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Message from the Chair
A Tribute to the Department of Veterans Affairs and to the
Late Samuel Goldstein, A True Giant in Gerontology
 This
edition of Geriatric Rounds pays tribute to the unique contributions
the Department of Veterans Affairs (VA) has made to the development
of Geriatrics in the United States, and more specifically
to the central role the VA plays in Little Rock.
 Where
would Geriatrics be without the support of the VA? Virtually
every major leader in the field of Geriatrics was either trained
in or holds a senior appointment in the VA. The VA pioneered
the Geriatric Fellowship program and early on provided important
incentives for trainees who entered the field. Many physician
investigators, who are currently leaders in Geriatrics, turned
their attention to the field because of the research opportunities
offered by the VA. The commitment to Geriatrics continues
today with an expansion of the GRECC program, opportunities
for academic training for geriatric fellows, and continued
support of clinical and research efforts in the field.
Few realize
how many clinical geriatric programs the Central Arkansas
Veterans Healthcare System (CAVHS) piloted. This includes
the first Geriatric Evaluation Unit and the first Home Based
Hospital Care program in the nation. I want to particularly
acknowledge Dr. Owen Beard and Dr. Rodney Baker, who worked
closely with Dr. Eugene Towbin to develop these clinical efforts.
Dr. W. Jerry Carter, who recently retired as Associate Chief
of Staff for Extended Care, deserves special thanks. We will
also describe the contributions of Dr. Towbin, who as chief
of staff of the Little Rock VA Hospital and later the CAVHS,
was instrumental in persuading the VA to become interested
in Geriatrics. Thanks to his contributions and collaboration
with Dr. Paul Haber, then the head of Geriatrics and Extended
Care at VA Central Office in Washington D.C., Congress was
persuaded to earmark funds for the development of Geriatric
Research Education and Clinical Centers (GRECC).
CAVHS is
particularly well known for its important contributions to
the understanding of the basic biology of aging. This effort
was initiated and led by my friend and colleague, the late
Samuel Goldstein, M.D., Ph.D. In this column I want to pay
a special tribute to Sam, who died suddenly after completing
a 5-K run on July 4, 1994. He served as a Professor of Medicine
at the University of Arkansas for Medical Sciences and the
Associate Director of Research for GRECC at CAVHS, after moving
from McMaster University in Hamilton, Ontario, Canada in 1981.
Sam was
recognized by all of his peers as one of the true pioneers
in gerontologic research, devoting most of his career to the
elucidation of the fundamental mechanisms of cellular aging.
Using the fibroblasts as a model of cellular senescence, he
began the process of identifying genes that regulated the
aging process. At the time of his death, he remained enthused
and excited about his research and was looking forward to
major breakthroughs in the very near future.
 Sam
frequently participated in national and international symposia
on various aspects of aging and received high recognition
for his contributions. He was awarded a Fogarty Visiting Fellowship
at the National Cancer Institute in 1980 and a Guggenheim
Memorial Fellowship in 1987. He was elected to numerous prestigious
medical societies, including the American Society for Clinical
Investigation, and was named a Fellow in the Royal College
of Physicians of Canada. Sam received numerous grants from
the National Institutes of Aging, the Research Service of
the VA, and the National Science Foundation. Of particular
importance was an award received from the National Science
Foundation’s Experimental Program to Stimulate Competitive
Research (EPSCOR). This grant was used to enhance basic science
research on aging at UAMS and the VA. Funds were used to recruit
new faculty and to support research trainees in the field
of aging. Thanks to this award, a critical mass of scientists
continues to conduct research on aging at CAVHS and in the
Donald W. Reynolds Department of Geriatrics. Our program remains
highly regarded for this effort.
While Sam
was internationally regarded for his research contributions,
he will always be remembered for his scholarship, integrity,
mentorship and the close friendships he developed with many
of his colleagues. As an immigrant to the United States with
a heritage similar to my own, Sam became my closest and dearest
friend. I could always turn to him for sage advice and thoughtful
direction. Whether the concern was work or personal, Sam was
always there for me. I write this column on July 4, 2001,
exactly seven years after his death. Sam, I want you to know
that your legacy lives. How sad that you are not here to enjoy
our success and growth. Your contributions to this program
are immeasurable and you will always be honored for providing
us with the springboard to our current accomplishments. May
you rest in peace.
