Spotlight: Research Focused on Aging Veterans

August 2015

According to the National Center for Veterans Analysis and Statistics' most recent data, there are approximately 20 million living Veterans in the United States, ranging in age from 17 to over 100. Among the 8 million who are enrolled in VA care, 47 percent are over age 65.¹ As life expectancy increases, the number of Veterans seeking care within VA is also expected to increase. As such, VA is, and will continue to remain, the country's largest provider of care for the elderly.

Older Veterans face a unique spectrum of health conditions, ranging from manageable (age-related osteoarthritis) to complex (service-related polytrauma, chronic illness). While many manageable conditions may require only occasional outpatient treatment, aging Veterans with more complex or chronic conditions often require long-term care—such as that provided by a skilled nursing facility or through VA's Community Living Centers (CLCs). Because aging Veterans require such a diverse array of care, research that contributes to the evidence-base for effective treatment and policy decisions is critical. Investigators within VA's Health Services Research and Development Service (HSR&D) contribute to care for aging Veterans by conducting comprehensive studies on a variety of aging-related concerns. The following studies highlight just a few of those recently completed and ongoing investigations.

Collaborative Research to Enhance and Advance Transformation and Excellence (CREATE) Initiative: Long-Term Care. Approximately 800,000 Veterans enrolled in VA healthcare depend on assistance with at least one activity of daily living (ADL). Further, estimates indicate that by 2020, some 700,000 Veterans enrolled in VA healthcare will be over the age of 85—and most will require some kind of assistance with at least one ADL. These Veterans (and many others, particularly those wounded in combat) will need comprehensive long-term care (LTC). The studies included in the LTC CREATE Initiative aim to provide tools, evidence, and evaluation information necessary for VA's Geriatric and Extended Care (GEC) policymakers and staff to transform the spectrum of LTC services. The studies include:

• Medical Foster Homes: A Safe, Cost Effective Substitute for Nursing Homes?
  The innovative medical foster home (MFH) program serves as a VA alternative to nursing home (NH) placement for Veterans who are nursing home eligible but prefer to receive care in a private home with qualified caregivers. This study will describe characteristics of Veterans served in MFHs, how they differ from Veterans residing in NHs, and factors that lead Veterans to select or reject MFH placement over NH placement.
• Implementing and Evaluating INTERACT in VA CLCs
  The INTERACT intervention—which focuses on nurse-physician communication—is designed to reduce the rate of hospitalization of CLC residents. This study will assess the implementation and evaluation of INTERACT.
• Increasing Veterans' Use of Community-Based LTC via Timely Discharge from VA CLCs
  This project seeks to evaluate the impact of recent VA Geriatrics and Extended Care (GEC) initiativesintended to reduce length of CLC stays and readmission rates.
• Developing and Implementing a Toolkit for Measuring CLC Cultural Transformation
  This project seeks to strengthen the resident-centered culture of CLCs by helping CLC staff use structured observation and improvement processes to help increase positive interactions between CLC residents and staff and to help maintain an environment that constantly engages residents.

Veteran Affairs Older Adult Safety in Surgery (VA OASIS) II. Physical functional status has proven to be a powerful predictor of both chronic care outcomes and longevity. However, there has been little study around the role of physical function in predicting the development of life-threatening, post-operative medical complications. Clinicians in VA have risk-assessment guidelines for post-operative complications, but those do not focus on older adults and only incorporate very coarse measurements (such as the ability to climb stairs) of physical function.

In 2002, VA embarked on an innovative path of systematically measuring functional status by including the Veterans RAND 12-Item Health Survey (VR-12) as part of its Survey of Healthcare Experiences of Patients consumer satisfaction survey. This study sought to link VR-12's "Physical Component Score" (PCS) survey data with surgical records for older Veterans undergoing major surgery, and measure the independent association of PCS with medical complications both compositely and separately. Complications included morbidity, cardiac and pulmonary conditions, venous thromboembolism, and renal failure.

Investigators identified 16,054 Veterans age 50 and older who had surgery between 2007 and 2012 and had responded to the VR-12 survey in the six months before surgery. In addition to global outcomes of major complications (renal, cardiac, VTE, etc.), additional outcomes included discharge to nursing home and readmission at 30 days post-surgery.

While final data are being assessed, investigators found that low PCS and Mental Health Component Score (MCS) predicted an adverse postoperative course. Further, investigators suggest that clinicians and policymakers should consider the incorporation of self-reported physical function derived from short form instruments like VR-12 when assessing older Veterans' suitability for major surgery.

This study currently has no associated journal publications.

Partners in Dementia Care. Investigators in this five-year study tested the effectiveness of VA's Partners in Dementia Care (PDC), a care-coordination program integrating healthcare and community services to support Veterans with dementia and their caregivers. Delivered via partnerships between Veterans Administration Medical Centers (VAMCs) and Alzheimer's Association chapters, PDC targeted both patients and caregivers.

