Nursing researchers will present at Gerontological Society of America symposium.

Linda Phillips, UCLA

Nurses who conduct research on aging issues often hear stories from older adult patients that highlight the inequalities in our health care system, illustrate the boundaries of ethical decision-making that can impact clinical outcomes, and bring into focus unresolved social policy issues.

Sadly, these voices do not get the attention they need or deserve.

Now, researchers from the UCLA School of Nursing will examine these issues of social justice and how nurses can give voice to the elderly and other vulnerable populations to influence policy and care-delivery during a symposium at the Gerontological Society of America Annual Scientific Meeting on Nov. 15. Their presentation, “Advocating for Hidden Voices, Social Justice Among Vulnerable Populations,” runs from 8 to 9:30 a.m.

“In their research, our nurses have heard stories about the discrimination and disparities among the marginalized in our society,” said Linda Phillips, director of the Center for Advancement of Gerontological Nursing Sciences at the UCLA School of Nursing. “As nurses and researchers, we have a responsibility to not tolerate these disparities for vulnerable populations.”

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Standing up for senior health.

Name: Lisa Gibbs
Title: UC Irvine clinical professor of family medicine, associate director of the Program in Geriatrics, medical director of the SeniorHealth Center
Education:  M.D., Stanford University
Project: Transformation of the Primary Care Practice to the Patient-Centered Medical Home Model

Innovation Profile is a monthly feature highlighting the work of a UC Center for Health Quality and Innovation  fellow or grantee.

By Alec Rosenberg

It’s not easy growing old. The golden years can be challenged by a myriad of conditions such as arthritis, heart disease and memory loss that often overlap and are increasingly costly to treat.

UC Irvine’s Dr. Lisa Gibbs has seen the toll that time can take on the health of older adults and their caregivers – and she has dedicated her career to improving geriatric care.

Gibbs became interested in working with older adults during medical school at Stanford, where she became involved in research on Alzheimer’s disease. She nurtured that interest at UC Davis, where she completed her residency in family medicine and then a fellowship in geriatric medicine. “I realized how vulnerable this population is,” Gibbs said.

She pointed to a couple married for 50 years. The wife had dementia, but then her caregiver husband developed prostate cancer. “His care was probably delayed because he was so focused on caring for her,” Gibbs said. “Caregivers also need our care and attention.”

Gibbs leads a team dedicated to providing the best in geriatric care as medical director of the UC Irvine SeniorHealth Center and clinical professor for the Program in Geriatrics. She was granted a UC Center for Health Quality and Innovation fellowship to enhance that care by turning the center into the UC system’s first patient-centered medical home (PCMH) for seniors.

A patient-centered medical home is a physician-led team approach to providing comprehensive primary care. Unlike traditional primary care, the PCMH model proactively manages all levels of care for an entire patient population, rather than focusing only on patients when they seek care for illness or injury.

“We’re hoping that with an interdisciplinary team approach and improved care coordination that we’ll be able to increase the quality of care, improve patient satisfaction and reduce overall health care costs,” Gibbs said.

The SeniorHealth Center already places the patient and family at the center of care, coordinating in teams with geriatricians, psychologists, pharmacists, nurses and social workers, Gibbs said. The fellowship will help lead the center to enhance its services by adding key features:

• Open access to care, leaving time slots available for same-day appointments. “This should reduce visits to the emergency room,” Gibbs said. “Patients will be able to be seen right away by physicians who know them instead of going to urgent or emergency room care.”

• Electronic medical records to help track patient outcomes and population data.

• Self-care support and resources.

• Care management, including individualized care plans.

• Referral tracking and follow up.

• Continuous quality improvement.

UC Irvine plans to apply next year for National Committee for Quality Assurance certification as a patient-centered medical home. Then educators will develop related curriculum for medical students, residents and fellows to learn how to optimally care for older adults and share its findings throughout UC Health.

“UC is a leader in developing innovations,” Gibbs said. “We’re willing to look at different models and newly developed models of health care because we truly do care about delivering the best care and service.”

View Lisa Gibbs’ talk at the UC Center for Health Quality and Innovation colloquium (begins at 8:46)

UC Irvine study of 90+ population adds to understanding of burgeoning demographic.