GRECC — A Vital Resource in Geriatric
Medicine
Physicians,
elderly patients, and the entire geriatric population have
reaped a multitude of benefits from a special program of the
Department of Veterans Affairs commonly known as GRECC —
the Geriatric Research Education and Clinical Center.
The brainchild
of Eugene Towbin, M.D., Ph.D., the “father of geriatrics”
in Arkansas, GRECCs were established in 1975 by the United
States Congress and the Veterans Administration as centers
of excellence; one of the original programs was established
at the Little Rock VA Medical Center, now the Central Arkansas
Veterans Healthare System (CAVHS). At that time, the need
for increased geriatric care had just been recognized, as
changing demographics indicated a steadily aging population
in the United States.
The Little
Rock GRECC has since been joined by 23 others, located throughout
the Department of Veterans Affairs. Directed by Dennis H.
Sullivan, M.D., the Little Rock GRECC operates with 12 full-time
employees (14 staff members) and a number of associated faculty
from the University of Arkansas for Medical Sciences (UAMS)
and CAVHS, and also works closely with the Donald W. Reynolds
Center on Aging at UAMS.
Still viable
today, the original GRECC mandate was to:
- Provide education to health care professionals;
- Establish clinical demonstration programs; and
- Conduct state-of-the-art basic science and clinical research.
GRECC
offers a broad variety of educational programs, including
continuing education symposia and seminars; video teleconferences
throughout Arkansas; and traineeships in nursing, occupational
therapy, and masters’ level dietetics; and for pharmacy
residents. Multidisciplinary training in geriatrics is offered
in social work, psychology, pharmacy, nursing, speech pathology/audiology,
and rehabilitation specialties (PT, OT, KT); and is also available
for medical students, geriatric fellows and staff through
a variety of teaching programs. GRECC’s highly requested
outreach programs include two to three major symposia a year,
which provide clinicians with the latest information on aging.
Annually, there is a nutrition and aging conference, a geriatric
medicine update, and a symposium on best practices in the
continuum of care, as well as conferences on special topics.
Local and national video teleconferences are broadcast four
times a year, videotapes are produced, and continuing education
credits offered. The GRECC, in partnership with the Arkansas
Geriatric Education Center of the Reynolds Center on Aging,
is moving towards Web-based educational products for health
care professionals and faculty who teach in programs that
train students in the health professions.
Innovative
clinical programs for elderly veterans are created and evaluated,
essentially to discover whether research findings will translate
well into clinical practice; sometimes they do not because
the concept is not economically feasible, or physicians or
other health professionals choose not to integrate new theories
into practice.
Widely
recognized for its studies in geriatric nutrition, metabolism
and exercise, one of the primary goals of the Little Rock
GRECC is to identify the most appropriate approach for delivery
of nutritional and rehabilitative care to frail, hospitalized,
elderly patients and to maintain optimal health in the frail
elderly. New programs are continually created and implemented
to improve the quality of care for a rapidly aging veteran
population, and to serve as a local and national resource
for care of the elderly.
The Little
Rock GRECC has witnessed significant success and growth in
geriatric research. A strong basic biomedical research program
is well-funded in the areas of Alzheimer’s disease, pathogenesis,
and the cellular and molecular biology of aging. Expansion
is planned for a highly successful health services research
program, which focuses on clinical outcome studies, such as
the impact of malnutrition and functional disability on morbidity,
mortality, and health resource utilization in the elderly.
To maximize
its effectiveness at the forefront of geriatric nutrition
and exercise research, the Little Rock GRECC, in collaboration
with the Donald W. Reynolds Department of Geriatrics, recently
established the Nutrition, Metabolism, and Exercise Laboratory
(NMEL). The purpose of NMEL is to study the combined interaction
of nutrition, exercise and aging on functional status, macronutrient
metabolism, and skeletal muscle function and metabolism. Current
studies include the effects of exercise in combination with
hormone replacement for elderly recuperating patients (see
“Research Spotlight” in this issue), and the effects
of exercise and various diets on protein and carbohydrate
metabolism in different elderly populations. Results from
these studies are expected to provide important information
needed to train physicians, health care providers, and the
public on delaying or reversing late-life dysfunction. The
NMEL also provides the expertise and facilities for the development
of health promotion and disease prevention programs for the
elderly.
