Fall 2012 Vol. XXII, No.

SLEEP and Aging

Sleep quality plays an important role in quality of life. Adequate sleep plays a key role in the bodys 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 particularly poor sleep. The average nursing home resident tends to sleep in bouts of about 20 minutes, then awakens, and
(continued on page 4)

Questions? FAX: 314-771-8575

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Aging Successfully, Vol. XXII, No. 1

SLU Faculty Named Best Doctors

Seven members of the faculty of Saint Louis Universitys 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 SLUs previous fellows were honored by being included in the Best Doctor list. They are: Lakshmi Bandi, Mark Gunby, and Hashim Raza.

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: Translating Aging Research into Clinical Practice 21 Mini-Falls Assessment and DVD set 22 SLU GEMS 22 Services 23 Continuing Education Opportunities

Milta Little Elected to AMDA

Milta Little, D.O., was elected to the American Medical 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 Foundations Board of Directors.

Malstrom Wins First Prize

Ted 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 predictive of poor functional outcomes.

Saint Louis University, Veterans Administration present at Alzheimers Associations International Conference
At the 2012 Alzheimers Associations International Conference (AAIC), held in Vancouver, British Columbia, Dr. Lenise Cummings-Vaughn presented 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 Duncan, 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 Alzheimers disease (SAMP8 mouse), it also produced earlier death for the majority of animals. email: aging@slu.edu Questions? FAX: 314-771-8575

Aging Successfully, Vol. XXII, No. 1

Editorial
t is now clear that persons who monic (see page 7) to is effective as a screener in are either pre-frail or frail are look for treatable cause middle-aged as well as older of weight loss. more likely to develop disability, persons. Besides predicting be institutionalized, and have excess Having demona decline in Activities of Daily mortality. The concept that frailty could strated that the FRAIL Living (ADLs) and Instruquestionnaire is a simbe objectively measured was first shown mental Activities of Daily Livple, effective screen, by Dr. Linda Fried and her colleagues in ing (IADLs), it also predicts and that it also is a the Cardiovascular Health Study. Their gait speed. Slow gait speed guidepost to treatment, methodology for measuring frailty has has been shown to be highly I feel strongly that this proved too complex to be utilized by predictive of increased morscreen should be used the average primary care physician. tality. Thus, we now have a by all physicians seeing The Study of Osteoporotic Fractures simple, easy-to-administer, John E. Morley, MB, BCh older persons. If they (SOF) had a simpler screen of fatigue, screening test for frailty. do not feel comfortable weight loss, and 5-chair stands. Besides the previous treating the older person, the patient Recently, the FRAIL questionnaire, complexity of the frailty questionnaires, should be referred to a geriatrician. developed by the International Associaphysicians have questioned the utility The International Association of Gertion of Nutrition and Aging, has been of screening for frailty as they felt they ontology and Geriatrics (IAGG) has called demonstrated to be validated in Ausdid not know what to do if they found for this screening to be universally impletralia, Hong Kong, and by our group in someone to be frail. The FRAIL questionmented. Professor Bruno Vellas, from the United States. This is a very simple naire actually points to the appropriate questionnaire which can be adminisToulouse, France, is the President of the interventions in someone who is frail: IAGG, and he has spearheaded this initiatered in under 30 seconds. FATIGUE test for hypothyroidism, tive. In the area around Toulouse, general It has been shown that the FRAIL hypotension, anemia, vitamin B12 questionnaire practitioners have been trained to screen deficiency, and depression performs as F atigue (Are you tired?) for frailty and offered the opportunity to and treat if present. we ll a s the R esistance (Can you refer frail persons to the geriatric center RESISTANCE Enroll person other two in Toulouse if they do not feel comfortable in a resistance exercise walk up a flight of treating the older person themFRAIL screens program. stairs?) selves. and the Ca- A erobic (Can you walk a AEROBIC Enroll person The time for FRAIL has nadian Health in a walking and balance block?) come. Using it will greatly imC are (Ro ckexercise program. I llness (Do you have prove the quality of life for all of wood) ap ILLNESS Consider if polymore than 5 illnesses?) us as we age! proach which pharmacy is a risk factor, L oss of weight (Have adds up the and reduce medications you lost more than 5% whenever possible. number of disof your weight in the LOSS OF WEIGHT Utilize the eases and dislast year?) MEALS-ON-WHEELS mneabilities. FRAIL
Questions? FAX: 314-771-8575 email: aging@slu.edu

