Activities in geriatrics and gerontology education and research
Virginia Center on Aging
Virginia Geriatric Education Center
Virginia Department for the Aging

Case Study - Merging a Divided System: The Need to Integrate Care for Individuals Participating in Both the Medicare and Medicaid Programs
    by Regina L. Anderson-Cloud, M.S.

Educational Objectives

1. Identify the underlying premises of the need to integrate care between the Medicare and Medicaid programs for individuals eligible for both insurances.

2. Discuss innovations aimed at assisting older adults with an improved Medicare/Medicaid system.

3. Describe relevant health care concerns related to the current fragmentation of the health care system for older adults who possess both Medicare and Medicaid.

Background

When the Medicare and Medi-caid programs were conceived, the need to think of a full continuum of integrated care and services was not really on the forefront of the U.S. health care agenda.  The origination of these two insurance programs evolved in many ways independently, with states in control of the general workings of the Medicaid program and the federal government administering Medicare.

The somewhat independent evolution of Medicare and Medicaid has yielded two very different insurance coverage systems with resulting problems for the population frequently referred to as "dual eligibles;" those eligible for coverage under both programs.  These problems are evident in that the systems have very different coverage rules and benefit criteria, separate administrative oversight, unique grievance rules and appeal policies, and a general lack of coordination of health care delivery or care planning.  Additionally, another serious and sharp division between the two insurance programs is that Medicare is the primary payer of acute care, while Medicaid is primarily responsible for funding long-term care.  The result, traditionally, has been cost shifting between the two programs and fragmented health care delivery, which has been viewed by consumers as inefficient and costly.  Disincentives in the administration of both programs have been cited as factors contributing to a health care system that is biased toward institutionalization (Wiener and Skaggs, 1995).

With the fragmentation and inherent divergence that has occurred in health care delivery for the population of dual eligibles, state policy makers have sought solutions aimed at an integrated system of health care.  According to the Muskie School Public Service and the National Academy for State Health Policy (1997), states have been prompted to merge these two very different insurance programs based upon the influence of three primary factors: (1) the desire to improve continuity of care across settings and to provide flexible benefits that prevent or reduce institutionalization; (2) the need to control costs; and (3) an interest in expanding managed care to all Medicaid beneficiaries and minimizing the administrative complexities of operating both fee-for-service and risk-based systems.

The state of Virginia, under a grant from the Robert Wood Johnson Foundation called "The Medicare/Medicaid Integration Program," is one of a small number of states working to develop pilot programs to integrate Medicare and Medicaid.  Virginia's program is entitled "Virginia Cardinal Care."  While some programs are farther along in development than Virginia Cardinal Care, most states have similar program goals.  The goals of the Virginia Cardinal Care Program are to provide improvements in quality of life to consumers while assuring an efficient use of care resources through:

• delaying or deterring institutional placement;
• improving access to care;
• providing for a model of care coordination that reduces fragmentation and inefficiencies in the current delivery system;
• promoting improved health status and/or decreased progression of disability through screening, chronic disease management, education, and prevention; and
• improving patient/caregiver satisfaction over the current fee-for-service system.

The integrated care models of most states seek to pool Medicare and Medicaid funding in a managed care arena.  With this pooling of funds, an emphasis is placed on improving the care delivery system and new provisions that allow providers flexibility in delivering services aimed at keeping individuals well and in their homes longer.

Similar to the model being proposed by the state of Virginia, most state models also first attempt to develop programs for integration of Medicare and Medicaid for the largest segment of dual eligibles, those age 65 and older.  Once experience is gained in serving the older adult population, states will move to develop related programs for those under age 65.  Additionally, most states venture into integration projects on a pilot basis hoping to gain experience that will bridge to larger programs.

The following case study is provided to illustrate the need for integration of Medicare and Medicaid for individuals age 65 and older.

Case Study

It was not unusual for Peggy to have terrible pain from her worsening arthritis.  What was unusual to her was that she was feeling worse physically and it was not just the pain.  She was more tired, unsteady on her feet, and dizzy at times.  Her stomach bothered her and she was obviously losing weight.

With her son living away, Peggy’s closest contacts were her friends.  Some had become concerned about her recently, especially with the weight loss, but they guessed that she was "just going down hill."

Time passed, and Peggy grew weaker.  She stopped attending church as she had done weekly for at least 60 of her 83 years.  She saw her doctor routinely and was told that she needed to try eating more.  He told her to buy Ensure and drink at least two cans a day.  She tried, but with her best efforts, she still did not feel well.  Although she quietly figured that this was part of her approach toward death, she tried to keep up a bright front with her son when he called.  She would just tell him that she was "getting old" and that she "guessed old Arthur (itis)" was getting the best of her.

A nurse from the hospital called Peggy’s son because she had fallen in the bathroom during a dizzy spell.  She was in the local hospital with a broken hip, and surgery would be necessary.  It looked as if she may never walk again.  Her son was advised that she may need nursing home placement or a similar level of care for the rest of her life.

What had happened to her?  Why the decline in her health, the loss of weight, the unsteadiness, the dizzy spells?

Out of concern, Peggy’s son requested a review of her complete physical condition once she was safely recovering from surgery.  Much to her family doctor's surprise, the review found she had been taking four different medications prescribed to treat her arthritic pain, only one of which had been prescribed by him.

When the family doctor asked about the other three drugs, Peggy, feeling embarrassed that he had discovered the other drugs, explained that she had heard of a few other doctors who were good at treating arthritis and that she had been to see them as well.  Each doctor had prescribed different medication for the same symptoms.  None of the doctors had asked if she was taking anything else for her arthritis; each assumed he was the only physician treating her condition.  Because she had gone to doctors in different areas of the city, she had also used different pharmacies for each doctor's prescription.  Therefore, no one knew, except for her, that she had been given all of these drugs.

