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Fall 2011 Vol. XXI, No.

Its a Winner!

Treating Dementia with Baseball Memories

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

eminiscence therapy has been developed for people with Alzheimers disease to stimulate them to talk about their memories. Therapists show older people with memory problems photographs, old programs and other familiar items, and patients eagerly share pleasant memories from their past experiences. The simple yet innovative

treatment enhances mood and communication skills and may even improve intellectual ability. A Saint Louis University geriatrician and the acting director of the Geriatric Research, Education, and Clinical Center (GRECC) at the St. Louis Veterans Affairs Medical Center (VAMC) are convinced that
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Aging Successfully, Vol. XXI, No. 2

Dr. Tumosa Assumes New Role

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

1 Its a Winner! Cardinals Reminiscence League 2 News at SLU 5 Morley Receives Prestigious Award 6 SLU Listed in Best Hospitals 6 JAMDA Takes Lead in Impact Factor Ranking 7 Improving Care for Veterans 8 DVD Series Promotes Quality Care 8 Team Based Care for Older Veterans 10 Transitions and Medications 12 Immunosenescence 13 Sarcopenia 14 Editorial 15 Dementia with Agitation 17 PTSD in Older Adults 20 The Significance of Red Flags 21 Geriatric Syndromes and Options for Interventions 23 Continuing Education Opportunities

SLU Faculty Named Best Doctors

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

Golden Apple Award

This year, the Class of 2011 has chosen Andrew J. Lechner, PhD, (pre-clinical) and the Division of Geriatrics own Miguel A. Paniagua, MD, (clinical) to honor for their teaching, mentoring and over-all positive influence during the Class of 2011s clinical years.

Miguel A. Paniagua, MD, Appointed to the National Board of Medical Examiners

The National Board of Medical Examiners (NBME) is pleased to announce that Miguel A. Paniagua, MD, was appointed as a member of the National Board of Medical Examiners as a Test Committee Representative. Dr. Paniagua serves as Associate Professor of Medicine and Director of the Internal Medicine Residency Program at Saint Louis University School of Medicine. He has been involved in test development activities at the National Board since 2008. The NBME is an independent, not-for-profit organization that provides highquality examinations for the health professions. Protection of the health of the public through state of the art assessment is the mission of the NBME, along with a major commitment to research and development in evaluation and measurement. The NBME develops the three-step USMLE, which provides a common evaluation system for applicants seeking initial licensure to practice medicine in the United States. USMLE is a joint program of the National Board of Medical Examiners and the Federation of State Medical Boards. Results of USMLE are reported to individual licensing authorities in the United States and its territories for use in granting the initial license to practice medicine.

Aging Successfully, Vol. XXI, No. 2


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Cardinals Reminiscence League

if they build it, fans will come. The two have founded a new support group for Veterans who have dementia that uses baseball to trigger happy memories and engage participants in socializing. The idea has the backing of the St. Louis Cardinals and the Alzheimers Association. This project provides social interactions for people with memory problems on a topic they can remember well- their love of baseball, says Nina Tumosa, Ph.D., acting director of the St. Louis VAMC GRECC. Were reaching a group of patients - typically older men - who have trouble socializing and maintaining friendships. Weve gotten feedback from caregivers on how engaged and happy their loved ones have been after sessions, says Tumosa, who also is a professor of geriatrics at Saint Louis University. Baseball is a universal language, particularly for St. Louisans, says John Morley, M.D., a SLUCare geriatrician, Director of Geriatrics at Saint Louis University and a dyed-in-the-wool Cardinals fan. In launching the therapy group, he borrowed the idea of using sports to engage older adults with memory problems from Debbie Tolson, a Scottish nurse and professor at Glasgow Caledonian University who helped develop a similar program reflecting on soccer. Their project had the support of the Scottish Football Museum and Alzheimer Scotland.

Many other therapy groups that use happy memories to spark discussions revolve around topics like cooking, movies and old music - subjects that many men may not be so passionate about. In St. Louis, the Cardinals are such a prominent part of peoples lives and most of us have many fond memories about the Cardinals, making baseball an ideal topic for reminiscing, adds Dr. Morley. The effort is embraced by all of the collaborators. Brian Finch, Manager of the Stadium Tours and Museum Outreach at the St. Louis Cardinals Hall of Fame Museum expressed his support of the Cardinals Reminiscence League, saying, Baseball provides a great narrative for the history of our city, country, and culture. I dont think Ive been a part of a more meaningful application of this concept, especially when you consider the positive benefits of the League to these Veterans and its impact to them on a daily basis. He added, Clearly the League was established to share memories, but it is clearly creating new memories for these Veterans as well. Its really special to see them respond with vigor to stories and recollections of their colleagues. Carroll Rodriguez, Chief Operating Officer of the St. Louis chapter of the Alzheimers Association said, The Cardinals Reminiscence League provides stimulation and socialization for people with early memory loss... a fun approach that helps keep people with dementia engaged and focused on a favorite pastime, the St. Louis Cardinals. (continued on page 4)

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Aging Successfully, Vol. XXI, No. 2