Aging Successfully, Vol. XXII, No. 1

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 activity (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 earlier than do younger persons.

Insomnia
Insomnia 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 pulmonary disease, and neurological disorders are particularly common causes of sleep dis4

turbances. Persons with Parkinsons disease tend to have fragmented sleep with frequent awakenings. Dopamine agonists increase neuronal activity leading to sleep disruption. Persons with Alzheimers 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 insomnia requires an aggressive sleep hygiene program.The components of a sleep hygiene program are: Increase daytime exercise Increase daytime socialization Avoid daytime naps Increase daytime exposure to sunlight or high lux (2000) light Avoid caffeine at night Have a regular sleep routine Use bed only for sleeping (and sex), i.e., do not read or watch television in bed Do not drink fluids for three hours before bedtime Keep bedroom as dark and noise-free as possible TABLE 1. Common sleep Have a small glass of hot milk before going to bed complaints in older persons Get up if after 15-30 minutes you fail to fall asleep Difficulty falling asleep Treat nocturia Early waking If these fail, consider a cognitive behavioral therapy Disturbed sleep program for sleep. Increased wakefulness at night Numerous drugs have Decreased sleep time been used to treat insomnia. All of these, with the excep Daytime sleepiness tion of melatonin and its email: aging@slu.edu Questions? FAX: 314-771-8575

Aging Successfully, Vol. XXII, No. 1

SLEEP and Aging

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

(continued from page 4)

are constipation and drugs, e.g., anticholinergic drugs and cholinesterase inhibitors. The approach to treating nocturia includes: Av o i d f l u i d , alcohol, or caffeine for 3 hours before going to bed. If edema is present, use compressio n s t o ck i ng s ,
(continued on page 6)

synthetic form, Remelteon, have numerous side effects. 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.

Nocturia
Nocturia 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 vasopressin (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, increased urge incontinence, and lower urinary tract symptomatology increasing the desire to void at night. Persons with Alzheimers disease also have a decrease in arginine vasopressin. Edema fluid is reabsorbed at night when the person be come s re cu mb e nt , increasing the urine volume at night. A number of medical conditions, e.g., diabetes mellitus, hypercalcemia, and renal failure, and medications, e.g., diuretics and lithium, lead to polyuria. Prostate hy per t rophy results in an increased bladder volume. Other factors altering bladder storage Questions? FAX: 314-771-8575

TABLE 3. Drugs associated with insomnia

Donapezil Selective Serotonin Reuptake Inhibitors (SSRIs) Steroids Theophylline Caffeine Beta agonists Diuretics

email: aging@slu.edu

Aging Successfully, Vol. XXII, No. 1

SLEEP and Aging

(continued from page 5)

take an afternoon nap, and elevate legs for one to two hours before going to sleep. Hypnotics can reduce nighttime urine volume. If the person has urge incontinence, use a short-acting anticholinergic at bedtime. Treat lower urinary tract symptomatology. In persons with a large postvoid residual, consider urinary catheterization before going to bed. Low-dose desmopressin (0.1 mg) may help, but it can lead to hyponatremia.