The doctor's discovery, prompted by her son's concern, revealed that in her efforts to receive relief from chronic arthritic pain, she had been poisoning her system with the interactions of the four drugs.  Thus, she experienced the side effects of a severely upset stomach, weight loss, dizziness, and weakness.  These side effects were directly related to the fall that resulted in the broken hip which, unfortunately, would alter the course of her remaining years.

Discussion

This case is a severe example, and the placing of blame could be aimed in many different directions.  Was it Peggy’s fault for doctor shopping and not telling her routine doctor that she was taking new medicines?  Was it the fault of the doctors involved for not asking about other medicines she was taking?  Was it her family doctor's fault for not looking for reasons for her recent decline?  Was it her son's fault for not visiting more frequently and identifying the stark changes in her condition?  Was it her friends' fault for not taking a more active role in discerning what was wrong?

The reality is that the "blame game" really does not benefit anyone when irreversible damage has already been done.  The challenge is to try to seek solutions that will structure a system aimed at reducing the probability of the negative outcomes seen in the case above.

Separate articles could be written on the difficulty in managing arthritis in old age, of coping with chronic pain, or about the perils of polypharmacy for the aging population.  However, key to this case are many concomitant factors related to the health care of the aging, especially the vulnerable older adult population that is eligible for both Medicaid and Medicare.  The concern, as evidenced in the case study, is of how quickly negative outcomes that lead to eventual nursing facility placement can occur when symptoms and/or conditions go untreated.  Too often, changes, side effects, and symptoms are dismissed with a "she's getting to be that age" or "he's done well for so long, it must be time that he…"

How can integrated care from the Medicare and Medicaid programs make a difference?

The goals of programs like Virginia Cardinal Care are to work on a one-on-one basis with older adults in health screening, preventative strategies, monitoring of existing conditions, and health education.  Through the use of the principles of managed care, especially with vulnerable populations, health plans and providers are motivated by the obvious incentives of keeping the population they serve at the highest functional level possible for the longest period of time.  Managed care principles have often proven to yield improved outcomes while reducing cost in the care of older adults.  For example, Leveille et al. (1998) found that overall function can be improved and that inpatient hospital utilization can be significantly reduced when applying health care management principles to a population of chronically ill older adults.  Moreover, Wasson et al. (1998) suggested that potential cost savings in better management of inpatient hospital usage could provide significant funds for use toward supportive services aimed at providing essential care in the home verses the institutional/long-term care environment.

In addition to applying new principles to managing care through primary care physicians and care coordination models, the integration of Medicare and Medicaid in managed care decreases the incentives toward cost shifting between the two payment sources.  Linking payment systems provides a consumer-focused system verses a payer-driven system.

As states like Virginia continue to plan and work toward innovations that yield integrated structures and services, many challenges loom.  Current problems with payment from the Health Care Financing Administration (HCFA) for Medicare managed care services are a key challenge.  Payment systems, as well as administrative structures, must strive to be amenable to change to support the population in need.  Many states, advocates, and other concerned parties are working with HCFA as well as Congress to work toward positive change for dually eligible beneficiaries.  With all this activity, and with the support of those like the Robert Wood Johnson Foundation, a better health care system for Medicare and Medicaid eligibles is sure to emerge.

Study Questions

1. In your experience, have you seen a need to merge the Medicare and Medicaid programs?  What suggestions could you make to policy makers about how this could be achieved most effectively?

2. An early effort to merge care and services for a subset of dual eligible beneficiaries has been PACE (Program of All-Inclusive Care for the Elderly).  Research the PACE program model and detail the differences and similarities between PACE and programs like Virginia Cardinal Care.

References

    Leveille, S. G., Wagner, E. H., Davis, C., Grothaus, L., Wallace, J., LoGerfo, M., & Kent, D. (1998).  Preventing Disability and Managing Chronic Illness in Frail Older Adults: A Randomized Trial of a Community-Based Partnership with Primary Care.  Journal of the American Geriatrics Society, 46(10).
    The Muskie School of Public Services and The National Acad-emy for State Health Policy.  (1997).  Integration of Acute and Long-Term Care for Dually Eligible Ben-eficiaries through Managed Care.  A technical assistance paper of the Robert Wood Johnson Foundation, Medicare/Medicaid Integration Program.
    Wasson, J.H., Bubolz, T.A., Lynn, J., & Teno, J. (1998).  Can We Afford Comprehensive, Supportive Care to the Very Old?  Journal of the American Geriatrics Society, 46(7).
    Wiener, J.M. & Skaggs, J. (1995).  Current Approaches to Integrating Acute and Long-Term Care Financing and Services.  AARP Public Policy Institute, December 1995.

From the Executive Director, Virginia Geriatric Education Center
    Iris A. Parham, Ph.D.

This last quarter has been an exciting one for the VGEC.  Training for the Virginia Department of Social Services successfully included over 1,000 trainees at the scheduled programs across the state.  The Virginia Guardianship Association held a very well-attended annual conference.  The Geriatric Interdisciplinary Team Training (GITT) project staff and advisory team made great progress in the videotaping and preparation for the upcoming Fall course by the same name.  There will now be five on-site locations across the state, including Richmond, Abingdon, Northern Virginia, Charlottesville, and the Norfolk/Virginia Beach area.  This course will have three full day sessions at each of these sites and the remainder will be taught via video.  A more detailed overview of the course is included on page 13.  Students may still register for this course by calling the VGEC at 804-828-9060.  Also under successes for the GITT project this quarter, was the completion of revisions of the video courses in both Social Gerontology and the Biology and Physiology of Aging.  Additionally, there were several training sessions at Bon Secours and Sentara, and training begins shortly for staff of MCV Hospitals of VCU.  Special kudos to the staff:  Leigh Peyton, Katie Benghauser, Michelle Utterback, Wendy Boggs, and Felicia Brown.

