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The 2003 Dennis W. Jahnigen Career Development Scholars Abstracts Jayakrishna Ambati, MD Susan M. Day, MD Brooke H. Gurland, MD Clifford Y. Ko, MD, MS, MSHS Laura W. Lee, MD Stacy Lindau, MD Manish N. Shah, MD Edward Weaver, MD, MPH Scott T. Wilber, MD David Yuh, MD   Jayakrishna Ambati, MD, University of Kentucky Dr. Ambati is Professor & Vice Chair in the Department of Ophthalmology & Visual Sciences at the University of Kentucky in Lexington. Dr. Ambati is committed to alleviating eye diseases of the elderly, and has devoted much of his career to understanding age-related macular degeneration (AMD) and developing better therapeutic and preventive strategies. Dr. Ambati furthered his research on AMD while working with two strains of genetically modified mice that develop many features of AMD as they age.   Novel Mouse Models of Age-Related Macular Degeneration Age-related macular degeneration (AMD) is the leading cause of blindness among those over 65 in the U.S., Western Europe, and Japan. It affects over 11 million persons in this country alone, and with the aging population will exact a greater toll. The absence of a faithful animal model has hampered the study of AMD and the development of therapeutics. We have discovered two strains of genetically modified mice that develop many features of AMD as they age. Elderly mice (9 - 24 months) deficient either in the monocyte chemoattractant protein-1 (MCP-1) or CC chemokine receptor-2 (CCR2) genes develop lipofuscin (autofluorescent lysosomal storage bodies in the retina), drusen (lipoproteinaceous deposits between the retina & choroid), and thickened Bruch’s membrane (an extra cellular matrix between the retina and choroid), the earliest manifestations of AMD in humans, as well as choroidal neovascularization, the late exudative, blinding form of AMD. These lesions are ophthalmoscopically, angiographically, and histopathologically similar to those in patients with AMD. These pathologies are absent in age-matched wild type mice and several other knockout strains.   We hypothesize that the accumulation of drusen and lipofuscin associated with senescence is normally cleared by the recruitment of scavenger macrophages, which is impaired in the absence of MCP-1 or its receptor CCR2, and that rescue of MCP-1 or CCR2 function can regress AMD. These hypotheses will be directly tested by (1) characterizing the temporal development of AMD features in MCP-1 or CCR2 -/- mice from ages 9 to 24 months by ophthalmoscopy, angiography, and histopathology, compared to wild type age-matched mice, and (2) testing whether rescue of MCP-1 or CCR2 function will lead to regression of AMD in elderly MCP-1 or CCR2 -/- mice. The rescue strategies will include intraocular injection of an adeno-associated viral vector coding for MCP-1 in elderly MCP-1 -/- mice, systemic delivery of MCP-1 via osmotic pumps in elderly MCP-1 -/- mice, or introduction of CCR2 bearing stem cells capable of differentiating into macrophages into bone marrow-ablated CCR2 -/- mice.   These mice represent the first faithful models of both early and late AMD. As such they can provide mechanistic insights into the development AMD and assist in efficacy testing of candidate drugs. Opthalmology   Back to the top Susan M. Day, MD, Michigan State University Dr. Day is a graduate of Michigan State University College of Human Medicine. She completed her orthopaedic surgery training at the Grand Rapids Orthopaedic Surgery Residency Program. Dr. Day recently completed a two-year Jahnigen Career Development Grant funded by the John A. Hartford Foundation in Geriatric Orthopaedics. She is currently a staff attending physician with the Grand Rapids Orthopaedic Residency Program and a clinical instructor with Michigan State University, College of Human Medicine, Department of Surgery and a clinical instructor with Grand Valley State University.   Development of a Problem-Oriented, Computer-Based Geriatric Curriculum For most people, increasing age leads to degeneration of the musculoskeletal system. By the year 2020 about 20% or an estimated 60 million people will be over the age of 65. Approximately 80% of those individuals will have musculoskeletal complaints.   The development of a geriatric orthopaedic curriculum and the teaching of that curriculum are necessary to improve the care of the older orthopaedic patient with a musculoskeletal complaint. This project will address both development of the curriculum as well as instruction. A geriatric orthopaedic curriculum will be put into a problem-oriented format and presented using a computer based, self-directed learning module. A problem-oriented curriculum allows the integration of orthopaedic techniques and concepts with problems unique to geriatric patients. This computer-based curriculum will be accessible to all surgeons as part of residency education or continuing medical education. Orthopaedic Surgery   Back to the top Brooke H. Gurland, MD, Maimonides Medical Center/Mt. Sinai School of Medicine Dr. Gurland is a staff member at the Cleveland Clinic Foundation in Cleveland, OH. Focusing her career on pelvic floor disorders, Dr. Gurland realized that the combined pelvic disorders many of her older patients were suffering from were routinely dismissed as an inevitable part of aging. This attitude significantly diminishes the quality of life for elderly patients, which Dr. Gurland is committed to correcting. Her study intended to establish a multidisciplinary approach to geriatric patients with pelvic floor pathology, to perform a standardized workup evaluating all three compartments, and to educate health care professionals and the community to identify patients with pelvic floor disorders.   