Sleep Apnea
Sleep apnea occurs when a person has multiple episodes of apnea during sleep, leading to hypoxia. It is commonly associated

with excessive snoring. The most common type is obstructive sleep apnea which is seen in obese persons 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 POINTS Excessive daytime sleepiness 1 Excessive snoring 1 Abnormal breathing pattern at 1 night Person has more than 3 apneic 3 episodes at night Person falls asleep while driving 2 Person falls asleep while reading 1 Person has BMI > 32 1 Person has a short neck 1
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SLEEP and Aging

ure, is a form of central sleep disordered breathing. Sleep apnea is associated with excessive daytime sleepiness, nighttime sweating, and morning headaches. Persons with sleep apnea tend to develop high blood pressure, hyperglycemia, memory disturbances, stroke, arrhythm i a s , and heart failure. A simple screen for sleep apnea is given in Table 4. W h e n sleep apnea is suspected, a person should be referred to a sleep specialist for nocturnal polysomnography testing. Treatment is using Continuous 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 appliances and surgery.

Meals on Wheels
mnemonic for treatable causes of weight loss

(continued from page 6)

(as mentioned in the editorial)

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 ones legs due to tingling or unpleasant feelings in the leg. The treatment of choice is the dopamine agonist

Medications E motional (depression) A lcoholism, elder abuse L ate-life paranoia S wallowing problems O ral problems N osocomial infections (H
pylori, tuberculosis)

Wandering and other Hyperthyroidism,

dementia-related behaviors hyperglycemia, hypoadrenalism, hypercalcemia, hypertension (pheochromocytoma) disease, pancreatic disease)

E nteral problems (Celiac

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 elaborate 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. email: aging@slu.edu

E ating problems L ow-salt, low-cholesterol

(therapeutic) diets

S tones (cholecystitis),

shopping/meal preparation problems

Other sleep disorders

Periodic limb movements during sleep result in difficulty in falling asleep, nocturnal awakenings, and non-restful sleep. When Questions? FAX: 314-771-8575

Aging Successfully, Vol. XXII, No. 1

Aging and Sleep 2012

The 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 successfully. On the second day, Professor Joseph Flaherty introduced the problems of delirium and its relationship to anesthesia.

New Edition of Pathy Textbook of Geriatrics published

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, Pathys 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. Questions? FAX: 314-771-8575

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.

Saint Louis University Highly Ranked in US News & World Report

Once again, Saint Louis University remains highly ranked in US News & World Reports academic geriatric rankings.
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Aging Successfully, Vol. XXII, No. 1

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Transfers are Dangerous

umerous studies have demonstrated that transfers between hospitals and nursing homes are associated with numerous miscommunications and medication errors. One in four persons admitted from a hospital to a nursing home is liable to be readmitted to the hospital 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) program, developed by Joseph Ouslander, MD, and his
Questions? FAX: 314-771-8575

colleagues. This program provides a variety of tools to help reduce transfers and improve the transfer process when it occurs. The process begins by ensuring that appropriate advance directives are in place at the time of nursing home admission. A major innovation was to develop the STOP AND WATCH tool for nurses aides to allow early detection of condition changes. Other tools include care paths, transfer forms, and a form to help develop a quality improvement program. These forms are available at www.interact2.net.
email: aging@slu.edu

STOP AND WATCH TOOL

S eems different from usual T alks or communicates less than usual O verall needs more help than usual P articipated in activities less than
usual

A te less than usual N D rank less than usual Weight change A gitated or nervous more than usual T ired, weak, confused or drowsy C hange in skin color or condition H elp with walking, transferring, toileting more than usual
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Aging Successfully, Vol. XXII, No. 1

SLU Develops Two New Screening Tests

St. 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 effective 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 (agerelated 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 screening tests The St. Louis University ADAM for late onset hypogonadism, the VA St. Louis University Mental Status Exam (SLUMS Exam), and the Simplified Nutritional Assessment Questionnaire (SNAQ).

