members about their loved ones who were seri-ously ill and confused in the hos-pital, “My husband’s mind was never quite the same.”

Who gets delirium? The most common characteristic (or risk factor) of patients who get delirium is current cognitive im-pairment, i.e., dementia. Discrete defects in the brains of people with dementia cause problems such as memory loss and inability to do daily tasks. Since delirium is con-sidered an “acute injury” to the brain, it makes sense that people with dementia might be more sus-

tive changes attributable to a general medical condi-tion; it tends to have a f luc-tuating course. DSM-V will also likely add supportive features and subtypes, such as hypoactive, hyperactive, and mixed.4

Although the criteria to make a diagnosis of de-

Table 1. • More than 7 million hospitalized Americans suffer from de-

lirium each year.• Among hospitalized patients who survive their delirium epi-

sode, many have “persistent delirium:” � 45% at discharge� 33% at 1 month� 26% at 3 months� 21% at 6 months

• In more than 60% of cases of patients with delirium, delirium is not recognized by the doctors or nurses in the health care system.

• Compared to hospitalized patients with no delirium (after ad-justing for age, gender, race, and comorbidity), delirious pa-tients have:� Higher mortality rates at one month (14% vs. 5%), at six

months (22% vs. 11%), and 23 months (38% vs. 28%);� Longer hospital lengths of stay (21 vs. 9 days); � A higher probability of receiving care in long-term care

setting at discharge (47% vs. 18%), 6 months (43% vs. 8%), and at 15 months (33% vs. 11%);

� A higher probability of developing dementia at 48 months (63% vs. 8%).

got delirium?(continued from page 11)


ceptible to, and suffer more often from, delirium. There are other risk factors such as decreased sensory function (like impaired vision and hearing), dehydration, indwelling urinary catheter use (Foley catheter), restraint use and age over 80 years. Delirium can occur anywhere. It is most com-mon in the ICU and after surgery. It also occurs on the general medical f loors, in the emergency department, in nursing homes and rehabilitation centers.7

What causes delirium? While exact mechanisms aren’t known yet, there is something serious go-ing on in the brain. In fact, some physicians call delirium “acute brain injury.” One of the current theories involves neurotransmit-ters in the brain, the chemicals that are responsible for regula-tion of everything from appetite to sleep. An imbalance in these chemicals can cause confusion, hallucinations, paranoia, and even odd behaviors. Neurotransmitters are involved in psychiatric dis-orders, such as bipolar disorder and schizophrenia. Other theories involve oxygen to the brain and imbalance in hormones such as cortisol and melatonin. Lastly, there are new data to support a neuro-inflammatory hypothesis.

A research group in Ireland has shown that systemic inflamma-tion induced by gram-negative bacterial endotoxin induces work-ing memory deficits in mice with prior pathology in a part of the brain called the basal forebrain cholinergic nuclei.8 This research may help explain why some older people with a urinary tract infec-tion get delirium, while others do not.

While researchers continue working on identifying the un-derlying mechanisms of delirium, what should doctors, nurses, pa-tients and families know about the medical causes of delirium? As noted above (and this needs to be emphasized), delirium is usu-ally caused by a combination of medical illnesses or medications. This situation of many prob-lems leading to one big prob-lem is referred to as “multi-factorial.” For example, a frail older woman with Alzheim-er’s disease who lives in a nursing home may develop pneumonia, which causes a cas-cade of events, such as difficulty sleeping because of the cough, low oxygen, decreased appetite, poor f luid intake and electrolyte abnormalities (high sodium). While all of these problems might make an otherwise healthy person feel very ill and weak, and might even make thinking a bit sluggish,

in this patient, these “insults” to the body, and brain, may lead to delirium.

There are many potential causes of and contributing fac-tors to delirium. Table 2 shows a list of these, and it should be em-phasized that clinicians need to balance a high level of suspicion with a practical approach to the diagnostic work up for patients with delirium.