Szofia Bullain, UC Irvine

Poor physical performance on activities such as walking was associated with increased odds of dementia in a survey of individuals 90 and older, according to UC Irvine researchers involved with the 90+ Study, conducted by the Institute for Memory Impairments & Neurological Disorders (UCI MIND).

Between January 2003 and November 2009, 629 subjects were measured on their grip strength, standing balance, ability to walk four meters and ability to do five chair stands. Each task was scored from 0 (unable to perform) to 4 (best performance).

The average age of participants was 94, and most — 72.5 percent — were women. A quarter were classified as having dementia. Those who scored lower on the tasks were more likely to be among this group.

“The results reveal that even modest declines in physical performance are associated with increased odds of dementia. The strongest association is seen with gait slowing, followed by five chair stands, grip strength and standing balance,” said Dr. Szofia Bullain, study leader and a clinical instructor and fellow in UCI’s Department of Neurology.

Findings appear online today (Oct. 22) in Archives of Neurology, a JAMA Network publication. Individuals 90 and older constitute a unique segment of society that has not been well studied, Bullain said. Previous research has suggested a relationship between poor physical performance and cognitive impairment in elderly populations under 90.

Participants who were unable to walk were almost 30 times more likely to have dementia than those with the fastest walking times. Subjects with even minimal slowing of walking speed (warranting a score of 3) were four times more likely to have dementia, according to the results.

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UC Irvine gerontologist Kerry Burnight shares her lessons on living well.

Kerry Burnight, UC Irvine

When giving talks on how to live a full, meaningful life, UC Irvine gerontologist Kerry Burnight often invokes the memory of her two grandmothers. One was a self-centered woman who complained constantly about her health, her various discomforts and her declining appearance. “She was tough to visit,” Burnight recalls.

The other grandmother, she says, was just the opposite: “She was interesting, funny and lovely. And she was truly interested in each of her grandchildren. We could never get enough of her. I often bring her to mind and think, ‘OK, how can I position myself to be more like her?’”

It’s a question that interests Burnight both personally – as someone in her early 40s who hopes to end her days as the good grandmother — and professionally — as a professor of family medicine in UCI’s Program in Geriatrics and co-director of the university’s Elder Abuse Forensic Center.

By interacting with seniors, she’s learned a lot about how to live well and make the most of each day, not just in later years but now. “I’m lucky,” she says. “Working with older people holds up a mirror to my own life. If you can picture the way you want to age, you’ll be much more likely to go down that path.”

With her high energy (she’s a marathon runner) and upbeat personality, Burnight hardly appears in danger of morphing into a cranky crone. Is it simply favorable circumstances or good fortune that makes some people more content than others? She doesn’t think so.

She regularly encounters individuals who’ve endured significant hardships and loss — such as the death of a spouse, neglect or even abuse — but still maintain a positive outlook. Others she’s met have enjoyed all the trappings of worldly success but remain unfulfilled.

“By seeking your own comfort, your own happiness, you often end up less so,” Burnight says. “That’s not a new idea, but now there’s growing research that shows people who are generous live longer, have fewer diseases and are happier.

“Wisdom, generosity, gratitude — these areas are linked to a healthier, longer life and lower depression. Maybe if we cultivate them when we’re young, we won’t feel so alone when we get to the end of life.”

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Related link:
UC Irvine Magazine

UCLA team finds way of assessing risk without knowledge’s of a person’s race.

Arun Karlamangla, UCLA

For women of mixed racial or ethnic backgrounds, a new method for measuring bone health may improve the odds of correctly diagnosing their risk of osteoporosis and bone fractures, according to a UCLA-led study.

Currently, assessing osteoporosis and the risk of fractures from small accidents like falls requires a bone density scan. But because these scans don’t provide other relevant fracture-related information, such as bone size and the amount of force a bone is subjected to during a fall, each patient’s bone density is examined against a national database of people with the same age and race or ethnicity.

This approach, however, doesn’t work for people of mixed race or ethnicity because comparison databases can’t account for mixed heritage. A similar problem exists for those from smaller racial or ethnic groups for which there are not comparison databases.

“All the current ways of determining your risk for fractures require knowing your race and ethnicity correctly, and they ignore the fact that racial and ethnic groups are not homogenous,” said study co-author Dr. Arun Karlamangla, a professor of medicine in the geriatrics division at the David Geffen School of Medicine at UCLA. “It also flies in the face of the current reality in Southern California, where so many people are of mixed ethnicity.”

