Integrating Geriatrics inPrimary Care: Progressand Prospects

by Daniel A. Bluestein, MD, MS, AGSF and

Ryan M. Diduk-Smith, PhD,MPH

Educational Objectives

1. Demonstrate the need for prima-ry care redesign to better meet theneeds of older patients.2. Identify prospective redesignsolutions.3. Appreciate educational implica-tions that redesign engenders.

Introduction

As readers of Age in Action arewell-aware, the “Silver Tsunami” isupon us. Nowhere is this realiza-tion more acute than in primarycare, wherein the vast majority ofolder adults receive medical ser-vices. Unfortunately, there is oftena mismatch between the structure ofprimary care and the needs of olderpatients. We first identify character-istics of primary care that lead tothis mismatch, and then describe

our experiences with an ongoingredesign intervention. We concludewith a brief consideration of theeducational implications of thiseffort.

Background: The Challenges ofPrimary Care “As Usual”

Primary care of robust older adultscan occur with our current system,which relies on short visits of 15-20minutes and the knowledge the par-ticipants gain though on-going fol-low-up over time. This is not suffi-cient, however, for vulnerableelders, those afflicted with geriatricsyndromes such as falls and demen-tia, as well as poorly regulated mul-timorbid chronic illnesses.

Proper care of these complicatedissues is extremely challenging inbrief encounters wherein the clini-cian is expected single-handedly toidentify and manage multiple, oftenacute, concerns as well as chronicillnesses. There usually is littletime for systematic assessment,education, coordination of care, andattention to psychosocial needs. Inother words, primary care as it cur-rently exists is prey to “tyranny ofthe urgent,” the need to respond to

presenting and often acute con-cerns, while underlying determi-nants of these issues go unad-dressed (Moore, 2006).

Primary care is also “silo-ized” to aconsiderable extent. There is oftena disconnect between various sitesand providers of care, making tran-sitions hazardous. There is no sys-tem for communication betweenprimary care and other disciplineswith important roles in geriatriccare, such as nursing, social work,and pharmacy. Moreover, a divideexists between primary care and thesystem of community-based ser-vices and supports. This divide isespecially noteworthy as social andbehavioral determinants of healthaccount for about two-thirds of thevariance in adverse health out-comes, such as hospitalizations andpreventable deaths (Alley et al.,2016).

To understand the difficulties of“primary care as usual” for com-plex older adults, let’s meet Mr. A.

Case Study 1

Mr. A, 79 years old, is dischargedfollowing a hospitalization for heart

Inside This Issue:

VCoA Editorial, 7DARS Editorial, 9VGEC Faculty Development, 11ARDRAF Recipients, 12

The Paradox of Aging, 15Age Wave Re-Cap, 16VCU Assisted Living Program, 17

Shepherd’s Center, 17 Calendar of Events, 18 Walks to Remember, 20

Case Study

Volume 32 Number 3 Summer 2017

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failure. Mr. A does keep his oneweek follow-up appointment. Hisclinician updates the medicationlist, orders some laboratories,reviews the need to follow-up withhis cardiologist, and asks him toreturn in a month. However, Mr. Ano-shows for this appointment andis brought by ambulance to theemergency room a few days laterwith decompensated heart failure,requiring readmission. Mr. A isalso delirious, has fallen, and isdehydrated. He is stabilized, but istoo deconditioned to return homeand is transferred to a skilled nurs-ing facility. He is eventually dis-charged to live with is daughter,who has had to quit her job to behis caregiver. He is no longer ableto live independently.

What went wrong for Mr. A? Thereis no simple answer. However, sev-eral possibilities come to mind: DidMr. A understand the instructionsgiven him at discharge? Were theresensory impairments that got in theway? Did he have pre-existing cog-nitive impairment? Could he affordhis medications? Did he know thewarning signs that his conditionwas worsening? Did he lack trans-port to doctors’ appointments? Washis home environment safe? Was hedrinking? What was the involve-ment of his caregiver?

Ideally, Mr. A’s doctor would haveassessed the above questions, real-ized that he was at high risk and puttogether a more proactive, targetedplan to avert the readmission andloss of independence. The fact thatthis did not occur is not an indict-ment of the individual physician’sknowledge and judgement but isinstead a system issue. Mr. A’splight vividly underscores the need

for a different primary careapproach in which challenges suchas those listed above can morereadily be identified and addressed.

A Redesign Initiative: Progress to Date

In order to foster redesign, the fed-eral Health Resources and ServicesAdministration (HRSA) initiatedGeriatrics Workforce EnhancementProgram (GWEP) grants in 2015.The GWEP program represented amajor shift from prior HRSA fund-ing in that GWEPs must includeclinical patient care activities, suchas practice redesign initiatives thatintegrate geriatrics in primary careand build interprofessional educa-tion around this framework.

The Virginia Geriatric EducationCenter, a consortium of VirginiaCommonwealth University (VCU),Eastern Virginia Medical School(EVMS), and the University of Vir-ginia (UVA), led by the VirginiaCenter on Aging (VCoA) at VCUand partnering with several otherorganizations, was one of 44GWEP awardees nationwide.EVMS’s Department of Family &Community Medicine addressesrequired integration of geriatrics inprimary care practice and trainingwith a program entitled Excellencein Primary Integrated Care-Geri-atric Patients (EPIC-GP).

The workings of EPIC-GP is illus-trated by the story of Ms. B.

Case Study 2

Ms. B is also 79 and is seen oneweek following discharge from aheart failure hospitalization. Herdoctor develops a plan like that

devised for Mr. A but suggests Ms.B get a Medicare Wellness Visit(MWV) as her next appointment.The physician introduces Linda,one of the department’s RN caremanagers, to describe the wellnessvisit and get Ms. B scheduled.Linda finds at the MWV that Ms. Bhas had several falls and isunsteady getting up. She also notesthat Ms. B has limited understand-ing of how to care for her heart andhas questions about the future if herheart failure should worsen. Lindamakes sure Ms. B keeps her follow-up with her doctor. In addition,Linda refers Ms. B to fall preven-tion and chronic illness self-man-agement classes offered at theregional area agency on aging.When seen three months later, Ms.B feels well, has increased confi-dence in her ability to avoid fallsand manage her heart failure, and isactively discussing advance carewishes with her family.

What went right for Ms. B? Sever-al things. First, the MWV identi-fied important unmet needs thatwere not evident on the first officevisit: she was falling, had limitedhealth literacy, and was interestedin advance care planning but didnot know how to go about it. Sec-ond, Linda leveraged her relation-ship with Ms. B to ensure that shedid get needed medical follow-up.Third, Linda referred Ms. B tocommunity-based services toaddress her issues of falls and limit-ed health literacy. Fourth, Lindafacilitated the process of advancecare planning by providing infor-mation and helping her schedule avisit dedicated to this issue with herprimary care clinician.

More generally, Ms. B benefitted

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from systemic assessment, activecare coordination and management,and resource linkage. These princi-ples are the crux of EPIC-GP,which overcomes “tyranny of theurgent” by using the MedicareWellness Visit (MWV) for assess-ment, combined with active coordi-nation of follow-up for identifiedneeds and care management forhigh-risk patients. The approach issummarized in Figure 1.

The MWV, an annual benefit forMedicare enrollees, is an hour-longvisit to review and update medicalhistories, the status of chronic con-ditions, medication reconciliation,attention to preventive serviceneeds, screening for geriatric syn-dromes, and discussion of advanceddirectives. In addition, the MWValso includes a health risk assess-ment to help clinicians identify andaddress adverse health behaviors.In other words, the MWV is a geri-atric assessment geared to primarycare.

It is widely recognized that geriatricassessment must be linked to subse-quent management to be effective.Accordingly, there is actively guid-ed follow-up of MWV-identified

needs (e.g., failed screens for geri-atric syndromes; inadequately treat-ed chronic illness) with subsequentcare. A care manager facilitatesscheduled follow-up with continu-ity clinicians, entry into non-face-to-face case management for highrisk patients, linkages with perti-nent community resources, appoint-ments dedicated to discussion ofadvance care preferences, follow-up on preventive care, and interpro-fessional geriatric consultation if

needed. Care management inEPIC-GP goes beyond coordinationand includes functions of monitor-ing, self-management support, care-giver care, resource linkages, andcare plan development (Aliotta, etal., 2008).

The sections to follow detail ourprogress to date in implementingthis clinical model, as well asprospects and future directions.Similarly, we discuss current statusand future plans for educationalprograms based on this clinicalframework.

