Biomedical subjects

Laurence Z Rubenstein

Publications and source records attributed to Laurence Z Rubenstein.

At least 19 recordsLinked to original sources

PubMed2007

Will my patient fall?

CONTEXT: Effective multifactorial interventions reduce the frequent falling rate of older patients by 30% to 40%. However, clinical consensus suggests reserving these interventions for high-risk patients. Limiting fall prevention programs to high-risk patients implies that clinicians must recognize features that predict future falls. OBJECTIVE: To identify the prognostic value of risk factors for future falls among older patients. DATA SOURCES AND STUDY SELECTION: Search of MEDLINE (1966-September 2004), CINAHL (1982-September 2004), and authors' own files to identify prospective cohort studies of risk factors for falls that performed a multivariate analysis of such factors. DATA EXTRACTION: Two reviewers independently determined inclusion of articles and assessed study quality. Disagreements were resolved by consensus. Included studies were those identifying the prognostic value of risk factors for future falls among community-dwelling persons 65 years and older. Clinically identifiable risk factors were identified across 6 domains: orthostatic hypotension, visual impairment, impairment of gait or balance, medication use, limitations in basic or instrumental activities of daily living, and cognitive impairment. DATA SYNTHESIS: Eighteen studies met inclusion criteria and provided a multivariate analysis including at least 1 of the risk factor domains. The estimated pretest probability of falling at least once in any given year for individuals 65 years and older was 27% (95% confidence interval, 19%-36%). Patients who have fallen in the past year are more likely to fall again [likelihood ratio range, 2.3-2.8]. The most consistent predictors of future falls are clinically detected abnormalities of gait or balance (likelihood ratio range, 1.7-2.4). Visual impairment, medication variables, decreased activities of daily living, and impaired cognition did not consistently predict falls across studies. Orthostatic hypotension did not predict falls after controlling for other factors. CONCLUSIONS: Screening for risk of falling during the clinical examination begins with determining if the patient has fallen in the past year. For patients who have not previously fallen, screening consists of an assessment of gait and balance. Patients who have fallen or who have a gait or balance problem are at higher risk of future falls.

Accidental Falls↗

PubMed2006

National outpatient medication profiling: medications associated with outpatient fractures in community-dwelling elderly veterans.

AIMS: The primary objective of this retrospective case-control study in an elderly veteran population was to assess the impact of specific medications with recognized side-effects that increase the risk of a fall and were prescribed prior to fractures treated in the outpatient setting compared with patients treated for nonspecific chest pain. METHODS: Two national Veterans Health Administration (VHA) databases were used to identify 17 273 unique patients, aged > or =65 years, treated in outpatient settings with a fracture in fiscal year 2005, and for whom we could link to all of their outpatient prescriptions (809 536). For comparison, we identified other elderly patients with outpatient clinic visits for nonspecific chest pain (N = 62 331) for whom we could link with their 2 987 394 outpatient prescriptions. We categorized the fall-related medications as drugs that primarily affect the cardiovascular (CVS), the central nervous (CNS) or the muscular skeletal system (MSS). RESULTS: Significant differences in the two patient groups occurred in the CNS category. Approximately 41% of the patients with fracture-coded encounters were prescribed CNS drugs compared with 31% of the patients in the comparison group (P < 0.0003). Finally, the use of muscle relaxants in the MSS category was significantly higher in the fracture group than in the nonspecific chest pain group. CONCLUSIONS: Studies using administrative data can foster the development of more proactive pharmacovigilance systems and assist in formulary refinement, particularly in countries with national healthcare systems that have integrated patient data. Particular attention and monitoring of elderly patients taking CNS medications may be important for injury prevention.

Accidental Falls↗

PubMed2006

Orthostatic hypotension in the nursing home setting.