Given that osteoporosis and hip fractures are leading causes of injury in older people, alternative means of measuring risk are needed. Now, a UCLA-led team of researchers has found a way of assessing risk without knowledge of a person’s race or ethnicity. The method involves combining bone mineral density measures with body size and bone size to create composite bone strength indices.

The findings are published in the October issue of the Journal of Clinical Endocrinology and Metabolism.

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Grant is one of five nationwide to implement new federal initiative.

Laura Mosqueda, UC Irvine

UC Irvine’s Program in Geriatrics has received a three-year, $1 million grant from the U.S. Administration on Aging to combat elder abuse. The funding is part of a major new federal initiative to test promising community-based elder abuse prevention practices. U.S. Health & Human Services Secretary Kathleen Sebelius announced the five recipients of grants for the pilot program today (Oct. 11) at a meeting of the Elder Justice Coordinating Council in Washington, D.C. UC Irvine will implement its new approach to preventing the abuse of people with dementia, called Take AIM Against Elder Abuse.

Testifying today before the council, Dr. Laura Mosqueda, chair of UC Irvine’s Department of Family Medicine, director of its geriatrics program and Ronald Reagan Chair in Geriatrics, said: “Adults with dementia are particularly vulnerable to abuse. The sad fact is that about one of every two people with dementia is abused or neglected. With our rapidly aging population, combined with the fact that one of every two people over 85 is diagnosed with dementia, this impacts a huge number of individuals and those who love them.”

UC Irvine has created an innovative model to address the multiple, complex and interrelated factors that lead to abuse. “This grant allows us to develop and evaluate a new model to reduce the risk of elder abuse,” Mosqueda said.

UCI will partner with the California Department of Aging, the California Department of Social Services, the Legal Aid Society of Orange County and the Orange County Elder Abuse Forensic Center in pilot-testing the approach.

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Funded by National Institute on Aging, center will focus on brain health in older Latinos.

Assembling a nationally respected team of nurse, physician and mental-health leaders with broad expertise in brain health and minority aging, UC Davis has established the Latino Aging Research Resource Center (LARRC), through a prestigious five-year, $3 million grant from the National Institute on Aging (NIA).

Latinos are a rapidly aging population comprising one-third of the Central Valley’s residents. They face health disparities such as socioeconomic disadvantage and a lack of adequate health care that place a disproportionate burden on their families, particularly Latinas, in part because Latinos traditionally care for family members at home.

The center is the one of seven NIA-funded Resource Centers for Minority Aging Research in the nation and is the only one focused on aging Latino cognitive health. It builds on the internationally respected leadership in Latino mental-health disparities and cognitive decline of the UC Davis Alzheimer’s Disease Center, UC Davis Center for Reducing Health Disparities as well as excellence in gerontological nursing of the Betty Irene Moore School of Nursing at UC Davis.

“We need to identify and train a larger cadre of committed researchers if we are to advance the science and reduce cognitive health disparities for aging Latinos and their families,” said principal investigator and center Director Ladson Hinton, director of geriatric psychiatry in the Department of Psychiatry and Behavioral Sciences and a researcher at the Alzheimer’s Disease Center.

The center includes faculty at both the schools of medicine and nursing. Its co-directors are Heather M. Young, associate vice chancellor for nursing and dean of the Betty Irene Moore School of Nursing at UC Davis and Sergio Aguilar-Gaxiola, director of the Center for Reducing Health Disparities, a part of the Clinical and Translational Science Center.

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Individuals at highest risk are those with existing chronic conditions and those on steroids.

Courtney Lyder, UCLA

A new clinical study spearheaded by the dean of UCLA’s School of Nursing has found a direct correlation between pressure ulcers — commonly known as bedsores — and patient mortality and increased hospitalization.

The research is believed to be the first of its kind to use data directly from medical records to assess the impact of hospital-acquired pressure ulcers on Medicare patients at national and state levels.

According to the study, featured as the lead article in the current issue of the Journal of the American Geriatrics Society, seniors who developed pressure ulcers were more likely to die during their hospital stay, to have longer stays in the hospital and to be readmitted to the hospital within 30 days of their discharge.

To arrive at their findings, the researchers tracked more than 51,000 randomly selected Medicare beneficiaries hospitalized across the United States in 2006 and 2007.