Progress to Date: An Exercise in“PDSA”

Despite the face validity of the

MWV and the fact that it is a fullycovered benefit with no additionalco-pays (although there may be co-pays for other services like immu-nizations, lab draws, or evaluationand management of other clinicalissues during the wellness visit), theMWV benefit is surprisingly under-utilized nationally and at ourEVMS practices. In 2015, only 153of some 4,000 EVMS Medicarepatients ages 65 and above com-pleted a MWV.

Thus, low MWV recruitment was a“rate-limiting” barrier that wouldhave to be addressed if EPIC-GPwas to get off the ground. Weresponded to this challenge using aPDSA approach. PDSA stands forPlan, Do, Study, Act, a model fortesting quality improvement ideasquickly and easily (Leis & Shoja-nia, 2016). In contrast to research,PDSA methods do not require for-mal design, sample size calcula-tions, or statistical methods.Results are pragmatic and measuresare simple. The goal is program-matic improvement rather than newor generalizable knowledge. PDSAmethods are prominently featuredin GWEP projects to foster rapiddevelopment and refinement.

The “P” in PDSA stands for Plan-ning. As we had little idea whyMWVs were so under-used, weneeded planning information and sobegan with a survey based on scantextant literature and some guessesbased on experience. Our aim wasto understand barriers. We first sur-veyed patients (those who had[N=29] and had not [N=70] had aMWV) at our two clinics duringJanuary and February of 2016.

Patients were 50.4% female, 33.4%

Figure 1: Structure of EPIC-GP

African-American, 53.2% white,and 13.4% percent “other”. Meanage was 74.2 years. Demographicfindings did not vary by practicesite and hence are pooled. Demo-graphics did not vary betweenMWV recipients and non-recipi-ents. Response rates for surveyitems were between 85% and100%. Results are summarized inTable 1.

These findings indicated little tosupport “bad press,” concern abouthidden costs, or unmet needs as rea-sons for underusing the MWV.Most respondents felt that variousitems in the MWV were importantor very important. Most who hadan MWV did so at the recommen-dation of their physician. Mostwho had not had an MWV had notheard of it, and, unexpectedly,

wanted to get scheduled for one.Several noted that being asked tofill out the survey by a staff mem-ber who clearly believed in thevalue of the MWV had encouragedthem.

We also surveyed our providers andreceived responses from 38 of 64(59%). Most thought the MWVwas valuable, but were deterred by

its complexity and time demands.

Together, these findings suggestedour “D” (Do) in PDSA, an interven-tion leveraging the weight of thephysician’s recommendation, com-bined with enthusiastic recruitmentby an RN care manager who wouldconduct the visit, thereby unburden-ing the physician. A one-monthobservation period increased MWV

recruitment from approximately 10per month to 30. Based on this ini-tial success, we expanded theapproach by engaging other nursingstaff as recruiters (the “S” [Study]and “A” [Act] of PDSA).

At present, we are a year into ourimplementation. We have complet-ed 489 MWVs from April 1, 2016through March 31, 2017, a 320%increase over the 153 completed in2015. Details of our intervention(Bluestein, et al., 2017) and anaccompanying editorial (Adler,2017) have just appeared in FamilyPractice Management, a refereedjournal sponsored by the AmericanAcademy of Family Physicians thatis widely read by practicing prima-ry care clinicians.

Challenges and Future Directions

Getting patients to undergo MWVsis necessary, but not sufficient.This is underscored by our qualitymetrics, comparing patients whohad MWVs to those who had not.We did relatively well with preven-tive care. MWV recipients wereabout 6% more likely to have got-ten a colonoscopy and 12% morelikely to have gotten a mammo-gram. MWV recipients were morethan twice as likely to have com-pleted an advance directive andother advance care planning docu-ments (11.5% vs. 5.3%), thoughoverall numbers are still low.

Some of these positive differencesmay have been due to counsellingreceived during the wellness visit.However, it is also possible thatpersons who got MWVs had a morepositive orientation to health tobegin with, motivating both greateruse of preventive care and advance

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Had MWV (N = 29)

Did not have MWV (N = 70)

*Heard of MWV N/A 37%

*Heard negative thingsabout MWV

N/A 13%

*Concern for unexpectedcosts

3.4% 15%

*MWV suggested by yourdoctor?

89.7% 18.6%

**Importance of history &medication review

96.6% 95.7%

**Importance of preven-tive care

96.6% 92.9%

**Importance of screeningfor community-based ser-vice needs

96.6% 84.3%

**Importance of screeningfor geriatric syndromes

89.7% 87.1%

**Importance of advancecare planning

96.6% 82.9%

Table 1: Perceptions of the MWV by Recipients and Non-Recipients

* Yes ** Important or very important

care planning, as well as obtainingthe wellness visit.

It is also noteworthy that chronicillness metrics do not vary bygroup. Approximately 39% ofhypertensive patients are not at goaland about 16% have poorly con-trolled diabetes, regardless ofMWV status. This lack of differ-ence suggests that, even though themajority of our MWVs were con-ducted by experienced RN caremanagers, we are not leveragingtheir expertise to improve qualitymetrics through education, self-management support, and coordina-tion.

An important process metric inregard to chronic illness outcomesis improving “health confidence.”Health confidence is a proxy forpatient self-efficacy, self-care, andself-management, all of which per-tain to patient engagement, whichin turn is highly correlated with bet-ter health behaviors and health out-comes (Wasson & Coleman, 2017).Health confidence is assessed as asingle question: “How confident areyou that you can control and man-age most of your health problems?”Responses are on a scale from 1(totally unconfident) to 10(absolutely certain). Responses inthe range of 4-7 indicate patientsare preparing to take action andperhaps most likely to benefit frominformation and support. Ratingsover 7 imply successful enactmentof behavioral change.

What is the health confidence ofour patients? An audit of 50 chartsindicated mean confidence levels of8, mostly around healthy eating andexercise. A subsequent review,however, showed no evidence of

behavioral change. These unrealisti-cally high levels have severalpotential explanations: a) Socialdesirability bias, a desire to pleasean important “other,” in this casethe care manager; b) Not knowingwhat you don’t know about barri-ers; c) Simple fatigue and lack ofattention, as Health Confidence isassessed in an action plan at the endof an hour-plus visit.

The results of this audit are the “P”in our second PDSA cycle; weknow we have a problem. As this iswritten, we are engaged in “Ds”(Dos) to test various alternatives,such as use of visual scales, differ-ent wording of the health confi-dence question, and differences inwhen the question is asked.

Getting a better gauge on healthconfidence brings to mind the apho-rism from the movie “Field ofDreams”: “If you build it, they willcome.” In other words, identifyinga larger number of patients needinghelp with behavioral changeimplies a need for resources toaccomplish this. Our care man-agers can help with this, to be sure.However, the increased volume willnecessitate additional resources tosupport behavioral change that ulti-mately affects quality metrics. Thiscan most likely occur through out-reach and partnerships, with an areaof future endeavor being to seek“win-win” relationships with ourarea agencies on aging and othercommunity-service organizationsthat offer support services and dis-ease self-management programs.This approach also has the benefitof working to address social deter-minants of health, an approach thatis not widely possible in “primarycare as usual.”

Educational Implications

EPIC-GP is first and foremost aclinical innovation. However,GWEP programs have importanteducational mandates and any inno-vation is bound to “wither on thevine” unless it is understood andvalued by upcoming generations oflearners in health care professions.Accordingly, EPIC-GP incorporatesthree educational initiatives: train-ing in clinical geriatrics, the socialmodel of care, and advance careplanning in the non-acute, ambula-tory setting. To date, we haveaddressed these through lecture for-mat and creation of resources (clini-cal templates). A 2016 “visitingprofessorship” showcased theimport of social services and thesocial model of care through a two-day visit by Dr. Dick Lindsay, aretired geriatrician from UVA, andAdrienne Johnson, CEO of VirginiaNavigator. They spoke to multipleaudiences through grand roundspresentations and informal discus-sions. We have also used a series ofdidactic (lecture) sessions to fosterlearning about basic topics inadvance care planning.

While we have expended consider-able effort in providing various pre-sentations at EVMS, especially ontopics that lie outside “medicine”such as understanding/leveragingcommunity-based services and sup-ports, and advance care planning,these interventions have not led topractice change. This is not sur-prising, however, given the com-plexity of the topics and the limitsof traditional classroom/lectureactivities.