In other news, the School of Social Work was just funded by the Hartford Foundation to do the planning for a major project in geriatric social work.  Details will be in the next issue of the newsletter.  This issue also contains pictures of our wonderful celebration in April with Bill Benson as our keynote.  We had the pleasure of honoring Dr. Betsy Flanagan for her 15 years of commitment to excellence in her teaching and mentoring in the Gerontology Department.  We also had the fun of awarding our A.D. Williams award to our first ever PharmD./Certificate in Aging Studies graduate, Becky Garner, and our Gerontology Student of the Year Award to Sonya Sterbenz.  Special congrat-ulations went to our own Alumni of the Year, Dr. Joan Wood.  As you all know, Dr. Wood was the Associate Director of the VGEC and is now the newly appointed director of the National Learning Center of the American Society on Aging.  We look forward to the Fall and will keep you updated on all that is happening here at the VGEC.

From the Director,  Virginia Center on Aging
    Edward F. Ansello, Ph.D.

Stand up, Commonwealth of Virginia, and take a bow.  This issue contains Dr. John Savory’s message to us that his small pilot grants from the Alzheimer’s and Related Diseases Research Award Fund (ARDRAF) had paid off.  He’s obtained an Army research award of over $600,000 to continue his line of investigation.  The Common-wealth deserves the applause, because its leaders had the vision back in 1982 to create ARDRAF for VCoA to admin-ister.  Back then, Alzheimer’s disease was barely on anyone’s radar.  Yet, the General Assembly saw clearly the need to investigate Alzheimer’s and other dementing illnesses from a range of perspectives, studying its causes, treatments, and consequences.

The General Assembly’s broad mandates for ARDRAF have meant research into such diverse lines of inquiry as behavior and personality changes with dementia, cellular changes, immunological responses, pharmaceutical interventions, family caregiving, clinical care issues, brain chemistry, and several others.  Unlike sources of research funds that are tied to a specific line of investigation, ARDRAF has no such restriction.  This freedom has encouraged and enabled researchers across Virginia to explore the unexplored or the understudied.  Nor have Virginia researchers been sanctioned to pursue pipe dreams.  Each year, the ARDRAF Awards Committee of highly regarded scientists and professionals scrupulously judges submitted proposals for their scientific merit, innovation, potential for more extended research, research design, investigator’s background and training, as well as other criteria.

The ARDRAF has, to this point, invested some $692,000 in 64 research studies directed by investigators across the Com-monwealth.  Awardees, in turn, have brought an estimated $3.8 million to Virginia from research projects made possible by the ARDRAF’s pilot findings.  That’s better than a 5 to 1 return.  ARDRAF awardees, because of their ARDRAF-supported studies, have subsequently received funding from such diverse sources as the National Institute on Aging, the National Traffic Highway Safety Administration, the National Institute of Mental Health, the National Institute of Neuro-logical Disorders and Stroke, the National Institute on Alcohol Abuse and Alcoholism,  the Andrus Foundation, the Kellogg Corporation, and a number of other organizations.  At the same time, these researchers have contributed well over 100 articles to the research literature.

The Virginia Center on Aging has begun a follow-up of all previous ARDRAF recipients.  We want to quantify, in some way, the positive impact that this Fund has made upon those who study dementia as well as upon those who care for Virginians with dementing illnesses.  ARDRAF has been a diamond in the rough.  It’s now time to polish it for all to see.

From the Commissioner, Virginia Department for the Aging
    Ann Y. McGee, Ed.D.

Harvard Professor Robert Putnam's 1995 essay entitled "Bowling Alone: America's Declining Social Capital" documented the declining par-ticipation among Americans of all ages in community organ-izations and activities.  As one strategy for addressing this declining participation, Claude Allen, Virginia's Secretary of Health and Human Resources, and the Virginia Department for the Aging will be holding an Intergenerational Summit in Richmond on Wednesday, November 17, 1999.  Secretary Allen's goal is to encourage intergenerational programs already existing in our communities to bring young and old together and develop new intergenerational strategies.

Intergenerational programming is a new name for something that Americans once did naturally, namely, getting people of all ages together to work for the common good of the larger community.  Intergenerational programs have proven particularly effective because they meet numerous needs of the young, the old, families, and communities, and they are almost always cost effective.  By promoting intergenerational contacts between young and old, we can once more infuse our society with a sense of intergenerational dependence.  In Virginia, intergenerational programs can be found which recruit older adults to tutor school children, mentor welfare recipients entering the work place, teach craft skills, or provide one-to-one counseling for teenagers.  Other programs recruit young people to visit nursing homes or provide chore services to the home-bound elderly.

Secretary Allen believes the Commonwealth's older pop-ulation is an expanding source of wisdom, energy, time, and talent which we must learn to harness to help address Virginia's growing family and community needs.  Please mark your calendars for November 17th and join Secretary Allen and others from around the Commonwealth to discuss ways to focus the energy of both older volunteers and youth on some of Virginia's most pressing social problems.

Focus on the Virginia Geriatric Education Center
    Wendy G. Boggs

Wendy Boggs joined the Virginia Geriatric Education Center (VGEC) in February, as a part-time Research Assistant.  Her responsibilities as a Research Assistant include the coordination and organization of training sessions as part of the Geriatric Interdisciplinary Team Training (GITT) grant received from the Virginia Department of Health and Human Services.  Wendy is also assisting in the development of the new GITT graduate level course and other VGEC activities.

