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Biomedical subjects

L Z Rubenstein

Publications and source records attributed to L Z Rubenstein.

At least 19 recordsLinked to original sources
PubMed1997

The benefits of in-home pharmacy evaluation for older persons.

OBJECTIVE: To assess the potential benefit of a pharmacist performing in-home medication evaluations on frail older people. DESIGN: Prospective analysis with pre-post comparison. SETTING: A hospital-based home care program at the Sepulveda Veterans Affairs Medical Center. PARTICIPANTS: Male veterans in a home care program who live within 15 miles of the medical center and take three or more prescription medications (N = 20, mean age: 75.1 years). MEASURES: Prescribed medications were documented from the medical records and compared with regimens actually being followed in the home. In addition, the home was inspected, patients were educated, and recommendations were made to the prescribing physicians when necessary. RESULTS: At first visit, patients had a mean of 6.0 prescribed daily medications but were only taking 4.7 of these regularly. Also noted were many potentially unnecessary medications (70% of subjects) and multiple problems with the medication regimen (e.g., incorrect drug frequency or dosage, expired medications, medication omission). Follow-up visit revealed a significant decrease in medication discrepancies and problems (P < or = .05). CONCLUSION: An in-home pharmacy assessment reveals many problems with drug administration not otherwise detected easily. These assessments can lead to potentially useful interventions that can improve medication regimens and compliance. Determination of long-term effects must await controlled trials.

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PubMed1996

Exercise in frail elderly men decreases natural killer cell activity.

Six frail male outpatients 70 years and older deemed at risk for fall, but not suffering from serious medical problems nor receiving immune-altering drugs, received an exercise intervention of increasing strenuousness for 60 minutes 3 times a week for 3 months in comparison with 7 controls having no intervention. Psychosocial and immunologic assessments were made at baseline (Time 1), and after 6 (Time 2) and 12 (Time 3) weeks of physical conditioning. Cytotoxic activity of natural killer (NK) cells significantly decreased during the course of the study, in spite of transient exercise-induced increases at times 2 and 3. Despite the many known benefits of exercise, this report suggests its possible adverse effects on NK cell cytotoxicity in the very frail elderly. Mild overexertion in frail old people may be clinically significant in view of the now recognized role of NK cells in the prevention of metastasis.

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PubMed1996

What do we know about patient targeting in geriatric evaluation and management (GEM) programs?

Evidence indicates that institution-based programs for interdisciplinary geriatric evaluation and management (GEMs) improve outcomes of care, but results vary considerably between studies. Targeting (i.e., selective admission of frail elderly patient subgroups who are thought particularly to benefit) has been advocated as a means to improve the cost-effectiveness of GEM programs, and results from meta-analysis give this concept some support. Our review has several objectives: 1) describing approaches to GEM targeting and development of selection criteria; 2) assessing evidence from randomized trials concerning effects of targeting on outcome; and 3) suggesting an agenda for further research and development on GEM targeting.

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PubMed1996

Measuring psychosocial aspects of well-being in older community residents: performance of four short scales.

Given that the assessment of multiple dimensions of health/well-being can create respondent burden, assessment scales that are both effective and brief hold great attraction. In this study, we used Cronbach's alpha and correlational methods, including factor analysis, to evaluate the performance of four short scales measuring psychosocial aspects of well-being (depression, quality of life, sense of coherence, social support) in two samples of community-dwelling persons aged 75 and over (n = 414, n = 50). All four scales exhibited good range, high internal consistency, strong temporal reliability, and reasonable levels of construct validity. We conclude that they are practical contributors to measuring health in community-based older adults.

Activities of Daily Living↗
PubMed1996

Falls and fall prevention in the nursing home.

The mean incidence of falls in nursing homes is 1.5 falls per bed per year (range 0.2-3.6). The most common precipitating causes include gait and balance disorders, weakness, dizziness, environmental hazards, confusion, visual impairment, and postural hypotension. The most important underlying risk factors for falls and injuries include some of these same items as well as others: leg weakness, gait and balance instability, poor vision, cognitive and functional impairment, and sedating and psychoactive medications. A focused history and physical examination after a fall can usually determine the immediate underlying cause(s) of the fall and contributory risk factors. Many strategies for fall prevention have been tried with mixed success. The most successful take into account the multifactorial causes of falls, and include interventions to improve strength and functional status, reduce environmental hazards, and allow staff to identify and monitor high-risk residents. Regular evaluations in the nursing home can help identify patients at high risk who can then be targeted for specific treatment and prevention strategies. Strategies that reduce mobility through use of restraints have been shown to be more harmful than beneficial and should be avoided. A number of promising fall prevention strategies, involving both specific quality assurance programs and technologic devices, are being evaluated currently.