Multidisciplinary Pelvic Floor Evaluation for Women with Lower Tract Dysfunction, Pelvic Organ Prolapse, and Defecation Disorders Pelvic floor disorders such as: urinary and fecal incontinence, constipation, pelvic organ prolapse (cystocele, enterocele, vaginal and rectal prolapse), pelvic pain disorders, and sexual dysfunction diminish the quality of life of the geriatric patient. These disorders are evaluated by sub -specialists in gynecology, urology, colorectal surgery and gastroenterology. This represents an artificial division of the pelvic structures into anterior middle and posterior compartments. The pelvic floor structures share a common muscular support and innervations and there is a growing consensus that a combined approach to evaluating and treating these disorders is beneficial.   The purpose of this study is 1. To establish a multidisciplinary approach to geriatric patients with pelvic floor pathology 2. To perform a standardized work up evaluating all three compartments 3. To educate health care professionals and the community to identify patients with pelvic floor disorders.   Patient selection will include geriatric patients presenting with urinary or fecal incontinence, obstructed defecation, or pelvic floor prolapse. A detailed history will be taken and pelvic and rectal examination will be performed. A standardized pelvic floor evaluation will include urodynamics, anal ultrasound, anal manometry, pudendal nerve terminal latencies, electromyography and cinedefecography. A multidisciplinary “pelvic floor team” will meet to review patient cases and to formulate treatment plans based on the standardized pelvic floor evaluation. Residents in primary care, obstetrics and gynecology, and surgery will participate in the “pelvic floor team” through direct patient evaluation and multidisciplinary conferences. Patient data will be collected in a centralized pelvic floor database. Data analysis will allow us to evaluate the incidence of symptomatic versus occult multi-compartment pathology and to follow its effect on postoperative success. The pelvic floor team will educate health care professionals and the community through seminars and lectures.   Ultimately, we hope to improve the recognition and diagnosis of elderly women with pelvic floor disorders through physician and patient education and our contributions to the literature. We hope to improve patient care by standardizing a pelvic floor evaluation prior to proceeding with surgery. General Surgery   Back to the top Clifford Y. Ko, MD, MS, MSHS, University of California Dr. Ko is an Associate Professor of Surgery in the Department of Surgery at UCLA School of Medicine, the Director of the UCLA Center for Surgical Outcomes and Quality, and a Research Scientist with the RAND Corporation. Clinically, he cares for patients with colorectal cancer, and his patients are primarily elderly. Dr. Ko recognized that older patients would continue to have an increasing effect on surgery, and saw the opportunities to address numerous perioperative care issues specific to this population. He led a study which developed quality process indicators and measures that signify higher quality care, which will be used to improve the surgical care of older patients. His pilot work developed measures for abdominal surgery. He subsequently received funding from the NIA to develop quality measures for surgical procedures in a variety of fields including orthopaedics, cardiology, vascular, oncology and others.   Developing Quality Indicators to Improve the Care in Geriatric Surgery Patients This proposal seeks to develop quality process indicators that will be used to improve the surgical care of older patients. (“Process” is defined as the set of activities that goes on between the patient and practitioners and commonly refers to whether the medically appropriate decisions are made). Quality process indicators are measures that signify higher quality care. Moreover, they typically set a standard that if not performed almost certainly identifies poor-quality care. While they can be used for evaluative purposes, our underlying aim is for the quality indicators to be used to educate surgeons as to what is important for improving the quality of care, as well as for teaching residents and medical students. Using validated methods, this study will produce quality indicators that may be used for improving the pre-, intra-, and post-operative care of the elderly patient undergoing surgery. We will specifically address the care revolving around the operative resection of the colon/rectum.   