Spring 2010 Vol. XX, No.

Fatigue makes cowards of us all. - Vince Lombardi

atigue is a common symptom seen amongst older persons. It is the harbinger of many diseases and is a key component of frailty. Fatigue is defined as a subjective complaint of tiredness or exhaustion without an objective finding of muscle weakness. Fatigue is also called asthenia. The major causes of fatigue are: Depression Sleep disorders such as sleep apnea and Restless Legs Syndrome Anemia Immobility and deconditioning Fibromyalgia Chronic Fatigue Syndrome, and Chronic illnesses such as COPD and heart failure.
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U.S. News & World Report:

1 Fatigue 2 News at SLU 9 Old Man and the SEA 12 Geriatrics in a Page: Aging Skin 13 Geriatrics in a Page: Weight Loss 15 SLU Geriatrics Welcomes New Faculty 16 An Active Life with Dementia 17 Research News 18 Editorial 19 Passport to Aging Successfully 21 Hey Doc! Am I At Risk for Falls? 22 Are You at Risk for Diabetes? 23 Continuing Education Opportunities

Ranked number 13 this year, Saint Louis Universitys geriatrics program has been listed among the top 20 in the nation by U.S. News & World Report for more than a decade. As baby boomers grow older, the field of geriatrics is becoming more a n d more c r it i cal, said John Morley, M.D., director of the Division of Geriatric Medicine at Saint Louis University. Were proud to be recognized as a national leader in conducting research on aging issues and teaching the next generation of physicians how to care for the elderly. Saint Louis Universitys Health Law program has been named the best in the nation for the seventh straight year. Saint Louis University also ranked in the top 25 schools nationally for its programs in international business (18), supply chain management (20), and entrepreneurship (21). These rankings appear in the Best Graduate Schools 2011 issue, on stands soon.

SLU Geriatrics Ranks in Top 20

SLU Students Win Award

Cong rat ulations to SLU st udents Maura Waldron and John Eppestei ner, two SLU premed students whose poster entry at the Central Group on Educational Affairs (CGEA) meeting in Chicago was awarded the 2010 Medical Student/Resident Travel Scholarship.

Gammack Named Medical Director of the Year

Julie K. Gammack, M.D., Division of Geriatric Medicine, was named the Heartland Division Medical Director of the Year by Life Care Centers of America on Friday, March 12, 2010, for her role as Medical Director at Life Care Center of St. Louis. The award was presented to Dr. Gammack at the American Medical Directors Association Annual Meeting in Long Beach, California.

Two Capture Distinguished Teacher Awards

The SLU School of Medicine Distinguished Teacher Awards were handed out in April. Two faculty members of SLUs Division of Geriatric Medicine received the Distinguished Teacher honor: Julie Gammack, M.D., in Clinical Teaching, and Miguel Paniagua, M.D., in Clinical Humanism.

Dr. Miguel Paniagua

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Dr. Julie K. Gammack

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Fibromyalgia and Chronic Fatigue Syndrome Fibromyalgia is a common condition in young and middle aged persons. By definition, these persons have widespread pain for at least 3 months. On examination, a patient with fibromyalgia has 11 to 18 tender points on his/her body. The condition may be due to poor blood flow to the capillaries in the muscle in these areas. The enzyme that produces nitric oxide, neuronal nitric oxide synthase, is attached to the muscle membrane. This allows nitric oxide to be released during exercise resulting in increased dilation of the muscle capillary bed. Congenital conditions that disrupt the release of nitric oxide are associated with muscle pain and fatigue. Treatment of fibromyalgia requires education about the condition and about treatment using relaxation techniques. Regular exercise may improve blood flow to the trigger points, as can isorbide denitrite. At present, the major treatment is to use a variety of drugs for pain and also hypnotics for sleep. Pregabalin, which

modulates the alpha 2 delta voltage dependent calcium channel, has proven to have a small positive effect. The ineffectiveness of medicines has been shown by the fact that over 74 medications have been recommended to treat fibromyalgia. Chronic fatigue syndrome is also known as myalgic encephalomyelitis. Persons with this condition have a variety of symptoms. Many find that after exercise there is onset of severe fatigue, weakness, pain, and flu-like symptoms, making it impossible for them to do things for a day or more after exercising. They also have trouble focusing and have a poor memory. Other symptoms include a sore throat, tender cervical and axillary lymph nodes, headaches, orthostasis, restless sleep, and muscle and joint pain. It is often associated with depression and irritable bowel syndrome. The causes are unknown but include infections, psychological distress,

environmental influences, and genetic predisposition. These result in an imbalance of neurotransmitters, immune regulators, and stress hormones which appear to trigger the symptoms. Treatment is symptomatic. Cognitive behavioral therapy coupled with progressive exercise therapy has produced the best outcomes. Frailty and Fatigue A person can be defined as frail when his/her ability to cope with a stressful situation (such as influenza or emotional distress) is so compromised that these stressors lead to an inability to carry out common activities of daily living and put the person at major risk of developing a permanent disability under these circumstances. Frailty should (continued on page 4) 3

Fig. 1. Potential Trajectory of Frailty

VO2 max Cardiac output Balance Muscle strength

Frailty Threshold
10 20 30 40

Exe rcise
e ea s Dis

50 60 70 Age (years)

80

90

100

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be considered a pre-disability and as such should be distinguished from disability1. Fried et al2 have provided an objective definition of frailty: Weight loss (10 lbs. in 1 year)

both the development of F atigue failure of basic activities of R esistance (inability to climb flight of stairs) daily living and mortality. A erobic (inability to walk one block) The International Association of Nutrition and I llnesses (more than 5) 4 Aging provided a simple L oss of weight (5% or more in a year) definition of frailty that is easy to use clinically (see causes of weight loss in older perbox). sons are easily remembered by the Frailty appears to be a universal mnemonic MEALS-ON-WHEELS concept in all species. The worm (see page 5). c. Elegans shows a decline in body The Simplified Nutrition Asmovement and behavior deficits with sessment Questionnaire (SNAQ) is aging, i.e., frailty. These changes an excellent predictor of weight loss are related, in part, to muscle dete(see Fig. 3 on page 6). rioration (sarcopenia). Development of frailty leads to death in these Weight loss and Fatigue worms. There are six major causes of The potential trajectory of weight loss: frailty over the lifespan is shown Anorexia in Fig. 1 (see page 3). The causes Sarcopenia (continued on page 5) and outcomes of frailty are shown in Fig. 2. Anorexia and Fatigue Older persons develop a physiological anorexia of aging which places them at risk of developing severe anorexia when they become ill5. Anorexia independently predicts mortality. The most common cause of pathological anorexia in older persons is depression, which is the cause in up to one-third of older persons for losing weight. Besides cancer, common treatable Fig. 2. Causes and Outcomes of Frailty