Orthostatic hypotension is a common condition among nursing home (NH) residents. NH residents tend to have multiple disease processes and tend to be on multiple medications associated with orthostatic hypotension and are predisposed to a myriad of negative clinical consequences, most notably falls. This article discusses a commonsense approach to diagnosis, evaluation, and treatment of patients with this disorder, with an emphasis on nonpharmacological interventions, such as patient and staff education.

Accidental Falls↗

PubMed2006

Falls in the nursing home: are they preventable?

INTRODUCTION: Falls are prevalent in elderly patients residing in nursing homes, with approximately 1.5 falls occurring per nursing home bed-years. Although most are benign and injury-free, 10% to 25% result in hospital admission and/or fractures. Primary care providers for nursing home residents must therefore aim to reduce both the fall rate as well as the rate of fall-related morbidity in the long-term care setting. Interventions have been demonstrated to be successful in reducing falls in community-dwelling elderly patients. However, less evidence supports the efficacy of fall prevention in nursing home residents. METHODS: The authors conducted a Medline search using the key words Falls and Nursing Homes. RESULTS: Several studies examined the efficacy of multifaceted intervention programs on reducing falls in nursing homes with varied results. Components of these intervention programs include: environmental assessment, assistive device evaluation and modification, medication changes, gait assessment and training, staff education, exercise programs, hip protector use, and blood pressure evaluation. Current literature supports the use of environmental assessment and intervention in reducing falls in nursing homes, and demonstrates an association between certain medications and falls. However, there are no studies that examine the effect of medication adjustments on fall rates. Also, the literature does not strongly suggest that exercise programs are effective in fall reduction. Although not effective in reducing fall rates, the use of hip protectors appears to result in less fall-related morbidity. CONCLUSION: More studies must be done to clarify the effects of high-risk medication reduction, the optimal nature and intensity of exercise programs, and patient targeting criteria to maximize the effectiveness of nursing home fall prevention programs. Based on the current literature, an effective multifaceted fall prevention program for nursing home residents should include risk factor assessment and modification, staff education, gait assessment and intervention, assistive device assessment and optimization, as well as environmental assessment and modification. Although there is no association between the use of hip protectors and fall rates, their use should be encouraged because the ultimate goal of any fall prevention program is to prevent fall-related morbidity.

Journal Article↗

PubMed2006

Promoting physical activity and exercise in older adults.

Although the benefits of increased physical activity and exercise are universally recognized, many older persons remain sedentary, and relatively few achieve recommended levels of activity. Effective interventions to reverse the lack of physical activity in older adults are clearly needed. By understanding correlates of inactivity and appreciating those factors that contribute to a sedentary lifestyle, appropriate strategies can be employed to help order patients reap the benefits of increased physical activity and exercise. In this article, we offer to the reader a brief overview of the field as well as our own thoughts on how clinicians might help individual patients at a more practical level.

Aged↗

PubMed2006

Falls and their prevention in elderly people: what does the evidence show?

A large proportion of falls and fall injuries in older people is due to multiple risk factors, many of which probably can be modified or eliminated with targeted fall prevention interventions. These interventions must be feasible, sustainable, and cost effective to be practical for widespread use. The most promising prevention strategies involve multidimensional fall risk assessment and exercise interventions. Incorporating these intervention strategies whenever feasible into a fall prevention program seems to be the most effective means for fall prevention in older adults.

Accidental Falls↗

PubMed2006

Falls in older people: epidemiology, risk factors and strategies for prevention.

Falls are a common and often devastating problem among older people, causing a tremendous amount of morbidity, mortality and use of health care services including premature nursing home admissions. Most of these falls are associated with one or more identifiable risk factors (e.g. weakness, unsteady gait, confusion and certain medications), and research has shown that attention to these risk factors can significantly reduce rates of falling. Considerable evidence now documents that the most effective (and cost-effective) fall reduction programmes have involved systematic fall risk assessment and targeted interventions, exercise programmes and environmental-inspection and hazard-reduction programmes. These findings have been substantiated by careful meta-analysis of large numbers of controlled clinical trials and by consensus panels of experts who have developed evidence-based practice guidelines for fall prevention and management. Medical assessment of fall risks and provision of appropriate interventions are challenging because of the complex nature of falls. Optimal approaches involve interdisciplinary collaboration in assessment and interventions, particularly exercise, attention to co-existing medical conditions and environmental inspection and hazard abatement.

