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Biomedical subjects

D I Baker

Publications and source records attributed to D I Baker.

15 recordsLinked to original sources
PubMed2001

The design and implementation of a restorative care model for home care.

PURPOSE: The increasing demand for geriatric home-based care makes it timely to examine how the existing system can become most effective and efficient in promoting the functional outcomes of older patients. DESIGN AND METHODS: A multidisciplinary work group identified home care agency policies, misconceptions of older adults and their caregivers, and practice patterns of nurses, therapists, and home health aides that can impede patients' progress toward functional independence. This article describes the process that one home care agency used to remove these obstacles. RESULTS AND IMPLICATIONS: The work group developed and implemented a restorative model of care that integrates the medical treatments for acute disease processes and the personal care and rehabilitative interventions directed toward chronic disabilities, to improve the functional outcomes of older adults receiving home care.

Activities of Daily Living↗
PubMed2000

The Hospital Elder Life Program: a model of care to prevent cognitive and functional decline in older hospitalized patients. Hospital Elder Life Program.

OBJECTIVES: To describe the Hospital Elder Life Program, a new model of care designed to prevent functional and cognitive decline of older persons during hospitalization. PROGRAM STRUCTURE AND PROCESS: All patients aged > or =70 years on specified units are screened on admission for six risk factors (cognitive impairment, sleep deprivation, immobility, dehydration, vision or hearing impairment). Targeted interventions for these risk factors are implemented by an interdisciplinary team-including a geriatric nurse specialist, Elder Life Specialists, trained volunteers, and geriatricians--who work closely with primary nurses. Other experts provide consultation at twice-weekly interdisciplinary rounds. INTERVENTION: Adherence is carefully tracked. Quality assurance procedures and performance reviews are an integral part of the program. PROGRAM OUTCOMES: To date, 1,507 patients have been enrolled during 1,716 hospital admissions. The overall intervention adherence rate was 89% for at least partial adherence with all interventions during 37,131 patient-days. Our results indicate that only 8% of admissions involved patients who declined by 2 or more points on MMSE and only 14% involved patients who declined by 2 or more points on ADL score. Comparative results for the control group from the clinical trial were 26% and 33%, and from previous studies 14 to 56% and 34 to 50% for cognitive and functional decline, respectively. Effectiveness of the program for delirium prevention and of the program's nonpharmacologic sleep protocol have been demonstrated previously. CONCLUSIONS: These results suggest that the Hospital Elder Life Program successfully prevents cognitive and functional decline in at-risk older patients. The program is unique in its hospital-wide focus; in providing skilled staff and volunteers to implement interventions; and in targeting practical interventions toward evidence-based risk factors. Future studies are needed to evaluate cost-effectiveness and longterm outcomes of the program as well as its effectiveness in non-hospital settings.

Activities of Daily Living↗
PubMed2000

PTEVAL: a computerized home-based physical therapy intervention instrument.

The determination of physical therapy treatment protocols, based on an in-home evaluation of a patient, is a complex task. The specific rules for treatment indications are individually simple, but numerous and hence time-consuming and prone to error using pencil-and-paper methods. This paper describes PTEVAL, a computerized Point-of-Care instrument designed to support the intervention protocols of an ongoing clinical trial. With appropriate modifications and extensions, PTEVAL can be a model for instruments used in clinical practice.

Activities of Daily Living↗
PubMed1999

Home-based multicomponent rehabilitation program for older persons after hip fracture: a randomized trial.