This project is important because it will, for the first time, provide valid processes of care – specifically for surgeons – with which surgical care to the elderly may be improved. Also, it is paving the way for subsequent important studies that could further change the clinical behavior of surgeons (and consulting geriatricians) in a significant way. Our preliminary workload studies have demonstrated that these resections will increase by over 40% in the next twenty years – and will be primarily performed in the elderly. General Surgery   Back to the top Laura W. Lee, MD, University of Virginia Health Systems Dr. Lee is an Assistant Professor of Physical Medicine & Rehabilitation and the Director of Orthopedic and Geriatric Rehabilitation at the University of Virginia Health Systems. She became interested in mobility disorders in older adults from experiences with family members, and pursued a residency in PM&R because of its focus on improving mobility and function. Her clinical, educational, and research endeavors all involve enhancing rehabilitation care for older adults. As a Jahnigen Scholar, she is investigating the effect of exercises that increase hip flexibility on gait, balance, and lower extremity function in people who have had hip fractures and those with Parkinson's disease.   The Effect of a Hip Stretching Program on the Gait of Elderly People Who Have Had Hip Fractures Approximately 340,000 people 65 years old or older are hospitalized for hip fractures annually in the United States, resulting in significant residual disability to those who survive the fracture. Studies have demonstrated that mobility and ambulation are particularly affected, with limited long-term improvement. People who have had hip fractures are more likely to be immobile than case matched controls that have not had hip fractures, but specific impairments causing the disability are unclear. From previous studies on a related population, the elderly fallers, reduced hip extension, increased anterior pelvic tilting, and decreased step length were noted during walking. The objective of this study is to determine the extent of dynamic hip extension and related joint motion abnormalities in subjects who have had a hip fracture, and whether a hip flexor stretching program will correct the gait abnormalities, leading to a more efficient gait and improved functional mobility. We propose a randomized prospective 8-week trial of a supervised hip flexor-stretching program (with controls undergoing shoulder stretching) for 70 subjects who have had hip fractures. Gait parameters, functional mobility, and activities of daily living measurements will be assessed before and after the stretching program. This study will offer information about specific gait impairments in people with hip fractures who are at high risk for loss of mobility and test an intervention, which may improve gait in this population. Physical Medicine & Rehabilitation   Back to the top Stacy Lindau, MD, The University of Chicago Dr. Lindau is an Assistant Professor of Obstetrics and Gynecology and Medicine-Geriatrics at the University of Chicago. Her work combines biomedical and social scientific techniques to study health and health behavior in the population setting. Her primary interest is deciphering the biological pathways linking sexual relationships to health, particularly in the context of aging and illness (e.g. cancer, diabetes, cardiovascular disease, HIV). Her Jahnigen proposal was a clinic-based longitudinal survey of older community-residing adults (age 65+) with life-threatening illness (LTI), which aimed to understand the relationship between social life, sexuality and intimacy among older people with LTI in relation to health outcomes for the individual and the significant other.   Sexuality, Intimacy, and Social Life in Older People with Life-Threatening Illness Little attention has been given to the role or experience of social life, sexuality and intimacy among elders and even less to those facing life-threatening illnesses (LTI). Physicians and public health policy makers lack a scientific base of information for advising patients and families or for designing programs that might maximize social and intimate relationships among older people with life threatening illness. Health researchers know little about the role of social life and sexual health in well being in later life or in the context of LTI.   We propose a clinic-based longitudinal survey of older community-residing adults (age 65+) with life-threatening illness, which aims to understand the relationship between social life, sexuality and intimacy among older people with LTI in relation to health outcomes for the individual and the significant other. This study also aims to explore the strategies used by people with LTI to navigate, negotiate, and bring closure to social, intimate and sexual relationships. A comparison sample of younger adults with comparable diagnostic and symptom criteria will be included to begin to examine the moderating effect of life stage on the relationships between LTI, social life, sexuality, and intimacy.   