Accident Prevention↗

PubMed2006

National Veterans Health Administration hospitalizations for syncope compared to acute myocardial infarction, fracture, or pneumonia in community-dwelling elders: outpatient medication and comorbidity profiles.

The authors used 2 national Veterans Health Administration databases to identify outpatient medications and all 30 Elixhauser comorbidities for 2579 unique patients, age 65+ years, hospitalized for syncope in fiscal year 2004. For comparison, we identified other elderly patients hospitalized with acute myocardial infarction (N = 4491), fracture (N = 2797), or pneumonia (N = 9473). The categories of medications included drugs that affect the cardiovascular, central nervous, or the muscular skeletal system. The most notable differences between syncope compared to acute myocardial infarction patients occurred in central nervous system drugs in anticonvulsants/barbiturates, antidepressants, antihistamine/antinauseants, antipsychotics, and cholinesterase inhibitors (P < .0018). Comparing syncope patients with fracture patients, the central nervous medication profile was similar, but the cardiovascular medication profile differed (P < .0018); their hypertension comorbidities also differed (60.45% vs 46.34%); (P < .0016). These findings indicate significant potential associations that warrant further study. Studies linking national outpatient medications to hospitalizations for specific conditions can foster the development of more proactive pharmacovigilance systems.

Aged↗

PubMed2005

Developing quality indicators for elderly patients undergoing abdominal operations.

BACKGROUND: Although the expanding and aging population will likely increase demand for surgical services, surgeons and other providers must develop strategies to optimize care. We sought to develop process-based quality indicators for elderly patients undergoing abdominal operations to identify necessary and meaningful ways to improve care in this cohort. STUDY DESIGN: Through structured interviews with thought leaders and systematic reviews of the literature, we identified candidate quality indicators addressing perioperative care in elderly patients undergoing abdominal operations. Using a modification of the RAND/UCLA Appropriateness Methodology, an expert panel of physicians in surgery, geriatrics, anesthesia, internal, and rehabilitation medicine formally rated and discussed the indicators. RESULTS: Eighty-nine candidate indicators were identified and categorized into seven domains: comorbidity assessment (eg, cardiopulmonary disease), elderly issues (eg, cognition), medication use (eg, polypharmacy), patient-to-provider discussions (eg, life-sustaining preferences), intraoperative care (eg, preventing hypothermia), postoperative management (eg, preventing delirium), and discharge planning (eg, home health care). Of the 89 candidate indicators, 76 were rated as valid by the expert panel. Importantly, the majority of indicators rated as valid address processes of care not routinely performed in younger surgical populations. CONCLUSIONS: Attention to the quality of surgical care in elderly patients is of great importance because of the increasing numbers of elderly undergoing operations. This project used a validated methodology to identify and rate process measures to achieve high-quality perioperative care for elderly surgical patients. This is the first time quality indicators have been developed in this regard.

Aged↗

PubMed2005

Using administrative data to track fall-related ambulatory care services in the Veterans Administration Healthcare system.