On the other hand, the success ofacademic detailing has been a very

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positive surprise. This is a recentundertaking wherein patients whohave failed geriatric screens, suchas the Mini-Cog or the Up & Gotest for falls, are being scheduledfor follow-up evaluations by theirprimary care clinicians, most oftenresident physicians. These appoint-ments are actively tracked, enablingDr. Bluestein and other EPIC-GPteam members to touch basebeforehand, review evaluationapproaches, provide resources, andbe available to answer further ques-tions. As most clinicians learn andinternalize information in the con-text of patient care experiences, thesuccess of this individualizedapproach was to be hoped for. Wewere not prepared, however, for theextent of the enthusiasm academicdetailing has generated, suggestingthat this approach be expanded toaddress not just core clinical topicsbut also use of social services andadvance care planning.

Conclusion

EPIC-GP has achieved notable ini-tial successes, leveraging PDSAmethods to understand obstaclesand test successful interventions.Challenges remain, most notablyusing care management to improvequality metrics and developing cre-ative approaches to increase healthprofession learners’ self-confidencein translating what they learn topractice change in working with thehuman services system and advancecare planning. PDSA methods willbe vital to moving these initiativesforward.

These approaches will be importantto primary care practice in the newworld of value based reimburse-ment under the new CMS programs

“MACRA” and “MIPS,” theMedicare Access and CHIP Reau-thorization Act and the Merit-basedIncentive Payment System, respec-tively (Mullens, 2016). Going for-ward, Medicare Part B paymentswill be adjusted based on scoresfrom performance categories whichinclude quality, practice improve-ment activities, 30-day readmis-sions, and eventually lower costs.Higher performance will result inbonuses, below average perfor-mance with penalties. MWV com-pletion, follow-up of positiveMWV findings, and application ofPDSA methods can all contribute tohigher scores in these parameters.

Despite the “face validity” of link-ing MWV assessment with subse-quent care management, it is imper-ative to document that this modelimproves outcomes. Showing thevalue of these services will allowtheir continuance, to the benefit ofpatients, families, and new cohortsof learners.

Study Questions

1. What are common barriers to pri-mary care of older adults?2. How can the Medicare WellnessVisit be used to improve the prima-ry care of older adults?3. Why is teaching geriatrics in pri-mary care best done by supportinglearners at the point of care?

References

Adler, K. G. (2017). What is thebest approach to Annual WellnessVisits for seniors? Family PracticeManagement, 24(2), 3.

Alley, D. E., Asomugha, C. N.,Conway, P. H., & Sanghavi, D. M.

(2016). Accountable health commu-nities—addressing social needsthrough Medicare and Medicaid.New England Journal of Medicine,374(1), 8-11.

Aliotta, S. L., Grieve, K., Giddens,J. F., Dunbar, L., Groves, C., Frey,K., & Boult, C. (2008). Guidedcare: A new frontier for adults withchronic conditions. ProfessionalCase Management, 13(3), 151-158.

Bluestein, D., Diduk-Smith, R., Jor-dan, L., Persaud, K., & Hughes, T.(2017). Medicare Annual WellnessVisits: How to get patients andphysicians on board. Family Prac-tice Management, 24(2), 12-16.

Leis, J. A., & Shojania, K. G.(2016). A primer on PDSA: Execut-ing plan–do–study–act cycles inpractice, not just in name. BMJ Quality & Safety, bmjqs-2016.

Moore, L.G. (2006). Escaping thetyranny of the urgent by deliveringplanned care. Family Practice Management, 13(5), 37–40.

Mullins, A. (2016). Medicare pay-ment reform: Making sense ofMACRA. Family Practice Man-agement, 23(2), 12.

Wasson, J., & Coleman, E. A.(2013). Health confidence: Anessential measure for patientengagement and better practice.Family Practice Management,21(5), 8-12.

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Editorials

7

About the Authors

Daniel Bluestein, MD,is the Charles F. Bur-roughs Professor ofFamily & CommunityMedicine at EasternVirginia Medical

School (EVMS) and holds board-certification in Geriatrics. Dandirects EPIC-GP (Excellence in Pri-mary Integrated Care-GeriatricPatients), funded by the HealthResources and Services Administra-tion as part of a statewide VirginiaGeriatrics Workforce EnhancementProgram. He was also a 2016 mem-ber of the Hartford Foundation/Atlantic Philanthropies PracticeChange Leaders program.

Ryan M. Diduk-Smith,PhD, was the GrantsProgram Manager atEVMS in the Depart-ment of Family andCommunity Medicine

until June 2017. Since 2006, herresearch has focused on under-served populations, community-based participatory research, mod-eling and simulation, and mixed-method design. Ryan currently isemployed by the Virginia Depart-ment of Health.

From theDirector, Virginia Center on Aging

Edward F. Ansello, Ph.D.

Laughter and Well Being as We Age

The cynic might say that there’s lit-tle to laugh about in growing older.Aging brings its challenges andlosses, so what’s funny about this?Of course, life can be tough, buteven in the awful there can be thefunny. Like, what else could gowrong?

Robert Frost said it (and JimmyBuffet put it to song): “If we couldn’t laugh, we would all goinsane.”

I met a veteran recently over dinnerat a shelter where I volunteer. Hehad lost an eye to bullet fragmentsand had irreparable damage to theother during a clandestine BlackOps mission in Central Americaalmost 40 years ago. He said thatthings could have been worse, as itwas for others on that mission. Heexpressed his gratitude for life witha grin and a laugh. As we talked, hediscussed his grown children andhis grandchildren. One son hadjoined the military, the other hadnot. He accepted their decisions andstated that we each have to live ourown lives. We exchanged ideasabout politics, religion, families,and so on, and I realized his wasn’tan act; he was the real thing. Heaccepted his life and laughed. Hesaid that maybe he’ll develop keen-er hearing once he loses sight in thedeteriorating eye.

Laughing at life, at ourselves, fallsunder the hackneyed category ofLaughter as the Best Medicine. It’san area replete with quotes fromfamous and unknown figures in his-tory, from Roman philosopherSeneca’s observation that it’s “morefitting …to laugh at life than tolament about it” to the contempo-rary Mel Brooks’ comment that“life abounds in comedy if you justlook around you.” But what sup-ports laughter as a medicine? Isthere research?

Turns out, there’s a fair amount ofit. First, we should distinguishbetween humor and laughter. Thefirst may or may not produce thelatter. There can be humor withoutlaughter. And laughter can be pro-duced without causal humor.Humor involves cognitive, social,and behavioral elements. Laughteris a physical response, a psycho-physiological reaction. This physi-cal response does, in fact, seem tobe associated with well-being inlater life.

As for humor, Houston, McKee,Carroll & Marsh (2010) foundhumor effective in reducing anxietyamong nursing home residents.Crawford & Caltabiano (2011)found, with 55 community-dwelling adults in Australia whowere randomly assigned to experi-mental or control groups, that aneight-step program to teach humorskills improved measures of emo-tional well-being, such as positiveaffect and self-efficacy; they con-jectured that humor helped reframeadverse events by increasing posi-tive thinking and perceptions ofcontrol, while decreasing negativethinking, perceptions of stress, andanxiety.

As for laughter, some time agoMartin & Kuiper (1995) reportedthat daily laughter decreased thenegative emotions associated withdaily stressors.

Some of our colleagues in theSouthern Gerontological Societyrecently published their pilot (pre-liminary) research in The Gerontol-ogist (August 2016 online) on theeffects of simulated laughter onvarious measures of well-being,including participation in physicalexercise, indices of mental health,and aerobic endurance. CelesteGreene, Jennifer Craft Morgan, andChivon Mingo (Georgia State Uni-versity) and LaVona Traywick(University of Central Arkansas)began by acknowledging that manypeople don’t enjoy exercise, so per-haps a laughter intervention mightinduce people to begin or continueto exercise.

In their pilot study with 27 assistedliving facility residents, they com-bined brief (30-60 seconds) simu-lated laughter exercises with a 45-minute, moderate-intensity physicalactivity program on strength, bal-ance, and flexibility. Their 12-week, twice weekly, exercise pro-gram used a wait list control designso that everyone eventually partici-pated in the six-week LaughActiveexercise regimen. The average ageof the participants was 82 years.The researchers found statisticallysignificant improvements amongparticipants in mental health (usingthe SF-36v.2 scale), aerobicendurance (using the two-minutestep test), and self-efficacy for exer-cise (using the Outcome Expecta-tion for Exercise scale).