What is the best treatment for delirium? There are two ways to “treat” delirium. The first is pre-vention. An older patient who is admitted to the hospital should be immediately considered “at risk” for developing delirium. Certain “interventions” may prevent or decrease this risk: early ambula-tion (don’t wait until the illness


is improved; start imme-diately; get out of bed and walk, even if it’s just a few steps); avoid sleeping pills or extra medications unless completely necessary; back rubs and herbal tea may be as effective as medica-tions to help sleep; drink


Table 2. Causes of and/or contributing factors to delirium rugs yes, ears ow O2 state (MI, stroke, PE) nfection etention (of urine or stool) ctal nderhydration/undernutrition etabolic ubdural

DELIRIUM

(S)


plenty of f luid, even if it means taking five sips of water every half hour.9 The second way is to use a hospital environment that is safe, with close nursing observa-tion and interaction, while those medical illnesses that are causing the delirium are identified and addressed. Saint Louis University Hospital and DesPeres Hospital, both located in St. Louis, Mis-souri, have a 4-bed unit within the ACE Unit (Acute Care of the Elderly Unit), to give special care for patients with delirium. This Delirium Room (DR) is often re-ferred to as the Delirium Intensive Care Unit because of the “inten-sity” of the nursing care. Physical restraints are not used, and at all times there is at least one certi-fied nurse assistant (CNA), and oftentimes, an RN or LPN, in the room. The nursing staff is trained to deal with the most difficult behaviors that may arise with de-lirium without using medications to calm or sedate patients. Two studies have shown that deliri-ous patients in the DR compared to non-delirious patients on the ACE Unit, with the same severity of illness, did NOT have loss of function, longer hospital stay and increased in-hospital mortality

that may appear to be potentially dangerous is contrary to our na-ture as healthcare providers (e.g., patients trying to get out of bed by themselves or pulling on oxy-gen tubing). However, allowing patients to respond naturally to their situation while under close observation (which often means standing or sitting very close by), gives the patient some semblance of control in their confused state. Tolerating behaviors also allows the providers clues about what might be bothering the patient. Note well, tolerance is not easy. Finding the proper balance be-tween tolerating an action that may not be immediately detri-mental to the patient and enforc-ing a treatment that, if missed, would have serious immediate consequences has to be individu-alized. Anticipating behaviors is an important part of the care in the DR. Certain behaviors, ac-tions and reactions of patients with delirium seem logical once

they are described and seen on a regular basis. A few of the most common ones with some options for management are described in Table 3.

“Don’t Agitate” is a nursing golden rule in the DR. There are numerous “agitators” in the hos-pital environment, some of which will agitate certain delirious patients while calming others. Reorientation is an example of this dichotomy. The nurses in the DR are trained to attempt it, but not to use it if it doesn’t seem to help. When reorientation does not work, nurses are trained to use distraction techniques (change the subject) or to go along with the disorientation, as long as it is safe. For more on the T-A-DA method, see the following videos that were produced by the VA: https://www.youtube.com/watch?v=GrJypBgHUxk&feature=plcp or https://www.youtube.com/watch?v=iORtNxwMK6o&feature=plcp.


rates, as one might expect with delirium.10,11 In addi-tion, the fall rates in the DRs are close to zero.12

Years of nursing and medical experience in the DR have led to the devel-opment of a model of care for the agitated patient called the T-A-DA meth-od. Tolerating behaviors


Other novel approaches to delirium management include the “Delirium Toolbox”13 and use of focus groups with nurses in order to implement the wealth of ideas nurses already have about man-aging delirium.14

What’s the future of “got de-lirium?” First and foremost, ev-eryone should be more aware of what delirium is. The lay public needs to be aware because of-tentimes the doctors and nurses may not recognize confusion in an older person as delirium. They may just attribute confusion to old age or underlying demen-tia. Public awareness may also drive public policy and behavior of health care professionals and health care systems, especially hospitals. The future for delirious patients, if public awareness has the correct impact, will be a safe, restraint-free hospital (or other environment), that can prevent delirium and support patients with delirium while their under-lying medical illnesses are being treated.