Wendy began working with older adults in 1997 as a nursing assistant in a local Alzheimer’s Special Care Unit, during which time she was also working on her B.S. degree in Psychology at VCU.  She graduated from VCU  in the Spring of 1998 with both University and Psychology Honors.  Prior to her graduation, she was inducted into the Golden Key National Honor Society, as well as the Phi Kappa Phi and Psi Chi honor societies.  Wendy is currently pursuing an M.S. degree in Gerontology at VCU, concentrating in the area of Psychogeriatrics.

Focus on the Virginia Center on Aging
    Jane F. Stephan, Ed.D.

Dr. Stephan joined the Virginia Center on Aging in May,1999. As Assistant Director of Education, she is responsible for ensuring the success of VCoA's Elderhostel and lifetime learning educational programming for older adults.  Dr. Stephan is a newcomer to Virginia, but not to Elderhostel.  She has been an enthusiastic supporter of Elderhostel since 1988, first at Ball State University in Indiana and subsequently at Northern Kentucky University, where she was coordinator and department administrator for Elderhostel and Senior Programming.

Dr. Stephan holds a B.S. in environmental and behavioral science from the University of Wisconsin-Superior and an M.A. in applied gerontology from Ball State University.  She earned her doctorate in adult and community education at Ball State while working on several pilot projects in the area of aging and alcoholism.  She continued this focus as older adult specialist for a four-county coalition in Greater Cincinnati. At the same time, she was a full-time adjunct instructor in gerontology and behavioral sciences for the College of Mount St. Joseph, and an adjunct professor for graduate studies in gerontology at The Union Institute.  Dr. Stephan has developed a variety of inservice workshops and seminars in the areas of caregiving, women's issues of aging, elder abuse, and substance abuse prevention and recovery for older adults.

More Services, More Choices, More Medicare
    by Joe Guarino, VDA

Over the next few years, Medicare will have undergone a metamorphosis unlike any it has seen since its inception in the mid 60s.  In 1997, Congress passed the Balanced Budget Act (BBA) which offered more rights, more assistance, more services, and more choices to Medicare beneficiaries.

What New Rights Are Available through Medicare?

Medicare beneficiaries have certain guaranteed rights that protect them when they get health care, assure access to needed health care services, and protect them against unethical practices.  These rights include the right to: (1) protection from discrimination in marketing and enrollment practices, (2) information about what is covered and how much a beneficiary has to pay, (3) information about all treatment options available, (4) receive emergency care, (5) appeal decisions to deny or limit payment for medical care, (6) know how a Medicare health plan pays its doctors, (7) choose a women's health specialist, and (8) receive a treatment plan that includes direct access to a specialist if a complex or serious medical condition exists.

What New Assistance Can Medicare Offer?

Medicare beneficiaries with low incomes can be assisted through Medicaid.  The program may pay some or all of the premiums, co-insurances, and deductibles for certain low-income or disabled people entitled to Part A.  If a beneficiary has Part A and bank accounts, stocks, bonds, or other resources below $4,000 for one person or $6,000 for a couple, he may qualify.  Other non-financial criteria must be met before the financial benchmarks are applied.

If a single person's monthly income is below $691, or if a couple's monthly income is below $925, the program may pay the premiums, co-insurance, and deductible.  If the monthly income is higher but below $1,194 for a single person and $1,603 for a couple, the program may pay for some or all of the Part B premium only.  Actual earned and/or unearned income would be higher due to the formulas used to derive the qualifying income amounts.

What New Services Does Medicare Cover?

Medicare will pay for most or all of several preventive screening services.  The frequency and payment schemes vary for each service.  Generally, they include: (1) screening mammograms for females 40 and older in Medicare, (2) pap smear and pelvic examinations for all females in Medicare, (3) colorectal cancer screening for people 50 and older in Medicare, (4) diabetes monitoring for all diabetics in Medicare (insulin is not covered.), (5) bone mass measurements for certain people in Medicare at risk for losing bone mass, and (6) certain vaccinations for all people in Medicare.

What New Choices Does Medicare Offer?

As of the 1997 BBA, Medicare now has three parts: Parts A, B, and C.  Each part helps pay for an eligible person's health needs differently. Part A is Hospital Insurance, and Part B is Medical Insurance.  Together, Part A and Part B are now called Original Medicare.  Part C, the newest part, is also called Medicare + Choice.  It helps pay for hospital and medical needs differently from Part A and Part B.  The new choices to help pay for a beneficiary's health needs were added here by Congress.

As of January 1, 1999, choices other than HMOs became available to Medicare beneficiaries.  These new choices, however, are not yet available in Virginia or any surrounding states.

For more details on the information presented, call Medicare at the national level at 1-800-MEDICAR(E) or the Virginia Department for the Aging at the state level at 1-800-552-3402.

VAAAA, Inc. Receives Medicare Senior Patrol Project Grant

The Virginia Association of Area Agencies on Aging, Inc. (V4A) has received a three year grant from the U.S. Department of Health and Human Services through the Administration on Aging.  A wide variety of government agencies, non-profit associations, private businesses, and the aging network were collaborative partners in the application and design of this project.  V4A and Area Agencies on Aging throughout Virginia will develop a volunteer pool of retired professionals to inform Medicaid and Medicare beneficiaries and their families about fraud, waste, and abuse.

During a press conference held on June 17, 1999, in Washington, Secretary Donna Shalala and Senator Tom Harkin announced the $7 million expansion of the Senior Patrol Projects.  V4A is one of two state aging associations which has been funded, along with 39 other grantees that include state units on aging, regional commissions on aging, and other human service programs.  Twelve states had piloted the programs with a 240% increase in health care fraud convictions.

V4A and the Virginia Department for the Aging were among the twelve grantees that received a similar three year grant in 1997 for Operation Restore Trust (ORT).  With the ORT grant, V4A staff trains human service programs staff, seniors, and various members of the community to better spot and report fraud, waste, and abuse in the Medicaid and Medicare programs.

