Impact of Veterans Affairs Geriatric Research, Education, and Clinical Centers: Incubators of innovation in geriatrics.

Since their inception in 1975, the Department of Veterans Affairs Geriatric Research, Education, and Clinical Centers (GRECCs) have served as incubators of innovation in geriatrics. Their contributions to the VA mission were last reviewed in 2012. Herein, we describe the continuing impact of GRECCs in research, clinical, and educational areas, focusing on the period between 2018 and 2022. GRECC research spans the continuum from bench to bedside, with a growing research portfolio notable for highly influential publications. GRECC education connects healthcare professions trainees and practicing clinicians, as well as Veterans and their caregivers, to engaging learning experiences. Clinical advancements, including age-friendly care, span the continuum of care and leverage technology to link disparate geographical sites. GRECCs are uniquely positioned to serve older adults given their alignment with the largest integrated health system in the United States and their integration with academic health centers. As such, the GRECCs honor Veterans as they age by building VA capacity to care for the increasing number of aging Veterans seeking care from VA. GRECC advancements also benefit non-VA healthcare systems, their academic affiliates, and non-Veteran older adults. GRECCs make invaluable contributions to advancing geriatric and gerontological science, training healthcare professionals, and developing innovative models of geriatric care.

Age-Friendly Health Systems and Meeting the Principles of High Reliability Organizations in the VHA.

Background: The Veterans Health Administration (VHA) is the largest integrated health care system in the US, providing care to more than 9 million enrolled veterans. In February 2019, the VHA identified key actionable steps to become a high reliability organization (HRO), transforming how employees think about patient safety and care quality. The VHA is also working toward becoming the largest age-friendly health system in the US to be recognized by the Institute for Healthcare Improvement for its commitment to providing care guided by the 4Ms (what matters, medication, mentation, and mobility), causing no harm, and aligning care with what matters to older veterans. Observations: In this article, we describe how the Age-Friendly Health Systems (AFHS) movement supports the culture shift observed in HROs. AFHS use the 4Ms as a framework to be implemented in every care setting. The 4Ms are used in conjunction with the 3 pillars (leadership commitment, culture of safety, and continuous process improvement) and 5 principles (sensitivity to operations, reluctance to simplify, preoccupation with failure, deference to clinical expertise, and commitment to resilience) that guide an HRO. We also share an HRO case study that is representative of many Community Living Centers involved in AFHS. Conclusions: AFHS empower VHA teams to honor veterans' care preferences and values, supporting their independence, dignity, and quality of life across care settings. The adoption of AFHS brings evidence-based practices to the point of care by addressing common pitfalls in the care of older adults, drawing attention to, and calling for action on inappropriate medication use, physical inactivity, and assessment of the vulnerable brain. The 4Ms also serve as a framework to continuously improve care and cause zero harm, reinforcing HRO pillars and principles across the VHA and ensuring that older adults reliably receive the evidence-based, high-quality care they deserve.

Age-friendly care in the Veterans Health Administration: Past, present, and future.

The Veterans Health Administration (VHA) has long recognized the need for age-friendly care. VHA leadership anticipated the impact of aging World War II veterans on VA healthcare systems and in 1975 developed Geriatric Research, Education, and Clinical Centers (GRECCs) to meet this need. GRECCs catalyzed a series of innovations in geriatric models of care that span the continuum of care, most of which endure. These innovative care models also contributed to the evidence base supporting the present-day Age-Friendly Health Systems movement, with which VHA is inherently aligned. As both a provider of and payor for care, VHA is strongly incentivized to promote coordination across the continuum of care, with resultant cost savings. VHA is also a major contributor to developing the workforce that is essential for the provision of age-friendly care. As VHA continues to develop and refine innovative geriatric models of care, policymakers and non-VHA health care systems should look to VHA programs as exemplars for the development and implementation of age-friendly care.

A Pilot Primary Stroke Prevention Program for Elderly Korean Americans.

BACKGROUND: Stroke is a significant health issue with devastating consequences among older adults in the United States. However, it can be prevented by improving stroke knowledge and managing risk factors. Many stroke education programs have been shown to be effective. Unfortunately, a minority of older adults, such as older Korean Americans, have not benefited from the programs because of language barriers. OBJECTIVE: The purpose of this study was to examine the feasibility and preliminary impact of a primary stroke prevention program on stroke knowledge, healthy eating, and physical activity behaviors among Korean Americans. METHODS: A randomized controlled pilot trial was conducted. A total of 73 persons were randomly assigned to either an intervention group (n = 37) or a control group (n = 36). The intervention program included in-person lectures and discussions. Sociodemographic data were analyzed using descriptive statistics. Analyses of covariance and logistic regression analysis were used to evaluate the effects of the intervention program. RESULTS: The mean age of participants was 71.49 ± 6.25 years, and most participants were female (74.0%) and married (65.8%). Upon intervention completion, the intervention group showed greater improvements than the control group in stroke knowledge and intake of sodium and total fats (F = 11.89, P = .001, ηp = 0.151; F = 4.04, P = .048, ηp = 0.057; and F = 4.51, P = .037,= ηp = 0.062, respectively). Step counts showed marginal effects (F = 3.27, P = .075, ηp = 0.049). CONCLUSION: This study demonstrated feasibility and effectiveness of the program to improve stroke knowledge and healthy behaviors in elderly Korean Americans.