Cardinals Reminiscence League

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About 10 Veterans from World War II and the Korean and Vietnam conflicts and nearly as many volunteers gather every other week for meetings that look as

much like happy hour at a sports bar (sans beer) as a therapy session. They shoot the breeze about Stan the Man Musial, Sportsmans Park, and sweet Lou Brock. An animated group of Veterans and their caregivers recently came together for the groups first meeting. After a rousing rendition of Take Me out to the Ballgame, where it seemed only a few words got lost, the meeting was underway. Veterans talked about their war experiences and some baseball connections. One Veteran, who lived next to Sportsmans Park, reminisced that when the game was over, the players would come over and drink his beer. Another talked about meeting Jack Buck at the race track. The volunteer coordinators then opened a book of baseball pictures that the Cardinals have created. Sparked by a photo of Stan the Man in his navy uniform, the conversation then focused on one of baseballs greatest all-time hitters. The idea is so simple, Morley says. When you get people talking about something they care about, their mood and ability to communicate im4

proves. Mental stimulation is a significant part of therapy for dementia. The group took a field trip to Busch Stadium to see sports memorabilia from the St. Louis Cardinals Hall of Fame collection. They talked about an enlarged photo from the 1934 World Champion Gashouse Gang. They then donned white gloves so as to be able to hold the bat used by Stan Musial, a recent Medal of Freedom recipient and himself suffering from Alzheimers disease. The impact of the program is shown by the quote from one of the patients sons. My dad really enjoys the Cardinals Reminiscence League. It is one of the big highlights in his life. I know he would hate to miss this special event. The whole program is beautifully summed up by this quote from one of the volunteers: As a life-long, die-hard Cardinals fan, I was happy to volunteer for the Cardinals Reminiscence League. I knew I could contribute some personal stories and baseball memories. What I didnt know was the impact I could have on our Veterans in such a short time. Most of them came into the League quietly and a little sad. By the end of the first meeting and throughout the season... they come in earlier and earlier each week, with so much anticipation and infectious enthusiasm, and I find not only a dramatic change in the Veterans, but in myself as well. - Kathy Leonard Reflecting on sports often brings joy and happy memories for those who have Alzheimers disease and their friends and families. To participate or volunteer as a coordinator for the St. Louis Cardinals Reminiscence League, call 314-894-6570.

Aging Successfully, Vol. XXI, No. 2


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Dedicated To Long Term Care Medicine

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

John Morley, MB, BCh, Editorin-Chief of the Journal of the American Medical Directors Association (JAMDA), is the 2011 recipient of the James Pattee Award for Excellence in Education from the American Medical Directors Association (AMDA). The Pattee Award recognizes significant contributions to the educational goals of AMDA and efforts to enhance the associations educational structure and framework, It is named after the physician who is considered the father of AMDAs Core Curriculum in Medical Direction, In 2006, Dr. Morley became JAMDAs editor. Within a year, the journal was included in Index Medicus, the prestigious index of scientific literature. Last year, JAMDA was rated as the 7th most-cited journal in a field of nearly 40 geriatric titles. Dr. Morley has filled JAMDAs pages with a sheer determination and the ability to express what long term care practice should be, said AMDAs 2010-2011 President Paul Katz, MD, CMD. In presenting the award, he added, Dr. Morley has talked about JAMDA across the globe and spread AMDAs message of the beauty of caring for the aged. For many, hearing him speak has been a turning point in their career choice. He has affected many, many people Questions? FAX: 314-771-8575 and singlehandedly elevated the stature of long term care physicians with every page and every word, Since 1989, Dr. Morley has been the Dammert Professor of Geronwhom he said, Someday I hope I have a physician who cares for me as much as he does about his patients. Dr. Morley spoke of his experiences attending AMDAs annual conven-

tology and Director, Division of Geriatric Medicine at Saint Louis University Medical Center. In addition, he is medical director of three nursing facilities. Any award comes to you because those around you have given you the opportunity to do things for others, said Dr. Morley in accepting the award. He talked about how Dr. Pattee first introduced him to geriatrics and got him involved in teaching for AMDAs Core Curriculum in Medical Direction. He thanked many of his colleagues, including Charles Marshall, MD, of email:

tion, Long Term Care Medicine, saying, I have been coming here for 21 years. It teaches about caring for our elder patients more than any other organization or meeting. Board certified in internal medicine, endocrinology, and geriatric medicine. Dr, Morley has edited 16 books, including Medical Care in the Nursing Home, Geriatric Nutrition, and Endocrinology of Aging. He has published more than 800 papers, with a major
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Aging Successfully, Vol. XXI, No. 2

Services of the Division of Geriatric Medicine at Saint Louis University Medical Center include clinics in the following areas:

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

Aging and Developmental Disabilities Bone Metabolism Falls: Assessment and Prevention General Geriatric Assessment Geriatric Diabetes

JAMDA Leads Impact Factor

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

Medication Reduction Menopause Nutrition Podiatry Rheumatology Sexual Dysfunction Urinary Incontinence

Impact Factors of Clinical Geriatric Journals

JAMDA J Gerontol Biol Med Sci JAGS Am J Geriatr Psychiat Age Aging Drug Aging J Nutr Health Aging 6 4.492 3.988 3.913 3.566 2.719 2.656 2.393 email:

Call for an appointment

(at Saint Louis University) (at Des Peres Hospital)

314-977-6055 or 314-966-9313

Aging Successfully, Vol. XXI, No. 2

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Improving Care for Veterans in Rural Clinics Across the Nation

By Josea Kramer, PhD

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

40% of veterans live in rural areas

Scholar initiating a quality improvement project to improve care for the older Veterans in his or her clinic. Eleven of these quality improvement projects were on display at the annual VA Geriatrics and Extended Care Leads conference this spring. These innovative improvements were designed and implemented entirely in the rural clinics. The projects addressed seven common issues: medication reconciliation, fall prevention, screening for age-related health problems, life planning, reducing morbidity and mortality related to poor dental hygiene, and improving process of care in home based primary care and in timely processing of laboratory work. Each Scholar received personalized coaching in the quality improvement process from the VA National Quality Scholars ProQuestions? FAX: 314-771-8575