More information is available in the full press release on the Health and Human Services' web page, http://www.hhs.gov.  Retired persons wishing to be trained to become volunteers in Virginia's Senior Patrol should contact V4A at 804-644-2804 or their local Area Agency on Aging.

Rollin' on the Ocean

Paradapt is a leading medical equipment, vehicle modification, and home modification company with three locations in Virginia.  Gary Melton, Founder and President of Paradapt, began offering free boating and fishing trips in 1994 on Paradocks II, a custom-built houseboat that accommodates 20 wheelchair and 30 ambulatory anglers.  He has set up a separate 501(C)(3) non-profit corporation to handle funding (via donations) for the boat.

The boat has a completely open upper deck, and its cabin is air-conditioned.  Those who enjoy fishing can take advantage of furnished gear, and electric reels are available for individuals with limited hand use.  For fishing or just getting away, this accessible houseboat opens up a whole new world for the aging and mobility impaired.  Free excursions, which leave from Rudee Inlet near Virginia Beach, will be offered through-out the summer.

To schedule an outing for mobility impaired individuals, or if you are interested in volunteering on the Paradocks II, contact Paradapt's Hampton location at 757-722-7700.  Questions concerning these trips or other Paradapt services may be directed to Gunnar Melder, Regional Manager.

Past ARDRAF Recipient Receives Funding

John Savory, Ph.D., a past recipient of the small ARDRAF pilot grants, wrote that he has received funding of over $600,000 from the Department of the Army for his proposal entitled “Opening of the mitochondrial permeability transition pore by reactive oxygen species is a basic event in neurodegeneration.”  Dr. Savory stated that his project is directly related to his earlier ARDRAF studies and expressed his thanks to VCoA and ARDRAF for supporting his research over the years.

The Alzheimer's and Related Diseases Research Award Fund (ARDRAF) was established by the Virginia General Assembly in 1982 to stimulate innovative research into the causes and treatment of Alzheimer's and related diseases, as well as the social and psychological aspects of these disorders.  The ARDRAF is intended to increase public understanding about how dementing illnesses affect individuals, families, caregivers, and society; support pilot projects from a broad spectrum of scientific disciplines; foster the application of knowledge about Alzheimer's and related diseases; investigate the impact of these conditions on the Commonwealth of Virginia and determine appropriate public policy.  The ARDRAF competition is administered by the Virginia Center on Aging at Virginia Commonwealth University in Richmond.  The five grant recipients of the 1999-2000 awards are as follows:

GMU Giorgio Ascoli, Ph.D. (Krasnow Institute), "Effect of Dendritic Morphology on Neuronal Electrophysiology in a Lesion Model of Alzheimer's Disease"
This proposal explores the hypothesis that changes of neuronal anatomy known to occur throughout the Alzheimer's pathology are one of the direct causes of the impaired electrophysiological behavior of nerve cells at the basis of memory loss and dementia.  Particularly, in recent studies of Alzheimer's disease significant alterations in dendritic morphology have been observed in the principal cells of the hippocampus, one of the brain structures responsible for spatial associative learning in all mammals and semantic, or declarative, cognition in humans.  The research will investigate the effects of such morphological alterations on the integrative behaviors of various classes of hippocampal neurons, and will compare the results with the pathological electrical responses reported in the literature.  This research project should provide significant evidence about a basic anatomical mechanism underlying the neuronal malfunction that typifies Alzheimer's and related diseases.  (Dr. Ascoli can be reached at 703/993-4383)

UVA Suzanne Holroyd, M.D. (Dept. of Psychiatric Medicine) & Andrew Wolf, M.D. (Dept. of Internal Medicine), "Attitudes on Whether Physicians Should Tell Alzheimer's Disease Patients Their Diagnosis"
Although "truth telling" is now well established for serious terminal diagnoses such as cancer, no established protocol guides physicians who diagnose dementing illnesses such as Alzheimer's disease (AD).  Physicians may confront multiple dilemmas with this issue.  For example, families often seek diagnoses for relatives who do not have insight that anything is wrong and are not requesting a diagnosis.  In addition, families may ask the clinician not to tell the patient the diagnosis.  As well, issues of competency and decision-making capacity arise with such patients.  While much has been written on how to make a reliable diagnosis of AD, there has been little research on whether or how to inform patients of the diagnosis.  Our own preliminary study of this issue confirmed the difficulty clinicians and patients face.  In the proposed study, elderly patients without AD from diverse racial and socioeconomic backgrounds will be assessed on their attitudes towards being told a diagnosis of AD, and families of patients with AD will be surveyed regarding their attitudes about telling patients the diagnosis of AD, drawing on their own experiences.  The study will provide pilot data for further research and may produce valuable preliminary advice for physicians on "truth telling." (Drs. Holroyd and Wolf can be reached at 804/924-2241)

VA Tech Shannon E. Jarrott, Ph.D. (Dept. of Human Development), "The Effects of Instrumental Assistance on Family Caregivers of Patients with Dementia"
Caring for an elderly relative with a dementing illness has consistently been associated with increased levels of overload and decreased well-being of the caregiver.  Caregivers may turn to informal (family and friends) and formal (paid) sources for assistance with the care of their relative, but often with mixed results.  The present study proposes an analysis of how the amount of help that family caregivers of elderly dementia patients receive effects their perceived stress and well-being (e.g., depression, anger, overload, and worry).  While previous research has largely relied on subjective caregiver evaluations and has not considered the number of hours of help a caregiver receives, the present study will utilize multiple objective measures of the nature and extent of assistance that caregivers receive.  By considering urban and rural caregivers who are receiving a wide range of informal and formal assistance, this project will have both theoretical and practical implications important to understanding the relationship between formal and informal assistance and caregiver stress and well-being. (Dr. Jarrott can be reached at 540/231-5434)