Exhaustion (self-report) Weakness (grip strength = lowest 20%) Walking speed (slowest 20% over 15 feet) Low physical activity (lowest 20%) They found females more likely to be frail than males and a prevalence of 6.9% in an older population. Ken Rockwood and his colleagues3 believe that frailty can be defined by just counting the number of problematic conditions a person is suffering from. For them, frailty is just a measure of disease burden. However frailty is defined, it has been shown to predict 4

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MEALS ON WHEELS

M edications E motional (depression) A norexia tardive, elder Abuse, Alcoholism L ate life paranoia S wallowing problems O ral problems N osocomial infections (e.g., tuberculosis, helicobacter pylori) and No money (poverty)

W andering and other dementia-related behav-

iors H yperthyroidism, Hypercalcemia, Hypoadrenalism, Hyperglycemia, Hypertension (pheochromocytoma) E nteric problems (pancreatitis, celiac disease, bacterial overgrowth) E ating problems L ow salt, Low cholesterol or other therapeutic diets S tones (gall stones) or Shopping problems
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Cachexia Malabsorption Hypercatabolism Dehydration Sarcopenia is defined as the age-associated loss of muscle mass6. Pathological sarcopenia occurs when a person is below 2 standard deviations of the mean muscle mass of healthy young persons. Approximately 3.6 million persons in the United States have severe sarcopenia. Sarcopenia is associated with an increase in disability and mortality. Persons who are obese and have muscle loss (the so-called sarcopenic obese or fat frail) have the highest risk of developing disability and of dying. There are multiple causes of sarcopenia. The primary cause is a decrease in exercise. Immobility in a person over 60 years of age who goes to bed for 10 days can result in the loss of one kilogram of muscle mass. An older person admitted to hospital loses a kilogram in three days. There is evidence that essential amino acids can prevent this muscle loss. Older persons require at least 1.2 g/kg of protein a day and as much as 1.5 g/kg if admitted to hospital. Creatine has been shown to improve knee power in older persons. Hypovitaminosis D is associated with a decline in muscle strength, sarcopenia, falls, hip fracture, and disability. Replacement of vitamin D to a level above 25 ng/dl reverses these problems to the normal risk level. Vitamin D replacement also decreases mortality. Testosterone declines at the rate of 1% per year after the age of 30 years in men and more rapidly between 20 to 45 years in women. Testosterone

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fatigue

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Fig 3. Simplified Nutritional Assessment Questionnaire

replacement improves physical perfor mance, decreases frailty, and decreases hospitalization7,8,9. Selective androgen receptor molecules (SARMs) such as Ostarine, appear to be more potent at increasing power. There is limited evidence for the use of growth hormone to improve frailty. Ghrelin, a hormone produced from the fundus

Fig. 4. Causes of Sarcopenia

Increased leptin Visceral obesity Adiponectin Decreased calorie and protein intake GENETIC Myostatin Notch 1 IGF-2 CNTF Insulin resistance Hypertriglyceridemia Increased fat infiltration Hypoxia

of the stomach, increases growth hormone and food intake, and improves memory. Ghrelin agonists are under development to treat frailty. Stem cells that overproduce muscle insulinlike growth factor (IGF) have been shown to increase muscle mass in rodents. A loss of motor units to muscle with aging plays a role both in loss of muscle mass and a loss in coordinated muscle activity. The causes of sarcopenia are delineated in Fig. 4. Cachexia or Wasting Disease is caused by an excess of cytokines. Cytokines, such as tumor necrosis factor alpha or interleukin-6 activate the ubiquitin-proteasome system to cause muscle loss and lipolysis, resulting in loss of fat. They also produce anorexia, decrease circulating albumin levels, and lead to insulin resistance. Cytokines are produced by immune cells. They have multiple effects that can lead to frailty (Fig. 5)10. These include alterations in immunomodulation, anorexia, cognitive decline, osteopenia, anemia, sarcopenia, nitrogen loss, and extravasation of albumin into the extravascular space. Conclusion Frailty can be objectively defined by the Fried or IANA criteria and it represents predisability. Frailty has multiple causes. Prevention of frailty involves exercise, adequate essential amino acid supplementation, and possibly hormonal (anabolic steroid) and cytokine manipulation.

Atherosclerosis Decreased motor units Decreased IGF-1Ea MGF Decreased CNTF

Decreased physical activity

Mitrochondrial abnormalities Decreased anabolic hormones Cytokine excess e.g. TNFa IL6 Testosterone DHEA

Vitamin D deficiency

Decreased growth hormone and ghrelin

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Fig. 5. Cytokines effects that lead to frailty

Anorexia Cognitive Decline Sickness Behavior Osteopenia

ACCOLADES
Dr. Miguel Paniagua is the new Internal Medicine Residency Program Director as of July 1, 2010. Dr. Paniagua, an Associate Professor of Internal Medicine in the Division of Geriatric Medicine, has been at Saint Louis University Miguel Paniagua, M.D. since 2007. A graduate of Saint Louis University and the University of Illinois College of Medicine in Chicago, he completed his internal medicine residency training and twoyear fellowship in gerontology and geriatric medicine at the University of Washington in Seattle. He is a two-time recipient of a Geriatric Academic Career Award (GACA) from Health Research Service Administration and the Department of Health and Human Services. He has received the Attending Physician Excellence in Teaching Award for the Department of Internal Medicine as well as the Caring Physician Award at Saint Louis University Hospital. Congratulations, Dr. Paniagua! Dr. Miriam Rodin, an Associate Professor of Internal Medicine in the Division of Geriatric Medicine, has been named an associate editor of the Journal of the American Geriatric Society (JAGS). Dr. Rodin joined the Division of Geriatric Medicine in October 2007. She is board certified in internal medicine, with certificates of added qualification in geriatrics and the American Association of Hospice and Palliative Medicine. Congratulations Dr. Rodin! Miriam Rodin, M.D., Ph.D.