Second, screening and assess-ment for delirium will become more standardized, as will, third, the non-pharmacological ap-proach to prevention and manage-ment of delirium. A good example of this is what has happened in the ICU. An approach called the A-B-C-D-E bundle (Awake and Breathing coordination, Choice of sedatives, Delirium monitor-ing, and Early mobilization) has improved several outcomes for ICU patients, including delirium rates and duration of delirium.15

Table 3. Common behaviors and situations to anticipate among delirious patients, with options for management.

Behaviors/Situations

Patients may pull on things they feel are not normal.

Telemetry monitor and oxygen tubing that most patients are “re-quired” to have to meet admission criteria or because of non-prima-ry physicians involved/ordering interventions (for example, the emergency department physician orders).

What if “attachment” is needed?

Wanting to get out of bed is natural. It may occur more often in delirious patients and at unnatural times.

Management options

“Hiding” these unnatural attachments can help. Us-ing a decoy can also help, for example, taping a false IV on (not in) the patient’s non-dominant arm.

Getting rid of attachments that are not completely necessary and being flex-ible with attachments that do seem necessary.

It is not easy for nurses to get physicians to discon-tinue certain attachments. One of the teaching points in the nursing inservices is the principle of not being afraid to ask physicians to withdraw these.

Try to use it briefly, then get rid of it or hide it. For example, give IV fluids as boluses, instead of a con-tinuous rate. Cover up the precious IV in between the boluses.

This action is so anticipated and encouraged (to promote physical functional recovery) that “standby observation” is better than standby as-sistance.




Are you looking for a past issue of

Aging Successfully? Maybe an article on a particular topic?

Or a screening tool? Ideas for living longer and living stronger?

Upcoming continuing medical education opportunities?

Visithttp://aging.slu.edu

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

RefeRencesOne of the most dramatic and culture-changing practices now involves getting patients who are on ventilator support out of bed within 1-2 days, while they are still on the ventilator.16 (photo).

Fourth, it is possible that new drugs could be developed to block what is causing the insult to the brain, but first research must improve the understanding of the mechanisms of the different behaviors during delirium. Until that time, use of medications to control behavior is just a pharma-cological restraint.17

In summary, delirium is, and should be, in the public eye. De-lirium has serious consequences. Although basic science research into the mechanisms is in its in-fancy, current clinical research has shown that delirium can be prevented some of the time, and if not prevented, it can be managed safely without the use of physi-cal or pharmacological restraints. The future of delirium care is bright! Got delirium?


11. Flaherty JH, Steele DK, Chibnall JT, Va-sudevan VN, Bassil N, Vegi S An ACE unit with a delirium room may improve function and equalize length of stay among older de-lirious medical inpatients. J Gerontol A Biol Sci Med Sci. 2010 Dec;65(12):1387-92

12. Flaherty JH, Little MO. Matching the en-vironment to patients with delirium: lessons learned from the delirium room, a restraint-free environment for older hospitalized adults with delirium. J Am Geriatr Soc. 2011 Nov;59 Suppl 2:S295-300

13. http://www.heartbrain.com/delirium/(ac-cessed August 3, 2012)

14. Yevchak A, Steis M, Diehl T, Hill N, Kolanowski A, Fick D. Managing delirium in the acute care setting: a pilot focus group study. Int J Older People Nurs. 2012

15. Morandi A, Brummel NE, Ely EW. Seda-tion, delirium and mechanical ventilation: the ‘ABCDE’ approach. Curr Opin Crit Care. 2011 Feb;17(1):43-9.