So, participants faked laughing, but

the results were nonethelessimpressive. As the Georgia Stateinformation office summarized,“Because the laughter exerciseswere combined with playful behav-ior and eye contact, and becauselaughter is ‘contagious,’ it usuallytransitioned to genuine laughter,the researchers noted. In any case,‘the body cannot distinguishbetween genuine and self-initiatedlaughter,’ they said. (Similarly,other research has found that fakesmiling can improve mood andreduce stress.) In addition, ‘whenlaughter is self-initiated as bodilyexercise, older adults do not needto rely on cognitive skills to ‘get thejoke,’ or a positive mood state toreap the benefits of laughter.”

The latter points warrant emphasis.Faked or simulated laughter helpedproduce physical and mental healthbenefits, at least in this pilot study.And simulated laughter apparentlyworks without the cognitiveengagement associated with humor,an important point when one maybe concerned about the well-beingof individuals with dementia.

Coming full circle to the veteran atthe shelter, being able to laugh,even faked laughter can be thera-peutic. I can vividly remember oneof my most embarrassing incidentsas a child. When I was nine yearsold, we spent a summer week onvacation in Maine with my cousins.Returning home, we drove Southalong the Maine Turnpike. Mymother was driving and my auntwas up front with her. I was behindthe driver’s seat, wearing my newlyacquired tee shirt emblazoned witha huge, green pine tree and themotto Maine: The Pine Tree State.

When we stopped to pay the toll,the man looked in the back seat atme and asked, “Did you have fun?”I nodded. “What kind of trees didyou see?” I hesitated, being caughtoff guard in the spotlight, thenreplied, “Oh, maples, and oaks, Iguess.” He looked at me strangely.As soon as we drove on, bothturned to me and said somethingabout me looking at my shirt andthe state’s motto. I was mortified.That embarrassment stayed with mefor decades, and I couldn’t think ofthe incident without cringing.

Later, as a 30-something adult, itwas my task one Thanksgiving tocarve the roasted turkey. I started,hit bone, and quietly sidled up tomy wife to whisper that we were introuble, having an apartment full ofguests and no turkey meat to share.She went back with me to thekitchen and saw at once what I’ddone: I had the turkey upside downand had been carving the back. Thistime, with added years, we bothsaw the silliness and burst outlaughing.

As for The Pine State fiasco, it’sonly been recently that I havelearned to put it in context: I wasonly nine years old! I can now bal-ance the cringe factor with “Was Iever so young and so clueless?”Yes, now I’m older and clueless.

Laughing at mistakes, laughing atstressors, is demonstrably healthy.We all make mistakes and we allhave circumstances and events thatcan be serious, damaging, or harm-ful. As we get older, we have accu-mulated a lifetime of them. Humorand laughter, laughing at ourselvesor our circumstances, can indeed betherapeutic.

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Editorials

9

From theCommissioner, Virginia Departmentfor Aging and Rehabilitative Services

Jim Rothrock with Marcia C. DuBois

Director, Division for the AgingVirginia Department for Aging

and Rehabilitative Services

Leadership, Learning, and Legacies

A busy and bustling spring culmi-nated with the celebration of OlderAmericans Month and the 2017Virginia Governor’s Conference onAging in May. As promised, thisyear’s conference was better thanever, following an extremely suc-cessful 2016 predecessor andincreased demand for an expanded,more inclusive conference. Thisdemand was met through a changein location to the Hotel Roanoke inorder to improve access for partici-pants from Southwest Virginia andto make room for a wide array ofaccomplished presenters,exhibitors, and engaged advocates.Approximately 400 attendeesenjoyed presentations on topicsrelated to the four focus areas: Cul-ture Change in Long Term SupportServices, Livable Communities,Safety and Financial Security, andVolunteer and Community Engage-ment. We are sincerely grateful toall of the generous sponsors thatmade this conference possible,including our Presenting Sponsor,Dominion Energy; our PlatinumSponsor, AARP Virginia; and theVirginia Association of Area Agen-cies on Aging; who partnered withthe Department for Aging and

Rehabilitative Service to host theconference.

In keeping with the Age Out Loudtheme for Older Virginians Month,Governor McAuliffe provided theluncheon address with the sametitle and highlighted how the Com-monwealth’s innovative aging net-work is creating and implementingculture change in long term servicesand supports and livable communi-ties. McAuliffe said that hereestablished the conference lastyear because, in three years, twomillion Virginians will be olderthan 60, representing 20 % of theCommonwealth’s population andthe percentage will continue togrow over the next decade. Henoted the need to cultivateresources that allow Virginians over60 to live independently andstressed the importance of strength-ening laws to spot and prosecutefinancial exploitation against olderadults.

Other keynotes featured Dr. BillThomas, a nationally recognizedexpert geriatrician, who providedthe opening plenary session andinvited participants to reframe theirperceptions of age and aging; Dr.Richard Lindsay, who led a paneldiscussion on caregiver leave poli-cies that explored workplace solu-tions to support family caregivers;and John W. Martin of SIR, whooffered the policy wrap up and out-lined ten steps that needed to betaken over the next few months inorder to truly move forward inmeeting our policy goals.

In addition to the Governor’s Con-ference, we have celebrated twovery exciting launches over the pastfew months. The Virginia Poverty

Law Center recently announcedinauguration of the new statewideSenior Legal Helpline that is up andrunning. The helpline is made pos-sible through a contract betweenVirginia Poverty Law Center andthe Department for Aging andRehabilitative Services, with fund-ing from a three-year ModelApproaches to Statewide LegalAssistance Systems grant from thefederal Administration on Commu-nity Living.

The Senior Legal Helpline toll-freenumber (844-802-5910) is nowavailable for Virginians aged 60 andolder and for those calling on theirbehalf. Advice may be sought onthe following topics: long term careissues, public benefits (includingMedicaid, SSI and Social Security,Medicare), guardianship and alter-natives to guardianship, financialexploitation, adult abuse andneglect, age discrimination, and alimited number of consumer issues.

DARS and our partners also cele-brated a terrific public launch ofour No Wrong Door (NWD) net-work, the public-private effortwhich helps Virginians gain stream-lined access to needed servicesthrough a virtual network ofresources. The Library of Virginiahosted the launch with many peopleattending. Senator Mark Warnerspoke at the event, attended by Sec-retary Hazel as well as many ofNWD’s 100 partners.

Over the past few years, several ofour efforts have received nationalacclaim for innovation. However,recognition of our No Wrong Door(NWD) System, begun almost adecade ago, has been significant. Aconstant behind this system change

Editorials

10

initiative has been our DARS col-league, Katie Roeper. After muchthought and consideration, Katiehas decided to conclude her careerwith the state and join an excitingbusiness venture with her husband,Ken.

All system-change projectsencounter occasional speed bumps,and NWD has withstood its share.But Katie’s commitment, creativity,and entrepreneurial expertise havehelped to bring solutions to thesechallenges and identify and securefederal, state, and private funds.New partners ranging from small,private non-profits to major healthcare systems and health plans haveemerged with growing interest. Anarray of agencies, many of whichwere once “siloed” and incapable ofinformation-sharing, are now con-nected through common goals andelectronic tools, linking Virginianswith the supports they need tomaintain independence and thequality of life they desire. All ofthis is being accomplished throughNWD, in large part due to hervision, passion, and focus.

Virginia’s NWD just celebrated its100th partner and Katie has beencalled on again to share her wisdomand best practices we have estab-lished in the Commonwealth, witha national audience. Her leadershipwill surely be missed.

We are working on a plan to fill thevoid created by her retirement.Thankfully, Katie has helped Vir-ginia build an incredible network ofNWD champions, supported by anaccomplished NWD Team. Togeth-er, they will be developing strate-gies to assure that the great momen-tum that NWD has experienced will

endure, as we strengthen the NWDnetwork of communities across theCommonwealth.

Katie will be continuing her leader-ship of NWD through August 11th.We know you all will join us inthanking Katie for her dedicatedefforts and wishing her the verybest in all she does.

Tri-Cities Area SupportGroups, SocialEngagement, andEducational Programs

The Alzheimer’s Association offersmany programs in the Tri-Citiesarea (Petersburg, Colonial Heights,Hopewell).

Support GroupsHopewell: First Baptist Church,Hopewell. First Tuesday of eachmonth at 3:00 p.m.

Petersburg: Petersburg PublicLibrary, 1st Floor ConferenceRoom, Petersburg. Second Wednes-day of each month at 4:00 p.m.

Petersburg Memory CaféPerks Coffee Shop, Petersburg. Fourth Wednesday of each month at3:00 p.m. Come join us for free cof-fee or tea provided by Care Advan-tage and fellowship with other per-sons with Dementia and theircaregivers.