OBJECTIVE: To determine whether a home-based systematic multicomponent rehabilitation strategy leads to improved outcomes relative to usual care. DESIGN: A randomized controlled trial with 12 months of follow-up. SETTING: General community; 27 home care agencies. PARTICIPANTS: Three hundred four nondemented persons at least 65 years of age who underwent surgical repair of a hip fracture at two hospitals in New Haven, CT, and returned home within 100 days. INTERVENTION: Systematic multicomponent rehabilitation strategy addressing both modifiable physical impairments (physical therapy) and activities of daily living (ADL) disabilities (functional therapy) versus usual care. MAIN OUTCOME MEASURES: A battery of self-report and performance-based measures of physical and social function. RESULTS: There was no significant difference in the proportion of participants in the two groups who recovered to prefracture levels in self-care ADL at 6 months (71% vs 75%) or 12 months (74% in both groups) or in home management ADL at 6 months (35% vs 44%) or 12 months (44% vs 48%). There also was no difference between the two groups in social activity levels, two timed mobility tasks, balance, or lower extremity strength at either 6 or 12 months. Compared with participants who received usual care, those in the multicomponent rehabilitation program showed slightly greater upper extremity strength at 6 months (p = .04) and a marginally better gait performance (p = .08). CONCLUSIONS: The systematic multicomponent rehabilitation program was no more effective in promoting recovery than usual home-based rehabilitation. Compared with previous cohorts, however, participants randomized to usual care in our study received more rehabilitative and home care services and experienced a higher rate of recovery. This finding is important given the current pressures to reduce home services. The challenge is to determine the composition and duration of rehabilitation and home services that will ensure optimal functional recovery most efficiently in older persons after hip fracture.

Activities of Daily Living↗
PubMed1997

Systematic home-based physical and functional therapy for older persons after hip fracture.

OBJECTIVE: To describe the development, implementation, and results of a home-based rehabilitation protocol for older persons after hip fracture. DESIGN: Demonstration study. SETTING: Community. PARTICIPANTS: One hundred forty-eight community-living, nondemented participants at least 65 years of age who underwent repair of a fractured hip at two local hospitals. INTERVENTION: A linked assessment-intervention, home-based rehabilitation strategy. The physical therapy (PT) component of the intervention was designed to identify and ameliorate impairments in balance, strength, transfers, gait, and stair climbing; the functional therapy (FT) component was designed to identify and improve unsafe and/or inefficient performance of specific activities of daily living (ADL). MAIN OUTCOME MEASURES: The percentage of participants able to complete each component and the extent of progress noted in strength, balance, transfers, gait, and daily functioning. RESULTS: A total of 104 of the 148 participants (70%) completed the 6-month PT and FT program; 4 completed only PT and 6 refused both PT and FT. The remaining 32 participants (22%) received partial PT and FT that was terminated by death, hospitalization, or institutionalization. Seventy-seven percent of participants reported performing at least half of the recommended daily exercise sessions. Ninety-four percent and 96% of participants progressed in upper and lower extremity conditioning respectively; 33% progressed to the highest level in the graduated resisted exercise program. All participants progressed in the competency-based graded balance program, with 55% progressing to the fifth (most difficult) level. Similarly, the majority progressed in transfer maneuvers, stair climbing, and outdoor gait. One repetition maximum (RM) elbow extension increased from a mean of 5.8 (SD 4.6) pounds at baseline to 7.2 (SD 3.8) pounds at 6mo (t 2.22; p < .02). One RM knee extension increased from 5.8 (SD 5.8) pounds to 10.8 (SD 5.4) pounds (t = 8.06; p < .0001). The number of gait deviations decreased from 2.1 (SD 1.3) to 0.6 (SD 0.9) (p < .0001), while the mean modified Berg Balance Scale Score increased from 13.0 (SD 4.8) to 20.5 (SD 6.8) (t = 16.6; p < .0001). Finally, the Total ADL Score increased from a mean of 48.2 (SD 15.0) to 77.7 (SD 18.8) (t = 17.03; p = .0001). CONCLUSIONS: This systematic assessment and intervention protocol, targeting impairments and ADL, was feasible, safe, and effective. Protocols such as the one presented should enhance the ability to implement rehabilitation programs for the increasing number of multiply impaired older persons receiving home-based therapy and to document the process and outcomes of this care.

Activities of Daily Living↗
PubMed1996

Self-efficacy, physical decline, and change in functioning in community-living elders: a prospective study.