UVA  Virginia Simnad, M.D. (Dept. of Neurology), "Alteration in Proton Spectra of the Hippocampus to Oral Ingestion of Glucose in Alzheimer's Disease"
Recent studies have shown that glucose improves memory in Alzheimer's patients and healthy elderly people.  Magnetic resonance spectroscopy (MRS) is a cutting-edge neuroimaging technique that has considerable clinical and experimental potential for the diagnosis and treatment of Alzheimer's disease (AD).  This non-invasive technology allows researchers to monitor changes in certain brain metabolites (i.e., myo-inositol, glucose, and N-acetylaspartate).  These chemicals are of interest because they are involved in energy production and utilization.  The neurophysiology of the human hippocampus, an area of the brain particularly affected by AD, has remained understudied.  In this investigation MRS will be used to quantify hippocampal changes in metabolism following oral ingestion of glucose or saccharin.  The study will provide important information about the energy-related chemical brain changes secondary to blood glucose elevations in patients with probable AD, as well as in healthy elders. (Dr. Simnad can be reached at 804/924-5548)

VCU  Patricia W. Slattum, Pharm.D., Ph.D. & Vivien E. James, Pharm.D. (Dept. of Pharmacy and Pharmaceutics), "Anticholinergic Medication Use in Elderly Patients Diagnosed with Dementia or Taking Acetylcholinesterase Inhibitors"
This research will assess the use of prescription anticholinergic medications in elderly patients, particularly those suffering from dementia.  Anticholinergic medications are used to, among other things, reduce Parkinsonian symptoms, treat spastic disorders of the GI tract, and regulate heart impulses.  Patients with Alzheimer's disease or other dementias are at increased risk of adverse effects of anticholinergic drugs.  When used concurrently with acetylcholinesterase inhibitors (donepezil (Aricept®) or tacrine (Cognex®)) prescribed to improve cognition in Alzheimer's patients, anticholinergics may counteract the cognitive enhancing effects and predispose patients to other adverse drug effects.  The extent of anticholinergic medication use in dementia patients and their concurrent use with acetylcholinesterase inhibitors are unknown.  Results of this study are essential to understanding the magnitude of the problem and designing educational interventions for prescribers of these medications.  Further, the findings will provide important information for those who design drug trials and those who manage care. (Drs. Slattum and James can be reached at 804/828-5429)

On April 29, 1999, the Department of Gerontology at Virginia Commonwealth University invited its faculty, staff, alumni, students, and their family and friends to its First Annual Gerontology Spring Symposium.  Bill Benson, The Benson Consulting Group, Inc. and Former Assistant Secretary for the U.S. Administration on Aging, was the keynote speaker.  The Department also honored its 1999 M.S. and Certificate in Aging Studies graduates and payed tribute to Dr. Elizabeth Flanagan for her 15 years of dedicated service.
 

Rebecca Garner
A.D. Williams Award.  An annual award is made to a student who demonstrates, by virtue of high scholastic attainment and professional competence, unusual promise and ability in the field of aging.

Sonya Sterbenz
Gerontology Student of the Year.  Each year, the faculty chooses a graduating student who has exhibited outstanding scholastic achievement and demonstrated service in gerontology.

Joan Wood, Ph.D.
Distinguished Alumni Award.  Each year, the Gerontology Student Association, in consultation with the departmental faculty, chooses an alumna or alumnus who best exemplifies the standards of the profession.

Geriatric Interdisciplinary Team Training: Fall 1999
    from the Department of Gerontology, Virginia Commonwealth University

This course emphasizes interdisciplinary teamwork focusing on geriatrics.  A primary goal of the course is to increase the awareness of students and current health care providers of the importance of interdisciplinary teamwork when working with older adults.  A case-focused approach will be used to discuss care for older adults in a variety of settings, including acute care, long-term care, rehabilitation, PACE, and home health care.

This course will be taught via three six-hour interactive video sessions with instructors on-site in five locations, complimented by eight videotapes for student home-instruction.  Currently, there are ten slots available at each site (Northern Virginia, Tidewater, Richmond, Abingdon, and Charlottesville).  Dates for the three six-hour on-site video sessions are September 17, October 22, and December 10, 1999.  If interested in this course, please call the Virginia Geriatric Education Center at (804) 828-9060.

The course instructors will be Dr. Ellen Netting, Ms. Alison Englade, Dr. Howard Garner, Ms. Leigh Peyton, Dr. Ayn Welleford, Dr. Iris Parham, and Ms. Donna Dawson.  This is a three-credit course at the graduate level and may be taken under special graduate student status.  You must have a baccalaureate degree to register.  This course can be considered as an elective course as part of the Certificate in Aging Studies program.  For all Certificate in Aging Studies students, this course may be substituted for the independent study.

AARP Foundation Employment Service
    by Carolyn Crighton, AARP

It is estimated that over 70% of Americans age 55 and older work every day to keep our economy running.  As our population continues to age, the experience and contributions of mature workers will play an important role in maintaining our country's leadership in a highly competitive, international market.  Throughout the country, more people are working past the traditional retirement age of 65.  As the baby boom gener-ation ages and people live longer because of healthier life-styles, our current concept of retirement will change dramatically.  In fact, studies show that more workers will remain in the work-force longer, either because they want to work or because limited finances dictate that they do so.

Some factors that keep people working include: (1) need for career options due to downsizing or plant closings, (2) need to supplement retirement and for Social Security income, (3) need to be around others to fight boredom, loneliness and depression, and (4) desire to give back to the community by sharing skills and knowledge gained through years of experience.

