Arizona Program of Applied
Geriatrics:
The Role of the Informationist
Carol Howe, MD, MLS: Librarian
Sandra Kramer, MA, MS: Assistant
Director for Services
1
College of Medicine (COM) and the
Donald W. Reynolds Foundation
In 2006 the COM of the Arizona Health Sciences
Center (AHSC) was one of 10 academic centers
chosen to receive an almost $2 million dollar grant
in the third phase of the Reynolds Aging and
Quality of Life Program.
2
The Aging and Quality of Life Program was
established in 1996 by the Donald W. Reynolds foundation to
revolutionize geriatric training within our medical centers in
order to meet the complex needs of the ever-expanding
population of elders in the United States
From the Administration on Aging’s
“A Profile of Older Americans : 2004”
3
So far, three cohorts of ten medical centers each have
been awarded 4-year, approximately $2-million grants.
4
Each center has, or is in the process of, developing
a unique approach to integrating geriatric
awareness and expertise at every level of medical
training and practice.
5
An annual meeting is held where all the
Reynolds programs convene and exchange
resources, ideas and educational products
that they have developed or are working on.
6
Examples of innovative ideas that have
emerged so far include:
 Geriatric
Quick Consult Web site for students and
clinicians --Virginia Commonwealth University
 A Chief Resident Immersion Training Program -Boston University
 CHAMP-Curriculum for the Hospitalized Aging
Medical Patient—University of Chicago
 Focus on training primary care physicians –
University of Utah
7
8
Reynolds Scholars in Aging Program
 Considered
the “Key Driver”
 Based
on principle that non-geriatrician physician
leaders within both primary and specialty fields
will become true agents of change when they
themselves receive intensive training in the
principles of geriatrics
9
The Informationist
One of the unique features of the Arizona
Reynolds Program is the inclusion of an
informationist to participate at every level of the
program.
“The Librarian”
a 1556 painting by
Giuseppe Arcimboldo
From Wikipedia.org
10
In their groundbreaking 2000 editorial in the Annals of
Internal Medicine, Davidoff and Florance proposed the
establishment of a “new health profession,”
that of the informationist. With a “clear
and solid understanding of both information
science and the essentials of clinical work,”1
the informationist is poised to bridge the gap “between the
huge body of information hidden away in the medical
literature and the information needed at the point of
care.”2
1- Davidoff F and Florance V. The informationist: a new health profession?
Ann Intern Med. 2000 Jun 20; 132 (12):997.
2-Davidoff F and Florance V. The informationist: a new health profession?
Ann Intern Med. 2000 Jun 20; 132 (12):996.
11
Informationist as Team Member
 Offers
research support to
 Medical
students
 Residents
 Fellows
 Faculty Members
12
Tied in to day to day information needs
Attends weekly leadership meetings
Answers reference questions as they arise
Locates hard to find documents
Composes bibliographies
Contributes to Consumer Newsletters
Contributes to Professional Journals
(such as the Journal of the Arizona Geriatrics Society)
13
Most vital role,
however, is with the
Reynolds Scholar in
Aging Program
(RSIA)
William Hogarth 's 1736 engraving,
Scholars at a Lecture
14
Who are the scholars?






Dr. C.C.: Associate Professor of
Surgery/Urology; Chief of the Section of
Urology; Residency Director.
Dr. H.V., Professor of Surgery and Interim Head
of the Department of Surgery
Dr. W.G., Professor of Orthopedics and Head of
Department of Orthopedics
Dr. S.B., Professor of Anesthesiology and Head,
Department of Anesthesiology
Dr. G.W.: Associate Professor of Clinical
Medicine-- actively involved in developing the
new curriculum.
Dr. H.M. Professor of Emergency Medicine;
Department Head for Emergency Medicine;
Director of the Arizona Emergency Medicine
Research Center