This study examines whether high self-efficacy is protective against a decline in functional status in community-residing elderly persons. Data came from a sample of 1,103 subjects aged > or = 72 years who were ambulatory within the household and who received in-home assessments at baseline and 18 months later to obtain information on sociodemographic, psychosocial, and health status variables, including physical performance tests. Functional status was based on six basic self-care tasks (ADLs). Using OLS regression, lower self-efficacy was marginally related to decline in functional status, after controlling for sociodemographic and health-related variables. As hypothesized, there was a significant interaction effect between self-efficacy and change in physical performance, suggesting that low self-efficacy was particularly predictive of functional decline among older individuals who showed a decline in physical performance at follow-up. These findings provide support for the buffering effect of self-efficacy on functional decline in the face of diminished physical capacity.

Activities of Daily Living↗
PubMed1996

The cost-effectiveness of a multifactorial targeted prevention program for falls among community elderly persons.

OBJECTIVES: Falls and fall injuries are common-potentially preventable-causes of morbidity, functional decline, and increased health-care use among elderly persons. The current analyses, performed on data obtained as part of a randomized controlled trial conducted within a health maintenance organization, describe the costs of a multifactorial, targeted prevention program for falls, present total net health-care costs, estimate the cost per fall prevented, and describe acute fall-related health-care costs. METHODS: The 301 participants were at least 70 years of age and possessed at least one of eight targeted risk factors for falling. The 153 participants randomized to the targeted intervention (TI) group received a combination of medication adjustment, behavioral recommendations, and exercises as determined by their baseline assessment. The 148 participants randomized to the usual care (UC) group received a series of home visits by a social work student. RESULTS: The mean intervention cost per TI participant was $925 (range $588 to $1,346). Total mean health-care costs were approximately $2,000 less in the TI than UC group, whereas median costs were approximately $1,100 higher in the TI than UC group. The TI strategy was unequivocally cost effective when mean costs were used because the intervention was associated with both lowered total health-care costs and fewer total and medical care falls. In sensitivity analyses, the cost-effectiveness of the TI strategy appeared robust to widely differing assumptions about total health-care costs (25th to 75th percentile of the actual distribution) and intervention costs (minimum to maximum costs). In subgroup analyses, the TI strategy showed its strongest effect among individuals at high risk of falling, defined as possession of at least four of the eight targeted risk factors. CONCLUSIONS: Consideration should be given toward incorporating and reimbursing the cost of fall-prevention programs within the usual health care of community-living elderly persons, particularly for those persons at high risk for falling.

Accidental Falls↗
PubMed1995

The influence of urinary incontinence on publicly financed home care services to low-income elderly people.

Urinary incontinence (UI) has been shown to be prevalent and a risk factor for permanent institutionalization; yet it is not routinely measured in research of home care utilization. A retrospective cohort design is used to directly estimate the effect of UI on the public costs of home care services to elderly individuals. Multivariate analyses controlling for other individual, household, and supply characteristics demonstrate that those with UI generate significantly greater public costs for home care services. Patterns of service use suggest palliative rather than rehabilitative service, raising questions regarding the effective use of resources.

Activities of Daily Living↗
PubMed1994

A multifactorial intervention to reduce the risk of falling among elderly people living in the community.

BACKGROUND: Since falling is associated with serious morbidity among elderly people, we investigated whether the risk of falling could be reduced by modifying known risk factors. METHODS: We studied 301 men and women living in the community who were at least 70 years of age and who had at least one of the following risk factors for falling: postural hypotension; use of sedatives; use of at least four prescription medications; and impairment in arm or leg strength or range of motion, balance, ability to move safely from bed to chair or to the bathtub or toilet (transfer skills), or gait. These subjects were given either a combination of adjustment in their medications, behavioral instructions, and exercise programs aimed at modifying their risk factors (intervention group, 153 subjects) or usual health care plus social visits (control group, 148 subjects). RESULTS: During one year of follow-up, 35 percent of the intervention group fell, as compared with 47 percent of the control group (P = 0.04). The adjusted incidence-rate ratio for falling in the intervention group as compared with the control group was 0.69 (95 percent confidence interval, 0.52 to 0.90). Among the subjects who had a particular risk factor at base line, a smaller percentage of those in the intervention group than of those in the control group still had the risk factor at the time of reassessment, as follows: at least four prescription medications, 63 percent versus 86 percent, P = 0.009; balance impairment, 21 percent versus 46 percent, P = 0.001; impairment in toilet-transfer skills, 49 percent versus 65 percent, P = 0.05; and gait impairment, 45 percent versus 62 percent, P = 0.07. CONCLUSIONS: The multiple-risk-factor intervention strategy resulted in a significant reduction in the risk of falling among elderly persons in the community. In addition, the proportion of persons who had the targeted risk factors for falling was reduced in the intervention group, as compared with the control group. Thus, risk-factor modification may partially explain the reduction in the risk of falling.