Physical activity and exercise recommendations for stroke survivors: a statement for healthcare professionals from the American Heart Association/American Stroke Association.

PURPOSE: This scientific statement provides an overview of the evidence on physical activity and exercise recommendations for stroke survivors. Evidence suggests that stroke survivors experience physical deconditioning and lead sedentary lifestyles. Therefore, this updated scientific statement serves as an overall guide for practitioners to gain a better understanding of the benefits of physical activity and recommendations for prescribing exercise for stroke survivors across all stages of recovery. METHODS: Members of the writing group were appointed by the American Heart Association Stroke Council's Scientific Statement Oversight Committee and the American Heart Association's Manuscript Oversight Committee. The writers used systematic literature reviews, references to published clinical and epidemiology studies, morbidity and mortality reports, clinical and public health guidelines, authoritative statements, personal files, and expert opinion to summarize existing evidence and indicate gaps in current knowledge. RESULTS: Physical inactivity after stroke is highly prevalent. The assessed body of evidence clearly supports the use of exercise training (both aerobic and strength training) for stroke survivors. Exercise training improves functional capacity, the ability to perform activities of daily living, and quality of life, and it reduces the risk for subsequent cardiovascular events. Physical activity goals and exercise prescription for stroke survivors need to be customized for the individual to maximize long-term adherence. CONCLUSIONS: The recommendation from this writing group is that physical activity and exercise prescription should be incorporated into the management of stroke survivors. The promotion of physical activity in stroke survivors should emphasize low- to moderate-intensity aerobic activity, muscle-strengthening activity, reduction of sedentary behavior, and risk management for secondary prevention of stroke.

The short physical performance battery as a predictor of functional capacity after stroke.

BACKGROUND: The short physical performance battery is a widely used instrument for quantifying lower extremity function in older adults. However, its utility for predicting endurance-based measures of functional performance that are more difficult to conduct in clinical settings is unknown. An understanding of this could be particularly relevant in mobility impaired stroke survivors, for whom establishing the predictive strength of simpler to perform measures would aid in tracking broader categories of functional disability. This cross-sectional study was conducted to determine whether the short physical performance battery is related to functional measures with a strong endurance component. METHODS: Functional measures (short physical performance battery, peak aerobic capacity, and 6-minute walk) were obtained and compared for the first time in stroke survivors with hemiparetic gait. Pearson correlation coefficients were used to assess strength of the relationships (α P < .05). RESULTS: Forty-three stroke participants performed a standardized short physical performance battery. Forty-one of the subjects completed a 6-minute walk, and 40 completed a peak treadmill test. Mean short physical performance battery (6.3 ± 2.5 [mean ± SD]), 6-minute walk (242 ± 115 meters), and peak aerobic capacity (17.4 ± 5.4 mL/kg/min) indicated subjects had moderate to severely impaired lower extremity functional performance. The short physical performance battery was related to both 6-minute walk (r = 0.76; P < .0001) and peak fitness (r = 0.52; P < .001). CONCLUSIONS: Our results show that the short physical performance battery may be reflective of endurance-based, longer-distance performance measures that would be difficult to perform in standard clinical stroke settings. Additional studies are needed to explore the value of using the short physical performance battery to assess rehabilitation-related functional progression after stroke.

Test-retest reliability of portable metabolic monitoring after disabling stroke.