Dr. J.W.: Associate Professor, Department of
Surgery; Residency Director.
Dr. P. L.: Associate Professor, Clinical Family &
Community Medicine; Program Director for the
Family Medicine Residency--also completed a
fellowship in Integrative Medicine in 2005.
Dr. R.M.: Associate Professor, Clinical Medicine;
Program Director for the Internal Medicine
Residency Program; Section Head for the Medical
Education Office; chair of the Graduate Medical
Education Committee.
Dr. S.C :Professor, Gynecologic Oncology; Director
of Women’s Cancers, Arizona Cancer Center;
Associate Head for Academic Affairs, Department of
OB/GYN.
Dr. J.U.: Hospitalist and Division Chair, Department
of Medicine at the Southern Arizona Veterans
Administration Health Care System
15
In addition to university-bases Scholars in Aging,
physicians are also chosen from Indian Health Service
(IHS) and tribal medical facilities.
Whiteriver IHS
Hospital
Hopi Health Care Center
16
17
Reynolds Scholars in Aging: The Program
1.
2.
Intensive training in basic
principles of geriatric care with
particular attention to how it
relates to their individual
specialties.
Collaboration between scholar and
mentor (physician with additional
training and certification in
geriatrics). The scholar and mentor
team in turn work closely with the
informationist.
18
3.
4.
5.
Development of Reynolds Care in Aging (CAPstone)
Project-in which each scholar develops a research
question that addresses and contributes to the solution of
a real world problem.
Integration of geriatric themes into the physicianscholars’ teaching at every level—from undergraduate
medical student to colleagues at international
conferences.
Generation of Scholarly Activity- such as lectures,
publications and abstracts in an aging-related aspect of
the individual scholar’s field.
19
The Scholars and the Informationist
The informationist is
available to assist the
scholars with any and all
of the above.
20
One of the most unique features of the
informationist's role in the Scholar in Aging
Program, however, is the “Question of the Month”
21
In collaboration with their
mentors, scholars compose
queries which run the full
range
from very specific, technical,
medical questions to very broad
cultural/ethical/philosophical questions.
22
Examples of focused medical questions:
 In
PICO format: in older adults who have been
vaccinated for zoster, compared with similar adults
who have not been so vaccinated, what is the event
rate of herpes zoster?
 What are causes of persistently elevated d dimers
in older patients with recurring clots (PE/DVT
etc)?
23
Examples of broader medical questions:
 How
does treatment of ovarian cancer differ
between younger and older women?
 What is the evaluation and management of
hypogonadism in elderly men?
 What tools, if any, are validated for comprehensive
evaluation of the older adult (>65) with cancer to
determine his/her ability to tolerate chemotherapy?
24
Example of broader systems-type questions:
What is known about creating an effective ED
Emergency Department] care environment for
elder care (from first responders, through
discharge)-- in terms of obtaining adequate data,
maximizing communication, supporting sensory
deficits, configuring the physical environment to
optimize functioning, incorporating safety features,
enabling efficient care for providers, and providing
transitional data to discharge environment?
25
Example of a question embedded in a case scenario:
Older male from NH [nursing home] with advanced dementia
admitted to hospital as full code. No MPOA, [medical power of
attorney] no relatives, no guardian per records from NH. His wishes
are unobtainable given current dementia or perhaps co-existing
delirium due to acute illness – i.e., he is oriented only to self. He has
progressive respiratory failure and team forced to make decision to
intubate/send to ICU or no. Given current legal climate in US, team
decides to send to ICU, is intubated, and eventually dies while in
ICU. [Physician] wonders if there is any literature to support not
sending him to the ICU - could he have decided on hospice or
similar using ethics committee - or any recommendations on this
topic in the geriatric literature?
26
Examples of questions in which cultural
context plays a major role:

Are there references for discussing or implementing code
status (do not resuscitate/allow natural death) in Navajo or
Hopi communities? (see appendix)

What is known about depression among American Indian/
Apache and/or Navajo? Or other tribes? In terms of
epidemiology and risk factors, clinical presentation,
effects of treatments?
27
After receiving a question, the informationist
Conducts a search in PubMed
 Looks at many of the evidence based databases such as

Cochrane Database of Systematic Reviews
 Database of Abstracts of Reviews of Effectiveness (DARE)
 ACP Journal Club
 Up to Date
 Our own AHSL custom search engine