There are also many educationalprograms offered in the Tri-Citiesarea. Pre-registration is requiredfor all programs. For more infor-mation, or to register, please callCindy Hamlin at (804) 446-5860 oremail chamlin@alz.org.

2017 DARS Meeting Calendar

Commonwealth Council on AgingJuly 12, September 20

Alzheimer’s Disease and Related Disorders CommissionAugust 22, December 12

Public Guardian and Conservator Advisory BoardSeptember 14, November 9

For more information, call (800) 552-5019 or visithttp://vda.virginia.gov/boards.asp.

Visit Our Websites

Virginia Center on Aging www.sahp.vcu.edu/vcoa

Virginia Department for Aging and Rehabilitative Services https://www.vadars.org/

Editorials

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Electronically?

We currently publish Age inAction in identical print and PDFversions. Age in Action is transi-tioning to an electronic versiononly. You can subscribe at nocost. Simply email us and includeyour first and last names and yourbest email address. If you nowreceive hard copies by postal mail,please consider switching toemail distribution. Send an emaillisting your present postal addressand best email address for futuredeliveries. Send requests toeansello@vcu.edu.

11

VGEC Faculty Development Program June Graduates

The Virginia Geriatric Education Center (VGEC), a consortium of faculty from VCU, Eastern Virginia MedicalSchool, and the University of Virginia, annually conducts a 200-hour Faculty Development Program (FDP), Sep-tember through June. FDP Scholars commit to this interprofessional geriatrics training program with the expec-tation of passing their training to colleagues in order to maximize the impact of their training. Our 2016-17 FDPScholars celebrated the conclusion of their training year on June 16, 2017.

Pictured (Back Row): Deborah Clarkston, MSN, RN; Chris-tianne Fowler, DNP, GNP-B; Amy Bodman, MBA, OTR-L;Karen Kott, PT, PhD; Georganne Poole, MSN, RN; AnnetteGreer, PhD, MSN; Terry Wright, RN, MS; Tonia Parker,MSN, RN; Milena Staykova, EdD, FNP-BC

Front Row: Sunny Alperson, PhD, FNP-C; Laurie Daigle, PT,MA; Rachana Patel, RPH; Jaisri Thoppay, DDS, MBA; JennaClemons, PharmD

Not Pictured: Dorolyn Alper, MSN, RN; Jillian Dur, DO;Dorothy Harriman, MSW; Keiko Kuykendall, DNP; EliseSideris, MD

Hearing Health Care: Priorities for Improving Access and Affordability

The National Academies of Sciences, Engineering, and Medicine has compiled a list of online resources foradults with hearing loss. A small portion of these resources is listed below. For the complete list, visitwww.nas.edu/hearing.

Consumer and Patient OrganizationsAmerican Cochlear Implant Alliance

www.acialliance.orgAssociation of Late-Deafened Adults

www.alda.orgHearing Link

www.hearinglink.orgHearing Loss Association of America

www.hearingloss.org

U.S. Federal Government AgenciesAmericans with Disabilities Act information

www.ada.govCenters for Disease Control and Prevention

www.cdc.gov/niosh/topics/noise

Department of Defense Hearing Center of Excellencewww.hearing.health.mil

Department of Education Rehabilitation Services Administration, https://rsa.ed.gov/

Professional AssociationsAcademy of Doctors of Audiology

www.audiologist.org/patient-resourcesAmerican Academy of Audiology

www.howsyourhearing.orgAmerican Academy of Otolaryngology-Head & Neck

Surgery, www.entnet.org/content/patient-health American Speech-Language-Hearing Association

www.asha.org/public/hearing/hearing-loss

12

COMMONWEALTH OF VIRGINIA

Alzheimer’s and Related Diseases Research Award Fund

2017-2018 ALZHEIMER'S RESEARCH AWARD FUND RECIPIENTS ANNOUNCED

The Alzheimer's and Related Diseases Research Award Fund (ARDRAF) was established by the Virginia GeneralAssembly in 1982 to stimulate innovative investigations into Alzheimer's disease and related disorders along avariety of avenues, such as the causes, epidemiology, diagnosis, and treatment of the disorder; public policy andthe financing of care, and the social and psychological impacts of the disease upon the individual, family, andcommunity. The awards this year have been enhanced by a $25,000 donation from Mrs. Russell Sullivan of Fred-ericksburg, in memory of her husband who died of dementia. Sullivan awards are indicated by an asterisk (*).The ARDRAF competition is administered by the Virginia Center on Aging in the School of Allied Health Profes-sions at Virginia Commonwealth University. Questions about the projects may be directed to the investigators orthe ARDRAF administrator, Dr. Constance Coogle (ccoogle@vcu.edu).

VCU Heather Lucas, PhDDeveloping an Expression Platform for Tetrameric Alpha-Synuclein to Advance Systemic Biochemical Studies

The aggregation-prone protein α-synuclein (αS) has been linked to neurodegenerative diseases such asAlzheimer’s disease (AD) and, more commonly, to Parkinson’s disease and Lewy Body Dementia. This proteinhas been suggested as a modulator of cognitive function, yet its native function and disease-related conformationremain ill-defined. New findings have indicated the presence of a native tetrameric alpha-helical conformationthat is stable to aggregation. A convenient method to isolate tetrameric αS for biochemical studies has yet to bereported, even though stabilization of this aggregation-resistant conformer may represent a viable therapeuticapproach. Moreover, metal dyshomeostasis has long been linked to PD, but the influence of biometals on theaggregation propensity of tetrameric αS cannot be studied systematically until a robust method of accessing thetetramer is identified. Accordingly, an expression and purification platform will be developed for tetrameric αSthat exploits fusion protein technology and relies on mild isolation techniques available through affinity chro-matography, rather than conventional ion exchange chromatography methods that require high salt and dilute pro-tein conditions. This platform will extend the reach of biochemical and biophysical investigations of αS, yieldingvaluable insight into a key protein that lies at the crossroads of several neurodegenerative diseases and setting thestage for the identification of new targets for drug development. (Dr. Lucas may be contacted at (804) 828-7512,hrlucas@vcu.edu.)

VA Tech Harald Sontheimer, PhD*Is Amyloid Toxic for Glial Cells?

It is commonly assumed that amyloid contributes to functional impairment of neurons, albeit how amyloid istoxic to brain remains unclear. While plaques are found near neurons, they are often close to brain support cellscalled astrocytes as well as along blood vessels. The astrocytes touch blood vessels throughout the brain andhave been shown to support the integrity of the blood brain barrier (BBB) that prevents entry of blood born mole-cules into the brain. Astrocytes also regulate blood flow by releasing vasoactive molecules. The investigator hasdemonstrated that vascular amyloid separates the astrocytic attachments on blood vessels called endfeet. Byforming a rigid cast around arterioles and penetrating arteries, the amyloid deposits hinder the release of vasoac-tive molecules and impair the regulation of blood flow. This study will explore whether amyloid deposits alsocause local impairment of blood flow and BBB integrity. The over-arching hypothesis is that amyloid impairsastrocyte function and, therefore, vessel health and local regulation of blood flow. Obviously, impairments ofblood flow will starve neurons of energy and could hasten their demise, thereby explaining the progressivedementia. These studies may show a completely unexplored pharmacological target. (Dr. Sontheimer may be con-tacted at (540) 526-2229, sontheimer@vt.edu.)

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VCU Xuejun Wen, MD, PhDAn In Vitro Model for Alzheimer's Disease Based upon 3D Self-Assembled Neurovascular Microtissues

Conventional model systems that rely on in vivo transgenic/lesion and cell line studies are unable to capture thecomplexity and biology of the human system. As a result, therapeutic strategies that are efficacious in animalmodels fail in pre-clinical and clinical human trials. In order to improve the translational potential of experimen-tal studies, establishing an in vitro humanized model for AD is imperative. The investigator previously fabricatedan in vitro AD tissue model based upon 3D self-assembled neurovascular microtissues of primary AD corticalneurons and glia cells that are associated with microvasculatures. This project aims to validate the model throughtesting of neurovasculature-delivered drugs in comparison to 2D co-culture model and in vivo profile. Once vali-dated, the in vitro AD tissue model would offer a stable experimental framework to facilitate AD modeling, anddrug discovery and testing in a dynamic, high-throughput manner. The project would also define guidelines forthe development of in vitro models of the specialized neurovascular tissue environment to advance understandingof healthy states and pathologies, identifying therapeutic targets, and drug testing. (Dr. Wen may be contacted at(804) 828-5353, xwen@vcu.edu.)