BACKGROUND AND AIMS: The Veterans Administration (VA) Healthcare system, containing hospital and community-based outpatient clinics, provides the setting for the study. Summary data was obtained from the VA Ambulatory Events Database for fiscal years (FY) 1997-2001 and in-depth data for FY 2001. In FY 2001, the database included approximately 4 million unique patients with 60 million encounters. The purpose of this study was: 1) to quantify injuries and use of services associated with falls among the elderly treated in Veterans Administration (VA) ambulatory care settings using administrative data; 2) to compare fall-related services provided to elderly veterans with those provided to younger veterans. METHODS: Retrospective analysis of administrative data. This study describes the trends (FY 1997-2001) and patterns of fall-related ambulatory care encounters (FY 2001) in the VA Healthcare System. RESULTS: An approximately four-fold increase in both encounters and patients seen was observed in FY 1997-2001, largely paralleling the growth of VA ambulatory care services. More than two-thirds of the patients treated were found to be over the age of 65. Veterans over the age of 65 were found to be more likely to receive care in the non-urgent setting and had higher numbers of co-morbid conditions than younger veterans. While nearly half of the encounters occurred in the Emergency/Urgent Care setting, fall-related injuries led to services across a wide spectrum of medical and surgical providers/departments. CONCLUSIONS: This study represents the first attempt to use the VA Ambulatory Events Database to study fall-related services provided to elderly veterans. In view of the aging population served by the VA and the movement to provide increased services in the outpatient setting, this database provides an important resource for researchers and administrators interested in the prevention and treatment of fall-related injuries.

Accidental Falls↗

PubMed2005

Appetite assessment: simple appetite questionnaire predicts weight loss in community-dwelling adults and nursing home residents.

BACKGROUND: Anorexia-related weight loss can have devastating consequences on quality-of-life, morbidity, and mortality. Without a simple tool to evaluate appetite, health care providers often use inaccurate surrogates, such as measurement of energy consumption and nutritional risk, to reflect appetite. OBJECTIVE: We aimed to validate a simple tool for assessing appetite and predicting weight loss. DESIGN: This was a cross-sectional measurement study conducted on long-term care residents and community-dwelling adults. Construct validity of the 8-item Council on Nutrition appetite questionnaire (CNAQ) and its 4-item derivative, the simplified nutritional appetite questionnaire (SNAQ), were examined through correlation with a previously validated research tool: the appetite hunger and sensory perception questionnaire (AHSP). The length and complexity of the AHSP render it inefficient for clinical use. The sensitivity and specificity of the CNAQ and SNAQ to predict significant weight loss were calculated. RESULTS: Cronbach's alpha coefficients for the CNAQ were 0.47 (long-term care group) and 0.72 (community-dwelling group). In the long-term care group, the CNAQ correlated with the AHSP (r = 0.60, P < 0.001) and with the AHSP domains of taste (r = 0.47, P < 0.0001), hunger (r = 0.51, P < 0.0001), and smell (r = 0.53, P < 0.0001). The CNAQ showed sensitivities and specificities for 5% and 10% weight losses of 80.2 and 80.3 and 82.4 and 81.9, respectively. The SNAQ had sensitivities and specificities for 5% and 10% weight losses of 81.3 and 76.4 and 88.2 and 83.5, respectively. CONCLUSIONS: The SNAQ and CNAQ are short, simple appetite assessment tools that predict weight loss in community-dwelling adults and long-term care residents. The SNAQ is a 4-item derivative of the CNAQ and thus is clinically more efficient.

Adult↗

PubMed2005

Monitoring falls in cohort studies of community-dwelling older people: effect of the recall interval.

OBJECTIVES: To determine whether the interval over which patients are asked to remember their falls affects fall reporting. DESIGN: Systematic literature review. SETTING: Community. PARTICIPANTS: Individuals being monitored for falls in prospective studies that asked participants to recall falls over varying intervals. MEASUREMENTS: Sensitivity and specificity of retrospective recall compared with a criterion-standard prospective assessment using some form of ongoing fall monitoring. RESULTS: Six studies met the inclusion criteria. Recall of falls in the previous year was specific (specificity 91-95%) but less sensitive (sensitivity 80-89%) than the criterion standard of ongoing prospective collection of fall data using fall calendars or postcards. Patients with injurious falls were more likely to recall their falls. Lower Mini-Mental State Examination score was associated with poorer recall of falls in the one study addressing this issue. CONCLUSION: Whenever accurate data on all falls are critical, such as with interventions to decrease the rate of falls, researchers should gather information on falls every week or every month from study participants. The optimal method of fall monitoring--postcard, calendar, diary, telephone, or some combination of these--remains unknown.