gram and from the Tennessee Valley Geriatric Research Education and Clinical Center (GRECC). The GRECCs are centers of excellence dedicated to advancing knowledge and improving care for older Veterans. The director of the Geriatric Scholars Program, Dr. Josea Kramer from the VA Greater Los Angeles GRECC, explained that these presentations to thought-leaders demonstrate effective approaches to problems faced in many clinics and may stimulate similar improvements in other VA settings. While addressing common problems, each project took a unique approach. For instance, medication reconciliation was part of a strategy to improve adherence at Rutherford, NC, and was part of the discharge planning process for staff at Fallon, NV. The projects included the typical clinic setting as well as home-based primary care. For example, staff at the clinic at Tulare, CA, initiated screening for cognitive impairment among all older patients, finding that this common syndrome had

been under-identified among clinic patients. Staff from home-based programs at Mt. Vernon, MO, and Montrose, NY, initiated fall assessments and interventions reducing falls among home-bound patients. Some projects streamlined VA processes to improve patient care such as timely processing of laboratory orders at Peru, IL, or improvements to home-based primary care at Missoula, Anaconda, and Bozeman, MT, and at Grand Island and North Platte, NE. Screening processes were improved for diabetes in Clarksville, TN, and for depression and dementia as part of life planning at Morehead City, NJ. Scholars in Grand Island, NE, created a referral system to streamline the process of connecting Veterans to local dental resources. That project was so successful that a local on-line newspaper carried a story describing the happy life-changing experience on one Veteran. Forty percent of Veterans live in rural areas. In these areas, older adults are particularly vulnerable to

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Aging Successfully, Vol. XXI, No. 2

The Veterans Health Administration in cooperation with Saint Louis University has produced a series of five instructional DVDs to promote quality care for Veterans. The titles of the DVDs are: Team-Based Care for Older Veterans Agitated Behaviors PTSD in Older Veterans Discharge & Medications Delirium: Quiet & Excited/Dementia with Agitation An overview of the five topics covered in this series is included in this issue. These articles are designed to educate providers about why these training videos are important. To obtain a set of the DVD series, contact Dr. Nina Tumosa at
eams are the training. key to providMany factors are necessary for successful intering high qualdisciplinary training. They include acceptance of the ity geriatric care(1, necessity of interdisciplinary teams(9), enthusiastic 2) . Normally these participation of all disciplines(9), effective modeling healthcare teams and mentoring of interdisciplinary teamwork(3) and consist of small recognition that the teams differ across care settings(3). groups of persons Using adult learning principles which promote with complementary multi-faceted educational approaches, such as pracskills which allow tice-based tools, quality improvement data, and using the team to work opinion leaders to influence practice behaviors, have synergistically to the most success in effecting practice changes(10, 11, 12, 13) solve problems that individuals could not solve alone. such as the acceptance and adoption of the use of inThe goals of the team are listed in Table 1. terdisciplinary team-based care. Teams need to show Good teams do not spring into that they make a difference to the perfect existence just because they bottom line, they need advocates TABLE 1: GOALS OF THE HEALTHare needed. It takes training to creto promote their use and they need CArE TEAM ate a functional team and it takes constant vigilance to ensure that Improve patient function or maineven more training to keep a team they remain effective. Sometimes tain maximum patient indepenfunctional. The American Geriatteams need a good example to edudence rics Society Partnership for Health cate newcomers and to encourage Enhance patient well-being in Aging has recently posted a poparticipants. Should your institu Increase patient satisfaction (3) sition statement that succinctly tion require such an example, the reduce use of hospital services states why team based training is Team Based Care for Older Veter Optimize the work satisfaction of important in geriatrics. Table 2 ans DVD provides a brief (22-minall team members lists training goals in the position ute) example of what can go wrong statement for interdisciplinary team if care is not coordinated and how 8

DVD Series Promotes Quality Care


Aging Successfully, Vol. XXI, No. 2


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TABLE 2: TrAINING GOALS 1. Understand their respective roles and responsibilities on the team 2. Establish common goals for the team 3. Agree on rules for conducting team meetings 4. Communicate well with other members of the team 5. Identify and resolve conflict 6. Share decision-making and execute defined tasks when consensus is reached 7. Provide support for one another, including the development of leadership roles 8. Be flexible in response to changing circumstances 9. Participate in periodic team performance reviews to ensure that the team is functioning well and that its goals are being met ( 4, 5, 6,7, 8) . Questions? FAX: 314-771-8575

a team approach can make a difference. The Red Flags and Geriatric Syndromes that a good team looks for in anticipation of a problem and reacts quickly to avert a disaster are listed on pages 20-21.
1. Boult C, Green AF, Boult LB, et al. Successful models of comprehensive care for older adults with chronic conditions: evidence for the Institute of medicines retooling for an aging America report. J Am Geriatr Soc. 57:2328-37; 2009. 2. Morley JE, Tumosa, N. Geriatrics is a Team Sport. Aging Successfully XVI (5), 1-6, 2005.


4. 5. 6. 7. 8.


9. 10.


12. 13.