16. Schweickert WD, Pohlman MC, Pohl-man AS, Nigos C, Pawlik AJ, Esbrook CL, Spears L, Miller M, Franczyk M, Deprizio D, Schmidt GA, Bowman A, Barr R, McCal-lister KE, Hall JB, Kress JP. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a ran-domised controlled trial. Lancet. 2009 May 30;373(9678):1874-82

17. Flaherty JH, Gonzales JP, Dong B. An-tipsychotics in the treatment of delirium in older hospitalized adults: a systematic re-view. J Am Geriatr Soc. 2011 Nov;59 Suppl 2:S269-76

are you missing some-thing?

1. http://www.npr.org/templates/story/story.php?storyId=111623212 (accessed July 27, 2012)

2. www.americandeliriumsociety.org (ac-cessed July 27, 2012)

3. Lipowski ZJ. Delirium. Acute brain failure in man. Charles C. Thomas (publisher), Springfield, IL. 1980

4. http://www.dsm5.org/Pages/Default.aspx5. Long-term cognitive impairment and func-

tional disability among survivors of severe sepsis. Iwashyna TJ, Ely EW, Smith DM, Langa KM. JAMA. 2010

6. Girard TD, et al. Delirium as a predictor of long-term cognitive impairment in survivors of critical illness. Crit Care Med 2010 July; 38(7):1513-20.

7. Flaherty JH. The evaluation and manage-ment of delirium among older persons. Med Clin North Am. 2011 May;95(3):555-77

8. Field, R.H., Gossen, A. & Cunningham, C. (2012) Prior pathology in the basal forebrain cholinergic system predisposes to inflam-mation induced working memory deficits: reconciling inflammatory and cholinergic hypotheses of delirium. Journal of Neuro-science, 32 6288-6294.

9. Inouye SK, Bogardus ST Jr, Charpentier PA, Leo-Summers L, Acampora D, Holford TR, Cooney LM Jr. A multicomponent in-tervention to prevent delirium in hospital-ized older patients. N Engl J Med. 1999 Mar 4;340(9):669-76.

10. Flaherty JH, Tariq SH, Raghavan S, Bak-shi S, Moinuddin A, Morley JE A model for managing delirious older inpatients. J Am Geriatr Soc. 2003 Jul;51(7):1031-5.


High Impact Factor for JAMDAJAMDA, the Journal of the American Medical Directors Association,

was given an impact factor of 4.6 by ISI. A medical journal’s impact fac-tor is a complicated, multi-factoral measurement of the average number of times the papers printed in that journal have been cited in similar medical journals. The number is calculated over a two-year period.

This impact factor is better than those obtained by any other clinical geriatric journals including Age and Aging, Journal of the American Geri-atric Society, and Journals of Gerontology A: Biological and Medical Sci-ences. The journal is edited by Dr. John Morley at Saint Louis University. The table below provides the highest-impact papers of all time which have been published in JAMDA.

Table 1. All Time Top Ten JAMDA Articles Based on Google Scholar1

No. Year 1st Author (Ref No.) Subject Number of Citations 1. 2003 Warden et al2 Develop pain assessment scale 304 2. 2005 Vu et al3 Falls in the nursing home 126 3. 2006 Bostick et al4 Review of staffing/quality in NH 104 4. 2003 Villaneuva et al5 Pain assessment...dementing elderly 97 5. 2005 Oliver et al6 End of life care U.S. Nursing homes 87 6. 2008 Rolland et al7 Physical activity/Alzheimer’s 86 7. 2008 Abellan van Kan et al8 Frailty: Toward a clinical definition 80 8. 2003 Baum et al9 Effectiveness-group exercise program 74 9. 2004 Mitchell et al10 Tube-feeding versus hand-feeding 7110. 2007 Rockwood et al11 How should we grade frailty? 71

Ref, reference; NH, nursing homeSource: Google Scholar. Accessed July 14, 2012.1RefeRences