VCU-Shenandoah Jonathan Winter, MD*Family Practice Changes in Physician Approaches to Behavioral and Psychological Symptoms ofResidency Dementia Since CMS's National Partnership to Improve Dementia CareAfter CMS's 2012 initiative to reduce 'inappropriate' antipsychotic use in nursing homes, such prescribingdecreased 27% in four years. Excluded from this calculation, however, were antipsychotics 'appropriately' pre-scribed for schizophrenia, Tourette's, and Huntington's. Over this same period, CMS described a greater than 20percent increase in the reporting of these diagnoses. In addition, since the initiative’s debut, CMS has been care-ful to trend the prescribing of other psychiatric medications commonly used for dementia symptoms includinganxiolytics, antidepressants, and sedative-hypnotics to ensure that medication substitution is not occurring as theuse of anti-psychotics decreases. The investigator’s previously funded ARDRAF study hinted that the use ofother risky medications also used off-label for dementia symptoms in nursing homes (i.e., lithium and anticonvul-sant mood stabilizers) have increased since 2012. Because utilization of these is not being trended by CMS, thisstudy will retrospectively query de-identified data from the VA Department of Medical Assistance Service forrates of these diagnoses and medications since 2011. The objective is to better clarify how reactionary changes indiagnosing and prescribing distort the apparent reduction in pharmacologic solutions to dementia symptoms sinceCMS's 2012 National Initiative. (Dr. Winter may be contacted at (540) 631-3700, jwinter@valleyhealthlink.com.)

VA Tech Ling Wu, MD, PhD and Bin Xu, PhD*Drug Repurposing for Tau Aggregation Inhibitors as Neuroprotective Agents for Alzheimer's Disease

AD is characterized by the accumulation of two types of abnormal structures, extracellular amyloid plaques andintraneuronal neurofibrillary tangles in brain. Small, soluble oligomers of the neuron-specific, axon-enriched,microtubule-associated protein, tau, the building blocks of the tangles, represent the most toxic molecular speciesin AD pathogenesis. Moreover, toxic, misfolded oligomers of both Aβ and tau self-propagate by prion-likeprocesses, whereby their direct contact with normally folded counterparts catalyzes the latter’s conversion intotoxic, misfolded forms. This project will screen repurposed drugs from an NIH Clinical Collection library of 700small molecules and identify compounds that can block tau oligomer formation and protect neurons from tau-induced cytotoxicity. Further tests will establish whether validated lead compounds from the screens and addi-tional in vitro assays can protect cultured neurons from the adverse effects of extracellular tau oligomers. (Dr. Wu may be contacted at (540) 231-8442, wul3@vt.edu; Dr. Xu may be contacted at (540) 231-1449,binxu@vt.edu.)

14

VCU Shijun Zhang, PhD*Development of NLRP3 Inflammation Inhibitors for AD

Neuroinflammation has been recognized as an essential player in the pathogenesis of AD, especially for the late-onset AD. Inflammasomes have been recently identified as multi protein complexes that tightly regulate theinnate immune response and the production of pro-inflammatory cytokines, and the NLRP3 inflammasome is themost extensively studied and widely implicated. The NLRP3 inflammasome regulates the production of inter-leukins (IL-1ß and IL-18) and has been indicated as having a critical role in the pathogenesis of AD. The investi-gator recently developed small molecule NLRP3 inhibitors and one lead compound was identified with in vivoefficacy to reduce AD pathology and to improve memory functions. The goal of this study is to develop morepotent analogs based on the newly identified lead structure. The results will significantly facilitate developmentof more potent inflammasome inhibitors as potential disease-modifying agents for AD. (Dr. Zhang may be con-tacted at (804) 628-8266, szhang2@vcu.edu.)

UVA Zhiyi Zuo, MD, PhD*Empathic Transfer of Postoperative Cognitive Dysfunction

Caregiving spouses of patients with dementia have an increased chance of suffering from dementia. Although themechanism of this phenomenon is not clear, increased stress due to caregiving and similar living environmentsare thought to contribute to it. Postoperative cognitive dysfunction (POCD) is a relatively new but well-docu-mented clinical entity that affects patients after heart and non-heart surgeries. POCD not only affects patients'daily activity but also predicts high mortality. Recent studies from the investigator’s laboratory and others haveindicated that inflammation in the brain, an abnormal process for many chronic brain diseases includingAlzheimer's disease, may be involved in POCD. Preliminary data showed that mice living in the same cage withmice that have surgery also develop neuroinflammation and POCD. In this project, the investigator will deter-mine how this empathic transfer works and which brain regions are activated in the cage-mates of the mice withsurgery. These studies have a significant implication for bystander health and will help us understand how care-giving spouses of patients with dementia may develop dementia as well. (Dr. Zuo may be contacted at (434) 924-2283, zz3c@virginia.edu.)

2017-2018 ARDRAF Awards Committee

Paul Aravich, Ph.D.Eastern Virginia Medical School

Charlotte Arbogast, MSVA Dept. of Medical Assistance Services

Kathleen Fuchs, Ph.D.University of Virginia

Hamid Okhravi, MDEastern Virginia Medical School

John Lukens, PhDUniversity of Virginia

Mikell Paige, PhDGeorge Mason University

Linda Phillips, Ph.D.Virginia Commonwealth University

Webster L. Santos. PhDVirginia Tech

J. Tina Savla, PhDVirginia Tech

Patricia A. Trimmer, PhDVirginia Commonwealth University

Gregorio Valdez, PhDVirginia Tech Carilion Research Institute

Ishan Williams, PhDUniversity of Virginia

Yan Zhang, PhDVirginia Commonwealth University

Wondrous and Wild:The Paradox of Aging

by Carol Orsborn

(Excerpted from LPNQ: The Quar-terly Journal of the Life PlanningNetwork, Spring 2017, by permis-sion.)

“We who are old know that age ismore than a disability. It is anintense and varied experience,almost beyond our capacity attimes, but something to be carriedhigh.” Florida Scott-Maxwell, TheMeasure of My Days.

What is age to those of us living it?Poised on the eve of my seventiethyear, I am filled with equal portionsof wonder and dread. The youngcannot possibly fathom what itmeans to live with one’s cheekpressed hard against the shadows.Earlier in our lives, we had expect-ed either to continue on as is forev-er, punctuated by a hard stop at theend, or to fade away gently into thedark night. We did not expect to befacing a new threshold, feelingmore alive than ever. The ironynearly breaks us, as we leapfrogthrough the mystery of age oneparadox at a time.

Aging is a time full of irony. Wefind ourselves brimming with unex-pected passion, but frequently lackthe energy to see things through.We experience ourselves to be atthe peak of our knowledge and abil-ities, only to realize that we aremasters of a world that no longerexists. We who are old discoveruntapped reservoirs of compassionfor humanity, while having lesspatience for individuals than ever

before. We crave to be includedwhile yearning to be left alone. Weworry we won’t have enough forthe demands of a cavernous futurewhile fearing that tomorrow may beour last. It seems just yesterday, wefound our own aging parents’crankiness to be irritating. Today,we realize that insisting we beallowed to do things our own way,no matter how inconvenient for oth-ers, is not only our hard-earnedright, but the essence of what wewant most: the freedom to makeour own choices to the very end.

There is nothing quiescent or sereneabout any of this, even should therebe moments or even long stretchesof indescribable peace and joy. Butin their place, we can discover thatwe have become somehow trans-formed by aging to become notonly older and wiser but somethingwondrous. More and more I feelmyself to have a numinous beauty,not what the young refer to as pret-ty, but expressive: a natural wondereroded by time into somethingwonderful. It is as if with everylightning strike, every assaultendured and paradox accepted, Godhas been saying: “Now do youunderstand?”

This transformation cannot beforced, only allowed. And it is onlyby dint of how we formulate ouranswer to the question that webecome something to behold ratherthan a pile of rubble.

Love is the answer, bursting insideof me, begging for expression yetoften confined to the page. For inreal life, sharing everything I am isoften too much for others. Especial-ly the young. They need their ener-gy for their own lives while I blaze

secretly beneath as serene a facadeas I can manage. When my heartburns clean, remembering that Ihave chosen to temper the fullexpression of myself out of love, Igaze clear-eyed at the whole of life,every act of the human drama, feel-ing a peace that goes beyond mereacceptance.

Ah, the privilege of life, somethingI’ve longed to experience throughmy achievements, by doing. With alove this big, I now feel as if Icould conquer the world, it feelsendless, infinite. And yet, how iron-ic, I write one page and feel wornout. Anything that requires effortlifts me up then drops me backdown again, but it is to a place newto me, where the love is not condi-tional nor exhaustible, back towhere I can simply be.