IL-1 IL-2 IL-6

TNFa FRAILTY IMPAIRED FUNCTION INCREASED MORTALITY

Immunomodulation

Albumin Synthesis Sarcopenia Loss of Nitrogen

Anemia

Atherosclerosis Extravasation of Albumin into Extravascular Space

1 Morley JE. Developing novel therapeutic approaches to frailty. Curr Pharm Des 2009;15(28):3384-95. Review. 2 Fried LP, et al. Cardiovascular Health Study Collaborative Research Group. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci 2001 Mar;56(3):M146-56. 3 Rockwood K, et al. How should we grade frailty in nursing home patients? J Am Med Dir Assoc 2007 Nov;8(9):595-603. 4 Abellan van Kan G, et al. Frailty: Toward a clinical definition. J Am Med Dir Assoc 2008 Feb;9(2):71-2. 5 Abellan van Kan G, et al. The I.A.N.A. Task Force on Frailty Assessment of older people in clinical practice. J Nutr Health Aging 2008 Jan;12(1):29-37. Review. 6 Morley JE, et al. Editorial: Something about frailty. J Gerontol A Biol Sci Med Sci 2002 Nov;57(11):M698-704. Review. 7 Page ST, et al. Exogenous testosterone (T) alone or with finasteride increases physical performance, grip strength, and lean body mass in older men with low serum T. J Clin Endocrinol Metab 2005 Mar;90(3):1502-10. 8 Chapman IM, et al. Effect of testosterone and a nutritional supplement, alone and in combination, on hospital admissions in undernourished older men and women. Am J Clin Nutr 2009 Mar;89(3);880-9. 9 Srinivas-Shankar U, et al. Effects of testosterone on muscle strength, physical function, body composition, and quality of life in intermediate-frail and frail elderly men: a randomized, double-blind, placebocontrolled study. J Clin Endocrinol Metab 2010 Feb;95(2):639-50. 10 Morley JE, et al. Cytokine-related aging process. J Gerontol A Biol Sci Med Sci 2004 Sep;59(9):M924-9.

RefeRences

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Are you missing something?

Are you looking for a past issue of Aging Successfully? Maybe an article on a particular topic? Or a screening tool? Ideas for living longer and living stronger? Upcoming continuing medical education opportunities?

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

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Nutrition and physical activity play key roles in staying young, keeping healthy, and enjoying life. Thats the message of the newly released The Science of Staying Young: by John E. Morley, M.D. and Sheri R. Colberg, Ph.D., from HealthSpan Solutions, LLC. The Science of Staying Young reveals the key factors for looking and feeling young fish, alcohol, proteins (especially leucine), and exercise.

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Old Man and the SEA

SUCCESSFUL EMOTIONAL AGING

By Abhilash K. Desai MD, and Nina Tumosa PhD

The world breaks everyone, and afTerward, some are sTrong aT The broken places. buT Those ThaT will noT break, iT kills.
A Farewell To Arms - Ernest Hemmingway The Old Man and the Sea (1951) is a beautiful work of fiction written in Cuba by Ernest Hemmingway. The central character is Santiago, an aging Cuban fisherman who shows extraordinary emotional strength and dignity as he struggles with a giant marlin far out in the Gulf Stream. Santiago, in many ways, exemplifies/personifies successful emotional aging or SEA. Santiagos SEA enabled him to survive a dangerous undertaking that would have destroyed others with less resolve and faith. Questions? FAX: 314-771-8575 SEA is not easy to achieve. Persons with SEA have many attributes including: High emotional and cognitive reserve A physically, socially and intellectually active lifestyle, Inherited genes and how these genes are changed by other health conditions, diet, and psychosocial factors (e.g., social support), and A manageable environment. In the 21st century, it is no longer good enough to pay attention email: aging@slu.edu to just the mental and physical health problems of older adults. In order to promote overall health, providers must also consider whether their patients also have the determinants of successful biopsychosocial aging (Vaillant and Mukamal, 2001). Do they have positive personality changes, such as better tolerance, regulation of affect, and ability to appreciate different points of

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Old Man and the SEA

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Come to terms with lifes finitude (Erikson and Kivnick 1986). Research to date has identified many predictors of successful aging that are to a large extent under the individuals own control - such as absence of both alcohol abuse and cigarette smoking before the age of 50. A stable marriage and

to turn lemons into lemonade, are able to learn from their children and remember that ones entire life is a journey and that the seeds of love must be perpetually resown (Vaillant 2002). The presence of a spiritual belief system has also been correlated with decreased depression and faster recovery from

view, that often occur with aging (Erickson and Kivnick 1986)? In other words, do they have SEA? These attributes can contribute to a high quality of life through successful adjustment to lifes changes and challenges. Older persons accumulate wisdom through the lifecycle and, therefore, are better prepared to manage stressful events (Baltes and Staudinger 2000). At the neurobiological level, wisdom involves an optimal balance between functions of phylogenetically more primitive brain regions (limbic system) and newer ones (prefrontal cortex) (Meeks and Jeste 2009). Both the accumulation of wisdom over many years and the development of supportive social networks (a norm in later life) are important protective factors against late-life depression. Older adults who are thought to be wise have many unique skills that they have developed. These include the abilities to: Challenge their own belief systems depending on life events; Re-examine past failures and see them with a more nuanced view; Be comfortable with uncertainty (rather than constantly seeking answers), Selectively optimize the positive in the experience, forgetting future difficulties (Cartensen et al, 2000) Act beyond self-interest, and 10

the development of positive adaptive defenses are also predictive of successful aging, subjective satisfaction, and objective mental health. Among factors outside the individuals control, only depression before the age of 50 years was a significant predictor of mortality, medical morbidity, and sadness during late life (Alexopoulos, 2001). SEA also predicts subsequent functional independence and improved survival. Older adults with strong feelings of personal control and self-efficacy (i.e., the personal conviction that one can respond appropriately in novel or stressful situations) are more likely to cope successfully with late-life challenges. Those who have SEA understand how to savor joy and email: aging@slu.edu