S O C I A L
C

sadness

outside activity

cognition

income adequacy

adaptation to neighborhood

lethargy

sluggishness

assistance walking

rising from chair

climbing one flight stairs

falls

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got delirium?
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
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 delirium is very common among older patients in the hospital, is often missed or misdiagnosed (as dementia or just confusion because the patient is older and in the hospital), and has serious consequences.2 (See Questions? FAX: 314-771-8575 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 important to recognize the hypoalert or somnolent type of delirium. These patients are often just considered sleepy or sedated, but in fact, some underlying medical illness could be smoldering. Even if the cause is medication (e.g., oversedation in the intensive care unit, or use of medication for patients who email: aging@slu.edu are agitated), this is still delirium, and is associated with the negative consequences noted in Table 1 (see page 14). So what exactly is delirium? References to patients with delirium date as far back as the time of Hippocrates. The first textbook dedicated solely to this topic (published in 1980), described delirium as a clinically important sign of cerebral functional decompensation
(continued on page 14)

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GERIATRICS in a PAGE

Falls Older Adults: Prevention is the Falls ininOlder Adults:Prevention is the Key Key
Facts On Falls

Reducing Reducing Risks Risks Can Make a Difference! Risk factors for falls include difficulty walking, Can 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

1/3 of community dwellers > 65 fall each year

4 or more medications, foot problems, unsafe footwear, dizziness or orthostasis, visual problems, and an unsafe home environment.

Of those who have fallen will fall again 1/6 of nursing home residents will fall

What You Can Do to Prevent Falls

In the Office Patients dont 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 multifactorial 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 General Fall Prevention Exercise should include muscle strengthining, flexibility and balance training In the hospital or Long-term Care

Assess patients for fall risks Assess patients for of risks Individualize a planfall care to address risks + communicate to teamaddress Individualize a plan of care to risks + communicate to team Encourage activity levels and exercise Encourage activity levels and exercise as to prevent decline so as to prevent decline Make sure the older adult has their Make sure the older adult has his/her glasses, hearing aids, and walking aids glasses, hearing aids, and walking aids Refer to therapy if needed to evaluate Refer to therapy if needed to evaluate walking, balance, and activities of daily walking, balance and activities of daily living living Identify dementia and delirium and Identify dementia and delirium and monitor frequently monitor frequently Make regular bathroom rounds Make regular bathroom rounds Check environmentand bathroom for Check environment and bathroom for fall risks fall risks

In the Hospital or Long Term Care

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 4.4-6.0 4.8-6.4 4.9-7.1 Average Scores for Men (Seconds) 60-64 65-69 70-74 3.8-5.6 4.3-5.9 4.4-6.2 785-79 5.2-7.4 80-84 5.2-7.4 85-89 6.2-9.6 90-94 7.3-11.5

785-79 4.6-7.2

80-84 5.2-7.6

85-89 5.5-8.9

90-94 6.2-10.0

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GERIATRICS in a PAGE

Leukemia
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) Acute Lymphoblastic Leukemia (ALL) Usually involves B cells, that are Lymphoblastic infection-fighting cells Lymphocytic Leukemia Most common type in children, it also tends to affect adults over 65 Acute Myelogenous Leukemia (AML) Affects the marrow cell that has the Myeloid potential to become white blood cells, Myelogenous Leukemia red blood cells or platelets (myelocyte) More common in adults and men Chronic (slow progression) Chronic Lymphocytic Leukemia (CLL) Also involves B cells Most common type of leukemia Usually occurs in adults > 55 and men Incurable, but treatable Chronic Myelogenous Leukemia (CML) Also affects the myelocyte Mostly affects young adults Very slow-growing (90% of people with CML are alive after 10 years)

Leukemia is cancer of the bone marrow and blood.

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 Previous chemotherapy Table 2. Treatment of Leukemia

ALL

AML CLL

CML

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. High-dose chemotherapy is the main treatment option. The aim of treatment is complete remission. Median survival is 1-2 years in the elderly. 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. 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.