GRECC’s
research is perhaps even more important today than when it
first began, as the national veteran population continues
to age at a much higher rate than that of the general American
society. The largest segment of American veterans served during
World War II and the Korean War, and as these veterans reach
85 years and older, the need for extended care services will
increase.
Always at the vanguard of geriatric research, the GRECCs were
almost singularly responsible in gaining recognition of geriatrics
as an area of medical expertise. Now, with solid geriatric
practices established nationwide, the GRECCs will continue
work to improve the quality of life for these aging veterans
and the elderly population.
FACULTY SPOTLIGHT
Charlotte Peterson, Ph.D.
The frailty
that often develops as people age is a serious concern for
both geriatric patients and their practitioners — and
is the primary research focus of Dr. Charlotte Peterson, an
associate professor with the UAMS Department of Medicine and
Donald W. Reynolds Department of Geriatrics, and a health
research scientist for the Central Arkansas Veterans Healthcare
System (CAVHS).
Peterson
joined the UAMS faculty in 1991, and has studied how genes
expressed in skeletal muscle help to maintain both muscle
size and function. “We’re studying gene expression
profiles … because they may have an impact on your tendency
to become frail,” she said. “One of our main focuses
is trying to prevent frailty and maintain functional independence.”
Peterson
obtained her Ph.D. in biology in 1984 from the University
of Virginia, in Charlottesville, Virginia. She then completed
two fellowships, one with the National Eye Institute’s
Laboratory of Molecular and Developmental Biology at the National
Institutes of Health in Bethesda, Maryland; and one with the
Department of Molecular Pharmacology at Stanford University
School of Medicine in California. Immediately following her
completion of the Stanford fellowship, she accepted a dual
position at UAMS as assistant professor for the Department
of Medicine and Department of Biochemistry and Molecular Biology,
and as a health research scientist for the Geriatrics Research,
Education and Clinical Center at CAVHS.
 Peterson
is widely recognized for her research into the aging process.
She was a 1990 award finalist for the American Heart Association
Louis B. Katz Award and the 1992 recipient of the David Pryor
Research Award from the American Heart Association, Arkansas
affiliate. She also received the NIH Research Career Development
Award from 1995 to 2000. She is currently an NIH study section
member, Biological and Clinical Aging Invited Reviewer and
an NSF external grant reviewer. She also served as an NIH
ad hoc study section member from 1993 to 1996. She currently
receives extramural research funding from NIH/NIA, NINDS,
and the Department of Veterans Affairs.
Peterson’s
interest in the molecular biology of skeletal muscle led to
further studies in stem cell biology, which offers great potential
as a means to maintain tissue and organ function, for example
in the heart, as a person ages. She and others at the Donald
W. Reynolds Center on Aging have begun to look at frailty
within the context of Alzheimer’s disease and are developing
a graduate course on the biology of aging for the UAMS curriculum.
Last year
Peterson accepted the directorship of the new University Microarray
Core Facility at UAMS. The core’s establishment was funded
by the Chancellor’s Office to support genetic research
on campus and is expected to be available to investigators
campus-wide this fall. “We’re now able to study
gene expression using microarray technology that allows one
to analyze samples in a more high-throughput fashion. We can
monitor the expression of hundreds or thousands of genes at
the same time,” Peterson explained. She said the core
will also do genotyping, a means of monitoring individuals
for specific gene mutations that may increase the risk for
a particular disease or condition.
“There’s
so much excitement and so much going on in genomics research.
The mechanisms and processes that underlie frailty, Alzheimer’s
disease, osteoporosis, and a variety of other conditions that
become prevalent as we age are beginning to be identified,
which should allow the design of very rational ways of intervening.
It would be nice to think that if you lived to be 90, you’d
have a full, independent, and healthy life. That’s our
goal: to improve the quality of life and help people maintain
their functional independence for as long as possible.”