For this initial phase of the research, we will study a cohort of people with lung cancer and their significant others. Lung cancer provides an excellent initial model of the relationship between sexuality/intimacy and LTI because it is so prevalent, affects men and women, affects younger and older people, is not hormonally mediated, does not directly distort the sex organs, is not generally grossly disfiguring, and is frequently complicated by pain and fatigue. Additionally, because of its poor prognosis, studying people with lung cancer will allow us to follow dyads through the transition of death. Gynecology   Back to the top Manish N. Shah, MD, University of Rochester Medical Center Dr. Shah is Associate Professor of Emergency Medicine and Associate Professor of Community and Preventive Medicine at the University of Rochester. He is also the Director of Emergency Medical Services (EMS) Research and the Regional Medical Director for EMS Services. Dr. Shah sees emergency medicine as a field that can proactively improve the community health by using each medical encounter to screen, educate, and refer older adult patients. Dr. Shah's Jahnigen Award project evaluated the feasibility of an EMS-based prevention program to identify individuals at risk for preventable injuries and diseases.   Prehospital Screening to Prevent Injuries and Illness The goal of this project is to prevent injuries and diseases among older adults through the development and evaluation of a novel emergency medical services (EMS)-based screening program to identify individuals at risk for preventable injuries and diseases.   The National Institute on Aging has declared that its challenge is to maximize the health of older adults by preventing frailty and disability. However, prevention programs based in physician offices and local departments of health have had difficulty achieving targeted results.   The EMS system has the unique ability to use a community-wide medical delivery system that can perform unscheduled in-home evaluations to uniformly implement prevention programs. Furthermore, because older adults use EMS services at high rates, EMS can contact a significant proportion of the older adult population. However, very few prevention programs have used this unique ability of the EMS system to implement and evaluate the outcomes of an EMS-based older adult screening program.   To prevent injuries and diseases among older adults, this study specifically aims to:   1. Evaluate the feasibility of an EMS-based primary prevention program that screens older adults for need of pneumococcal vaccination and for risk of falling during emergency medical responses in a rural setting.   2. Evaluate the outcome of the EMT-implemented screening and education program by performing a 30-day telephone follow-up on older adults cared for by EMTs.   At the conclusion of this award, we will determine if an EMT-implemented primary prevention program for older adults is feasible and results in interventions. Most importantly, by forming a collaborative relationship between geriatricians and emergency medicine physicians, at the conclusion of this award we will have developed a Geriatric Emergency Medicine “laboratory” through which we can continue to study health issues faced by older adults. Emergency Medicine   Back to the top Edward Weaver, MD, MPH, University of Washington Dr. Weaver is an Assistant Professor of Otolaryngology at the University of Washington. He is also the Surgical Program Director of the University of Washington Sleep Disorders Center. He is involved with the American Academy of Sleep Medicine and the Chair of the Sleeping Disorders Committee of the American Academy of Otolaryngology. Dr. Weaver's career has been focused on understanding and treating sleep apnea in adults, a condition which affects 47 - 81% of adults 60 years old. The goal of his project was to characterize the perioperative risk associated with sleep apnea in geriatric patients ( 60 years), focusing initially on patients having total hip or knee replacement.   Sleep Apnea and Perioperative Complications in Geriatric Patients Obstructive sleep apnea occurs in 47-81% of adult’s ≥ 60 years old. It is characterized by recurrent upper airway obstructions during sleep that result in serious physiologic abnormalities and medical risks, including a presumed increased risk for serious perioperative complications. This proposal supports the career development of the principal investigator to characterize the perioperative risk associated with sleep apnea in geriatric patients (≥ 60 years), focusing initially on patients having total hip or knee replacement. The study hypothesis is that sleep apnea is associated with an elevated 30-day mortality and with other serious perioperative complications in these patients. The principal investigator will examine this association in a retrospective cohort study of 27,779 elderly hip or knee replacement patients from the VA National Surgical Quality Improvement Program, using multivariate logistic regression and adjusting for demographic variables. He will further examine the association in a nested case-control study of the 242 cases of 30-day mortality and 242 age- and gender-matched controls from the cohort by extracting more detailed data (e.g., sleep apnea severity and treatment) from the record and again employing multivariate regression techniques. Future studies will examine the association of sleep apnea and perioperative complications of other surgeries and the impact of sleep apnea treatment on reducing complications. Otolaryngology   Back to the top Scott T. Wilber, MD, Summa Health System/Northeastern Ohio Universities Dr. Wilber is an Associate Professor of Emergency Medicine at Northeastern Ohio Universities College of Medicine and the Director of the Emergency Medicine Research Center at Summa Health System in Akron, OH. Geriatric issues in emergency medicine became important to Dr. Wilber as he realized that ¼ of the patients he treated were over 65, a proportion that will increase in the coming years. He has concentrated his research on geriatric emergency medicine to help guide emergency care for the growing population of older adults. The aims of his study were to describe the functional status of older ED patients with blunt injuries and to determine factors predictive of short-term functional decline.   