PURPOSE: Impaired economy of gait, prevalent in chronic stroke secondary to residual gait deficits, is associated with intolerance for performing activities of daily living. Gait economy/efficiency is traditionally assessed by determining the rate of oxygen consumption during submaximal treadmill walking. However, the mechanics and energetics of treadmill versus overground walking are very different in stroke survivors with ambulatory deficits. Clearly, overground cardiopulmonary measures are needed to accurately profile movement economy after stroke. An obstacle to obtaining such measures after stroke has been the absence of reliable portable metabolic monitoring equipment. The purpose of this study was to establish the test-retest reliability of a portable metabolic monitoring device during overground walking in hemiparetic stroke survivors. METHODS: Twenty-three chronic hemiparetic stroke survivors underwent two 6-minute walk tests while wearing a COSMED K4b(2) portable metabolic measurement system. Intraclass correlations coefficients (ICC) were calculated for both cardiopulmonary parameters and distance covered to determine test-retest reliability. An ICC of ≥ 0.85 was considered reliable. RESULTS: ICCs for relative Vo2 (0.90), absolute Vo2 (0.93), Vco2 (0.93), and minute ventilation (0.95) demonstrated high reliability, but not for heart rate (0.76) or respiratory exchange ratio (0.64). There was no significant difference in the distance each participant walked between the first and second tests, eliminating distance as a potential confounder of our analyses (ICC = 0.99). CONCLUSIONS: Our results strongly support the reliability of the K4b(2) for quantifying overground gait efficiency after stroke. Use of this device may enable researchers to study how varying poststroke rehabilitation interventions affect this central measure of health and function.

The Worksite Heart Health Improvement Project (WHHIP): feasibility and efficacy.

OBJECTIVE: Test the feasibility and efficacy of the Worksite Heart Health Improvement Project (WHHIP). DESIGN: The WHHIP was a quasi-experimental 6-month pilot performed in 2 long-term care facilities. SAMPLE: Thirty-nine female minority nursing assistants participated in this study with a mean age of 42.39 (SD = 12.79) years. MEASUREMENTS: Measures were collected at baseline, 3, and 6 months and included blood pressure, lipid panel, body mass index, physical activity levels, diet behaviors, depressive symptoms, and self-efficacy outcomes. INTERVENTION: The 3-month WHHIP intervention included 3 components: environmental and policy assessment; education; and on-going motivation. The control site received education only. RESULTS: Subject participation averaged 47% and 58% in exercise and diet related activities, respectively. Generalized estimating equations showed the treatment group showed significant improvements in depressive symptoms (p = .012), systolic blood pressure (p = .028), total cholesterol (p = .002) and triglycerides (p = .011) over time. The treatment group also showed trends for improvement in diet behaviors (p = .069) and diastolic blood pressure (p = .073). CONCLUSIONS: This study provided feasibility evidence for the WHHIP and preliminary evidence that the WHHIP can improve heart healthy behaviors and subsequent outcomes among nursing assistants in long-term care settings.

Delirium: a very common problem you may not recognize.

Older adults with multiple pre-existing conditions are admitted to hospitals with acute illnesses and injuries every day. Delirium is not recognized by clinicians across health care settings. With awareness of risk factors and knowledge of delirium, nurses can play a pivotal role in the early identification, treatment, and, most important, prevention of delirium in older adults. Nurses often display a lack of knowledge related to delirium and the complex symptoms that appear differently in the presence of other complicating co-morbid conditions in aging adults. Nurses play a crucial role in keeping patients safe and ensuring optimal outcomes, regardless of the setting. With the growing population of older adults and the expected increases in chronic illness and dementia, delirium is a problem nurses are likely to experience in all practice settings. Knowing what to look for facilitates recognizing the risk and acting early to minimize (or even prevent) delirium.

Impact of treadmill exercise on efficacy expectations, physical activity, and stroke recovery.

Stroke survivors are at high risk for cardiovascular mortality which can be in part mitigated by increasing physical activity. Self-efficacy for exercise is known to play a role in adoption of exercise behaviors. This study examines self-reported psychological outcomes in a group of 64 stroke survivors randomized to either a 6-month treadmill training program or a stretching program. Results indicated that, regardless of group, all study participants experienced increased self-efficacy (F = 2.95, p = .09) and outcome expectations for exercise (F = 13.23, p < 0.001) and improvements in activities of daily living as reported on the Stroke Impact Scale (F = 10.97, p = .002). No statistically significant between-group differences were noted, possibly because of the fact that specific interventions designed to enhance efficacy beliefs were not part of the study. Theoretically based interventions should be tested to clarify the role of motivation and potential influence on exercise and physical activity in the stroke survivor population.

People reducing risk and improving strength through exercise, diet, and drug adherence (PRAISEDD): a case report on long-term single site adoption.

African-American and low-income older adults have heightened risk for cardiovascular disease (CVD). Culturally and socially congruent community-based programs can promote risk-reduction behaviors, including physical activity (PA), and can demonstrate durability. The purpose was to increase lifestyle PA and promote self-management of CVD risk factors in a sample of at-risk older adults and to sustain a PA program within low-income housing. Exercise and education sessions were conducted three times/week for 12 weeks. A community champion was trained to carry on the classes thereafter, with monthly inoculation visits by a nurse and exercise trainer. Outcome measures included attendance and CVD risk factor control. This ongoing community-based program, incorporating peer leadership, inoculation visits, and self-efficacy enhancement, has been sustained for over 3 years with classes one to two times per week and routine attendance of about 12-18 residents. PRAISEDD demonstrates that a community-based PA program can be maintained using within-community leadership, periodic involvement of health care experts, and social support and self-efficacy enhancement.