1.http://scholar.google.com/scholar?q=JAMDA+most+cited+articles&hl=en&as_sdt=1%2C26. Google Scholar. Accessed July 14, 2012.2.Warden V, Hurley AC, Volicer L. Development and psychometric evaluation of Pain Assessment in Advanced Dementia (PAINAD) scale. J Am Med Dir Assoc 2003;4:9-15.3.Vu MQ, Weintraub N, Rubenstein LZ. Falls in the nursing home: Are they preventable? J Am Med Dir Assoc 2005;6(3 Suppl):S82-S87.4.Bostick JE, Rantz MJ, Flesner MK, Riggs CT. Systematic review of studies of staffing and quality in nursing homes. J Am Med Dir Assoc 2006;7:366-376.5.Villaneuva MR, Smith L, Erickson JS, et al. Pain assessment for the dementing elderly (PADE): Reliability and validity of a new measure. J Am Med Dir Assoc 2003;4:1-8.6.Oliver DP, Porock D, Zweig S. End of life care in U.S. nursing homes: A review of the evidence. J Am Med Dir Assoc 2005;6(3 Suppl):S21-S30.7.Rolland YM, Abellan van Kan G, Vellas B. Physical activity and Alzheimer’s disease: From prevention to therapeutic perspective. J Am Med Dir Assoc 2008;9:390-405.8.Abellan van Kan G, Rolland YM, Morley JE, Vellas B. Frailty: Toward a clinical definition. J Am Med Dir Assoc 2008;9:71-72.9.Baum EE, Jarjoura D, Polen AE, et al. Effectiveness of a group exercise program in a long-term care facility: A randomized pilot trial. J Am Med Dir Assoc 2003;4:74-80.10.Mitchell SL, Buchanan JL, Littlehale S, Hamel MB. Tube-feeding versus hand-feeding nursing home residents with advanced dementia: A cost comparison. J Am Med Dir Assoc 2004;5(2 Suppl):S22-S29.11.Rockwood K, Abeysundera MJ, Mitnitski A. How should we grade frailty in nursing home patients? J Am Med Dir Assoc 2007;8:595-603.


GRECCs: Translating Aging Research Into Clinical Practice

An article published in the July issue of the Journal of the American Geriatrics Society has highlighted the tremen-dous impact of the Geriatric Research, Educat ion , and Clinical Centers (GRECCs) on aging research and improving care for the elderly. The article concluded that, after more than 30 years, the GRECC program remains a “jewel in the crown of the Veterans Administra-tion.” At present, there are 20 GRECCs around the United States.

T h e G R E C C s p u b l i s h about 1000 articles each year and many of these are highly cited. GRECC research has covered multiple areas from basic mechanisms in the patho-genesis of sarcopenia and de-mentia to a number of clinical intervention programs. The GRECCs have been leaders in

research into late life hy-pogonadism. They have developed sc reen i ng programs for early onset dementia and also for di-agnosing delirium in the intensive care unit. The outstanding translation achievement has been

the development of Geriatric Evaluation and Management Units and the demonstration of their effectiveness.

GRECCs have been lead-ers in geriatric education. In the last decade, 63,000 health professionals received educa-tion from the GRECCs at na-tional conferences and nearly a quarter of a million health pro-fessionals in the VA received education at local conferences. The GRECCs have been a major resource for teaching medical students, residents, and other health professionals about geri-atrics. The VA has also funded

an advanced geriatric fellow-ship to prepare physicians and other health professionals to be academic gerontologists. There have been 136 advanced geriatric fellowships in the last decade. The GRECCs have also produced a large number of enduring clinical education materials.

O v e r a l l , t h e G R E C C s have led the rapid advances in geriatrics in the United States. Their ability to rapidly translate their findings to the clinical arena has made them a particularly potent force in gerontology.