“Hospital-acquired pressure ulcers were shown to be an important risk factor associated with mortality,” said Dr. Courtney Lyder, lead investigator on the study and dean of the UCLA School of Nursing. “It is incumbent upon hospitals to identify individuals at high risk for these ulcers and implement preventive interventions immediately upon admission.”

According to Lyder and his research team, individuals at the highest risk are those with existing chronic conditions, such as congestive heart failure, pulmonary disease, cardiovascular disease, diabetes and obesity, as well as those on steroids.

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Half of middle-aged voters likely to need long-term care for family member in next five years.

Nearly half of California voters aged 40 and older say they will need long-term care for a close family member within the next five years, yet just as many say they couldn’t afford even a single month of nursing home care, according to a new poll from The SCAN Foundation and the UCLA Center for Health Policy Research.

The poll, now in its third year, shows that Californians — regardless of their political party or income level — are struggling in the weak economy to save money for future long-term care expenses. One month of nursing home care in California costs an average of $6,800.

Nearly half of those polled (47 percent) said their household income has declined in the past year, and 22 percent had to borrow money from someone because they were struggling to meet their expenses. Forty-two percent said they had to cut back on food and other costs.

Voters also expressed worries about the costs of growing older at a time when the number of senior citizens is increasing and the state’s budget woes continue. In California, the population of those aged 65 and older is expected to double to 8 million in the next 20 years.

Roughly two-thirds of respondents (64 percent) said they’re worried about being able to afford long-term care, and nearly 90 percent said that despite the state’s economic crisis, state leaders should make it a priority to provide affordable options for long-term care and services so that older people can stay in their communities instead of going into nursing homes.

“A significant wave of demand for long-term care is headed our way — we cannot, as a state, stand around and wait for it to hit us before we do something about it,” said Dr. Bruce Chernof, president and CEO of The SCAN Foundation. ”The voters have spoken for a third straight year, and the message is clear: They want affordable options for care and to ensure that individuals can age in their homes with dignity and independence.”

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Removing molecular “garbage” may be key to successful aging, Steven Clarke says.

Steven Clarke, UCLA

Steven G. Clarke, a distinguished professor in the department of chemistry and biochemistry in UCLA’s College of Letters and Science, has been named to UCLA’s Elizabeth and Thomas Plott Chair in Gerontology.

The endowed chair, held for a five-year term, is intended for a scholar who conducts research and education activities related to aging and longevity in the areas of molecular biology, neuroscience and immunology.

An authority in his field, Clarke focuses on the biochemistry of the aging process and conducts research aimed at understanding, on a molecular level, how human functions are maintained during aging.

UCLA research on how RNA of a single-cell organism assembles enzymes could help predict function in humans.

Mahavir Singh, UCLA

UCLA biochemists have mapped the structure of a key protein–RNA complex that is required for the assembly of telomerase, an enzyme important in both cancer and aging.

The researchers found that a region at the end of the p65 protein that includes a flexible tail is responsible for bending telomerase’s RNA backbone in order to create a scaffold for the assembly of other protein building blocks. Understanding this protein, which is found in a type of single-celled organism that lives in fresh water ponds, may help researchers predict the function of similar proteins in humans and other organisms.

The study was published June 14 in the online edition of the journal Molecular Cell and is scheduled for publication in the print edition on July 13.

The genetic code of both the single-celled protozoan Tetrahymena and humans is stored within long strands of DNA packaged neatly within chromosomes. The telomerase enzyme helps create telomeres — protective caps at the ends of the chromosomes that prevent the degradation of our DNA, said Juli Feigon, a UCLA professor of chemistry and biochemistry and senior author of the study.

Each time the cell divides, the telomeres shorten, acting like the slow-burning fuse of a time bomb. After many divisions, the telomeres become eroded to a point that can trigger cell death.

Cells with abnormally high levels of telomerase activity constantly rebuild their protective chromosomal caps, allowing them to replicate indefinitely and become, essentially, immortal. Yet undying cells generally prove to be more of a curse than a blessing, Feigon said.

“Telomerase is not very active in most of our cells because we don’t want them to live forever,” said Feigon, who is also a researcher at UCLA’s Molecular Biology Institute and a member of the National Academy of Sciences. “After many generations, DNA damage builds up and we wouldn’t want to pass those errors on to subsequent cells.”

