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A Chat with Our Experts

GRECCs are hubs for geriatric research

VA's Office of Geriatrics and Extended Care Services is committed to optimizing the health and well-being of Veterans with multiple chronic conditions, life-limiting illness, frailty or disability associated with chronic disease, aging, or injury. Their programs maximize each Veteran's functional independence and lessen the burden of disability on Veterans, their families, and caregivers.

GEC manages 19 Geriatric Research Education and Clinical Centers (GRECCs). Each year, these research units publish hundreds of peer-reviewed articles, provide thousands of person hours in geriatric education, and are awarded millions of dollars in research grants. They provide care to the aging Veteran population and help train many of the health care professionals who will provide that care for years to come.

The Office of Research and Development has full funding approval over the intramural research efforts of VA researchers supported by the GRECCS. A special committee reviews the merits of research proposals related to aging issues. ORD has no direct administrative control over individual GRECCs, and no responsibility for monitoring their work.

VARQU spoke with Dr. Susan Cooley, the office's chief of geriatric research and evaluation and chief of dementia initiatives, and Dr. Kenneth Shay, director of geriatric programs.

VARQU: The Office of Geriatrics and Extended Care Services has committed itself to optimize the health and well-being of older Veterans. How do VA researchers contribute to those efforts?

CooleyDr. Susan Cooley

Cooley: There are lots of ways in which VA researchers contribute to our office's overall effort. Obviously, they conduct high-impact research funded by VA, NIH, and other organizations. They also contribute to the development of new approaches and new models of patient care.

In addition to their actual research activities, they participate in educating health professionals and students—medical students, nurses, and others—so they may be involved in professional education. We also use their specific expertise on work groups that are either within VA or with another federal agency, to ensure scientific as well as clinical perspectives are taken into account.

Researchers also develop information we use for program development and evaluation, clinical guidance, and policy. One of the things that's really important to me is helping us avoid "a premature leap into policy." This is a phrase I originally heard from a colleague, and it fits a concern that I have.

To the extent that we now use evidence-based practice, we have to know if a particular idea is "ready for prime time." Is it ready to be disseminated widely in our system and beyond the VA system? Is it ready to inform a policy that will mandate everyone should do a particular thing? Or, are the data inconclusive on the particular topic so that further research is needed?

What I often look to VA researchers for is their expertise and objectivity to help me anticipate unintended consequences of something before we try to write a policy or to mandate it. So I really like the connection—and I think it's a very important connection—between our researchers and our policy development to avoid "premature leaps into policy."

How is the work of GRECC-based researchers coordinated?

 Dr. Ken Shay
Dr. Ken Shay

Dr. Ken Shay

Shay: VA has centers of excellence in a number of different areas, but to my understanding they all derive from the model set up with GRECCs, and Clinical Centers), and we've got 19 of those. They do a great deal of VA's geriatric research. They constitute about $113 million in total research expenditures from all sources every year, and that's over 10 percent of VHA's total research expenditures.

The GRECCs have comprehensive research programs, including biomedical lab science, clinical science, health services, rehabilitation research, and participation in cooperative studies. Each GRECC has different selected focus areas: some just one or two, others more than that because they are older and have expanded into additional areas.

They cover the whole spectrum of geriatric syndromes, disease entities, aging, chronic illness, and new models of care. In addition, they also conduct clinical demonstration projects that are not truly research, but generate data for more formalized research; that is, they create a mechanism for generating pilot information on which more formal proposals for research support can be developed.

GRECC research funding is about two-thirds from the National Institutes of Health, the Department of Defense, and other non-VA government sources, about one-quarter from the Office of Research and Development, and the remainder comes from foundations or other sources such as private industry. Those proportions are relatively stable. Currently, the amount from VA is at a relative high because the amount from NIH and other governmental agencies is down because of their lower funding rates.

Other ways we coordinate things include a monthly call Dr. Cooley runs with the GRECC associate directors for research. On those calls, they share information and opportunities for inter-GRECC collaboration. This is at a pretty high pitch right now. Dr. Greg Cole of the Greater Los Angeles GRECC has pulled together a series of three different monthly calls of GRECC investigators presenting on their work having to do with Alzheimer's disease and other dementias from the standpoint of basic science and relationships with health services, physical activity, and models of care.

Dr. Miriam Morey, the associate director for research at the Durham (N.C.) GRECC, and an exercise physiologist, has been identifying areas of research at all of the GRECCs that have to do with the benefits of physical activity in the elderly, which is something that is highly touted in general.