Mini Falls assessMent

1. Less than 7 medicines 2. Not receiving: Antipsychotics or Antidepressives or Benzodiazepines 3. Receiving Vitamin D or 25(OH) vitamin D level >25ng/ml 4. Systolic blood pressure >130 mm Hg 5. No standing BP drop: On standing <10mmHg At 3 min <20mmHg 6. Sitting with buttocks behind trunk 7. Able to rise from chair: With assistance Without assistance 8. Balance: Center of balance not backward Stand with eyes shut Stand on one leg Obvious body sway standing still 9. Gait: Lifts foot off ground Space between feet No knee flexion Heel strike Step over keys Turns without loss of balance Doesn’t stop when asked capital of country 10. No fear of falling 11. No foot deformity 12. No cataracts nor bifocals 13. Not fatigued 14. Can walk one block 15. Can climb one flight of stairs 16. Not lost >5% of weight in 6 months 17. No Fall in last 6 months

naMe sex age place oF residence

YES NO

From: Morley JE, Rolland Y, Tolson D, Vellas B. Increasing awareness of the Factors Producing Falls: The Mini Falls Assessment. J Am Med Dir Assoc. 2012;13(2):87-90.

total

Any checks in the NO column should be addressed immediately.

New Falls Videos for Nursing Home CareThe Geriatrics in a Page on Falls (see page 12) tells us that prevention is the key. Saint Louis University and the

VA have produced two DVDs concerning fall prevention in the nursing home: one on assessments and one on com-mon locations of falls. These 2 DVDs, used in conjunction with the mini-fall assessment below, are designed for brief in-services of nursing home staff. Only one DVD is shown because the second DVD is still being created. How’s that for providing our readers with the latest updates?! To make a request for your own copies of the 2 DVDs, email us at [email protected], and give us your mailing address. You’ll love them. We guarantee it!


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

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

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

Services of the Division of Geriatric Medicine at Saint Louis University

Medical Center include clinics

in the following areas:

Aging and Developmental Disabilities

Bone Metabolism

Falls: Assessment and Prevention

General Geriatric Assessment

Geriatric Diabetes

Medication Reduction

Menopause

Nutrition

Podiatry

Rheumatology

Sexual Dysfunction

Urinary Incontinence

Call for an appointment

314-977-6055(at Saint Louis University)

or314-966-9313

(at Des Peres Hospital)

SERVICES


Upcoming continUing edUcation pRogRams

ever building on the foundation

24TH Annual Saint Louis University

Summer Geriatric Institute

June 11-12, 2013St. Louis, Missouri

USAFor more information, call 314-977-8462.

Multi-disciplinary Certificate Program in Geriatrics for Non-PhysiciansWednesdaysSeptember 19, October 3, 17, 31, November 14, 28, 2012Glendale Heights, ILandThursdaysSeptember 20, October 4, 18, November 1, 15, 29, 2012Canton, IL

OTHER PROGRAMS ARE AVAILABLE. PLEASE CALL 773-930-3200 FOR MORE INFORMATION.


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

This newsletter is a publication of:

Division of Geriatric Medicine

Department of Internal Medicine

Saint Louis University School of Medicine

St. Louis Veterans Affairs Medical Center

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

This project is supported by funds from the Division of State, Community and Public Health (DSCPH), Bureau of Health Professions (BPHr), Health Resources and Services Administration (HRSA), Department of Health and Human Services (DHHS) under grant number UB4HP19060; Gateway Geriatric Education Center for $1.2 million, and the VA Office of Rural Health grant FY2012 ORH Project ID Number: 811. This information or content and conclusions are those of the authors and should not be construed as the official position or policy of, nor should any endorsements be inferred by the DSCPH, BHPr, HRSA, DHHS, or the U.S. Government.

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

Nina Tumosa, Ph.D.Editor; Health Education Officer, St. Louis VA Medical Center - Jefferson Barracks; Executive Director, Gateway GEC; Professor, Division of Geriatric Medicine, Department of Internal Medicine, Saint Louis University School of Medicine.

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

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

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

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