28
The informationist
then summarizes and synthesizes a response.
29
An annotated bibliography with links to full text is appended
to the response and submitted to the mentor/scholar team
References
Balducci, L., & Extermann, M. (2000). Management of cancer in the older person: A practical approach. The oncologist, 5(3), 224-237.
The management of cancer in the older aged person is an increasingly common problem. The questions arising from this problem
are: Is the patient going to die with cancer or of cancer? Is the patient able to tolerate the stress of antineoplastic therapy? Is
the treatment producing more benefits than harm? …..
Chen, C. C., Kenefick, A. L., Tang, S. T., & McCorkle, R. (2004). Utilization of comprehensive geriatric assessment in cancer patients.
Critical reviews in oncology/hematology, 49(1), 53-67.
A growing and diverse aging population, recent advances in research on aging and cancer, and the fact that a disproportional
burden of cancer still occurs in people aged 65 years and older have generated great interest … articles were identified through
the bibliography of relevant articles.
Extermann, M. (2003). Comprehensive geriatric assessment basics for the cancer professional. The Journal of oncology management :
the official journal of the American College of Oncology Administrators, 12(2), 13-17.
A comprehensive geriatric assessment (CGA) has been a cornerstone of geriatric practice for many years. However, oncology
practitioners are still unfamiliar with it. Yet, recent ……
Extermann, M. (2003). Studies of comprehensive geriatric assessment in patients with cancer. Cancer control : journal of the Moffitt
Cancer Center, 10(6), 463-468.
BACKGROUND: The comprehensive geriatric assessment (CGA) has been developed to individually assess the health status of
older patients. METHODS: This article reviews the findings ….pact on patients with this disease. CONCLUSIONS: More work is
needed to simplify such assessments to make them more feasible and to determine when they should be used during a patient's
clinical course.
Fosser, V. (2002). Multidimensional evaluation in geriatric oncology: The reasons "contra". Tumori, 88(1 Suppl 1), S103-4; discussion
S105.
Friedrich, C., Kolb, G., Wedding, U., Pientka, L., & Interdisziplinare Arbeitsgruppe der DGHO/DGG. (2003). Comprehensive geriatric
assessment in the elderly cancer patient. Onkologie, 26(4), 355-360.
The proportion of older cancer patients is increasing due to demographic and disease-specific reasons., as CGA has also a key
role in the decision process….
30
The teams are invited to submit further
clarifying questions and also to evaluate the
usefulness of the response.
31
Through this process, we hope to achieve the
goal, articulated in the original Arizona
Reynolds Program Summary, of providing
evidence based material in response to
clinical questions.This inquiry process is
important because it…
32
1.
2.
3.
Provides a real ‘needs assessment’ from which the
curriculum can be modified
Builds an evidence-based library within each
specialty
Can be the basis for extension of academic
activities, such as lectures, web-based training,
case-based training or journal articles
33
The responses will form the basis of a regular
feature in the Arizona Geriatrics Society Journal
34
There will also be a “Question of the Month”
feature on the Web Site of the Arizona
Reynolds Program of Applied Geriatrics
35
As our program progresses we are realizing that not only
is there a gap between the vast stores of information
available and actual medical practice at the bedside,
but equally vast gaps between
information that is needed at the
bedside and available information.
36
Particularly in geriatrics, there simply are not
conclusive evidence-based answers to many of the
questions that clinicians are asking.
37
It is our hope, therefore, that through the collaboration of
the Arizona Health Sciences Library and the Arizona
Reynolds Program of Applied Geriatrics we will be able to
positively influence not only the practice patterns of
physicians caring for older individuals, but the nature and
structure of the research and clinical studies upon which
those thought and practice patterns ultimately depend.
38
References
 Arizona
Reynolds Program of Applied Geriatrics:
Program Summary (2006) (internal document).
 Davidoff,
F. & Florance, V. (2000). The
Informationist: A New Health Profession? Annals
of Internal Medicine 132(12) 996-998.
39
The Arizona Reynolds Program of Applied Geriatrics is
Funded by the Donald W. Reynolds Foundation through
its Aging and Quality of Life Program. The goal of the
program is to improve the quality of life for America’s
elderly by preparing physicians to provide better care for
them when they become ill. The Donald W. Reynolds
Foundation is a national philanthropic organization
founded in 1954 by the late media entrepreneur for whom it
is named. Headquartered in Las Vegas, Nevada, it is one of
the largest private foundations in the United States.
40