Accidental Falls↗
PubMed1995

A trial of annual in-home comprehensive geriatric assessments for elderly people living in the community.

BACKGROUND AND METHODS: The prevention of disability in elderly people poses a challenge for health care and social services. We conducted a three-year, randomized, controlled trial of the effect of annual in-home comprehensive geriatric assessment and follow-up for people living in the community who were 75 years of age or older. The 215 people in the intervention group were seen at home by gerontologic nurse practitioners who, in collaboration with geriatricians, evaluated problems and risk factors for disability, gave specific recommendations, and provided health education. The 199 people in the control group received their regular medical care. The main outcome measures were the prevention of disability, defined as the need for assistance in performing the basic activities of daily living (bathing, dressing, feeding, grooming, transferring from bed to chair, and moving around inside the house) or the instrumental activities of daily living (e.g., cooking, handling finances and medication, housekeeping, and shopping), and the prevention of nursing home admissions. RESULTS: At three years, 20 people in the intervention group (12 percent of 170 surviving participants) and 32 in the control group (22 percent of 147 surviving participants) required assistance in performing the basic activities of daily living (adjusted odds ratio, 0.4; 95 percent confidence interval, 0.2 to 0.8; P = 0.02). The number of persons who were dependent on assistance in performing the instrumental activities of daily living but not the basic activities did not differ significantly between the two groups. Nine people in the intervention group (4 percent) and 20 in the control group (10 percent) were permanently admitted to nursing homes (P = 0.02). Acute care hospital admissions and short-term nursing home admissions did not differ significantly between the two groups. In the second and third years of the study, there were significantly more visits to physicians among the participants in the intervention group than among those in the control group (mean number of visits per month, 1.41 in year 2 and 1.27 in year 3 in the intervention group, as compared with 1.11 and 0.92 visits, respectively, in the control group; P = 0.007 and P = 0.001, respectively). The cost of the intervention for each year of disability-free life gained was about $46,000. CONCLUSIONS: A program of in-home comprehensive geriatric assessments can delay the development of disability and reduce permanent nursing home stays among elderly people living at home.

Activities of Daily Living↗
PubMed1995

A randomized trial of comprehensive geriatric assessment in the care of hospitalized patients.

BACKGROUND: Although many studies describe benefits from the comprehensive assessment of elderly patients by an interdisciplinary team (comprehensive geriatric assessment), the most supportive evidence for the process has come from programs that rely on specialized inpatient units and long hospital stays. We examined whether an inpatient geriatric consultation service might also be beneficial in a trial involving four medical centers of a group-practice health maintenance organization (HMO). METHODS: We conducted a randomized clinical trial with 2353 hospitalized patients 65 years of age or older in whom at least 1 of 13 screening criteria were present: stroke, immobility, impairment in any basic activity of daily living, malnutrition, incontinence, confusion or dementia, prolonged bed rest, recent falls, depression, social or family problems, an unplanned readmission to the hospital within three months of a previous hospital stay, a new fracture, and age of 80 years or older. Of the 1337 patients assigned to the experimental group, 1261 (94 percent) received a comprehensive geriatric assessment in the form of a consultation, with limited follow-up; the 1016 patients assigned to the control group received usual care. The functional and health status of the patients was measured at base line and 3 and 12 months later; survival was assessed at 12 months. Subgroups of patients who might be presumed to benefit from comprehensive assessment were also studied. RESULTS: The survival rate at 12 months was 74 percent in the experimental group and 75 percent in the control group. At base line, 3 months, and 12 months the scores of the two groups on measures of functional and health status were similar. The analysis of 16 subgroups did not identify any with either clearly improved functional status or improved survival. CONCLUSIONS: In this HMO, comprehensive geriatric assessment by a consultation team, with limited follow-up, did not improve the health or survival of hospitalized patients selected on the basis of screening criteria.

Activities of Daily Living↗
PubMed1995

A geriatric assessment and intervention team for hospital inpatients awaiting transfer to a geriatric unit: a randomized trial.