Overactive telomerase has potentially lethal consequences far beyond the propagation of erroneous DNA. The enzyme is particularly lively within cancer cells, which prevents them from dying out naturally. Finding a way to turn off telomerase in cancer cells might help prevent the diseased cells from multiplying.

Flipping the switch on telomerase might mean stopping it from forming in the first place, said Feigon.

“Any time you want to stop an enzyme, you can target activity, but you can also target assembly,” she said. “If you keep it from assembling, that’s just as good as keeping it from being active, because it never even forms.”

While there is enormous interest in telomerase due to its connection to cancer and aging, very little is known about its three-dimensional structure or its formation, Feigon said.

Four years ago, UCLA postdoctoral scholar Mahavir Singh set out to determine how a strand of RNA and multiple proteins bind together to form telomerase. He set his sights on the p65 protein, one of the key components of the enzyme. Like many proteins, p65 is a long chain of both stiff and supple links that fold in upon one another in a prescribed pattern. At the very end of the p65 protein is a floppy, disordered tail.

“We knew the tail was important for the protein’s function, but it wasn’t clear how or why,” said Singh, first author of the current study. “From the structure, it became evident how it interacts with the telomerase RNA.”

When Singh snipped off the flexible tail from p65, he found that the assembly of telomerase became severely limited. The tailless p65 simply couldn’t help put together the enzyme.

Using both X-ray crystallography and nuclear magnetic resonance spectroscopy, Singh probed the structure of the protein and its interaction with telomerase RNA. He found that upon assembly, the flexible tail transforms into a rigid crowbar that pries apart the strands of the RNA double helix. The newly altered protein tail bends the RNA into a new shape required for binding an essential component of telomerase, a protein called telomerase reverse transcriptase, or TERT.

The p65 protein not only brings two parts of the RNA closer together to allow for the attachment of the TERT protein, but it also folds around the end of the RNA strands to protect them before the telomerase assembles. Without its protein shield, the “naked” RNA is susceptible to degradation and could be chewed up by other enzymes, Singh said.

The p65 protein belongs to a family of “La-motif” proteins, molecules that act as “RNA chaperones” in many organisms including humans, said Feigon.

“How the p65 protein binds with RNA has never been clear,” Feigon said. “Nobody could figure it out, and that’s partly because they were missing a critical, extra part of the protein which changes from being a completely random coil to being folded and ordered when it interacts with RNA.”

Studying p65 within the humble Tetrahymena may help Singh and Feigon better understand its La-motif cousins within the human body, which may also sport protein tails.

“A lot of data indicates that the protein tail is important for the binding of all kinds of RNAs in human cells,” Feigon said. “It is particularly critical for the translation of the hepatitis C viral RNA. Now we can potentially predict how those proteins will assemble and interact with their RNAs.”

The researchers who first discovered telomerase were awarded the Nobel Prize in 2009. They also used Tetrahymena thermophila, a tiny microorganism with hair-like flagella commonly found in fresh water.

This research was federally funded by the National Science Foundation and the National Institutes of Health. Other co-authors included UCLA senior staff scientist Duilio Cascio, UCLA postdoctoral scholars Zhongua Wang and Bon-Kyung Koo, UCLA undergraduate researcher Anooj Patel, and UC Berkeley professor of molecular and cell biology Kathleen Collins.

UCLA is California’s largest university, with an enrollment of nearly 38,000 undergraduate and graduate students. The UCLA College of Letters and Science and the university’s 11 professional schools feature renowned faculty and offer 337 degree programs and majors. UCLA is a national and international leader in the breadth and quality of its academic, research, health care, cultural, continuing education and athletic programs. Six alumni and five faculty have been awarded the Nobel Prize.

Surprising finding: Loneliness doesn’t necessarily correlate with living alone.

Loneliness — the unpleasant feeling of emptiness or desolation — can creep in and cause suffering to people at any age. But it can be especially debilitating to older adults and may predict serious health problems and even death, according to a new study by UC San Francisco researchers.

The team analyzed data in the Health and Retirement Study, a nationally representative study by the National Institute on Aging conducted on 1,604 older adults between 2002 and 2008. The research, published today (June 18) in the Archives of Internal Medicine, focused specifically on the question of loneliness and its impact.