American Geriatrics Society Partnership for Health in Aging. Position Statement on Interdisciplinary Team Training. http://www. interdisciplinary_team_training_statement/introduction. Clark PG, Leinhaas MM, Filinson R. Developing and evaluating an interdisciplinary clinical team training program: Lessons taught and lessons learned. Educ Gerontol 2002;28:491-510. Medical Team Training: Strategies for Improving Patient Care and Communication. Joint Commission Resources. Oakbrook Terrace, IL. 2008:67-76. ISBN: 978-1-59940-092-1. Katzenbach J, Smith D. The Wisdom of Teams: Creating the High Performance Organization. McKinsey & Co; 2003. HarperCollins Publishers, Inc. New York, NY. West M. Effective Teamwork: Practical Lessons from Organizational Research. 2nd ed. BPS Blackwell; 2004. Mellor MJ, Hyer K, Howe JL. The geriatric interdisciplinary team approach: Challenges and opportunities in educating trainees together from a variety of disciplines. Educ Gerontol 2002; 28:867880. Reuben DB, Levy-Storms L, Yee MN, et al. Disciplinary Split: A threat to geriatrics interdisciplinary team training. J AM Geriat Soc . 52: 1000-0; 2004, Bradley EH, Holmboe ES, Mattera JA, et al. Data feedback efforts in quality improvement: Lessons learned from U.S. hospitals. Quality and Safety in Health Care, 13, 26-31; 2004. Gifford DR, Holloway RG, Frankel MR, et al. Improving adherence to dementia guidelines through education and opinion leaders: A randomized, controlled trial. Annals of Internal Medicine, 131, 237-246; 1999. Grol, R, Grimshaw J. From best evidence to best practice: Effective implementation of change in patients care. The Lancet, 362, 1225-1230; 2003. Vickrey B. Effective strategies for changing physicians behavior: Insights from research on diffusion of innovations. Clinical Gerontologist, 29(2), 25-34; 2005.


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

n returning home, patients often resume home medications in addition to those prescribed in hospital or in place of those that were changed in hospital. Similarly, on entering a hospital, a patient is often restarted on the list of home medications, despite the fact that the patient has been non-compliant at home. This can lead to disasters such as when a physician has been increasing a patients hypertensive medicines but the patient has not been taking the medicines. This failure of physician-patient communication can lead to a major hypotensive episode when medications are restarted in hospital. Polypharmacy has become a way of life for senior citizens. This is despite excellent studies demonstrating that as the number of drugs increase, there is an exponential increase in the number of side effects. Stephen Fitzgerald 2, using mathematical modeling has shown that more than five medications in older, frail individuals is associated with a marked increase in drug-induced side effects. This is true no matter whether the patient has a

good or bad indication for the medicine. Drugs are one of the primary causes of falls. Antipsychotic medicines lead to increased mortality, hip fractures, and aspiration pneumonia, and rarely are useful in treating aggressive behaviors. The combination of anticholinergic medicines and cholinesterase inhibitors is nonsensical. In persons over 80 years of age, there is no evidence for the use of statins and in the younger elderly, benefit is only seen in persons with clear atherosclerotic disease. Thus, a key to medication reconciliation during transitions is to question whether the medicine is indicated. To improve transitions, the following are essential: Hospital Physician and Health Professionals: Review medicines that the patient was taking in hospital and discontinue any that are no longer necessary. Check for medicines that negate one anothers effect or alter metabolism of one another. email:

Provide the patient with a typed list of medications with clear indications of dose and the time to be taken. For example, make sure the patient understands that neither calcium nor iron can be taken with other medicines. Explain to the patient that he/ she should not resume home medicines. Discourage the patient from taking over-the-counter medi(continued on next page)


Aging Successfully, Vol. XXI, No. 2

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cines including vitamins, before discussing this with his/ her health provider. Make sure the patient has all questions answered. Make sure an adequate followup with a healthcare provider is in place and communicate the medicine list and hospital nursing home course to the primary care provider. Patient: Make sure before leaving the hospital that there is understanding about how medicines have been changed. Keep a list of your medicines and check when home that you are taking them. If you have cognitive problems or depression, have someone else with

you when you are discharged and have them help you set up both new and old medicines in a pill box for each day. Do NOT resume home medicines unless they are on the list. Make sure you have all of the prescriptions necessary before leaving the hospital. Know who to contact if you have questions. Take a copy of your new medication list when you go to see your health care provider. Ideally, bring all of the medicines you are taking, as well. Do not take over-the-counter medications or vitamins without discussing them with your health care provider. Ask the physician on discharge if any of the medicines can be

replaced by those costing $4 per month instead of the more expensive ones prescribed. Transitions can be very dangerous3. It is incumbent on both the health care provider, patient, and carers to do everything they can to reduce medication-induced risks.
R efeRences 1. Forster AJ, Murff HJ, Peterson JF, et al. The incidence and severity of adverse events affecting patients after discharge from the hospital. Ann Intern Med 138:161-7; 2003. 2. Fitzgerald S, Bean NC. An analysis of the interactions between individual comorbidities and their treatments implications for guidelines and polypharmacy. J Am Med Dir Assoc 11:475-84; 2010. 3. Morley JE. Transitions (editorial). J Am Med Dir Assoc 11: 607-11;2010.

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Aging Successfully, Vol. XXI, No. 2


Physiology of Aging: immunosenescence Innate Immunity: Non-Specific

Decreased function of epithelial barriers of the skin, lung or gastrointestinal tract enables pathogens to invade mucosal tissues, presenting an increased challenge to the aging immune system Elevations of IL-6, IL-1B, TNF-A are seen in elderly patients, creating subclinical chronic inflammationInflamm-aging! possibly caused by partial inability of aging immune system to eliminate pathogens. Chronic inflammation is thought to contribute to age-related disorders: cancer, autoimmune disorders, neurodegeneration, and atherosclerosis.
Initiate inflammatory response Eliminate pathogens regulate adaptive immunity repair damaged tissue Decreased: Oxidative burst Phagocytic capacity Precursors in marrow Macrophage derived chemokines (MIP, eotaxin) Not affected: *Numbers


Play a major role in the MHC recognition of virally-infected cells and in rejection of tumor cells Decreased: Cytotoxicity Proliferation Increased: Numbers Not affected: *TNF production *Perforin synthesis

NK Cells

Defense of bacterial and fungal infections in acute inflammation Decreased: Oxidative burst Phagocytic activity Bactericidal activity Not affected: *Numbers *Chemotaxis *Adhesion *phagocytosis of Unopsonized bacteria