Prediction of Short-Term Functional Decline and Service Needs in Older ED Patients Injuries are common reasons for ED visits in older patients; the majority result from falls. Approximately ¾ of these patients are discharged from the ED; a significant proportion will experience some loss of functional independence at 3-month follow up. However, the injuries themselves or treatments such as splinting may result in an immediate decline in functional status. There is no instrument available to identify older patients at high risk for immediate post-injury functional decline. The care needs for these patients are unknown, which makes discharge planning difficult for treating physicians.   The study aims are to describe the functional status of older ED patients with blunt injuries and to determine factors predictive of short-term functional decline. This project will also describe their care needs, and develop and pilot an intervention aimed at maintaining functional independence in these patients.   Three hundred patients ≥ 65 years with blunt injuries will be enrolled. Interviews are derived from validated instruments and include information on mental status, comorbidities, medication use, social supports, ADLs, and service use. Current functional abilities will be assessed using the “Get-up and Go” test and the time to put on and remove a jacket (from the Physical Performance Test). All patients will be followed by telephone at one week to assess changes in ADLs, and repeat doctor visits for functional concerns. One-third of patients will be followed at 4 weeks by telephone to assess the trajectory of functional decline and monitor for recovery. The primary outcome is significant reduction in ADL score at one week. This information will be used to develop an intervention aimed at mitigating functional decline in these patients. Pilot testing of this intervention will lead to a federally funded grant proposal to evaluate its effectiveness. Emergency Medicine   Back to the top David Yuh, MD, The Johns Hopkins Hospital Dr. Yuh is an Associate Professor of Surgery in the Division of Cardiac Surgery at Johns Hopkins Hospital. An active cardiac surgeon, Dr. Yuh has experienced a growth in the numbers of older adults presenting for cardiac surgery. He has encountered issues specific to these patients, including a higher incidence of physical disability, stroke, and post operative delirium. In order to improve care for his patients and the growing number of older adults, Dr. Yuh has focused his research on issues which are relevant to the geriatric cardiac surgical patient. His project intended to develop and apply reasoned protocols for the treatment of postoperative delirium incurred after cardiac surgery   Assessing the Efficacy of a Neuroleptic, Benzodiazepine and 5-HT3 Receptor Antagonist Regimen in the Treatment of Postoperative Delirium in Geriatric Patients After Cardiac Surgery Postoperative delirium and agitation is a neuropsychiatric complication of cardiac surgery associated with significantly increased morbidity (e.g., falls, infections, pressure sores), mortality, prolonged hospital stays and costs, and increased requirements for post-discharge institutionalization. There is clear scientific evidence that geriatric patients suffer from delirium after cardiac surgery more frequently than younger patients, however, due to the variability in its presentation as well as the greater medical complexities inherent in this older patient population, delirium is often overlooked, misdiagnosed, and mistreated. Currently, neuroleptics and benzodiazepines comprise treatment for postoperative delirium in the elderly. Unfortunately, geriatric patients are particularly susceptible to the untoward side effects of these medications and an optimal dosing regimen has not yet been developed in an organized study. Furthermore, there has been promising preliminary evidence that ondansetron, a serotonin (a neurotransmitter) 5-HT3 receptor antagonist, effectively ameliorates postoperative delirium in cardiac patients. In this proposal, we seek to develop and apply reasoned protocols for the treatment of postoperative delirium incurred after cardiac surgery, specifically for geriatric patient population, based upon these medications. These protocols will be based upon substantial clinical experience with combined neuroleptic and benzodiazepine therapies for delirium accumulated over three years. They will be applied with careful perioperative neurocognitive monitoring to assess efficacy. This study would represent the first treatment protocol of its kind to be applied specifically to geriatric patients undergoing cardio thoracic surgery. Optimized treatment of postoperative delirium in the geriatric patient would most certainly yield positive effects upon their postoperative courses. Thoracic Surgery Back to the top