In the Richmond metropolitan area (Richmond, Henrico and Chesterfield Counties) the AARP Foundation coordinates training and employment opportunities for mature workers through its Senior Community Service Employment Program (SCSEP).  The goal of SCSEP is to affect changes in the competitive labor market, removing barriers to employment and vocational mobility based on age discrimination.  Through educational and advocacy efforts, SCSEP increases employer awareness of the value and contribution of older workers.  It also assists participants in locating permanent part-time or full-time employment, thus freeing funds to serve others in need of work.

Services of the AARP Foundation Employment Service

Paid Work Experience (on the job training).  This service allows participants to work 20 hours per week in temporary positions with community service organizations.  Individuals are given the oppor-tunity to improve marketable skills and develop new ones, to build a current job history and references, and to gain self-confidence through support and encouragement.

Job Search Assistance.  This service provides one-on-one counseling or group workshops, resume development, interviewing techniques and coaching, overcoming age bias in the workplace, and available job market information with referral to job openings provided.

Benefits of Maturity in the Workplace

Through the AARP Found-ation, we are able to reinvest in an invaluable and virtually untapped resource, our mature workers.  They make significant contributions to the workplace: dependability and stability, strong work ethic, create an atmosphere of trust and con-fidence, bring maturity to the workplace serving as role models for younger workers, low turnover, conscientiousness, and flexibility.

We would like to encourage job seekers, community service organizations, and businesses to utilize our no-fee recruitment, screening, and employment/ training services.  For additional information, contact Carolyn Crighton, Project Director, AARP Foundation Employment Service, 1806 Chantilly Street, Suite 100, Richmond, VA 23230, scccrighto@aol.com, (804) 355-3600.

Curated Video Collection

The Library Media Project announces the availability of “VideoCuration: Constructing Library Core Collections; the Issues of Aging,” a print and electronic publication.  For details, see http://librarymedia.org or call (800) 847-3671.

The Virginia Guardianship Association
    by Michelle Utterback, VGEC

The Virginia Guardianship Association (VGA) was formed in October 1991 as a statewide organization to strengthen guardianship and related services through networking, education, and tracking and commenting on legislation.  It is a network of individuals and organizations throughout the Commonwealth of Virginia.  Members include public and private, for-profit and non-profit agencies and organizations, as well as concerned individuals.  This diversity provides a forum for the exchange of ideas relating to services for those needing guardianship and related services.  Association members strive to improve services to this growing population which includes the elderly and people who suffer from mental illness, developmental disabilities, physical disabilities, and head injuries.

Membership Benefits

(1) The Membership Roster enables members to com-municate and network with each other and provide referrals throughout Virginia.  (2) The Virginia Guardianship Association Newsletter provides information on legislation, state and regional activities, issues dealing with guardianship and related services, and provides a forum for dialogue about current issues.  (3) The Annual Conference, held every spring, provides an opportunity for face-to-face interaction with persons from all areas of guardianship and alternative protective services.  Each conference features well-known speakers and provocative workshops. It is an excellent opportunity to meet with people from across the state who know, and are concerned, with the same issues as you.

Becoming a Member

Membership is available on an individual or organizational basis.  Individual membership entitles you to receive a Membership Roster, quarterly issues of the Virginia Guardianship Association Newsletter, discounted registration for the annual conference, and voting privileges on VGA business.  Organizational members receive discounted registration for the annual conference for all of their staff. They may select a second designee to receive mailings such as the Membership Roster, the Virginia Guardianship Association Newsletter, and conference announcements.

The membership year is January through December. Members who join in October, November, or December receive benefits of membership through December 31 of the following year.  The cost of membership is: Individual Membership - $30.00, Organizational Membership -$50.00.  If you have questions about member-ship, please contact VGA at: (804) 828-9622. To join VGA, return this form with your check for $30 or $50 to: VGA, P.O. Box 980228, Richmond, Virginia, 23298-0228.

Turning the Page: A New Vision for an Aging Virginia

The annual Fall conference of the Virginia Association on Aging (VAA) and the Virginia Coalition for the Aging (VCA) will be held on October 19-20, 1999, at the Sheraton Park South Hotel in Richmond, Virginia.  The conference will begin with lunch on Tuesday the 19th and end with lunch on Wednesday the 20th.  This conference will be of benefit and interest to long-term care professionals, educators, seniors, social workers, students, and advocates.

Keynote Address - Craig Spiezle, Microsoft, “Seniors and Technology: Bridging the Digital Divide”

Concluding Address - Robert Holsworth, Ph.D., VCU, “Virginia Politics in 1999”

Special Session - Physicians Panel, “The Latest Advances in Geriatric Medicine,” moderated by Richard Lindsay, M.D., UVA

Track 1: Creative Aging - Elderhostel and Creative Aging, Creative Aging through Exercise and Physical Fitness, Best Practices for Creative Aging: Community Collaborations

Track 2: Retirement Planning - Social Security and Medicare Update, Retirement Relocation: Preparing for “Downsizing”, Retirement Planning: Personal Finances

Track 3: Seniors and Technology - Web-Based Teaching for Older Adults, Dispelling the Myths of Y2K

Register by September 24th: $50 seniors/students, $60 members of VAA or VCA, $75 for non-members

Register after September 24th: $60 seniors/students, $70 members of VAA or VCA, $85 for non-members

The conference fee includes two lunches, breakfast, conference materials, reception, and raffle prizes.

Contact Lora Hamp at (540) 949-7141 before July 30th.  After July 30th, contact Kimberly Smith at (804) 828-1525.

Detailed conference registration information will be mailed in August.  The registration deadline will be September 24, 1999 (Conference facilities will limit registration to 200 people).  Please contact  Kimberly Smith if you have not received this information by mid September.