The objective of this study, designed as a randomized controlled trial, was to decrease the length-of-stay (LOS) of hospitalized patients on a waiting list for admission to an inpatient geriatric assessment unit (GAU), and to optimize use of the GAU and other hospital services. The participants included 108 elderly, functionally impaired inpatients referred for geriatric consultation, and appropriate for GAU admission, stratified into high and low ADL functioning groups. They were admitted to a 354-bed acute hospital, with a 31-bed long-stay ward and a 15-bed GAU; a 25-30 day delay occurred between screening and admission of inpatients to the GAU. Experimental subjects (N = 25) received the consultative services of a geriatric assessment and intervention team (GAIT) immediately after being qualified for GAU admission, in place of waiting for GAU services. Controls (N = 52) received usual hospital care until admitted to the GAU. While high-function patients randomized to the GAIT had significantly shorter hospital LOS than comparable controls (41.4 vs 56.5 days; p = 0.03), LOS reduction was even greater in the low-function stratum (44.5 vs 74.5 days; p = 0.001). Further, significantly more GAIT than control patients were discharged home (28% vs 11%; p = 0.044). A trend toward reduced mortality in the GAIT group was non-significant. We conclude that for Canadian hospitals in which extensive stays of frail elderly patients, "bed blockage", and thus access to unit-based geriatric services are common problems, the GAIT can efficiently decrease hospital LOS, increase home placement, and may improve outcomes.

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PubMed1995

The Sepulveda GEU Study revisited: long-term outcomes, use of services, and costs.

The randomized controlled trial of the Geriatric Evaluation Unit (GEU) at the Sepulveda Veterans Hospital was the first to document the clinical and cost-effectiveness of hospital-based comprehensive geriatric assessment (CGA). Frail elderly inpatients were assigned randomly to the GEU for CGA, therapy, rehabilitation, and placement (N = 63), or to standard hospital care (N = 60). At one year, GEU patients had much lower mortality (24% vs 48%) and were less likely to have been discharged to a nursing home (NH) (13% vs 30%), or to have spent any time in NHs (27% vs 47%). GEU patients were more likely to improve in personal self-maintenance and morale. Further, controls had substantially more acute-care hospital days, NH days, and hospital readmissions, resulting in higher direct institutional care costs, especially after survival adjustment. Here, we report the results of long-term follow-up. There was a significant survival effect through two years. Despite prolongation of life, there was no indication that quality of life was worse for survivors in the GEU group. In fact, the proportion of persons independent in > or = 2 ADLs at two years was somewhat higher for GEU patients (0.44) than controls (0.33) (z = 1.27; p = 0.056). By three years, 43% of GEU subjects and 38% of controls were still alive. Over the entire 3-year period, the per capita direct cost difference was not significant, either before or after survival adjustment (unadjusted: $37,091 GEU vs $34,205 control; survival-adjusted: $54,315 GEU vs $63,362 control; p = 0.17).(ABSTRACT TRUNCATED AT 250 WORDS)

Activities of Daily Living↗
PubMed1995

Community physicians' cooperation with a program of in-home comprehensive geriatric assessment.

OBJECTIVES: To study the cooperation of primary care physicians with a community-based prevention and health promotion program for older persons, to study physician factors related to cooperation, and to determine any relationship between physician cooperation and patient adherence to program recommendations and patient satisfaction with health care. DESIGN AND SETTING: A survey administered in subjects' homes and physicians' offices in Santa Monica, California. PARTICIPANTS: Patients (n = 81) were intervention group subjects in a 3-year, randomized, controlled trial of in-home comprehensive geriatric assessment paired with prevention and health promotion. Physicians (n = 50) were selected if they had been contacted at least once by a study nurse practitioner about one of these patients. MEASUREMENTS: Physician cooperation was rated by study nurse practitioners. Physicians were interviewed to identify factors associated with cooperation. Patients' satisfaction with health care and adherence were measured prospectively throughout the 3-year program. MAIN RESULTS: Physicians exhibiting better cooperation had fewer years in practice (P = .03) and were more likely to discuss the program with their patients (P = .005), see benefit for their patients from the program (P = .02), and rate program information as useful (P = .002). Higher physician cooperation did not predict higher patient satisfaction (P = .23) but did predict higher patient adherence to program recommendations (P = .02). CONCLUSIONS: Physicians rated as cooperative were more likely to have a positive appraisal of the program, and their patients had higher adherence to program recommendations. These findings suggest that strategies for increasing primary care physician cooperation might improve effectiveness of similar community-based prevention and health promotion programs.

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PubMed1995

Hyponatremia in a nursing home population.