Eugene Towbin, M.D.: A True Pioneer in
the Field of Geriatrics
 When
Eugene J. Towbin, M.D., Ph.D., came to work for the Central
Arkansas Veterans Healthcare System (CAVHS) in 1955, he brought
with him an “intellectual bias” — an insatiable
need to know the reasons behind his patients’ illnesses.
From that need evolved the Donald W. Reynolds Department of
Geriatrics at the University of Arkansas for Medical Sciences.
That evolution
has spanned 80 years, beginning with CAVHS’ establishment
in 1921 on the grounds of a military base located across the
river from Little Rock, which is now a part of North Little
Rock. In 1950, a second VA hospital opened in Little Rock,
giving this region a VA facility on both sides of the Arkansas
River. Both facilities have grown; but more importantly, many
patients have benefited tremendously from the advances in
geriatric medicine, thanks in great part to Towbin’s
40 years of tireless service.
Towbin’s
work began at the Little Rock VA Hospital, but he worked closely
with colleagues at the North Little Rock facility. Recalling
one of his early visits there, he said, “There were four
or five separate patient buildings, with several large wards
for patients who had degenerative diseases of some sort or
another. The patients received very good custodial care. But
what struck me was, nobody was asking any questions. What
was the progress of the disease? Could it be treated, or could
it have been avoided?”
That’s
when Towbin’s “intellectual bias” came into
play. Even though he had no formal training in geriatric research,
he knew he could find the answers to his questions. “I
was troubled by the fact that there was all this clinical
material, and nobody was asking any questions, or submitting
any proposals, or finding better ways to do things. That was
the genesis of my interest in geriatrics.”
His determination
to help veterans in Arkansas hospitals led him to the Veterans
Administration headquarters in Washington, D.C. There he found
a sympathetic colleague in Dr. Paul Haber, who helped him
design a geriatric fellowship. Towbin was adamant that it
emphasize direct M.D. involvement. “If one focused purely
on pre-clinical, Ph.D. research, you might as well put it
in an office building downtown, and not at the VA hospital,”
Towbin recalled telling Haber.
Towbin
and Haber persuaded the U.S. Congress that the VA must do
more for older veterans by creating centers on excellence
in geriatric care. From this effort came the first Geriatric
Research Education and Clinical Centers (GRECC). GRECC conducts
both basic and clinical research in human aging, develops
clinical programs for veterans, and educates health care professionals
and students in the care of aging veterans.
The Little
Rock GRECC, established in 1978 and directed by Towbin, was
one of the first in the nation. “We were one of the first
five of these centers funded by the VA, and we had the most
successful one,” Towbin said. The Little Rock GRECC began
with an annual budget of $12,000, but during its first seven
years, it grew to support 32 salaried employees with an annual
budget of about $2 million.
 The
centerpiece of Towbin’s program was developing clinical
models of care. Under his leadership, the Little Rock GRECC
developed several programs which served as models for VA hospitals
nationwide, including the first Geriatric Evaluation Unit,
the first Home Based Primary Care program, and one of four
VA-based Adult Day Health Care units. His partner in this
effort was Dr. Owen Beard, who served as the first head of
a geriatric section for the VA’s medical service. Towbin
was instrumental in recruiting Dr. Samuel Goldstein, one of
the leading gerontologic researchers in the United States,
to the Little Rock VA. He also persuaded Dr. David A. Lipschitz,
who became GRECC director in 1983 and now directs the Donald
W. Reynolds Center on Aging, to focus his energies exclusively
on Geriatrics.
Because
of Towbin’s efforts and dedication, and the VA’s
commitment to older veterans, the discipline of geriatrics
has flourished in the United States. The GRECC program has
grown from the original two designated in 1978 to 22 located
strategically throughout the United States. And beginning
with the initial geriatric fellowship training positions established
in 1978, the VA has played a vital role in the education and
support of the vast majority of geriatric fellows in this
country.