Questions? FAX: 314-771-8575

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Aging Successfully, Vol. XXII, No. 1

13

got delirium?
(continued from page 11)

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 confused with psychiatric disorders or diagnosis, such as bipolar affective disorder or schizophrenia,

Table 1. More than 7 million hospitalized Americans suffer from delirium each year. Among hospitalized patients who survive their delirium episode, 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 adjusting for age, gender, race, and comorbidity), delirious patients 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%).

tive changes attributable to a general medical condition; it tends to have a fluctuating 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 de14

both of which can have symptoms such as hallucinations or agitated behavior. Delirium should also not be confused with dementia, which can sometimes have agitated behavior. Is it serious? ABSOLUTELY. As the saying goes, Its as serious as a heart attack. The truth of the matter is that patients with deliremail: aging@slu.edu

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 problems in the hospital (such as falls and difficulty completing tests and treatment), to stay longer in the hospital, to lose physical function (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 hospitalization. One consequence of delirium is Long Term Cognitive Impairment (LTCI). In the past, most people believed that delirium is reversible. 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 complaints health care professionals hear from family members about their loved ones who were seriously ill and confused in the hospital, My husbands mind was never quite the same. Who gets delirium? The most common characteristic (or risk factor) of patients who get delirium is current cognitive impairment, 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 considered an acute injury to the brain, it makes sense that people with dementia might be more sus(continued on next page)

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got delirium?
(continued from page 14)

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 common in the ICU and after surgery. It also occurs on the general medical floors, in the emergency department, in nursing homes and rehabilitation centers.7 What causes delirium? While exact mechanisms arent known yet, there is something serious going on in the brain. In fact, some physicians call delirium acute brain injury. One of the current theories involves neurotransmitters in the brain, the chemicals that are responsible for regulation 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 disorders, 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. Questions? FAX: 314-771-8575

in this patient, these insults to A research group in Ireland has the body, and brain, may lead to shown that systemic inflammadelirium. tion induced by gram-negative There are many potential bacterial endotoxin induces workcauses of and contributing facing memory deficits in mice with tors to delirium. Table 2 shows a prior pathology in a part of the list of these, and it should be embrain called the basal forebrain phasized that clinicians need to cholinergic nuclei.8 This research may help explain why some older balance a high level of suspicion people with a urinary tract infecwith a practical approach to the tion get delirium, while others do diagnostic work up for patients not. with delirium. While researchers continue What is the best treatment for working on identifying the undelirium? There are two ways to derlying mechanisms of delirium, treat delirium. The first is prewhat should doctors, nurses, pavention. An older patient who is tients and families know about admitted to the hospital should be the medical causes of delirium? immediately considered at risk As noted above (and this needs to for developing delirium. Certain be emphasized), delirium is usuinterventions may prevent or ally caused by a combination of decrease this risk: early ambulamedical illnesses or medications. tion (dont wait until the illness This situation of many probTable 2. Causes of and/or contributing lems leading to factors to delirium one big probD rugs lem is referred E yes, ears to as multiL ow O2 state (MI, stroke, PE) factorial. For I nfection example, a frail R etention (of urine or stool) older woman I ctal with AlzheimU nderhydration/undernutrition ers disease M etabolic who lives in a (S) ubdural nursing home may develop is improved; start immepneumonia, which causes a casdiately; get out of bed and cade of events, such as difficulty walk, even if its just a few sleeping because of the cough, steps); avoid sleeping pills low oxygen, decreased appetite, or extra medications unless poor fluid intake and electrolyte completely necessary; back abnormalities (high sodium). rubs and herbal tea may While all of these problems might be as effective as medicamake an otherwise healthy person tions to help sleep; drink feel very ill and weak, and might (continued on page 16) even make thinking a bit sluggish, email: aging@slu.edu

Aging Successfully, Vol. XXII, No. 1

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got delirium?
(continued from page 15)