  A good deal of research at VA's GRECCs focuses on the benefits of physical activity for older adults. Here, a research participant works out at the Birmingham VA as part of a GRECC study. (Photo by Joe DeSciose) >
A good deal of research at VA's GRECCs focuses on the benefits of physical activity for older adults. Here, a research participant works out at the Birmingham VA as part of a GRECC study. (Photo by Joe DeSciose)

A good deal of research at VA's GRECCs focuses on the benefits of physical activity for older adults. Here, a research participant works out at the Birmingham VA as part of a GRECC study. (Photo by Joe DeSciose)

VA's most visible program, MOVE! (Managing Overweight and/or Obesity for Veterans Everywhere), generally discourages participation by Veterans over age 70 due to safety concerns. And yet, we have a lot of information that shows really positive effects of physical activity in older individuals in terms of cardiovascular fitness, reduction of risk factors for cerebral and cardiovascular illnesses, mood disorder and cognitive status improvements, as well as glycemic and lipid control. So there's a great deal of work in the GRECCs to really promote activity among older individuals.

Other topics that are being investigated include falls and mobility; infection control at long-term care facilities; and obesity and aging. So there's a lot of shared interests among the GRECCs, working independently initially and then we're trying to get them to "play in the same sandbox" whenever possible.

And then there's sharing information with other VA centers of excellence that have interests in common with GRECCs such as MIRECCs (Mental Illness Research, Education, and Clinical Centers of Excellence). Particularly with MIRECCs, there are shared interests in dementia, and serious mental illness and depression in advanced age. PADRECCs (Parkinson's Disease Research, Education, and Clinical Centers), study Parkinson's disease, a disease of the elderly that is also often associated with cognitive decline, so there's much shared interest there.

How do the GRECCs communicate to the public and to other professionals in the field about their work?

Cooley: We disseminate information in a variety of ways. We have a GRECC Internet website, and individual GRECC sites have their own websites with information about their own particular activities and products.

The GRECC Forum on Aging is a newsletter that's put out twice a year. It's coordinated by the Puget Sound GRECC and is distributed to senior VA leadership, members of Congress, and other stakeholders. We also have annual reports from the GRECCs, and we use that information to respond to inquiries from internal and external sources. Our office will often go to the annual reports and look for highlights of particular research topics to be able to give examples to respond to particular inquiries.

We also try, each year, to have multi-GRECC symposia at various meetings of professional organizations, for example at the Gerontological Society of America and the American Geriatrics Society. These are in addition to individual presentations at symposia that one or another GRECC might be doing.

VA researchers, themselves, are active participants in scientific and professional meetings, and, of course, publications are a bedrock way of disseminating information. GRECC researchers, for example, have some 1,300 articles published in peer-reviewed publications every year. So there are a variety of ways VA gets information out about aging and geriatric topics.

Dr. Cooley, your specialty is in dementia initiatives. What is the current state of research in that area?

Cooley: This is an area that is rapidly expanding—you might even say exploding. It's accelerated by the U.S. National Alzheimer's Plan, which is coordinated by the Department of Health and Human Services. The National Alzheimer's Plan—which refers also to related dementias, so it's broader than just Alzheimer's disease [AD]—has goals including preventing and effectively treating Alzheimer's and related dementias by 2025. That's not too many years off!

It's a very ambitious goal and has a very major research component in order to prevent and effectively treat Alzheimer's and related dementias by 2025. The other goals include enhancing care quality and efficiency; expanding supports for people with AD and their families; enhancing public awareness and engagement on this major public health issue; and improving data across agencies to track progress. Research has a role in accomplishing all of those, but particularly the first goal.

There are a variety of action items included in the National Alzheimer's Plan. One for VA is an action item for research collaboration with the Department of Defense. The action item is to begin meetings to leverage research in areas related to neurodegeneration. Also as part of the plan, VA is collaborating with NIH in many ways.

In addition, VHA has a Dementia Steering Committee, which has made recommendations for further research. The committee's basic idea is that we need further research on the development and implementation of best practice models for dementia care in the VA health care system. Topics include pathobiology; genomics and epigenomics; risk factors; use of new technologies; end of life care; caregiver support; the cost effectiveness of standardized processes; and others. Many, many areas have been defined by the steering committee as important and needing further research.