Exercise intervention research in stroke: optimizing outcomes through treatment fidelity.

BACKGROUND: Demonstrating the treatment fidelity of an intervention is a key methodological requirement of any trial testing the impact of the intervention. PURPOSE: The purpose of this report was to serve as a model for evaluating treatment fidelity in stroke exercise intervention studies and to provide evidence for treatment fidelity in the Exercise Training for Hemiparetic Stroke Intervention Development Study. METHODS: Treatment fidelity was evaluated based on study design, training of interventionists, and delivery and receipt of the intervention. RESULTS: There were some concerns about design fidelity as the control group and intervention group traveled to the study location together and received different exercise programs in the same facility. With regard to training of interventionists, observations were utilized to help maintain adherence to the protocol. There was strong support for the delivery and receipt of the intervention with participants exposed to the anticipated number of exercise sessions. As per study protocol, there was evidence that progress toward the proposed physical activity goal was made. Treatment fidelity findings are reported using cumulative data rather than at points throughout the study. Thus the findings may be conservative with regard adherence, for example, to time spent in exercise. CONCLUSION: In addition to assurance of true testing of the intervention in this study, treatment fidelity of this work provides a useful model for replication and critically important information to better understand the type, dose, and length of exposure to exercise interventions that is needed to optimize stroke recovery.

The effects of exercise-based rehabilitation on balance and gait for stroke patients: a systematic review.

This review evaluated the effects of balance and/or gait exercise interventions for stroke survivors and summarized the available evidence on these exercise interventions. A search for studies published between January 2001 and January 2010 was performed using the keywords stroke, walking or balance, and physical activity or exercise. Seventeen randomized clinical trials were identified. The findings suggest that initiating early rehabilitation during acute to subacute stroke recovery can improve balance and walking capacity. The findings also demonstrate that at least 1 hour, three to five times per week, of balance training and 30 minutes, three to five times per week, of gait-oriented exercise are effective to improve balance and walking. This review confirms that balance and walking capacity are improved with specific exercise modalities. A combination of balance, gait, and aerobic exercises would be ideal.

Pilot testing of the PRAISEDD intervention among African American and low-income older adults.

BACKGROUND AND RESEARCH OBJECTIVE: The incidence of cardiovascular disease (CVD) is particularly high among African American (AA) older adults, and these individuals are least likely to have access to CVD prevention activities. The purpose of this study was to test the feasibility of People Reducing Risk and Improving Strength through Exercise, Diet and Drug Adherence (PRAISEDD), which is geared at increasing adherence to CVD prevention behaviors among AA and low-income older adults. METHODS: This feasibility study was conducted in a senior housing site, using a single-group repeated-measures design and testing physical activity, diet, medication adherence beliefs and behaviors, and blood pressure at baseline and after a 12-week intervention period. Of 22 participants, mean (SD) age was 76.4 (7.6) years, and most were female (64%) and AA (86%). An intention-to-treat analysis was used. RESULTS: There were significant decreases in systolic (P = .02) and diastolic blood pressure (P = .01) and a nonsignificant trend toward improvement in cholesterol intake (P = .09). There were no changes in time spent in moderate-level physical activity, sodium intake, medication adherence, or self-efficacy and outcome expectations across all 3 behaviors. CONCLUSION: The PRAISEDD intervention was feasible in a group of AA and low-income older adults and, after 12 weeks, resulted in improvements in blood pressure. Future research is needed to test a revised PRAISEDD intervention using a randomized controlled design, a larger sample, and a longer follow-up period. The PRAISEDD intervention should be revised to incorporate environmental and policy changes that influence CVD prevention behaviors and explore the impact of social networking as it relates to diffusion of the intervention among participants in low-income housing facilities.

Using theory to develop an exercise intervention for patients post stroke.

Stroke remains a leading cause of disability for older adults. While is it well established in the literature that exercise programs can have significant benefit, many stroke survivors do not receive specific recommendations for exercise or lack the motivation to continue exercising following discharge from rehabilitation. This article describes an exercise intervention developed for subacute stroke survivors that utilizes the self-efficacy theory framework. The rationale for selection of this theoretical framework and specific examples of interventions linked to components of the model are provided. The article describes the motivational/educational program and the sequential follow-up designed to prepare stroke survivors to increase exercise behavior. Theoretical frameworks are useful tools for guiding and organizing research investigations from literature review through development and implementation of the intervention to interpretation of findings.