illness in later life, and increased longevity (Penninx 2000). Religious participation and spirituality improves mental health among older adults. Religiousness and/ or spirituality plays a large role in SEA. They may provide both (a) a sense of meaning or purpose that buffers stress and assists with coping, and (b) a network of likeminded persons who can serve as social resources and promote development of psychological resources, including self-esteem and a sense of personal growth. Clinicians have a moral obligation to address patients spiritual concerns. In considering the spiritual dimension of the patient, the clinician is sending an important message that he or
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she is concerned with the whole psychosocial factors. These factors person. This enhances the patientinclude regular exercise, a healthy provider relationship and is likely diet, intellectually challenging to increase the therapeutic impact leisure-time activity and an active of interventions (DSouza 2007). socially-integrated lifestyle. Thus, Referring older adults suffering suggesting strategies that promote from depression, pain, or other seSEA, such as a healthy lifestyle, rious symptoms to chaplains or to optimal control of VRFs, and their own personal clergy should secondary prevention of stroke (continued from page 10) be routinely considered. is prudent, despite the absence Emotional and cognitive health of evidence from randomized to Table 2 on page 15 for a list of as it pertains to the older adult controlled trials of risk factor resources to promote SEA. should be defined not just as the modification (Desai, et al, 2010). Visionary and determined older absence of disease. It is also the Integrative interventions (e.g., adults are reinventing the concept development and preservation of mindfulness-meditation practices, of SEA. These individuals believe the abilities to maintain social conexercise, healthy diet, and medithat each of us, no matter how old, nectedness and an ongoing sense of cations) may be more beneficial sick, frail, disabled, or forgetful, purpose, to function independently, to individuals, regardless of their deserves to have love and dignity, to recover function following illpersonal risk factors. Please refer not scorn and marginalization. ness or injury, and to cope Such individuals make well with residual func- Table 1. Vascular Risk Factors and Vascular Disorders the quality of life for tional deficits (Hendrie VASCULAR RiSk FACTORS themselves and others et al 2006). In daily life, life-affirming, create a High blood pressure emotional and cognitive culture that rekindles health are not separable. the human spirit, and Overweight and obesity Thus, promoting emotional mends the frayed social (Body Mass Index more than 25) wellbeing should be confabric of our current so Sedentary Lifestyle ceptualized hand-in-hand ciety. Such transformawith promoting cognitive tional change is needed Poor Eating Habits wellbeing. For example, not only in individuals regular intake of omega-3 Smoking but also in the entire supplements and Vitamin culture of aging. There High cholesterol D (both essential for opare several remarkable timal brain function but Diabetes organizations (such as generally deficient in older The Center for Aging Sleep Apnea adults) may have potential Successfully [http:// benefits for emotional and aging.slu.edu], and cognitive health in older The Center for Healthy VASCULAR DiSORDERS adults. Brain Aging [http:// There is a strong role neuroandpsych. Coronary artery disease for prevention in the develslu.edu/healthy Peripheral artery disease opment and maintenance brain/]) where of SEA. The pathogenic people with Stroke process and clinical manidrive, knowlfestation of depression and Atherosclerosis (disease of the large blood vessels) edge, wisdom, dementia in older adults creative zeal Arteriosclerosis (disease of the small blood vessels) with vascular risk facand compassion, tors (VRFs) and disorders strive to make Microangiopathy (disease of the tiny blood vessels) (see Table 1) can clearly this culture (continued on page 14) be ameliorated by several

Old Man and the SEA

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GERIATRICS in a page

AGING SKIN

With age, skin undergoes changes in structure and function.

Fig. 1 Histologic changes in aging normal skin.

Flattening of the dermoepidermal junction loss of dermal and subcutaneous mass shortened capillary loops reduced numbers of melanocytes, Langerhans cells, and mast cells (From Gilchrest BA: Age-associated changes in the skin. J Am Geriatr Soc 1982; 30:139-143.)

Loss of dermal thickness approaches 20% in older adults and may account for the paper-thin, almost transparent, quality. The remaining dermis is relatively acellular and avascular.

Physiologic parameters that increase with age Disordered connective tissue formation Skin tears Bullae formation Aberrant immune function Herpes Zoster infection Postherpetic neuralgia Skin cancer Bullous Pemphigoid

Physiologic parameters in human skin that decline with age Decreased Growth Rate
Epidermal turnover rate Repair rate in injured skin Hair and nail growth Sensory perception

Compromised Thermoregulation
Sweat production Vascular response Subcutaneous fat

Decreased DNA Repair

Chemical clearance rates Immune responsiveness UV radiation = more damage

Structural and Metabolic Integrity

Sebum production Hypersensitivity reactions Vitamin D production Collagen and elastin

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WEIGHT LOSS
What do you mean by weight loss?
Decrease in > 5% of your usual body weight over the last 6-12 months Whether or not the loss of weight is intentional, it may be a cause for concern

GERIATRICS in a page
Who is at risk?
Hospitalized, nursing home resident, cancer, stroke, infection, dementia, recent orthopedic surgery, depression, low income, too many medicines More than 80% of hospitalized older adults are malnourished and only about 40% were able to gain back lost weight

What are the potential causes of weight loss?

Why should I be concerned about losing weight?

Weight loss can contribute to memory loss, decreased immune function (predisposing to infections), decreased muscle mass and weakness, loss of function, and poor wound healing Weight loss has been associated with an increase in mortality

Medications Emotion (Depression) Alcohol; Abuse; Anorexia Late-life paranoia Swallowing problems Oral/dental problems No money; Nosocomial (hospital-acquired) infections Wandering (dementia-related behaviors) Hypothyroid; Hyperparathyroid; Hypoadrenal; Hyperglycemia Entry problems (malabsorption) Eating problems (tremor, weakness, stroke) Low salt and low cholesterol diets Shopping and food prep problems

How is weight loss evaluated?

It takes an interprofessional team, including your doctor, a dietician, nursing staff, food service staff, a social worker, and a speech therapist First goal is to look for and treat any underlying reversible causes Second goal is to provide nutritional support

What supplements and medications can be used?

Table 1. Management of unintentional weight loss First-line Treatments Examples Nutritional Milk based: Carnation Instant Supplements Breakfast, health shakes Lactose free: Boost, Ensure Vitamin Supplementation Other interventions Multivitamin Calcium, Vitamin D Get regular exercise, alter food texture, liberalize diets (no salt or fat restrictions), offer favorite foods and snacks, eat in company or with assistance, review your medicines

Benefits 1. Simple way to increase protein and calorie intake 2. Has been found to increase weight, promote wound healing and improve cognition and quality of life in the short-term 1. Replaces necessary vitamins and minerals that may be lacking in diet 2. Vitamin D is important for bone, brain, muscle, and heart health Simple, safe interventions to promote good nutrition and overall well-being.