Link innate and adaptive immune system; by initiating immune response, secreting cytokines, APC Decreased: Capacity to stimulate antigen specific T cells Lymph node homing Update of antigen Phagocytosis of apoptotic cells (contrib. to inflammaging) Migration

Dendritic Cells

Adaptive Immunity: Specific

Host defense against infection (virus, fungi, TB) Graft and Tumor rejection regulation of antibody response

Cell-Mediated Immunity:

Host defense against infection (opsonize bacteria, neutralize toxin and viruses) Autoimmunity

Humoral Immunity

Decreased numbers (age related involution of thymus) Shorter Telomeres restricted T cell receptor repertoire/decreased diversity (decreased ability to respond to new antigen.) Impaired expansion and differentiation into effector cells:

Aging T Cells Nave T cells

Aging B Cells

CD4 T Helper

(Inhibit intracellular bacteria/ fungi) *Decreased regulatory control & stimulation of B cells *reduced IL-2 production *Increased numbers memory

CD8 Cytotoxic T

(Kill virus-infected cells and tumor cells *Decreased proliferation *Produce cytokines *Increased #/clones *Loss of CD28

(Neutralizes toxins and viruses; kills extracellular, encapsulated organisms) Peripheral B cell numbers do not decline with age. Increased number of antigen-experienced memory B cells, with decreased apoptosis, accumulate in elderly Decreased nave B cells Serum immunoglobulin levels are stable in aging Shift in antibody isotypes from IgG to IgM, with lower affinity. Stimulated 70% less efficiently by dendritic cells than B cells in young subjects Decreased B cell expansion and antibody production. Questions? FAX: 314-771-8575


Aging Successfully, Vol. XXI, No. 2


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

Two physIoLogIc EvENTs LEAD To DEcrEAsED muscLE mAss:

1. increased catabolism
a. reduced activity of alkaline phosphatase indicates damage or disruption to the sarcolemma b. Elevated levels of acid phosphatase indicate lysosome degradation c. possibly from an increase in IL-1 and IL-6 a. Largely from hormonal factors b. reduced growth hormone, insulin-like growth factor, estrogen and testosterone c. Anorexia of aging leads to a decrease in protein intake


leading to sarcopenia of old age


leading to sarcopenia of old age Reduced metabolism, slowdown of protein synthesis and turnover Reduction of enzymatic activities and energy reserves Decreased mitrochondrial function Role of oxidative stress Changes in CNS functioning and neural stimulation Changes in hormonal secretion and regulation. Reduction in blood supply and capillary beds.

2. Decreased anabolism


Aging changes the number and type of muscle fibers.

Type I fibers: Red, oxidative fibers Slow-twitch, slow fatiguability Antigravity and tonic contraction Increased with aging Type II fibers: White, glycolytic fibers Fast twitch, rapid fatigue Coordination-related and phasic contraction reduced with aging

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

Other factors associated with age-related muscle changes:

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

Nutritional Hormonal Metabolic Immunologic Factors

Motor Units Muscle Fibers Muscle Fiber Atrophy Physical Activity

muscle mass muscle strength


Weakness Decreased Mobility

Men have significantly greater muscle mass but have greater losses with aging than women. Physical inactivity is a significant contributor to sarcopenia. Resistance exercise increases strength and mass in all age groups, even the frail elderly > 90 yrs old.
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Disability and Loss of Independence

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

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he International Association of Gerontology and Geriatrics (IAGG) together with the World Health Organization have recently released a position paper on the future of nursing homes world-wide and was written about in the Journal of the American Medical Directors Association1. The main message was that with the rapid aging of the population in both developing and developed nations, there is a need to increase the quality of nursing homes and the individuals who work in them. The paper stressed how important nursing homes were for the care of the vulnerable elderly. It called for increased reimbursement for the primary caregivers who work in the nursing home. There was also a perceived need to increase research into how to deliver the highest quality care in nursing homes. It was strongly recommended that, before drugs were released on the market, they should be tested in nursing homes

John E. Morley, MB, BCh


1 Morley JE. AMDA - A leader in developing international longterm care. J Am Med Dir Assoc 12(5):319-20, 2011. 2

to demonstrate their safety in the frail elderly. A strong recommendation was to enhance the education available for health professionals working in the nursing home. To this end, the IAGG has developed a certificate course to provide state-of-the-art education on nursing homes. The first two of these certificate courses were held in Hong Kong and Chengdu, China, in May this year. Both were highly successful2. It is exciting that, at long last, major organizations are starting to recognize the importance of nursing homes for the care of older persons. Professor Bruno Vellas, from Toulouse, France, needs to be especially congratulated for his leadership in this area.


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

gitation can vary in its presentation from excessive wandering and verbal aggression to physical aggression. The first component to managing agitation is to understand its precedents. What caused the person to become agitated? For example, did a nurse approach the patient from behind or in a way that could be considered threatening? Does the patient have unresolved pain? Has the patient had a history of being easily angered or violent before becoming demented? Do the episodes occur at certain times of the day, e.g., sundowning, or in relationship to the meal, e.g., hypoglycemia, hunger, or postprandial hypotension? Is there any evidence that the person has a condition that is triggering delirium? If the person is screaming, is s/he depressed or afraid? Are there environmental stimuli to trigger the agitation, e.g., poor lighting, shadows, pictures, television, or radio? Just as in every day life, when you or your friends or family get angry, there is often a trigger from other persons that sets off the agitation. So the first approach to the management of agitation is to provide caregiver education. Much of