Towbin’s
leadership in the field of geriatrics pervades all aspects
of the University of Arkansas for Medical Sciences, which
established a working relationship with CAVHS in 1946 as a
part of the VA’s nationwide effort to improve patient
care. Because of this association, geriatrics has always been
a high priority for the medical school. The university has
taken the lead in developing programs in gerontologic nursing,
pharmacy and nutrition, and has expanded programs in clinical
care. This continuing growth in geriatric care led to the
creation of a Center on Aging in 1995 and gained support from
the Donald W. Reynolds Foundation in 1997.
Towbin’s
long-time interest and unswerving dedication to the care of
older veterans has paid great dividends to our university
and to the field of geriatrics. Towbin is certainly one of
the true fathers and pioneers of geriatrics medicine.
RESEARCH SPOTLIGHT:
Nutrition and Physical Fitness in Geriatric Patients
Nutritional
and functional deficiencies can develop rapidly in geriatric
patients during periods of illness. These deficiencies develop
as a result of illness-associated anorexia and inflammation,
and the enforced inactivity of a prolonged hospital stay.
The consequences of such deficiencies can be significant.
Even after steps to alleviate an illness have been taken and
dietary supplements have been added, recovery can be slow,
and patients are at high risk of developing secondary complications,
according to Dennis H. Sullivan, M.D.
Sullivan
is the director of the Geriatric Research Education and Clinical
Center (GRECC) within the Central Arkansas Veteran’s
Healthcare System, the executive vice chairman of the Donald
W. Reynolds Department of Geriatrics, and professor of Geriatrics
at the University of Arkansas for Medical Sciences. He has
been studying the interrelationship between nutrition, physical
fitness, and illness for several years. The questions Sullivan
hopes to answer through his research are multifaceted: Is
the patient functionally disabled and even malnourished because
of the severity of the illness, or has the illness worsened
because of the patient’s inactivity and/or malnutrition?
Or, perhaps, is there a complex relationship among these three
factors that causes one to influence the other? And finally,
can the physician intervene to improve either the nutritional
status or functional status, and will that in turn lead to
a better medical outcome and a better quality of life for
the patient?
Dr. Sullivan
feels there is a strong link between nutritional and functional
status. “I’ve come to believe that you can’t
talk about nutritional status without talking about physical
status,” he said. “The two are essentially measuring
different components of the same thing.”
 To
further explore this relationship, Dr. Sullivan and his colleagues
have designed two randomized, blinded studies, supported by
five-year funding from federal, foundation and private sources,
to examine the benefits of exercise combined with hormone
therapy to affect a quicker and more complete recovery in
hospitalized, high-risk geriatric patients.
The first
study, now in its second year, is testing the efficacy of
muscle strength training and testosterone administration to
rectify nutritional deficits, improve muscle strength, accelerate
functional recovery, and reduce complication (mortality) rates
in a select population of frail (i.e., high-risk) elderly
male patients who experienced a recent functional decline
as a consequence of an acute illness from which they are recuperating.
Testosterone, an anabolic hormone that declines both in older
men and those experiencing illness, has been proven to help
rebuild muscle mass in middle-aged, hypogonadal men, either
alone or as an adjunct to exercise. Sullivan hopes that recuperating
geriatric males will experience similar results if testosterone
is replaced to levels common in a healthy 25-year-old male,
and the patients become involved in an exercise regimen. To
identify the relative importance of testosterone and exercise,
the participants are being randomized into four groups: those
receiving aggressive strength training and testosterone replacement;
those receiving aggressive strength training and a placebo;
those receiving mild or “sham” training and testosterone
replacement; and those receiving mild or “sham”
training and a placebo. At the end of the study, the four
groups will be compared to see which treatment regimen was
most effective.
A similar
study involves a group of male and female geriatric patients,
but uses megestrol acetate, a progestin often used as an appetite
stimulant, as the replacement hormone. The outcome of this
study will have important clinical implications: besides increasing
appetite, megestrol acetate also exhibits cortisone-like properties
that may cause a decline in muscle mass. The study will determine
whether any weight gain induced by this drug is muscle or
fat, and whether the combination of megestrol acetate and
exercise is better than exercise alone. Currently, it is not
certain whether appetite stimulation is beneficial or is counteracted
by other effects of the hormone.