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 observation 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, Missouri, 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 referred to as the Delirium Intensive Care Unit because of the intensity of the nursing care. Physical restraints are not used, and at all times there is at least one certified 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 delirium without using medications to calm or sedate patients. Two studies have shown that delirious 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 rates, as one might expect with delirium.10,11 In addition, the fall rates in the DRs are close to zero.12 Years of nursing and medical experience in the DR have led to the development of a model of care for the agitated patient called the T-A-DA method. Tolerating behaviors 16

that may appear to be potentially dangerous is contrary to our nature as healthcare providers (e.g., patients trying to get out of bed by themselves or pulling on oxygen 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 between tolerating an action that may not be immediately detrimental to the patient and enforcing a treatment that, if missed, would have serious immediate consequences has to be individualized. Anticipating behaviors is an important part of the care in the DR. Certain behaviors, actions 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. Dont Agitate is a nursing golden rule in the DR. There are numerous agitators in the hospital 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 doesnt 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/wat ch?v=iORtNxwMK6o&feature= plcp.

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got delirium?
(continued from page 16)

Other novel approaches to delirium management include the Delirium Toolbox13 and use of focus groups with nurses in order to implement the wealth of ideas nurses already have about managing delirium.14 Whats the future of got delirium? First and foremost, everyone should be more aware of what delirium is. The lay public needs to be aware because oftentimes the doctors and nurses may not recognize confusion in an older person as delirium. They may just attribute confusion to old age or underlying dementia. 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 underlying medical illnesses are being treated. Second, screening and assessment for delirium will become more standardized, as will, third, the non-pharmacological approach to prevention and management 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 monitoring, and Early mobilization) has improved several outcomes for ICU patients, including delirium rates and duration of delirium.15
(continued on page 18)

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. Management options Hiding these unnatural attachments can help. Using a decoy can also help, for example, taping a false IV on (not in) the patients non-dominant arm. Getting rid of attachments that are not completely necessary and being flexible with attachments that do seem necessary. It is not easy for nurses to get physicians to discontinue 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 continuous 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 assistance.

Telemetry monitor and oxygen tubing that most patients are required to have to meet admission criteria or because of non-primary 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.

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Aging Successfully, Vol. XXII, No. 1

17

got delirium?
(continued from page 17)

One 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 pharmacological restraint.17 In summary, delirium is, and should be, in the public eye. Delirium has serious consequences. Although basic science research into the mechanisms is in its infancy, 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 physical or pharmacological restraints. The future of delirium care is bright! Got delirium?

R efeRences
1. http://www.npr.org/templates/story/story. php?storyId=111623212 (accessed July 27, 2012) 2. www.americandeliriumsociety.org (accessed 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.aspx 5. Long-term cognitive impairment and functional 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 management 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 inflammation induced working memory deficits: reconciling inflammatory and cholinergic hypotheses of delirium. Journal of Neuroscience, 32 6288-6294. 9. Inouye SK, Bogardus ST Jr, Charpentier PA, Leo-Summers L, Acampora D, Holford TR, Cooney LM Jr. A multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med. 1999 Mar 4;340(9):669-76. 10. Flaherty JH, Tariq SH, Raghavan S, Bakshi S, Moinuddin A, Morley JE A model for managing delirious older inpatients. J Am Geriatr Soc. 2003 Jul;51(7):1031-5. 11. Flaherty JH, Steele DK, Chibnall JT, Vasudevan VN, Bassil N, Vegi S An ACE unit with a delirium room may improve function and equalize length of stay among older delirious medical inpatients. J Gerontol A Biol Sci Med Sci. 2010 Dec;65(12):1387-92 12. Flaherty JH, Little MO. Matching the environment to patients with delirium: lessons learned from the delirium room, a restraintfree environment for older hospitalized adults with delirium. J Am Geriatr Soc. 2011 Nov;59 Suppl 2:S295-300 13. http://www.heartbrain.com/delirium/(accessed 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. Sedation, delirium and mechanical ventilation: the ABCDE approach. Curr Opin Crit Care. 2011 Feb;17(1):43-9. 16. Schweickert WD, Pohlman MC, Pohlman AS, Nigos C, Pawlik AJ, Esbrook CL, Spears L, Miller M, Franczyk M, Deprizio D, Schmidt GA, Bowman A, Barr R, McCallister KE, Hall JB, Kress JP. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial. Lancet. 2009 May 30;373(9678):1874-82 17. Flaherty JH, Gonzales JP, Dong B. Antipsychotics in the treatment of delirium in older hospitalized adults: a systematic review. J Am Geriatr Soc. 2011 Nov;59 Suppl 2:S269-76