Accidental Falls↗
PubMed1994

Fear of falling and fall-related efficacy in relationship to functioning among community-living elders.

BACKGROUND: The relationships of fear of falling and fall-related efficacy with measures of basic and instrumental activities of daily living (ADL-IADL) and physical and social functioning were evaluated in a cohort of community-living elderly persons. METHODS: Sociodemographic, medical, psychological, and physical performance (e.g., gait speed, timed hand function) measures were administered, during an in-home assessment, to a probability sample of 1,103 residents of New Haven, Connecticut, who were > or = 72 years of age. Falls and injuries in the past year, fear of falling, and responses to the Falls Efficacy Scale were also ascertained. The three dependent variables included a 10-item ADL-IADL scale, an 8-item social activity scale, and a scale of relative physical activity level. RESULTS: Among cohort members, 57% denied fear of falling whereas 24% acknowledged fear but denied effect on activity; 19% acknowledged avoiding activities because of fear of falling. Twenty-four percent of recent fallers vs 15% of nonfallers acknowledged this activity restriction (chi 2 = 13.1; p < .001). Mean fall-related efficacy score among the cohort was 84.9 (SD 20.5), 79.8 (SD 23.4), and 88.1 (SD 17.9) among fallers and nonfallers, respectively (p < or = .0001). Fall-related efficacy proved a potent independent correlate of ADL-IADL (partial correlation = .265, p < .001); physical (partial correlation = .234, p < .001); and social (partial correlation = .088, p < .01), functioning in multiple regression models after adjusting for sociodemographic, medical, psychological, and physical performance covariates as well as history of recent falls and injuries. Fear of falling was only marginally related (p = .05) with ADL-IADL functioning and was not associated with higher level physical or social functioning. CONCLUSIONS: The strong independent association between self-efficacy and function found in this study suggests that clinical programs in areas such as prevention, geriatric evaluation and management, and rehabilitation should attempt simultaneously to improve physical skills and confidence. Available knowledge of the factors influencing efficacy should guide the development of these efficacy-building programs.

Accidental Falls↗
PubMed1994

An impairment and disability assessment and treatment protocol for community-living elderly persons.

BACKGROUND AND PURPOSE: Falls and immobility are common among community-living elderly persons and result from the accumulated effect of multiple impairments and disabilities as well as environmental hazards. We developed and tested a simple assessment and intervention protocol for use in prevention and treatment programs among community-living elderly persons. This article presents the components of the assessment; the criteria for intervening on diagnosed impairments contributing to falls and immobility; and the recommended treatments, environmental adaptations, training, and exercise programs targeting the diagnosed problems. SUBJECTS: A convenience sample of 11 residents of a senior housing complex who were cognitively intact and ambulatory were chosen for reliability testing of the assessment protocol. A random sample of 20 of the 153 elderly subjects involved in a multiple risk factor trial for fall prevention then were chosen to test the reliability of the intervention recommendations. METHODS: The assessment and intervention protocol was developed by a consensus approach among a group consisting of a geriatric physician, two nurses, and three physical therapists. The interrater reliability of both the assessment and the intervention components of the protocol was determined by comparing the results of two of the study physical therapists. RESULTS: There was excellent agreement in assessment and intervention results by the two physical therapists. The assessment required approximately 45 minutes to complete, suggesting it is feasible for use in clinical practice. CONCLUSION AND DISCUSSION: A simple, standardized assessment and intervention protocol, such as the one described, could aid physical therapists in evaluating and treating community-living elderly persons by improving communication among care providers, providing better documentation for reimbursers, and ensuring a direct linkage between assessment and intervention, thus simplifying the development of a treatment plan for elderly persons with complicated or multiple impairments. The ultimate test of this assessment and intervention protocol will be ascertainment of the goal of the protocol, namely a reduction in falls and improvement in mobility among multiply and chronically ill elderly persons.