Accidental Falls↗

PubMed2005

Depression in older patients admitted for postacute nursing home rehabilitation.

OBJECTIVES: To describe the prevalence, recognition, and persistence of depression in older adults undergoing postacute rehabilitation in a nursing home (NH) setting and to explore the effect of depression on rehabilitation outcomes. DESIGN: Prospective cohort study. SETTING: One rehabilitative NH in the Los Angeles area. PARTICIPANTS: One hundred fifty-eight patients (aged >/=65) admitted for postacute rehabilitation over a 9-month recruitment period. MEASUREMENTS: Depression was assessed using the 15-item Geriatric Depression Scale (GDS-15) or the Cornell Scale for Depression (in participants with dementia). Medical records were reviewed for documentation of depression and antidepressant use before and during the rehabilitative NH stay. Rehabilitation process was assessed using total amount of successfully completed therapy (minutes). Rehabilitation outcome was assessed using the motor component of the Functional Independence Measure (mFIM). Measures were performed at admission and 2 months later. RESULTS: Of the 646 potentially eligible patients admitted during the study, 158 consented, and 151 were screened for depression. Forty-two (27.8%) had depressive symptoms (GDS=6 or Cornell=5). Of these, only 15 had a documented diagnosis of depression, and 12 were receiving antidepressants. Depression was associated with longer NH stay but not with discharge mFIM score. Two months later, depression persisted in 24 participants and was associated with worse mFIM (55.5+/-22.7 vs 67.0+/-23.7, depressed vs nondepressed; P=.03). CONCLUSION: Depression was common, underrecognized, and undertreated in these postacute rehabilitation patients. Depression generally persisted and was associated with worse functional status at 2-month follow-up.

Acute Disease↗

PubMed2005

Home-based comprehensive assessment of rural elderly persons: the CARE project.

CONTEXT: Home-based comprehensive geriatric assessment (CGA) has been effective in urban areas but has had little study in rural areas. CGA involves medical history taking, a physical exam, and evaluation of functional status, mental status, cognitive status, gait and balance, medications, vision, extent of social supports, and home safety. We sought to develop and pilot a model of rural home-based CGA to determine whether successful urban models can be adapted to rural areas. METHODS: This study was a developmental demonstration project with qualitative and quantitative evaluation components of a home-based CGA model using a home health agency and a geriatrician participating from a remote location by teleconference. Findings and recommendations were relayed to patients, caregivers, and primary physicians. The population studied was elderly volunteers (N = 51) aged 75 years and older who did not have a terminal diagnosis or immediate plans to enter a long-term care facility. Survey instruments and focus groups were used with subjects, family members or caregivers, and physicians to generate refinements and outcome measures for the model. FINDINGS: Among the 51 patients undergoing CGA, Instrumental Activities of Daily Living dependency and balance and gait problems were highly prevalent. Means of 1.1 major problems and 4.9 nonmajor problems were identified per patient. Recommendations were implemented for 32% of major problems and for 35% of nonmajor problems. Primary physicians found recommendations for vaccination and home safety change helpful but were skeptical of physical examination findings by the nurse. Practitioners noted that this study resulted in several positive outcomes: (1) some subjects initiated regular clinic visits; (2) several visually impaired elders began services for the blind; (3) identification of gait and balance problems resulted in physical therapy treatment; and (4) identification of caregiver stress was addressed by social-work intervention. Potential further refinements of the model for rural home-based CGA were identified. CONCLUSIONS: Home-based CGA identifies important problems of rural older adults. However, modifications are still needed to create a truly effective process.