Possible concerns 1. Milk-based products may not be well tolerated 2. Must be taken between meals to avoid decreased intake at meal-time 3. Lactose-free products more expensive Lack of data showing significant benefit of a daily multivitamin None

Second-line Treatments *Note: None of the medications commonly used to treat weight loss are approved for this purpose by the FDA How it works How well it works Dosages 7.5 30 mg once daily, given In one study of depressed patients, it Mirtazapine An antidepressant, its side effect caused a 17% increase in appetite (Remeron) is an increase in appetite and at bedtime and a >7% increase in body weight. weight gain! Dronabinol (Marinol) THC, a synthetic analog of cannabis that works in the brain to stimulate appetite A hormone that increases appetite by unknown mechanisms An anabolic steroid, it works to increase muscle mass. A study of 15 Alzheimers patients noted an increase in weight. Most studies were done in patients with cancer or AIDS. Improved appetite and sense of wellbeing in a few studies done in nursing home residents. Most studies were done in burn victims but show a slowing of weight loss and some gain. 2.5 mg twice a day before lunch and dinner 400-800 mg a day (625 mg of ES) 5 mg twice a day for 2-4 weeks *NOTE: cannot use if history of prostate or breast cancer!

Megestrol acetate (Megace) Oxandrolone (Oxandrin)

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Common side effects Somnolence, Dizziness Dry mouth, Confusion Leg swelling Muscle and back pain Dizziness Confusion Anxiety Euphora & paranoia Nausea, vomiting, diarrhea Blood clot Uncontrolled blood pressure Masculinization of women Liver injury Increased cholesterol Edema

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Old Man and the SEA

Beautiful Old Age

It ought to be lovely to be old to be full of the peace that comes of experience and wrinkled ripe fulfilment. The wrinkled smile of completeness that follows a life lived undaunted and unsoured with accepted lies they would ripen like apples, and be scented like pippins in their old age. Soothing, old people should be, like apples when one is tired of love. Fragrant like yellowing leaves, and dim with the soft stillness and satisfaction of autumn. And a girl should say: It must be wonderful to live and grow old. Look at my mother, how rich and still she is! And a young man should think: By Jove my father has faced all weathers, but its been a life! D. H. Lawrence

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change a reality. Such an agedignifying culture will create more friends than restrictions and rules to follow. Such a culture knows that the single most important thing we value more than good food, good medical care, or clean facilities is the warmth of a caring relationship. Such a culture will sustain high-quality life through relentless adherence to friendshipcentered living. Government can give credit to organizations that engage in creating such a culture and create incentives and training for more organizations to join toward friendship-centered living. An ideal age-dignifying culture, conceived and driven by older persons with SEA, not only becomes a culture of choice in the community, but may also reduce emotional suffering and the cost of health care (e.g., reduced depression in latelife). The Beautiful Old Age shared by D. H. Lawrence can inspire all of us to age well. R efeRences
Alexopoulos G. New concepts for prevention and treatment of late-life depression. Am J Psychiatry 2001; 158:835-8. Baltes P, Staudinger U. Wisdom: a metahuerastic (pragmatic) to orchestrate mind and virtue toward excellence. Am Psychol 2000; 10:265-274. Cartensen L, Mayr U, Pasupathi M and Nesselroade J.

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Emotional experience in everyday life across the adult life span. J Personality and Soc Psychol 2000; 79:644-655. Desai AK, Grossberg GT, Chibnall JT.

Healthy Brain Aging: A Road Map. Clin Ger Med 2010; 26:1-16. DSouza R. The importance of spirituality in medicine and its applications to clinical practice. Med J Australia 2007;

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Questions? FAX: 314-771-8575

to Promote Healthy Brain Aging

BOOkS Improving Memory: Understanding age-related memory loss. A special health report from Harvard Medical School. 2006 Harvard Health Publications, Boston, Massachusetts. www.health.harvard.edu Healthy Eating. A guide to the new nutrition. A special health report from Harvard Medical School. 2006 Harvard Health Publications, Boston, Massachusetts. www.health.harvard.edu The No Sweat Exercise Plan. Lose Weight, Get Healthy, and Live Longer. Harvey B. Simon M.D. 2006. McGraw Hill Books, New York, NY. The Mature Mind: The Positive Power of the Aging Brain. Gene D. Cohen M.D., Ph.D. 2005. Basic Books. New York, NY. The Brain That Changes Itself. Norman Doidge M.D. 2007. Penguin Books. New York, NY. Aging Well. George E. Vaillant. 2002. Little, Brown and Company. New York, NY. Mind Your Heart: A mind/body approach to stress management, exercise, and nutrition for Heart Health. Aggie Casey and Herbert Benson. 2004 Free Press, New York, NY. Handbook For The Soul. Richard Carlson, Benjamin Shield 1995, USA. AUDIO-CD The Healthy Brain Kit. Andrew Weil M.D., Gary Small M.D. Sounds True. Also has 52-page workbook and 35 brain-training cards.

Old Man and the SEA

(continued from page 14)

Table 2: Resources for Patients That Physicians Can Recommend

186:S57-9. Erickson E, Kivnick H. Vital Involvement in Old Age: The Experience of Old Age in Our Time. London, UK: Norton; 1986. Hendrie HC, Albert MS, Butters MA, et al. The NIH Cognitive and Emotional Health Project: Report of the Critical Evaluation Study Committee. Alzheimers & Dementia 2006;2(1):12-32. Meeks TW, Jeste DV. Neurobiology of wisdom: a literature overview. Arch Gen Psychiatry 2009; 66:355-365. Penninx BWJH. A happy person, a healthy person? J Am Ger Soc 2000; 48:473-8. Vaillant GE & Mukamal K. Successful aging. Am J Psychiatry 2001; 158:839-47.

SLU Geriatrics Welcomes New Faculty

The Division of Geriatric Medicine is delighted to welcome five new faculty members. Dr. Milta Little, interested in long term care research, would like to become a certified medical director and improve transitions between hospital care and nursing home care. Dr. Lenise Cumming-Vaughns interests lie in epidemiology, African-American health study, and evidence-based geriatrics. Dr. Dulce Cruz-Oliver is particularly interested in palliative and hospice care as well as end-of-life care of nursing home residents. Dr. Frederick Yap, who did his fellowship training and his residency at SLU, returns to Geriatrics as a faculty member. His interests are in Alzheimers Disease, dementia, and frailty. Dr. Gerald Mahon, a faculty member from 1989-91, returns to Geriatrics as well, having had his own private practice in the interim. (left to right) Milta Little, D.O., Dulce Cruz-Oliver, M.D., Lenise Cum- Welcome all!
ming-Vaughn, M.D., Gerald Mahon, M.D., and Frederick Yap., M.D.