agitation is precipitated unintentionally by carers. Helping the carers to understand their behaviors that are creating the agitation is key. The carer also needs to be taught to keep an appropriate distance and learn how to tolerate many behaviors that are annoying but not dangerous to anyone. Social stimuli are associated with less agitated behaviors1. Taskorientated and reading stimuli are more calming than music stimuli. Manipulative stimuli are most likely to precipitate agitation. In general, many psychotherapeutics can calm the agitated person with dementia but evidence for lasting effects is limited. One study has suggested that, over the short term, Therapeutic touch may be calming2. In the CALM-AD trial, a brief psychosocial therapy for 4 weeks reduced agitation3. Multisensory stimulation (Snoezelen) has its advocates but limited evidence of effectiveness. The existence of a psychosocial intervention program may be of email:

more importance than the specific program. These programs may be more useful in improving staff satisfaction and therefore tolerance of agitated behaviors. The more physically active demented persons are, the less likely they are to become agitated4. A number of exercise trials, usually lasting for 30 minutes three times per week, have led to a decrease in agitation5. There is amazingly little data to support the wide range of medications utilized to decrease agitation. Valproate is widely used to treat agitation, yet the Cochrane meta-analysis found that valproate was ineffective for agitation in persons with dementia6. Haloperidol was also ineffective at reducing agitation7. High doses (>2mg/

day) may have reduced aggression but with the trade off of increased side effects. Resperidone and olanzapine modestly improved aggression but were associated with serious side effects including stroke and extra(continued on page 16)

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Aging Successfully, Vol. XXI, No. 2


Dementia with Agitation

(continued from page 15)

pyramidal side effects8. The Food and Drug Administration found that when atypical neuroleptics were used for treating behavioral symptoms in persons with dementia, there was a significant increase in mortality. The best treatments for agitated behavior in dementia appear to be psychosocial and exercise therapy. On the whole, drugs should be avoided. Two studies have suggested that SSRIs may reduce agitation. There is inadequate data for the use of trazodone. While we occasionally use low-dose lorazepam, no studies are available to support its use. Two DVDs offer examples for managing behaviors in the nursing home and in hospital (Agitated Behaviors) and at home (Delirium: Quiet and Excited/ Dementia with Agitation).
RefeRences 1 Cohen-Mansfield J, Marx MS, Dakheel-Ali M, et al. Can agitated behavior of nursing home residents with dementia be prevented with the use of standardized stimuli? J Am Geriatr Soc 58(8):1459-64; 2010. 2 Woods DL, Beck C, Sinha K. The effect of therapeutic touch on behavioral symptoms and cortisol in persons with dementia. Forsch Komplementmed 16(3): 181-9; 2009. 3 Ballard C, Brown R, Fossey J, et al. Brief psychosocial therapy for the treatment of agitation in Alzheimer disease (the CALM-AD trial). Am J Geriatr Psychiatry 17(9): 726-33; 2009. 4 Scherder EJ, Bogen T, Eggemont LH, et al. The more physical inactivity, the more agitation in dementia. Int Psychogeriatr 22(8): 1203-8; 2010. 5 Aman E, Thomas DR. Supervised exercise to reduce agitation in severely cognitively impaired persons. J Am Med Dir Assoc 10(4): 271-6; 2009. 6 Lonergan E, Luxenberg J. Valproate preparations for agitation in dementia. Cochrane Database Syst Rev 8(3):CD003945; 2009. 7 Londergan E, Luxemberg J, Colford J. Haloperidol for agitation in dementia. Cochrane Database Syst Rev (4):CD002852; 2001. 8 Ballard C, Waite J. The effectiveness of atypical antipsychotics for the treatment of aggression and psychosis in Alzheimers disease. Cochrane Database Syst Rev 25(1); CD003476; 2006.

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The ABCDs of Of-Life Care Endfor With Dementi People ball Memories Base a Treating Dementia with
By John T. Chibna Abhilash K. Desai M.D. Death and dying are comm sons with adva nced dementia. on issues in caring for concept that perYet, end-of-life imme care is not a respect to deme diately comes to mind as a priority ntia. There with are a number observation. For example, of reasons for the Health Statis this tics currently National Center for disease as the lists Alzheimer fifth leading the U.S. in cause of death s peop overall. As comple older than 65, and sevenin th pear, new resea elling as these statistics may aprch data sugge ally be unde st that they restimated. l to tiedTherapy Group This underestim may actua Homerun with Specia peopthe fact that health care skills ation may be as cationprofe SLU, St. Louis VA Hits le in ssionals, as mood and communi treatment enhances the community, often well intellectual ability. has been developed do and may even improve n and the act- not recognize eminiscence therapy to Alzheimers disease Louis University geriatricia ll Ph.D., Nina Tumosa Ph.D., and

Fall 2011 Vol. XXI, No. 2

Spring 2010 Vol. XX, No. 1

Spring 2009 Vol. XIX, No. 1

Spring 2008 Vol. XVIII, No. 1

and aging
Life in the shadows of death can be immensely rewarding and fulfilling.
Myles N. Sheehan, S.J., M.D.


Aging Successfully, Vol.

. for people with about their memories stimulate them to talk problems people with memory items, Therapists show older and other familiar photographs, old programs pleasant memories from share and patients eagerly innovative es. The simple yet their past experienc

A Saint Medical (continued on page Louis Veterans Affairs that if 4) ing director of a St. organization are convinced Center geriatrics have founded a will come. The two on page 3) they build it, fans

Fatigue makes cowards

of us all. - Vince Lombardi

(continued on page 4)

(continued on page


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No. 1

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Post-traumatic stress disorder (PTSD) has, in recent years, been widely recognized as a major problem in younger Veterans returning home from combat zones. Recently, there has been an increased recognition that PTSD may persist throughout life and symptoms may worsen in late life.
n a survey of over 17,000 Veterans aged 65 or older, 12% experienced symptoms of PTSD1. Rates of PTSD are higher in ethnic minorities. Among soldiers who had been prisoners of war, the rate of PTSD was 16.6% 2 . This higher rate was due to an extremely high rate of PTSD (34%) in those taken prisoner of war