OBJECTIVE: To determine the prevalence of hyponatremia in a nursing home population and to identify clinical factors that increase the risk for development of hyponatremia. DESIGN: Retrospective and prospective record review. SETTING: A Veterans Affairs nursing home care unit. PATIENTS: One hundred nineteen residents, who ranged in age from 60 to 103 years. Sixty ambulatory patients, 62 to 91 years of age, who attended a geriatric medicine outpatient clinic served as a reference population. MEASUREMENTS: Most recent serum sodium, creatinine, BUN, and all serum sodium determinations during the preceding 12 months; clinical diagnoses, diet, medications, and significant events at the time of recorded hyponatremic episodes; response to acute water loading in a subset of patients; number of deaths in the 12 months following entry into the study. RESULTS: In the 119 nursing home patients, ages 60 years or older, the most recent serum sodium identified 18% who were hyponatremic, compared with a prevalence of 8% in similarly aged ambulatory patients. When all serum sodium determinations for the previous 12 months were examined, 53% of the nursing home patients had at least one episode of hyponatremia during this time period. There was a high incidence of central nervous system (CNS) and spinal cord disease in the total nursing home population. Episodes of hyponatremia were frequently associated with an increased intake of fluids, given either orally or intravenously, and with tube feeding. Water load testing revealed abnormal water handling consistent with the syndrome of inappropriate antidiuretic hormone (ADH) secretion in 18 of 23 patients who had a history of hyponatremia. Seventeen percent of the patients with hyponatremia died over the following 12 months, compared to a death rate of 21% in the normonatremic patients. CONCLUSIONS: Hyponatremia is a common occurrence in nursing home residents and may be a consequence of abnormal ADH secretion resulting from CNS disease. Exposure to increased fluid intake, or to a low sodium tube-feeding diet, can lead to the onset of hyponatremia or to a worsening of an already present low-serum sodium concentration.

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PubMed1994

Inappropriate medication use in community-residing older persons.

BACKGROUND: Elderly patients taking inappropriate drugs are at increased risk for adverse outcomes. We investigated the prevalence of inappropriate drug use and its predisposing factors in community-residing older persons. METHODS: We conducted in-home interviews with 414 subjects aged 75 years and older living in the community of Santa Monica, Calif. Inappropriate medication use was evaluated using explicit criteria developed through a modified Delphi consensus process. These criteria identified drugs that should generally be avoided in elderly community-residing subjects regardless of dosage, duration of therapy, or clinical circumstances. RESULTS: Based on these conservative criteria, 14.0% of the subjects were using at least one inappropriate drug. The most common examples were long-acting benzodiazepines, persantine, amitriptyline, and chlorpropamide. Subjects using three or more prescription drugs, compared with one or two, were more likely to be taking an inappropriate medication (odds ratio, 3.9; 95% confidence interval, 1.9 to 7.9). Furthermore, subjects with depressive symptoms had a higher risk of receiving inappropriate medications than nondepressive subjects (odds ratio, 2.2; 95% confidence interval, 1.1 to 4.1). CONCLUSIONS: Inappropriate drug use is a common problem in community-residing older persons. The risk of inappropriate drug use is increased in patients taking multiple medications and in patients with depressive symptoms.

Age Factors↗
PubMed1994

Falls in the nursing home.

OBJECTIVE: To review the epidemiology and causes of falls and fall-related injuries in nursing homes and to provide clinicians with a structured framework to evaluate and treat nursing home residents at risk for falls. DATA SOURCES: All large-scale published studies documenting incidence, causes, risk factors, and preventive strategies for falls in nursing homes were reviewed. RESULTS: The mean incidence of falls in nursing homes is 1.5 falls per bed per year (range, 0.2 to 3.6 falls). The most common precipitating causes include gait and balance disorders, weakness, dizziness, environmental hazards, confusion, visual impairment, and postural hypotension. The most important underlying risk factors for falls and injuries include some of these same items and others, such as lower-extremity weakness, gait and balance instability, poor vision, cognitive and functional impairment, and sedating and psychoactive medications. Many strategies for the prevention of falls have been tried, with mixed success. The most successful consider the multifactorial causes of falls and include interventions to improve strength and functional status, reduce environmental hazards, and allow staff to identify and monitor high-risk residents. Strategies that reduce mobility through use of restraints have been shown to be more harmful than beneficial and should be avoided. CONCLUSIONS: A focused history and physical examination after a fall can usually determine both the immediate underlying causes of the fall and contributing risk factors. In addition, regular evaluations in the nursing home can help identify patients at high risk who can then be targeted for specific treatment and prevention strategies.

Accidental Falls↗