Questions? FAX: 314-771-8575

email: aging@slu.edu

Aging Successfully, Vol. XX, No. 1

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An Active Life with Dementia

disease and all other causes of dementia.
Winner 3rd Place, Professional class
Photographer: Paula Ines Conti, Argentina

The Alzheimers Disease International Photo Competition

In an effort to bring this organization to your attention, we a r e s h a r i n g the results of their 2010 photo competition. These

Winner 1st Place, Professional class

Photographer: Andreas Philippides, Cyprus

Alzheimers Disease International (ADI) is the worldwide umbrella organization of Alzheimer associations. Their mission is to help establish and strengthen Alzheimer associations throughout the world, and to raise global awareness about Alzheimers

Winner 3rd Place, Professional class

Photographer: Andreas Philippides, Cyprus

their caregivers. We are grateful to Sarah Smith, Administrator, Alzheimers Disease I n t e r n a t i o n a l fo r granting us permission to reprint these photographs here.

Winner 3rd Place, Amateur class Photographer: Janet Wood of Zimbabwe

photos and more information about Alzheimers Disease International can be found at www.alz.co.uk. These phenomenal winning photographs illustrate the universality of dementia and highlight the dignity of both those with dementia and
email: aging@slu.edu

Winner 1st Place, Amateur class

Photographer: Katherine Leong Peck Fun Malaysia

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Aging Successfully, Vol. XX, No. 1

Questions? FAX: 314-771-8575

The Latest News About Our Research Efforts

Members of the St. Louis VA GRECC and the Saint Louis University Division of Geriatric Medicine are active in a number of areas of research including:

Towards a Cure for Alzheimers Disease

ly. Studies are under development to test this antisense in humans. In addition, the GRECC has developed the VA-Saint Louis University Mental Status (SLUMS) Exam to diagnose mild cognitive impairment and dementia.

Original studies in the GRECC showed that high doses of amyloidbeta protein blocked memory formation. More recently, we have found that very low doses of amyloid-beta protein enhance memory. Amyloid-beta also increases acetylcholine at these low doses and enhances long-term potentiation. Blocking amyloid-beta activity in young animals decreases memory. These findings suggest that amyloid-beta proteins physiological role is memory enhancement. The SAMP8 mouse is a spontaneous animal model of Alzheimers disease. The SAMP8 develops early problems with learning and retention of memories. It has an increase in amyloid precursor protein and amyloid protein in the brain. Its deficits in memory and acetylcholine production can be reversed by antibodies to beta amyloid. In an attempt to reverse these problems, we developed an antisense to amyloid precursor protein. Antisenses block the ability of messenger RNA to produce protein. This antisense improves learning and memory in SAMP8 mice, reverses oxidative damage in the brain, improves the egress of amyloid-beta from the brain and lowers brain levels of amyloid-beta protein. It crosses the blood-brain barrier and can be given intranasalQuestions? FAX: 314-771-8575

Testosterone and the Older Male

The GRECC developed the widely used ADAM questionnaire for recognizing late-life onset of male hypogonadism. We were the first to demonstrate longitudinally that testosterone declines with aging. Our early studies led the way in showing that testosterone improved muscle strength in old males. Recently, we showed that testosterone, together with a protein supplement, reduced hospitalizations in older persons living in assisted living. Recent mouse studies have shown that testosterone has a direct effect on the insulin-signaling pathway and reduces the increase in interleukin-1 that occurs with castration.

We have shown that depression is the major pathological cause of weight loss in older persons. The importance of giving caloric supplements between meals was also demonstrated by our group. Recently, we showed the positive effect of the prebiotic oligofructosaccharide on enhancing the immune system in older persons. GRECC scientists have played a leading role in developing nutritional guidelines for malnourished nursing home residents. We also have been leaders in the field of defining cachexia and providing nutritional guidelines for managing both cachexia and sarcopenia.

Epidemiology

Anorexia of Aging

GRECC scientists developed the concept of the physiological anorexia of aging. Our studies in animals and humans have shown that this anorexia is mainly due to alterations in stomach motility and due to the increased activity of the satiating duodenal hormone, cholesystokinin. The greater amount of anorexia in males is due to falling testosterone levels resulting in increased leptin from adipose cells. Leptin inhibits food intake. email: aging@slu.edu

The GRECC is actively involved in studying the aging process in middle-aged African Americans. We have found that depression is underdiagnosed and undertreated in this population. Elevations in tumor necrosis factor alpha are predictive of functional impairment in this population. Separately from cytokines, the environment predicts poor outcomes. Dr. Flaherty has developed a collaboration in Chengdu, China, where he is studying highly healthy persons over 90 years of age. The earthquake in the area allowed him to demonstrate the increased (not directly earthquake related) mortality that the stress of the earthquake produced. The psychological stress of Hong Kong being returned to China also produced an increase in mortality in Chinese males over 80 years of age. 17

Aging Successfully, Vol. XX, No. 1

EDITORIAL
epression is a very common problem among older persons. It occurs in about one in five community dwelling older persons and in at least a third of older persons living in nursing homes. Despite this, the presence of depression is commonly missed in older Dr. John E. Morley persons, especially in the African American population. As depression is a highly treatable condition, there is little excuse for health care physicians to fail to make the diagnosis. Not only is depression a terrible condition in itself, but it also has numerous effects on physical diseases. Perhaps most importantly, persons with depression fail to comply with taking their medications. Persons who are depressed and have a myocardial infarction tend to have worse outcomes and may be more likely to have a second heart attack. Depressed persons do poorly during rehabilitation, claiming to be too fatigued to work hard during the rehabilitation period. Depression increases cortisol levels resulting in accelerated osteoporosis. Persons with stroke are highly likely to be depressed and depression leads to poor outcomes in stroke patients. Diabetics are also more likely to be depressed. We have shown that depression in diabetes mellitus is the major factor in hospitalization and in death. Depression is also a major cause of reversible dementia (pseudodementia). Treatment for depression consists of psychological therapy coupled with drugs. Severe cases do extremely well with electroconvulsive therapy (ECT). Exercise has been shown to have positive effects on decreasing depression. Most studies suggest that behavioral therapy does as well as pharmacotherapy. In older persons, there is about a 30% placebo response with another 30 plus percent responding to drugs or behavioral therapy. Response rates to ECT are higher. The use of electromagnetic therapy is still under development. Drug therapy in the United States consists of the older 18