This is a newfound ability, a gift ofage: newly able to detach from thefray of life, and my own ambition,to descend,—or is it elevate?—intosolitude. In this place of being, Igrow deeper and I grow wilder.After years of having to channel theessence of my vitality to make aliving, to be part of the world, myspirit has found sanctuary. I am, inthis place, not only fierce with age,but with life.

______________

Carol Orsborn is the author of morethan 25 books including The Spiri-tuality of Age: A Seeker’s Guide toGrowing Older, coauthored withRobert L. Weber. It was the 2015Nautilus Book Awards gold winnerin the category of ConsciouslyAging.

15

Age Wave ShowcasesTransportation Innovation, Education,and Future Planning

The Greater Richmond Age Wavehosted Transportation and Accessi-bility: Future Vision and Innovationin Our Region on May 10th atTriple Crossing’s Fulton location.The group posed the questions:“Why do 7.5 million rides go unful-filled in our region each year? Whoare the changemakers creating andplanning to push the needle on thisnumber as need rises?”

The audience first heard from thepersonal experiences of residentswho use public transportation, withvarying degrees of satisfaction. AgeWave Neighborhood LivabilityChair Ken Lantz, Principal Plannerwith the Richmond Regional Plan-ning District Commission, providedan overview of general transporta-tion needs. He was joined byCharles Rasnick of Hanover SeniorRides with a breakdown of how hisservice operates.

GRTC's Carrie Rose Pace, Directorof Communications, and AdrienneChargois, Planning Manager,shared upcoming developments inGRTC’s Bus Rapid Transit system.These changes have already begunto reshape the landscape in Rich-mond.

Marshall Contino, director of theCenter for Vehicle Safety with thenonprofit Altarum, addressed theways autonomous vehicles coulddramatically, if not completely,eliminate traffic deaths. His mostimpactful statistics: 110 people in

the U.S. die each day in an automo-bile accident, 94 percent of acci-dents are caused by a human driver, and our cars sit unused 96 percent of the time.

The final presenters were an Inno-vation Panel from UZURV, a Rich-mond-based TNC app startup; Per-rone Robotics, a Charlottesville-based company that creates soft-ware for autonomous vehicles; and RoundTrip, a local startup favorite that provides innovative medical transportation software.

The event included an audience brainstorm session. The full list of their ideas can be viewed at agewellva.com/trending.

The Fall tour will cap off a year of events organized by the group. In February, Age Wave joined forces with the United Way Young Lead-ers Society to host a networking event that included a brainstorming and sharing session about innova-tive ways to promote social con-nectedness in our communities. In March, the Age Wave organized an Aging2.0 Global Startup Search competition, where seven startups and small businesses delivered four minute pitches. Richmond Winner OnGuardian, an app designed to enhance the family care experience, hopes to head to the final round of the global competition this fall in San Francisco.

The Age Wave is jointly managed by VCU Department of Gerontol-ogy and Senior Connections, the Capital Area Agency on Aging. For more information about past and upcoming Age Wave projects, visit agewellva.com or contact macdonaldcs@vcu.edu.

Resource for DementiaCaregivers

Oftentimes, caregivers of persons with dementia can feel over-whelmed. They are in a new world of changes, dealing with a variety of medical, behavioral, and other issues; plus health and medical issues come with their own jargon. There’s a new resource for care-givers of individuals with dementia who are also beginning to experi-ence non-memory-related medical problems. With help from a grant from the National Institute of Nurs-ing Research, faculty at the Univer-sity of North Carolina at Chapel Hill and Duke University have writ-ten The Alzheimer’s Medical Advi-sor: A Caregivers Guide to Com-mon Medical and Behavioral Signs and Symptoms in Persons with Dementia.

This is an easy-to-read guide on 54 common medical and behavioral signs and symptoms experienced by older adults with dementia, such as cough, agitation or not eating or drinking, that can give caregivers more confidence in evaluating, talk-ing with providers about, and man-aging possible medical issues. This guide includes instruction on taking vital signs, recognizing pain and dehydration, basics of medication safety and management, guidance when conferring with health care providers, advice for navigating the health system, and more.

The Alzheimer’s Medical Advisor is published bySunriseriverpress.com.

16

VCU GerontologyAssisted Living Programon Track to Offer SpringClasses

The Department of Gerontology inVCU’s School of Allied Health Pro-fessions will begin its first officialacademic year of accreditation forAssisted Living Administration thisFall and offer new courses in thesubject beginning in Spring 2018.

The Assisted Living Concentrationhas received academic accreditationfrom the National Association ofLong Term Care AdministratorBoards (NAB).

“This accreditation has openedVCU Gerontology’s door to stu-dents across the country who wantto become licensed assisted livingadministrators, by providing them aquality educational experience thathas been endorsed by those whocreate the national standards,” saidCo-Program Director of the Assist-ed Living Administration Concen-tration Jennifer Pryor.

The final accreditation makes VCUGerontology the only NAB accred-ited program in Virginia, and thefirst-ever accredited program inAssisted Living Administration.The NAB is the nation’s leadingauthority on licensing, credential-ing, and regulating administratorsof organizations along the continu-um of long term care.

The accreditation journey began in2014, led by Pryor. She and VCUGerontology Professor JenniferInker appeared at the June NABmeeting to review the final steps

taken by VCU during the accredita-tion process. These include threenew courses within the specialtyarea added within the department.

“We’re eager to continue theimportant work of preparing stu-dents for this dynamic field,” Pryoradded.

For more information about theAssisted Living AdministrationSpecialty Area and VCU Gerontol-ogy, visit www.sahp.vcu.edu.

VCU Gerontology Professor JenniferInker, Karen Skaff, and Jennifer Pryor,Co-Program Director of the AssistedLiving Administration Concentration,just after receiving final approval at theNAB's June meeting in Salt Lake City.

Shepherd’s Center FallOpen University

The Shepherd’s Center of Rich-mond, serving older adults 50 andabove, has announced the fallschedule for its Open University.Offerings are available at threelocations around the city, beginningSeptember 18th.

The eight-week session of coursesfeatures topics in literature, geogra-phy of the Great Plains; history ofart and architecture, opera, musicaltheatre, faith of the foundingfathers, genealogy, topics in reli-gion, politics, and current events;yoga, Feldenkrais, and French,Spanish, German, Latin, and Japan-ese.

In addition, the Open Universitysponsors lunch-time speakers on avariety of topics. Richmond andVirginia’s past and present are thefocus of many of the talks, includ-ing: “Richmond and World War I”;“Mansions and Monuments andSouthern Identity in Richmond”;“Richmond’s Civil War Legacy”;“The Dooleys of Richmond”;“Lewis Ginter Botanical Gardens:Unearthing Potential”; “The RedCross in Richmond”; “Tobacco inVirginia”; “Jamestown Women andChildren”; “The Virginia Gover-nor’s Race”; and the digital collec-tion of the Virginia State Library.Other topics include North Korea’sthreat; Haiti; Cuba; money launder-ing; and coin collecting.

A full schedule with names ofteachers or speakers, dates, times,location, and cost is available atwww.TSCOR.org or by calling(804) 355-7282.

17

July 20, 20173rd Annual Senior Safety Day. Presented by the Senior Center of Greater Richmond, The Office of the Attorney General Mark Her-ring, and by Richmond’s First Bap-tist Church. First Baptist Church, Richmond. 9:00 a.m. to 3:00 p.m. For information, visit www.SeniorCenterOfGreater Richmond.org.

July 29-August 2, 201742ⁿd Annual Conference & Tradeshow of the National Associ-ation of Area Agencies on Aging. Savannah International Trade & Convention Center. Savannah, GA. For information, visitwww.n4aconference.org.

August 18, 2017Lifelong Learning Institute’s Fall Catalog. The Fall Catalog of the Lifelong Learning Institute in Chesterfield will be available on site and online. For information, visit www.LLIChesterfield.org or email info@LLIChesterfield.org.

August 28-30, 2017Justice for All: Protecting Vulnera-ble Adults. 28th Annual National Adult Protective Services Associa-tion Conference. Hilton Milwaukee City Center, Milwaukee, WI. For information, visit www.napsa-now.org/about-napsa/annual-conference/.

September 6 – October 11, 2017 Diabetes Self-Management Program. Sponsored by Senior Connections and St. Barnabas Episcopal Church. St. Barnabas Church, Chesterfield. Wednesdays only, 10:00 a.m. – 12:00 p.m. For information, call (804) 343-3004. For information, visit www.stbarnabasrichmond.org/health--wellness.html.