PTSD and 54% for past PTSD 4. PTSD occurs in 12% of Veterans in nursing homes 5. Late onset stress symptomatology (LOSS) in Veterans who have been exposed to combat is relatively rare, though occurrence of nightmares about war is not uncommon 6 . For most Veterans, symptoms are highest

these symptoms are more distressful than dyspnea but less stressful than pain. PTSD has three major symptom areas. These are reexperiencing, avoidance, and hyperarousal. Re-experiencing focuses on intensive recall of traumatic experiences, sleep disturbances, and combat-related nightmares, often associated

in the Pacific theater. im mediately with anxiety. Avoidance Women who have had a following disincludes feelings of being military sexual trauma episode charge, then dethreatened in crowds, feelings are particularly vulnerable to crease for several of detachment from others, and PTSD and it occurs at a higher decades only for sympa numbing feeling (decreased rate than in those experiencing toms to increase in late life 2,7. 3 affect). Hyperarousal includes a civilian sexual trauma . In the PTSD symptoms may increase 8 civilian population, women are in the last month of life . Acgeneral hyperalertness, more likely to experience PTSD cording to family members, irritability, anger, ag(10.4%) than men (5%) 3, gression, and but this sexual differan exaggerated Symptoms of PTSD Mnemonic ence is reversed in the startle response. P aranoia (feeling cut off or super watchful) Veteran population. In nursing home In patients admit- T houghts or images of stressful events residents with ted for another mental PTSD, anger, S leep disturbances (nightmares, insomnia) health problem to a psyi r r it a bi l it y, chogeriatric ward, 27% and aggressive D eath wishes met criteria for current (continued on page 18) Questions? FAX: 314-771-8575 email:

Aging Successfully, Vol. XXI, No. 2


(continued from page 17)


disorders have been reported in 47% of patients 9. Symptoms increase with the number of traumatic episodes. Depression is not necessarily more common in persons with PTSD10. In a large Veterans Administration study1, persons wth PTSD reported more poor health, were more likely to smoke and drink excessively, and to be divorced, reported limited social support, and had a high prevalence of mental distress, death wishes, and suicidal ideation.

Table 1. Veterans Administration Screening Test for PTSD

1. Some people have had terrible experiences that others never go through such as Being attacked Being sexually assaulted or raped Being in a fire or flood or natural disaster Being in combat Being in a bad accident Being threatened with a weapon Seeing someone being badly injured or killed

Did any of these things happen to you? YES (continue) NO (stop) 2. In the past month, have you been bothered by repeated, disturbing memories, thoughts, or images of one or more of the stressful events you experienced above? YES NO 3. In the past month, have you felt distant or cut off from other people? YES NO 4. In the past month, have you been super alert, or watchful, or on guard? YES NO

Aging Successfully, Vol. XXI, No. 2


Questions? FAX: 314-771-8575


(continued from page 18)

Table 1 provides a Veterans Administration screening test for PTSD. A simple mnemonic for remembering the symptoms of PTSD is shown on page 16. The treatment of choice for PTSD is Cognitive Behavioral Therapy (CBT)11. This requires learning to recognize distressful thoughts and replacing them with more pleasant thoughts. Exposure therapy is a form of CBT that includes allowing PTSD victims to re-experience distressing trauma related memories. Eye movement desensitization and reprocessing is a specific, successful therapy for PTSD. In general, it is CBT with the addition of and focus on eye movements. Diverse psychotropic medications have been used to treat PTSD in Veterans12, 13. Selective serotonin reuptake inhibitors have been most used for PTSD. Bupropion and Venlafaxine have been reported to have the

lowest drop-out rates. Trazodone helps with sleep and anger and agitation. Prazosin reduced nightmares in combat Veterans, but its hypotensive effect should limit its use in older persons. Topiramate may have a role in reducing f lashbacks and nightmares. Beta blockers, e.g., atenolol or propanolol, possibly reduce hyperarousal symptoms. Zolpidem can be used for sleep disturbances. Lorazepam can be utilized to treat anxiety. In older persons, medication use should be limited to avoid polypharmacy. Finally, engagement in exercise therapy has multiple benefits in older persons with PTSD, including socialization, reduction of dysphoria, and improvement in physical condition.
R efeR ences
1 Durai UNB, Chopra MP, Coakley E, et al. Exposure to trauma and posttraumatic stress disorder symptoms in older Veterans attending primary care: Comorbid

conditions and self-rated health status. J Am Geriatr Soc 59:1087-92; 2011. 2 Rintamaki LS, Weaver FM, Elbaum PL, et al. Persistence of traumatic memories in World War II prisoners of war. J Am Geriatr Soc 57:2257-62; 2009. 3 Himmelfarb N, Yaeger D, Mintz J. Posttraumatic stress disorder in female veterans with military and civilian sexual trauma. J Trauma Stress 19:837-46; 2006. 4 Rosen J, Fields RB, Hand AM, et al. Concurrent posttraumatic stress disorder in psychogeriatric patients. J Geriatr Psychiatry Neurol 2:65-9; 1989. 5 Lemke SP, Schaefer JA. Recent changes in the prevalence of psychiatric disorders among VA nursing home residents. Psychiatr Serv 61(4);356-64; 2010. 6 King LA, King DW, Vickers K, et al. Assessing late-onset stress symptomatology among aging male combat veterans. Aging Ment Health 11:175-91; 2007. 7 Port CL, Engdahl B, Frazier P. A longitudinal and retrospective study of PTSD among older prisoners of war. Am J Psychiatry 158:1474-9; 2001. 8 Alici Y, Smith D, Lu HL, et al. Familiesperceptions of veterans distress due to post-traumatic stress disorderrelated symptoms at the end of life. J Pain Symptom Manage 39:507-14; 2010. 9 Hart J Jr, Kimbrell T, Fauver P, et al. Cognitive dysfunctions associated with PTSD: evidence from World War II prisoners of war. J Neurospychiatry Clin Neurosci 20:309-16. 2008. 10 Schnurr PP, Spiro A 3rd, Aldwin CM, et al. Physical symptom trajectories following trauma exposure; longitudinal findings from the normative aging study. J Nerv Ment Dis 186:522-8; 1998. 11 Kar N. Cognitive behavioral therapy for the treatment of post-traumatic stress disorder: a review. Neuropsychiatr Dis Treat 7:167-81; 2011. 12 Mohamed S, Rosenheck R. Pharmacotherapy for older veterans diagnoses with posttraumatic stress disorder in Veterans Administration. Am J Geriatr Psychiatry 16:804-12; 2008. 13 Alderman CP, McCarthy LC, Condon JY, et al. Topiramate in combat-related posttraumatic stress disorder. Ann Pharmacother 43:635-41; 2009. 14 Rosenbaum S, Nguyen D, Lenehan T, et al. Exercise augmentation compared to usual care for Post-Traumatic Stress Disorder: A Randomised Controlled Trial (The REAP study: Randomised Exercise Augmentation for PTSD). BMC Psychiatry 11: 115; 2011. doi: 10.1186/1471-244X11-115.