 Leon Bryant spends time with his father, Leon Douglas Bryant, at the VA community living center in Baltimore where the elder Bryant now lives. (Photo by Mitch Mirkin)
Leon Bryant spends time with his father, Leon Douglas Bryant, at the VA community living center in Baltimore where the elder Bryant now lives. (Photo by Mitch Mirkin)

Leon Bryant spends time with his father, Leon Douglas Bryant, at the VA community living center in Baltimore where the elder Bryant now lives. (Photo by Mitch Mirkin)

What other recent research findings in the area of geriatrics are you excited about?

Cooley: I wanted to mention an area of research on behalf of our new chief consultant for geriatrics and extended care, Dr. Richard Allman, who was formerly the director of the Birmingham/Atlanta GRECC. That is "life-space" research, which is a measure of mobility. Mobility is the functional domain in which older adults most frequently report difficulty, and it highly coordinates with the quality of life.

Life-space reflects participation in the surrounding world. By contrast, most assessments of mobility focus on specific mobility related tasks such as walking, or climbing stairs or driving. Life-space, however, reflects the full continuum of mobility and involves a person's ability to carry out multiple different mobility-related tasks. That's a particularly exciting area of research, and it happens to be one that our new chief consultant has been working in for quite some time.

What are some GRECC studies on the horizon that promise to help improve the health and well-being of elderly Veterans, and all older Americans?

Cooley: I've made a list of a few such projects, and in looking back on it I can see the importance of these in my own life. It's reassuring that many of these topics are being investigated, and we hope that there will be findings that will be useful to us as individuals as well as to the Veterans that we serve, their families, and the public at large.

There are so many issues in our own aging, and in our caring for our parents and friends, and there are so many challenges that come with aging, but it is exciting that these things are now being investigated.

 Veteran Kenneth Hanners has his blood pressure taken at a fall prevention clinic at the Birmingham VA. (Photo by Joe DeSciose)
Veteran Kenneth Hanners has his blood pressure taken at a fall prevention clinic at the Birmingham VA. (Photo by Joe DeSciose)

Veteran Kenneth Hanners has his blood pressure taken at a fall prevention clinic at the Birmingham VA. (Photo by Joe DeSciose)

Fall risk reduction strategies are important. We all could go into stories about our parents and friends having a fall and what happens in its aftermath. It's crucial to reduce risk and prevent falls to the extent possible, as opposed to focusing only on what happens after a fall.

We're looking at risk factors for dementia, including the potential roles of traumatic brain injuries, posttraumatic stress disorder, and other factors. It's a rising area of research. There's also smart home technology, including home sensor technology for passive monitoring of people at home to provide respite for care givers, and other types of technology like telehealth adaptations for geriatric care. We have some studies of the use of telehealth for dementia diagnosis and care management, and we are looking at developing a smartphone application for caregiver support.

Delirium prevention as well as support is another big area for research, especially in hospital settings such as ICUs. We're using data to identify patients at higher risk for iatrogenic complications [illnesses caused by medical examinations and treatment]. Unfortunately, things can often get worse when we try to make them better, and some people may be at greater risk for that.

Some other things that come to mind include the REACH-VA (Resources for Enhancing All Caregivers Health in VA) caregiver initiative. This is based on a NIH-funded cooperative study, and VA has adapted it for use in our settings with dementia caregivers as well as with traumatic brain injury and spinal cord injury caregivers, and VA investigators will be looking at the cost-effectiveness of the initiative.

There is also planning underway for palliative care research cooperation through a state-of-the-art (SOTA) conference. There's a lot of work going on involving VA Community Living Centers [CLCs—formerly VA nursing homes]. Researchers are developing a toolkit for measuring cultural transformation at CLCs, which is a big initiative that's been going on for several years, and developing a roadmap for best practices in CLC resident-centered care, including the assignment of resident staff.

There's a long-term-care CREATE [VA HSR&D's Collaborative Research to Enhance and Advance Transformation and Excellence]. The CREATE has four projects underway to address Geriatric and Extended Care's interest in transforming long-term care to meet Veterans' needs: the use of medical foster homes; accelerating discharge from CLCs; the impact of staff training to reduce hospitalization; and, again, tools for CLC culture change.

Those are some things that are underway, on the horizon, and really address things we all recognize as important.

Shay: A kind of cross-cutting issue is the whole idea of shared decision-making and advance care planning. That certainly is something that our office has a role in, and several GRECCs have roles in. With VHA's focus on patient-centered care, that's going to continue to be important. Our office's website has tools for shared decision-making that help Veterans and families explore their options for long-term services and settings.

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