Caregivers for Veterans with dementia were recruited from VA facilities in five communities: four VAMCs, and one VA community-based outpatient clinic. Both intervention (n=299) and comparison caregivers (n=187) participated for 12 months and completed 3 telephone interviews (baseline, 6 months, and 12 months). Caregiver outcomes measured included unmet needs (i.e., accessing VA and other services, organizing family care, understanding dementia); caregiver strains (i.e., role captivity, physical strain, relationship strain); depression; and support resources (i.e., number of informal helpers, use of caregiver support services). Results suggest the PDC program is a promising model that improves linkages between VA healthcare services and community services for informal caregivers of Veterans with dementia. Additional results include:

• Compared to comparison caregivers, those who participated in the PDC program had significant improvement in outcomes representing unmet needs, all three types of caregiver strains, depression, and both support resources.
• Most improvements were evident after six months, with more limited improvements from months six through 12. However, improvements after the first six months were maintained during the entire study.
• Some outcomes improved for all caregivers, while others improved for caregivers with more initial difficulties—or those who were caring for Veterans with more severe impairments.

The study currently has 13 associated journal publications and includes both Veteran and cost outcomes. For a complete list of all publications, please visit the study abstract page on the HSR&D website.

Preparing Older Veterans with Serious and Chronic Illness for Decision Making. There are 4.5 million Veterans over age 65, and an increasing number of them are living with a chronic or serious illness. Over the course of a chronic or serious illness, many older Veterans—and their surrogate decision-makers—will eventually face complex or difficult decisions about their care. The existing paradigm of advanced care planning (ACP) has focused on making decisions about life-prolonging procedures (e.g., resuscitation) by completing advance directives; however, an estimated 50% of older Veterans have limited health literacy, and advance-directive forms can be difficult to understand. Further, these forms often fail to prepare patients with concrete skills—such as how to identify one's values and communicate with surrogates and clinicians.

In order to assist Veterans of all health-literacy levels to prepare for complex health decision-making, investigators sought to create an easy-to-understand (5^th grade reading level), culturally-appropriate tool based on a new paradigm (PREPARE). PREPARE focuses on helping Veterans learn how to communicate with their surrogate decision-makers and participate with clinicians in making the best possible, in-the-moment decisions. Further, PREPARE offers Veterans skills such as how to choose a surrogate and discuss surrogate decision-making and clarify personal values for specific health states.

In July 2012, investigators began a four-year, randomized, controlled trial designed to assess the effectiveness of PREPARE. The study will assess three aims:

1. Preparation skill behaviors (i.e., did they choose a surrogate, clarify their values, ask clinicians questions);

2. Determine the effectiveness of PREPARE to activate Veterans and clinicians within clinical encounters (i.e., did Veterans ask clinicians questions or discuss preparation topics and did clinicians respond) and to improve satisfaction with decision making; and

3. Obtain input from Veterans, surrogates, and clinicians about implementation of PREPARE within VA.

Investigators enrolled 200 Veterans, who were randomly assigned to receive either the intervention (PREPARE materials and an advance directive) or the control group (advance directive only). Based on pilot study results indicating that significant improvement in engagement around the process of advance care planning and behavior change occurred after using the PREPARE website, investigators expect the study to show similar results. Investigators also suggest that evidence from this study may support a change in the existing advance care planning paradigm policies within VA by moving beyond documentation of end-of-life wishes to the activation of Veterans to participate in ongoing communication of their values and goals.

This study has resulted in four journal publications and all citations are available on the study abstract page on the HRS&D website.

VA HSR&D Career Development Program Research: Improving Glaucoma Medication Adherence. Glaucoma is the leading cause of irreversible blindness worldwide and disproportionately affects the elderly and African-Americans in both prevalence and severity. The number of Americans with glaucoma is expected to increase by 50% in the next 15 years. Multiple studies have shown that with effective medical treatment, much vision loss can be prevented through reduction in intraocular pressure. Despite this, glaucoma medications often are not taken as prescribed.

Part of the VA HSR&D Career Development Award Program, this project was initiated in July 2011. Findings will stem from three discrete studies aimed at reducing vision loss in Veterans with glaucoma by identifying and reducing barriers to glaucoma medication adherence. The studies in the program include:

• An observational study comparing different methods for quantifying glaucoma medication adherence: electronic monitors, self-report, pharmacy refill records, and direct observation of drop instillation technique. All methods measuring adherence will be compared to each other and to clinical outcomes including intraocular pressure and visual field deterioration.
• The qualitative assessment and refinement of a prototype intervention to improve medication adherence.
• A pilot study testing the refined intervention in patients with glaucoma.

Investigators expect that the successful completion of these projects will reduce preventable vision loss in Veterans. While final study results are not yet available, the project has produced 18 associated journal publications. (For a list of publications related to this topic, please visit the study abstract page on the HSR&D website.)

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¹ National Center for Veterans Analysis and Statistics, 2013.

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