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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?
Visit http://aging.slu.edu or
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High Impact Factor for JAMDA

JAMDA, the Journal of the American Medical Directors Association, was given an impact factor of 4.6 by ISI. A medical journals impact factor 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 Geriatric Society, and Journals of Gerontology A: Biological and Medical Sciences. 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. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Year 2003 2005 2006 2003 2005 2008 2008 2003 2004 2007 1st Author (Ref No.) Warden et al2 Vu et al3 Bostick et al4 Villaneuva et al5 Oliver et al6 Rolland et al7 Abellan van Kan et al8 Baum et al9 Mitchell et al10 Rockwood et al11 Subject Number of Citations Develop pain assessment scale 304 Falls in the nursing home 126 Review of staffing/quality in NH 104 Pain assessment...dementing elderly 97 End of life care U.S. Nursing homes 87 Physical activity/Alzheimers 86 Frailty: Toward a clinical definition 80 Effectiveness-group exercise program 74 Tube-feeding versus hand-feeding 71 How should we grade frailty? 71

Ref, reference; NH, nursing home Source: Google Scholar. Accessed July 14, 2012.1
R efeRences

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 Alzheimers 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.

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Aging Successfully, Vol. XXII, No. 1

19

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 tremendous impact of the Geriatric Re se a rch , E ducat ion , a nd 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 Administration. At present, there are 20 GRECCs around the United States. T he GR ECCs publish about 1000 articles each year and many of these are highly cited. GRECC research has covered multiple areas from basic mechanisms in the pathogenesis of sarcopenia and dementia to a number of clinical intervention programs. The GRECCs have been leaders in research into late life hypogonadism. They have d e ve l o p e d s c r e e n i n g programs for early onset dementia and also for diagnosing delirium in the intensive care unit. The outstanding translation achievement has been
20

the development of Geriatric Evaluation and Management Units and the demonstration of their effectiveness. GRECCs have been leaders in geriatric education. In the last decade, 63,000 health professionals received education from the GRECCs at national conferences and nearly a quarter of a million health professionals 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 geriatrics. The VA has also funded

an advanced geriatric fellowship 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. Overall, the GR ECCs 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.

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New Falls Videos for Nursing Home Care

The 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 common 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. Hows that for providing our readers with the latest updates?! To make a request for your own copies of the 2 DVDs, email us at aging@slu.edu, and give us your mailing address. Youll love them. We guarantee it!

Mini Falls assessMent

naMe sex age place oF residence

YES 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 Doesnt 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
total Any checks in the NO column should be addressed immediately.

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.

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21

SERVICES
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 aging@slu.edu 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)

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

22

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Upcoming continUing edUcation pRogRams

ever building on the foundation
24TH Annual Saint Louis University

Summer Geriatric Institute

June 11-12, 2013 St. Louis, Missouri USA

Multi-disciplinary Certificate Program in Geriatrics for Non-Physicians

For more information, call 314-977-8462.

Wednesdays September 19, October 3, 17, 31, November 14, 28, 2012 Glendale Heights, IL

and Thursdays September 20, October 4, 18, November 1, 15, 29, 2012 Canton, IL

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

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Aging Successfully, Vol. XXII, No. 1

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Non-Profit Org. US Postage St. Louis, MO Permit No. 3252

PAID

Division of Geriatric Medicine Saint Louis University School of Medicine 1402 South Grand Boulevard St. 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 Medicine Division of Geriatric Medicine 1402 South Grand Boulevard, Room M238 St. Louis, Missouri 63104 e-mail: aging@slu.edu 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.

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