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Aging Successfully, Vol. XXI, No. 2


The Significance of Flags


RED flag
Hospitalization for appointment Late Walks slowly to waiting room dont know or other I short answers by patients We havent been doing so well Falls

Often Associated With:

Loss of function (changes in Activities of Daily Living [ADLs]) Delirium Medication side-effects Loss of function (changes in ADLs) Dementia, delirium, or depression Travel/driving issues Loss of function (changes in ADLs) Gait and balance disorder, falls Fear of falling Loss of muscle

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

New medications Confusion in hospital Dizziness


Polypharmacy Delirium Possible underlying dementia Possible underlying depression Orthostatic hypotension Medication side-effects
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Aging Successfully, Vol. XXI, No. 2

Geriatric Syndromes and Options for Interventions in the Outpatient Setting


Caregiver burden Delirium

Dementia Depression Falls; Gait & balance disorders; Fear of falling Incontinence: Urinary and/or fecal Loss of function; Reduction in ADLs Loss of strength/ Loss of muscle mass Polypharmacy Transportation/ driving issues Weight loss
Questions? FAX: 314-771-8575

Social worker consult Psychologist consult If patient has dementia, refer family members to the Alzheimers Association or a similar support group where available Screen using the Confusion Assessment Method (CAM) Evaluate medications as possible cause Rule out infection where appropriate Rule out metabolic causes where appropriate Screen using the VA SLUMS exam Refer family members to the Alzheimers Association or a similar group for education and support Rule out reversible causes (e.g., medications, depression) Screen using the Geriatric Depression Scale (GDS) Remember that depression is common, not normal, and should be treated Treat as appropriate with medications and/or refer to a psychologist Rule out orthostatic hypotension and/or low blood pressure Rule out lower extremity weakness using 5-chair stands Outpatient or home care referral for PT/OT Review medications as possible cause Rule out infection where appropriate Determine the type of incontinence (urge, stress, or overflow) Frequent or scheduled toileting Medications only when appropriate Home care or outpatient referral for Occupational Therapy (OT) Home care or outpatient referral for Physical Therapy (PT) Home care referral for medication evaluation and management Consultation with a pharmacist Medication reduction by the Nurse Practitioner (NP), Physician Assistant (PA), or Physician Look for medication side effects or errors Social worker or other consult Review medications for possible causes Avoid restricted diets

Aging Successfully, Vol. XXI, No. 2


Morley Awarded for Educational Excellence

(continued from page 5)

Improving Care for Veterans

(continued from page 7)

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

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

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Term Care (formerly the American Medical Directors Association) is the national professional association of medical directors, attending physicians, and other professionals practicing long term care medicine committed to the continuous improvement of patient care. AMDA provides education, advocacy, information, and professional development to enable its members to deliver quality long term care. 22

Aging Successfully, Vol. XXI, No. 2


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Upcoming continUing EdUcation programs

ever building on the foundation
Multi-disciplinary Certificate Program in Geriatrics for Non-Physicians

23rd Annual Saint Louis University

Wednesdays September 14, 28, October 12, 26, November 9, 30, 2011 Bloomington, IL

and Fridays September 9, 23, October 7, 21, November 4, 18, 2011 Palatine, IL
Regional Alzheimers Conference

Summer Geriatric Institute

June 12-13, 2012 St. Louis, Missouri USA

For more information, call 314-894-6570.


Friday, October 14, 2011 Mattoon, IL

Multi-Dimensional Functional Screening and Assessment of Older Adults

Thursday, October 27, 2011 Mt. Vernon, IL Other prOgrams are available. please call 773-930-3200 fOr mOre infOrmatiOn. Questions? FAX: 314-771-8575 email:

Aging Successfully, Vol. XXI, No. 2


Non-Profit Organization US Postage PAID St Louis MO Permit 3252

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

Please fax the mailing label below along with your new address to 314-771-8575 so you wont miss an issue! If you prefer, you may email us at Be sure to type your address exactly as it appears on this label.

John E. Morley, M.B., B.Ch. Dammert Professor of Gerontology; Director, Division of Geriatric Medicine; Department of Internal Medicine, Saint Louis University School of Medicine. Nina Tumosa, Ph.D. Editor; Acting Director and Associate Director of Education, GRECC, St. Louis VA Medical Center - Jefferson Barracks; 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: Previous issues of Aging Successfully may be viewed at
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Aging Successfully, Vol. XXI, No. 2


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