Accidental Falls↗
PubMed1994

Older adults' perceptions of their health and functioning in relation to sleep disturbance, falling, and urinary incontinence.FICSIT Group.

OBJECTIVE: To investigate variation in older adults' perceived health and functioning that is associated with self-reported sleep disturbance, falling, and urinary incontinence, controlling for self-reported depression, ambulation difficulty, number of chronic conditions, and subjects' sociodemographic characteristics. DESIGN: Multicenter prospective study (FICSIT). SETTING: Persons age 70 and older living in the community evaluated at baseline. PARTICIPANTS: 239 women, 113 men; mean age = 77. MEASUREMENTS: Sleep disturbance score based on EPESE questions, recent falls history (Y/N), incontinent episodes (Y/N), CES-D score, SIP Ambulation score, and 4 MOS SF-36 scale scores. RESULTS: Women were significantly more likely than men to report multiple conditions (sleep disturbance, falling, incontinence) and to report lower levels of functioning as measured by 3 of 4 SF-36 scales. In regression analyses, sleep disturbance and urinary incontinence were significant predictors of perceived limitations in usual role activities because of physical health problems. Depression and ambulation measures significantly predicted scores on all 4 SF-36 scales. CONCLUSIONS: Our analysis suggests that it is important to address depressive symptomatology and ambulation difficulty--which in turn are related to sleep disturbance, falling, and urinary incontinence--in efforts to enhance older adults' perceived health and functioning.

Accidental Falls↗
PubMed1993

Yale FICSIT: risk factor abatement strategy for fall prevention.

Based on finding a strong association between number of impairments and risk of falling in earlier studies, Yale FICSIT investigators are conducting an intervention trial comparing the effectiveness of usual care plus social visits (SV) and a targeted risk abatement intervention (TI) strategy in reducing falls among at risk community elderly persons. Subjects include members of a participating HMO who are > or = 70 years of age, cognitively intact, not terminally ill, not too physically active, and possess at least one fall risk factor. The targeted risk factors include postural hypotension; sedative use; at least four targeted medications; upper and lower extremity strength and range of motion impairments; foot problems; and balance, gait, and transfer dysfunctions. The interventions include medication adjustments, behavioral change recommendations, education and training, and home-based exercise regimens targeting the identified risk factors. The interventions are carried out by the study nurse practitioner and physical therapist in TI subjects' homes. The SV subjects receive a comparable number of home visits as the TI subjects during which a structured life review is performed by social work students. The primary outcome is occurrence of falls during the 12-month followup. Secondary outcomes include change in mobility performance and fall-related efficacy.

Accidental Falls↗
PubMedDate not supplied

Measuring the quality of life of the elderly in health promotion intervention clinical trials.

The Multicenter Trials of Frailty and Injuries: Cooperative Studies of Intervention Techniques (FICSIT) is a series of clinical trials of biomedical, behavioral, and environmental interventions to reduce the risks of frailty and injury among the elderly. Reliable assessment of the quality of life reported by the subjects is a central issue in evaluating the interventions. An intervention may have a significant impact on an elderly person's sense of well-being, even though significant improvement is not observed in selected physical outcome measures. Elderly persons' compliance with particular intervention regimens may be influenced by the quality of life effects that they perceive in relation to the intervention. The researchers review the definition and measurement of quality of life in the trials, with particular attention to issues in determining common measures used at all study locations. Practical considerations in the selection and use of quality of life measures in both community and institutional populations are addressed. Topics discussed include the interrelation of aging, functional capacities, and quality of life; the multi-dimensionality of quality of life in relation to differential intervention effects; and age-related issues in the collection of quality of life data. Preliminary observations are reviewed, and potential contributions of FICSIT to intervention-sensitive quality of life assessments among the elderly are noted.

Activities of Daily Living↗