Aging Successfully, Vol. XX, No. 1

tricyclics or the selective serotonin reuptake inhibitors (SSRIs) and now the mixed antidepressants. Monoamine oxidase inhibitors are rarely used in the United States. Emerging side effects of the SSRIs have required some rethinking about their safety. Classically, the SSRIs were known to produce the serotonin syndrome and hyponatremia associated with delirium. They also could cause weight loss, particularly in the case of the very long acting fluoxetine (Prozac). Then they were associated with an increase in gastrointestinal bleeding. This was due to the fact that they slow blood flow through the stomach. Next we became aware that SSRIs increased falls and hip fractures to a greater extent than the tricyclics. Most recently, they have been shown to produce osteoporosis, causing us to question their long term use in older persons. If tricyclics are used, their use in older persons should be limited to the less anticholinergic agents, viz. desipramine or nortryptilene. Mirtazapine in lower doses, up to 15 mg, increases appetite in depressed persons and so may be the drug of choice where weight loss is a problem. All drug therapy should be coupled with some supportive therapy to obtain maximum effectiveness. All older persons should be asked at every visit if they are sad. At least once a year, the 15-point geriatric depression scale (see the Passport to Aging Successfully on page 20) should be administered. Depression should be vigorously treated. It is unconscionable to miss the diagnosis of depression in older persons. Questions? FAX: 314-771-8575

email: aging@slu.edu

Please complete this questionnaire before seeing your physician and take it with you when you go. NAME_______________________________________________ AGE_____________ BLOOD PRESSURE sitting:_____________________ standing:____________________ WEiGHT now:___________ 6 months ago:__________ change:______________________ HEiGHT at age 20:______________________ now:____________________ RELiGiON:___________________ CHOLESTEROL LDL:___________ HDL:______________ VACCINATIONS Influenza (yearly) Pneumococcal Tetanus (every 10 years) Shingles TSH Date:___________ FASTiNG GLUCOSE Date:__________ Do you SMOkE? _______ if male age 60+, have you had an ultrasound of your abdomen?____________ How much ALCOHOL do you drink? _________ per day Do you chew TOBACCO?_____________ Do you use your SEATBELT? ____________ EXERCiSE: How often do you... do ENDURANCE exercises (walk briskly 20-30 minutes/day or climb 10 flights of stairs) _________/week do RESiSTANCE exercises?__________/week do BALANCE exercises?__________/week do POSTURE exercises?__________/week do FLEXiBiLiTY exercises?__________/week Can you SEE ADEQUATELY in poor light? ___________ Can you HEAR in a noisy environment?____________ Are you iNCONTiNENT?_____________ Have you a LiViNG WiLL or durable POWER OF ATTORNEY FOR HEALTH?_________________ Do you take ASPiRiN daily (only if you have had a heart attack or have diabetes)?________________ Do you have any concerns about your PERSONAL SAFETY?____________________ Do you need to discuss SEXUAL CONCERNS?___________________ When did you last have your STOOL TESTED for blood?___________________ When were you last screened for OSTEOPOROSiS?_______________________ Are you having trouble REMEMBERiNG THiNGS?______________________ Do you have enough FOOD?_____________________ Has your ViTAMiN D level been measured?____________ What is your BONE MiNERAL DENSiTY?______________ Are you SAD?____________ Do you have PAiN?_________ if YES, which face best describes your pain?

Passport to Aging Successfully

Saint Louis University Division of Geriatrics

Have you discussed PSA testing with your doctor?________ What is your ADAM score?_________

FEMALES

Do you have trouble passing urine? ________

When was your last pap smear?_______________ When was your last mammogram?____________ Do you check your breasts monthly?___________ Are you satisfied with your sex life?____________

MALES

Now, please answer the four questionnaires on the other side.

Questions? FAX: 314-771-8575

email: aging@slu.edu

Aging Successfully, Vol. XX, No. 1

19

Geriatric Depression Scale

Passport to Aging Successfully

Please fill out these short forms before seeing your physician and take them with you when you go.
(circle one) NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES

Nutrition Sheikh JI, Yesavage JA. Geriatric Depression Scale (GDS): Recent evidence and
development of a shorter version. Clin Gerontol 1986 June;5(1/2):165-73.

Are you basically satisfied with your life? Have you dropped many of your activities and interests? Do you feel that your life is empty? Do you often get bored? Are you in good spirits most of the time? Are you afraid that something bad is going to happen to you? Do you feel happy most of the time? Do you often feel helpless? Do you prefer to stay at home, rather than going out and doing new things? Do you feel you have more problems with memory than most? Do you think it is wonderful to be alive? Do you feel pretty worthless the way you are now? Do you feel full of energy? Do you feel that your situation is hopeless? Do you think that most people are better off than you are?

ADAM (Men only)

1. Do you have a decrease in libido? 2. Do you have a lack of energy? 3. Do you have a decrease in strength and/or endurance? 4. Do you have a decreased enjoyment of life? 5. Are you sad? 6. Are you grumpy? 7. Are your erections less strong? 8. Have you noticed a recent deterioration in your ability to play sports? 9. Are you falling asleep earlier after dinner? 10. Has there been a recent deterioration in your work performance?

______ ______ ______ ______ ______ ______ ______ ______ ______ ______

Epworth Sleepiness Questionnaire

How likely are you to doze off or to fall asleep in the following situations, in contrast to just feeling tired? This refers to your usual way of life in recent times. Use the following scale to choose the most appropriate number for each situation. 0-would never doze 1-slight chance of dozing

SNAQ

Simplied Nutritional Assessment Questionnaire

Name:________________________________ Sex: M F

Age:______ Height:___________ Weight:_________ Date:________

My appetite is
a. very poor b. poor c. average d. good e. very good

Food tastes
a. very bad b. bad c. average d. good e. very good

2-moderate chance of dozing 3-high chance of dozing

Situation

Chance of dozing

When I eat

a. I feel full after eating only a few mouthfuls. b. I feel full after eating about a third of a meal. c. I feel full after eating over half a meal. d. I feel full after eating most of the meal. e. I hardly ever feel full.

Normally I eat

Sitting and reading............................................. __________ Watching TV........................................................ __________ Sitting inactive in a public place...................... __________ As a passenger in a car for an hour................. __________ Lying down to rest in the afternoon................. __________ Sitting and talking to someone......................... __________ Sitting quietly after a lunch without alcohol.... __________ In a car while stopped for a few minutes........ __________ TOTAL.................................................................... ______/24 (continued on page 20)
Questions? FAX: 314-771-8575

a. less than one meal a day. b. one meal a day. c. two meals a day. d. three meals a day. e. more than three meals a day.

Tally the results based on the following numerical scale: a=1; b=2, c=3, d=4, e=5. The sum of the scores for the individual items constitutes the SNAQ score. A SNAQ score of < 14 indicates signicant risk of at least 5% weight loss within six months.
Wilson, et al. Am J Clin Nutr 82:1074-81, 2005.