September 11-15, 2017 Virginia Health Care Association-Virginia Center for Assisted Living Convention and Trade Show. Richmond Marriott and Greater Richmond Convention Center. For information, visitwww.vhca.org/2017convention.

September 12, 2017Living with Alzheimer's for Care-givers: Conversations About Alzheimer's and Dementia. Pre-sented by the Alzheimer’s Associa-tion. 6:30 p.m. - 7:30 p.m. Peters-burg Public Library. For informa-tion, call (804) 446-5860 or visit www.alz.org/.

September 24-30, 2017 International Active Aging Week. Initiated in 2003 by the Internation-al Council on Active Aging. For information, visit www.activeagingweek.com.

September 25, 2017Aging and the Arts. 3rd Annual Bon Secours Richmond Successful Aging Forum. West End Assembly of God, Richmond. For informa-tion, visit www.bsvaf.org/successfulagingforum.

October 10-11, 2017 Navigating the Waters of Leader-ship. Virginia Assisted Living Annual Fall Conference. Hilton Norfolk The Main, Norfolk. For information, visitwww.valainfo.org.

October 15-18, 201768th Annual Convention and Expo of The American Health Care Asso-ciation and National Center for Assisted Living. Mandalay Bay Resort, Las Vegas, NV. For infor-mation, visit www.eventscribe. com/2017/AHCANCAL.

October 19, 2017Legal and Financial Planning. Pre-senter: Fletcher Cooke, Esquire. Presented by the Alzheimer’s Asso-ciation. Dinwiddie Public Library. 5:30 p.m. - 6:30 p.m. For informa-tion, call (804) 446-5860 or visit www.colonialheightschamber.com/.

November 14, 2017Annual Conference of The Virginia Association for Home Care and Hospice. The Stonewall Jackson Hotel, Staunton. For information, visit www.vahc.org.

January 24, 2018Virginia Center on Aging's 32nd Annual Legislative Breakfast. St. Paul's Episcopal Church, Rich-mond. 7:30 a.m. - 9:00 a.m. For information, call (804) 828-1525 or email eansello@vcu.edu.

Age in ActionVolume 32 Number 3

Summer 2017

Edward F. Ansello, Ph.D. Director, VCoA

James A. RothrockCommissioner, DARS

Kimberly S. Ivey, M.S.Editor

Age in Action is published quarter-ly. Submissions, responses to casestudies, and comments are invitedand may be published in a futureissue. Mail to: Editor, Age in Action,P.O. Box 980229, Ricmond, VA23298-0229. Fax: (804) 828-7905.Email kivey220@yahoo.com.

Fall 2017 Issue Deadline: September 15, 2017

Calendar of Events

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Virginia Center on Agingat Virginia Commonwealth University, Richmond, Virginiawww.sahp.vcu.edu/vcoa

Staff:Director

Edward F. Ansello, PhDRoad Scholar Coordinators

Catherine Dodson, MS - RichmondBarbara Wright - Staunton

Associate Director for ResearchConstance L. Coogle, PhD

Road Scholar Program Administrator Jeffrey Ruggles, MFA

Project DirectorPaula Knapp Kupstas, PhD

Executive Director, Lifelong Learning InstituteRachel Ramirez

Assistant Director, Virginia Geriatric Education CenterBert Waters, PhD

Project CoordinatorsCourtney O’Hara, MEdRuth Anne Young, MEd

Research AssociatesSung Hong, PhDSarah Marrs, PhDMyra G. Owens, PhD

Madeline McIntyreAdministrative and Research Assistant Jessica LyonEditor, Age in Action

Kimberly S. Ivey, MS

Advisory Committee:Frank Baskind, PhDJessica L. Coleman, DORussell H. Davis, PhDCecil Drain, PhDMadeline L. Dunstan, MSJames Hinterlong, PhDPaul G. Izzo, JDChristine Jensen, PhDAdrienne Johnson, MSRichard W. Lindsay, MDChristopher M. McCarthy, EsqHon. Jennifer L. McClellanKenneth J. Newell, MSHon. John O'BannonSherry PetersonSaundra C. Rollins, MSSWJim RothrockRobert L. Schneider, PhD, ChairmanRalph E. Small, PharmDBeverley SobleThelma Bland Watson, PhD

Virginia Department for Aging and Rehabilitative Serviceshttps://www.vadars.org/

Staff:Commissioner: Jim RothrockTanya Brinkley, Service Referral / Administrative AssistantTim Catherman, MHA, Director, Aging OperationsBrenda Cooper, Program and Compliance AnalystMarcia DuBois, Director, Division for the AgingLeonard Eshmont, PMP, Director, Information TechnologyJacqueline Freeze, External Aging Services AuditorBet Gray, ASAPS ProgramElizabeth Havenner, MSW, Program CoordinatorApril Holmes, MS Ed, Prevention Program for Older AdultsDavid Hominik, Legal Services DeveloperMichele James, No Wrong Door TrainerNicole Keeney, RD, LDN, Nutrition Program CoordinatorLori Kvam, No Wrong Door Information SpecialistGeorgie Lewis, Customer Service SpecialistSara Link, No Wrong Door Policy Advisor & Lead StrategistNancy Lo, MSW, GrandDriver CoordinatorAmy Marschean, JD, Senior Policy AnalystPatti Meire, Esq, Public Guardian Program CoordinatorChristy Miller, PMP, CSTE, NWD IT/Business AnalystKathy Miller, RN, MS, MSHA, Director of ProgramsCarolyn Mines, No Wrong Door Help Desk Andi Platea, Lifespan Respite Voucher Grant AssistantKatie Roeper, Assistant CommissionerAnnette Sherman, Systems AnalystCecily Slasor, Administrative Program SpecialistPam Smith, VICAP DirectorAnita Squire, VICAP Program SpecialistKathleen Vaughan, MA, No Wrong Door CoordinatorErika Yssel, No Wrong Door

Commonwealth Council on Aging:Members

Kyle R. Allen, DO, AGSFBeth Barber, ChairMitchell Patrick DavisDavid M. FarnumJoni C. GoldwasserCarter HarrisonValerie L’Herrou, JDRichard W. Lindsay, MDShewling MoyDiana M. PaguagaValerie Price, Vice-ChairRoberto QuinonesKathryn B. ReidBeverley SobleVernon WildyVeronica WilliamsErica Wood, Esq

Ex Officio MembersThe Hon. William A. Hazel, Jr., MD , Secretary of Health and

Human ResourcesLeigh Wade, VAAAAJames A. Rothrock, DARSTerry A. Smith, DMASTara Ragland, VDSS

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Research AssistantsJenni Mathews

Virginia Commonwealth University Age in ActionVirginia Center on AgingP.O. Box 980229Richmond, VA 23298-0229

Return Service Requested

Nonprofit OrganizationU.S. POSTAGE PAID

Permit No. 869RICHMOND, VIRGINIA

Virginia Commonwealth University is an equal opportunity/affirmative action institution and does not discriminate on thebasis of race, gender, age, religion, ethnic origin, or disability. If special accommodations are needed, please contact Dr. Edward F. Ansello, VCoA, at (804) 828-1525.

2017 Walk to End Alzheimer’s

Walk to End Alzheimer's is the Alzheimer's Association's signature nationwidefundraising event. Each fall, tens of thousands of people walk together to help make adifference in the lives of people affected by Alzheimer's and to increase awareness ofthe disease. Become part of the group of individuals, corporations, and organizationsthat are proud to lead the fight against Alzheimer's disease!

Central and Western Virginia ChapterRegister for walks in this area atwww.alz.org/cwva.

Culpeper, September 9Danville, September 16Waynesboro, September 30Blacksburg, October 7Roanoke, October 14Harrisonburg, October 21Charlottesville, October 28Lynchburg, November 4

Greater Richmond ChapterRegister for walks in this area atwww.alz.org/grva.

Middle Peninsula-Northern Neck, Urbanna, October 7Fredericksburg, October 14Richmond (Glen Allen), November 4

National Capital Area ChapterRegister for walks in this area at www.alz.org/nca.

Solomons, MD, September 16 Washington, DC, October 14 Oxon Hill, MD, September 23 Manassas, VA, October 21Reston, VA, September 24 Winchester, VA, October 28La Plata, MD, September 30

Southeastern Virginia ChapterRegister for walks in this area atwww.alz.org/seva.

Suffolk, September 16 Newport News, October 7Virginia Beach, September 23 Onancock, October 14Farmville, October 5 Williamsburg, October 28