Virginia Association on Aging’s Call for Nominations

The Virginia Association on Aging (VAA) is pleased to announce opportunities for special recognition in the field of gerontology.  VAA is presently accepting applications for the following awards:

Outstanding Gerontology Student
$1,000 scholarship for Master’s Level Student
$1,000 scholarship for Doctoral Level Student

Outstanding Educator in the Field of Gerontology/Geriatrics
$300 Award

Outstanding Volunteer Service to Senior Citizens
$200 Award to Recipient
$100 Donation to Nominating Agency

Award winners will be recognized during the joint conference of  VAA and the Virginia Coalition on Aging (VCA) in October.

For more information on awards nominations, contact Carolyn Crighton, AARP Foundation Employment Service, 1806 Chantilly Street, Suite 100, Richmond, VA  23230, 804-355-3600, Fax 804-355-3842, e-mail scccrighto@aol.com.

Letter to the Editor

The following is an excerpt from a letter to the Editor of Age in Action.

The Age in Action [Spring 1999] arrived and I found it informative and interesting - as usual.

Dr. Jeanne Sorrell’s case study was especially interesting.  On page 3, Dr. Sorrell addresses driving privileges.  Her comments are right on target.

Additionally, readers should know that there are several approaches/resources to assist families and caregivers with this important issue of driving.  These are:

Older Driver - Skill Assessment and Resource Guide: Creating Mobility Choices.  Published by AARP; (C) 1992, #4994(1192).D14957.

Drivers 55 Plus: Test Your Own Performance - A Self-Rating Form of Questions, Facts, and Suggestions for Safe Driving.  Published by AAA Foundation for Traffic Safety, (C) 1986.

            Sincerely,
            Lawrence A. Pavlinski
                past Certified Ombudsman, Northern Virginia AAA LTC Program
                past Instructor & Trainer of Instructors for AARP’s Mature Driving Course

Service Award for Training in Aging

The University of Iowa Center on Aging offers a National Research Service Award from the National Institute of Aging.  Applications are being accepted for 1-year predoctoral and postdoctoral positions with start dates of October 1, 1999, or later, by September 20.  For an application, contact (319) 335-6576, lori-benz@uiowa.edu, or http://www.uiowa.edu/~centrage/.

Calendar of Events

July 23, 1999
Memory Walk.  Sponsored by the Alzheimer’s Association, Northern Virginia Chapter.  For info. call (703) 359-4440.

August 2-4, 1999
“Health in the New Millennium: Making Choices, Measuring Impact.”  National Center for Health Statistics, National Conference on Health Statistics.  Omni Shoreham Hotel, Washington, D.C.  For info. call (301) 436-7122.

August 23-26, 1999
“Responses to an Aging Florida.”  Annual Training Conference of the Florida Council on Aging.  Hyatt Regency, Miami, FL.  For info. call (850) 222-8877.

September 16-17, 1999
“Models of Integrated Long-Term Care: Rural Applications.”  Sponsored by the University of Kentucky.  Wyndham Garden Hotel, Lexington, KY.  For info. call (606) 257-8301.

September 23-26, 1999
21st Annual Interdisciplinary Health Care Team Conference.  Sponsored by the University of Louisville and the National Institute for Interdisciplinary Studies.  The Galt House Hotel, Louisville, KY.  For info. call (502) 852-1332.

September 25, 1999
Memory Walk.  Sponsored by the Alzheimer’s Association, Greater Richmond Chapter.  For info. call (804) 320-1101.

October 18-19, 1999
1st Annual Elder Rights Conference.  Sponsored by the Elder Rights Committee.  Sheraton Park South Hotel, Richmond, VA.  For info. call V4A at (804) 644-2804.

October 19-20, 1999
“Turning the Page: A New Vision for an Aging Virginia.” Annual conference of the Virginia Association on Aging and the Virginia Coalition for the Aging.  Sheraton Park South Hotel, Richmond, VA.

October 27-30, 1999
International Symposium on Endocrinology of Aging.  Sponsored by Serono Symposia USA.  Tempe, AZ.  Abstracts due by August 23, 1999.  For info. call (800) 283-8088.

December 2-4, 1999
“Promoting Independence and Quality of Life for Older Persons: An International Conference on Aging.”  Hyatt Regency, Crystal City, Arlington, VA.  For info. see http://www.asaging.org/independence.html.

February 24-27, 2000
“Gerontological and Geriatric Education: Where Have We Been and Where Are We Going?”  26th Annual Meeting of the Association for Gerontology in Higher Education.  Wyndham Myrtle Beach Resort, Myrtle Beach, SC.  For info. call (617) 353-5045.

March 25-28, 2000
“Passages Through Time: Facing Change, Finding Meaning.”  46th Annual Meeting of the American Society on Aging.  Town & Country Hotel & Convention Center, San Diego, CA.  For info. call (415) 974-9600.

March 28 - April 1, 2000
“Vital Aging: Our Second 50 Years.”  50th Anniversary Conference & Exposition of the National Council on the Aging.  Washington, D.C.  For info. call (202) 479-6991.

March 30-April 2, 2000
“Aging in the New Century: Linking Policy, Practice, and Research.”  21st Annual Meeting of the Southern Gerontological Society.  North Raleigh Hilton, Raleigh, NC.  For info. call (850) 222-3524.

These exciting educational programs for adults age 55 and over are self-contained learning experiences, as well as introductions to Elderhostel lifelong learning opportunities sponsored by the Virginia Center on Aging.  Participants stay in the Duke of York Hotel in Yorktown, Virginia, at the shore of the York River.  Enjoy waterfront rooms, private baths, and good food.  Classes are held in the Carriage House of the Watermen’s Museum (two blocks from the hotel).  The classroom’s many windows and a large deck offer students vistas to watch the ships passing under the Coleman Bridge on the York River.  Registration of $100/person or $185/couple per course includes all conference activities and programs, lodging for one night, dinner, and breakfast.  To register, or find out more, contact Kimberly Smith, Virginia Center on Aging, (804) 828-1525, kspruill@hsc.vcu.edu.