“We
want to see if the patients’ appetites improve, if they
gain weight, and if they do gain weight, where that weight
is going,” Sullivan explained. “If you take any
individual, young or old, who is malnourished and has lost
weight and simply feed that person, the very most you can
do is add fat. In order to build up muscle, you not only have
to have the nutrients but the exercise component as well.”
But adding
muscle mass becomes increasingly difficult as a person ages.
After age 60 to 65, most people begin to steadily lose weight,
tend to become less active, and often experience a progressive
decline in their appetite, even if they are otherwise in good
health, which leads to a further loss of both fat and muscle
mass. Loss of muscle mass is acerbated in the ailing geriatric
patient, since infection or other inflammatory disease increases
the rate of muscle deterioration. Elderly patients who regain
their lost weight after an illness usually only gain more
fat — but many who sustain drastic weight loss may never
regain it, even after extended rehabilitation. “Our goal
is to see if we can either limit the loss of weight and lean
body mass in the first place, or when it does occur, reverse
the loss and build up lean body mass. This will hopefully
translate into improved functional outcome and even improved
survival,” Sullivan said.
While hormone
therapy may provide additional benefits, it is the physical
activity which has a direct bearing on a patient’s mortality
rate. Current data shows a curvilinear relationship between
mortality and intensity of exercise, from an extremely high
mortality rate for the bed-bound to a much lower rate for
those who routinely engage in moderate exercise, such as walking
for an hour, two to three times a week. Interestingly, there
is only a very modest benefit in terms of mortality if the
intensity of exercise is increased beyond this point.
“There’s
a tremendous amount of improvement older people can receive
by increasing their physical activity to walking a few times
a week or its equivalent,” Sullivan said. In fact, he
believes exercise is so essential to the health of older people
that he and his colleagues recently initiated a pilot study
to investigate the establishment of community exercise programs
for the elderly, especially in rural areas. While the study
was only recently submitted for funding, Sullivan hopes that
if it is accepted, the proposed exercise programs will motivate
older people to increase their overall level of physical activity.
“I
think this will be a real challenge, particularly because
the elderly tend to become more and more sedentary, and more
and more homebound,” Sullivan said. “One of the
things I believe is true with any age group is that if people
are going to maintain an adequate level of physical activity,
they’ve got to be doing something they really like. That’s
what we’re trying to do: identify things that people
can relate to, that they would love to do, such as hunting,
bird watching, or gardening, and try to teach them how to
stay in shape so they can continue to do those things. Ideally
they will get as much of their exercise as they possibly can
from doing these things, so they won’t associate exercise
with pain or infringement on their free time, and stop doing
it.”
Sullivan
said a very slow increase in the intensity of activity, which
reduces the chance of injury, will help these people maintain
a regular exercise program. “I often tell my patients
to begin by walking for two minutes, two to three times a
week, and then increase that time by a minute a week. That
isn’t very much, but by the end of the year that patient
will be walking for an hour, or close to it, several times
a week. The other thing I tell my patients is that if in the
first few weeks they are tired after they exercise, they’ve
probably done too much.”
While the
effectiveness of exercise and hormone replacement therapy
to reverse age and illness-induced nutritional and functional
deficits remains to be proven by Sullivan’s studies,
it is prudent for the elderly to engage in regular moderate
exercise and to maintain an adequate diet. These practices
will help the elderly to sustain optimum functionality and
improve their health, therefore increasing the likelihood
of a more complete and rapid recovery in the event of an illness.
This newsletter is a publication
of:
The Donald W. Reynolds Department of Geriatrics and
Center on Aging
The University of Arkansas for Medical Sciences
David A. Lipschitz, M.D., Ph.D.
Chair, Donald W. Reynolds
Department of Geriatrics
Director, Center on Aging
University of Arkansas
for Medical Sciences
Editor, Geriatric Rounds
Donald W. Reynolds
Department of Geriatrics
and Center on Aging
Please direct inquiries to:
David A. Lipschitz, M.D., Ph.D.
Donald W. Reynolds
Department of Geriatrics
and Center on Aging
4301 W. Markham, Slot 748
Little Rock, AR 72205
Phone: 501/686-5944
Fax: 501/686-5884
E-Mail:
lipschitzdavida@uams.edu
Website:
www.centeronaging.com
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