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Aging Successfully, Vol. XX, No. 1

SLU Geriatric Evaluation Mnemonic Screening Tools

email: aging@slu.edu

SAINT LOUIS UNIVERSITY FALLS SELF-ASSESSMENT

2008 Ameri of Hey Doc! Am I at Risk for Falls? canOFJournalYEArNursing BOOK THE
Together, you and your health care provider can help prevent injuries from falls. Answer the questions below by circling Y for Yes or N for No. Then, take the completed form to your next doctor visit. Patient Name Age

New Book Just Released!

ME during the past 12 months...

Y N I fell two or more times. Y N I was injured by a fall that limited my
regular activities for at least one day.

Y N Ive

taken medications. activities.

or

more

different

Y N Ive dropped some of my regular Y N Ive been taking a calcium supplement

Y N I saw a doctor because I had a fall. Y N Its been hard for me to walk or climb stairs. Y N Ive had trouble getting up from a soft chair. Y N Ive been unable to stand on one foot for
12 seconds without losing my balance.

regularly. If Yes, how many milligrams per day? __________ regularly. If Yes, how many units per day? __________ in my blood.

Y N Ive been taking a vitamin D supplement

Y N Ive had trouble with my eyesight. Y N I was told that Im having memory trouble. Y N Ive felt dizzy or light-headed after a big
meal.

Y N My doctor checked the vitamin D level Y N Ive walked, danced, exercised, or

practiced tai chi at least 3 times a week. and modied as needed.

Y N Ive taken medication that caused me to

feel dizzy or light-headed.

Y N My home was checked for any dangers

Clinician Signature

Date/Time Reviewed

THE DANGER OF FALLS: IMPORTANT FACTS

About 1.5 million bone fractures occur in the United States each year. Hip fractures are increasing out of proportion to the aging population. Half of those who have fallen once will fall repeatedly. Of those who have had a bone fracture, 40% cannot walk independently and 20% have a permanent disability. There is a higher mortality rate for men who have bone fractures than for women.

Questions? FAX: 314-771-8575

email: aging@slu.edu

Aging Successfully, Vol. XX, No. 1

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Are you at risk for diabetes? New questionnaire provides the answer.
By Dr. John Morley
Diabetes mellitus is a very common and devastating disorder. A new, simple questionnaire published in the Annals of Internal Medicine allows you to estimate your risk for diabetes.

How old are you? under 40 years (0 points) 40 to 49 years (1) 50 to 59 years (2) 60 years and over (3) Are you a woman or man? Woman (0) Man (1) Do your family members (parent or sibling) have diabetes? No (0) Yes (1) Are you overweight or obese? Not overweight (0) Overweight (1) Obese (2) Extremely Obese (3)

Are you physically active? No (0) Yes (-1) If your score is 4 or greater you are at high risk for undiagnosed or pre diabetes. If your score is 5 or greater you are at high risk for diabetes. With either of these scores, ask your doctor to check for diabetes by measuring a fasting glucose level. The BOTTOM LINE: We cannot do anything about our age (the older we are the more likely we are to become diabetic), sex (males have more diabetes than females), or

our family history. However we can increase our physical activity and maintain a reasonable weight to decrease our risk of developing diabetes as we get older. If you have a high score, have your doctor get a simple blood glucose test when you are fasting. If the level is greater than 126 mg/dl you most probably have diabetes. Physicians are classically sugar blind and often fail to diagnose diabetes. If you have these risk factors, exercise and try to lose weight. Even a small amount of weight loss can improve your metabolic status.

This questionnaire is reprinted from Dr. Morleys blog. Find this and all of his blogs by visiting his Facebook page and clicking on the BLOG tab.

Coming Soon

FROM THE JOHNS HOPkINS UNIVERSITY PRESS

Psychiatric Consultation in Long-Term Care

A Guide for Health Care Professionals

DISCOUNT

25%

SPECIAL

By Abhilash K. Desai, M.D., F.A.P.A., and George T. Grossberg, M.D. Studies show that residents of nursing homes and assisted living facilities are at a substantial risk of having psychiatric disorders. This practical volume provides much-needed clinical guidance for the prevention and appropriate treatment of mental illness in long-term care settings. In the book, Abhilash k. Desai and George T. Grossberg offer a basic framework for a humanistic, team-based approach to meeting the needs of elder persons with mental disorders in long-term care facilities. Chapters cover the demographics of residents, the epidemiology of their psychiatric symptoms, the assessment process, and focus on major disorders including dementia, delirium, depression, psychosis, and anxiety. The authors discuss end-of-life issues and treatments and offer suggestions for improving care. Throughout, they highlight the importance of the relationship between staff and patients. This book may be ordered from Johns Hopkins University Press, c/o Hopkins Fulfillment Service, P.O. Box 50370, Baltimore, MD, 21211-4370. Be sure to mention the code NAF to receive your 25% discount. For more information, visit www.press.jhu.edu or call 1-800-537-5487.

Dr. Oz Promotes VAMC SLUMS Exam

The Dr. Oz Show has modified the VAMC SLUMS Exam for his viewing audience. The VAMC SLUMS exam is a great tool to assess memory deficits. To access the Dr. Oz online version of the exam, visit his website, w w w.doctoroz.com /quiz / memory-quiz.
Questions? FAX: 314-771-8575

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Aging Successfully, Vol. XX, No. 1

email: aging@slu.edu

upcoming conTinuing educaTion programs

ever building on the foundation
22nd Annual Saint Louis University

7th Annual GRECC Western Orbit

Medical Directors Conference

October 15, 2010 Kansas City, Missouri USA
For more information, call 314-894-6560.

June 7-8, 2011 St. Louis, Missouri USA

For more information, call 314-894-6560.

Summer Geriatric Institute

Preventing Cognitive Decline in Older Persons

October 28, 2010 St. Louis, Missouri USA
For more information, call Erica Collier at 636-227-2100.

4th Annual CAM and 25th Annual GRECC Conference

Questions? FAX: 314-771-8575

email: aging@slu.edu

Aging Successfully, Vol. XX, No. 1

23

Non-Profit Org. U.S. Postage PAID St. Louis, MO Permit No. 134

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 D31HP08827; 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.

Moving?

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 aging@slu.edu. 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; Director, Gateway Geriatric Education Center; Department of Internal Medicine, Saint Louis University School of Medicine. Director, GRECC, St. Louis VA Medical Center. Nina Tumosa, Ph.D. Editor; Health Education Specialist, 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: 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.