Carla Perissinotto, UC San Francisco

“In our typical medical model, we don’t think of subjective feelings as affecting health,” said first author Carla Perissinotto, M.D., M.H.S., assistant professor in the UCSF Division of Geriatrics. “It’s intriguing to find that loneliness is independently associated with an increased rate of death and functional decline.”

One of the top such programs in the nation, the UCSF Division of Geriatrics seeks to improve the care of older persons through teaching, discovery and the care of patients. Physicians care for patients in their homes and in hospitals, clinics and long-term care settings, teach medical students, resident physicians, physicians in practice and train the next generation of leaders of geriatric medicine. As scientists, they seek to understand the causes and outcomes of illness in older persons and to improve their health and well-being.

Lonely without being alone

One of the more surprising findings of the team’s analysis is that loneliness does not necessarily correlate with living alone. The study found 43 percent of surveyed older adults felt lonely, yet only 18 percent lived alone.

“We are interested in identifying the different factors that cause adults to become functionally impaired and ultimately at risk for nursing home admission,” Perissinotto said. “The aging of our population and the greater odds of institutionalization make it important for us to think about all the factors that are putting elders in danger, including social and environmental risks.”

Researchers at UCSF focused on death and a decrease in the ability to perform daily activities such as upper extremity tasks, climbing stairs and walking.

People who identified themselves as lonely had an adjusted risk ratio of 1.59 or a statistically significant 59 percent greater risk of decline. For death, the hazard ratio was 1.45 or 45 percent greater risk of death.

“This is one of those outcomes you don’t want to see because it was terrible to find out it was actually true,” Perissinotto said. “We went into the analysis thinking that there was a risk we could find nothing, but there actually was a strong correlation.”

Depression vs. loneliness

Perissinotto and her colleagues believe the impact of loneliness on an elderly patient is different from the effects of depression. While depression is linked with a lack enjoyment, energy and motivation, loneliness can be felt in people who are fully functional but feel empty or desolate.

The “baby boomer” generation — those born between 1946 and 1964 — represents the largest population growth in U.S. history. Some of them now are part of the 39.6 million population of people older than 65. That number is expected to more than double to 88.5 million by 2050.

As that population continues to expand, Perissinotto said she hopes to be able to start to integrate social and medical services for elderly patients more comprehensively and be more mindful of what kinds of social interventions they require.

“Asking about chronic diseases is not enough,” she said. “There’s much more going on in people’s homes and their communities that is affecting their health.  If we don’t ask about it, we are missing a very important and independent risk factor.

“We don’t think we can change genetics, but we can intervene when someone is lonely and help prevent some functional decline,” she said.

That’s what 85-year-old jazz singer Barbara Dane is trying to avoid as she continues to entertain well into her 80s. Dane’s husband passed away in September 2010. She stays active by continuing to perform in the East Bay.

“When your spouse dies, there’s a missing space in your heart,” she said. “You still want to know that someone cares about you. Connection to other people becomes even more important at this point in your life.”

Dane has been an accomplished jazz singer for more than seven decades. She credits her active social life to her positive outlook on life.

“A lot of people around me are aging, and some are not doing so well,” she said. “Some who never developed social skills are having the hardest time and those are the ones we need to watch out for.”

“People my age need to appreciate who they are,” she said. “Everyone has some skill and if they want to expand their horizons, they need to figure out what they can use to pull themselves back into the stream of life.”

The mean age of the 1,604 participants in the study was 71 years. Researchers limited their analysis to participants 60 and older. Eighty-one percent were Caucasian, 11 percent African American, 6 percent Hispanic and 2 percent of unknown ethnicity.

Co-authors are Kenneth Covinsky, M.D., M.P.H., of the UCSF Division of Geriatrics and the San Francisco Veterans Affairs Medical Center; and Irena Stijacic Cenzer, M.A., of the UCSF Division of Geriatrics.

This study was supported by the National Institute on Aging (Grant #5R01AG028481-03). Perissinotto is also supported in part by the Geriatric Academic Career Award, Health Resources and Services Administration.

The authors have reported that they have no relationships relevant to the contents of this paper to disclose.

UCSF is a leading university dedicated to promoting health worldwide through advanced biomedical research, graduate-level education in the life sciences and health professions, and excellence in patient care. For further information, please visit www.ucsf.edu.