Activities of Daily Living↗

PubMed2004

Interventions for the prevention of falls in older adults: systematic review and meta-analysis of randomised clinical trials.

OBJECTIVE: To assess the relative effectiveness of interventions to prevent falls in older adults to either a usual care group or control group. DESIGN: Systematic review and meta-analyses. DATA SOURCES: Medline, HealthSTAR, Embase, the Cochrane Library, other health related databases, and the reference lists from review articles and systematic reviews. DATA EXTRACTION: Components of falls intervention: multifactorial falls risk assessment with management programme, exercise, environmental modifications, or education. RESULTS: 40 trials were identified. A random effects analysis combining trials with risk ratio data showed a reduction in the risk of falling (risk ratio 0.88, 95% confidence interval 0.82 to 0.95), whereas combining trials with incidence rate data showed a reduction in the monthly rate of falling (incidence rate ratio 0.80, 0.72 to 0.88). The effect of individual components was assessed by meta-regression. A multifactorial falls risk assessment and management programme was the most effective component on risk of falling (0.82, 0.72 to 0.94, number needed to treat 11) and monthly fall rate (0.63, 0.49 to 0.83; 11.8 fewer falls in treatment group per 100 patients per month). Exercise interventions also had a beneficial effect on the risk of falling (0.86, 0.75 to 0.99, number needed to treat 16) and monthly fall rate (0.86, 0.73 to 1.01; 2.7). CONCLUSIONS: Interventions to prevent falls in older adults are effective in reducing both the risk of falling and the monthly rate of falling. The most effective intervention was a multifactorial falls risk assessment and management programme. Exercise programmes were also effective in reducing the risk of falling.

Accident Prevention↗

PubMed2004

Effect of preventive home visits for ambulatory housebound elders in Japan: a pilot study.

BACKGROUND AND AIMS: Programs of preventive home visits for ambulatory housebound elders have not yet become established in Japan. The aim of this randomized pilot study was to investigate effects of such visits by public health nurses in Japan. METHODS: A randomized controlled study with 18-month follow-up was conducted in a small Japanese agricultural town. Participants (n=119) were ambulatory housebound elders aged 65 and over, who were able to walk but who went outdoors less than three times a week at baseline survey. They were randomly assigned to intervention (n=59) or control group (n=60). Intervention group subjects received preventive home visits by public health nurses over 18 months (mean home visits=4.3). Control group subjects received usual primary and community care. Activities of daily living (ADLs), functional capacity, self-efficacy for daily activities, self-efficacy for health promotion, depression, and social support were collected via questionnaire at baseline and at the 18-month follow-up point. RESULTS: At follow-up, 81.4% of intervention group subjects were still living at home vs 73.3% of control group subjects (NS). Simple group comparisons following repeated measures (ANCOVA) showed that the intervention group had higher ADL scores than the control group at follow-up (p=0.044). CONCLUSIONS: These pilot results suggest that home visits by public health nurses may be effective in helping to reduce ADL decline among ambulatory housebound elders.

Activities of Daily Living↗

PubMed2004

Case finding for population-based studies of rheumatoid arthritis: comparison of patient self-reported ACR criteria-based algorithms to physician-implicit review for diagnosis of rheumatoid arthritis.

OBJECTIVE: To evaluate the interrater reliability of rheumatologist diagnosis of rheumatoid arthritis (RA) and the concordance between rheumatologist and computer algorithms for assessing the accuracy of a diagnosis of RA. METHODS: Self-reported data regarding symptoms and signs for a diagnosis of RA were considered by a panel of rheumatologists and by computer algorithms to assess the probability of a diagnosis of RA for 90 patients. The rheumatologists' review was validated through medical record. RESULTS: The interrater reliability among rheumatologists regarding a diagnosis of RA was 84%; the chance-corrected agreement (kappa) was 0.66. Agreement between the rheumatologists' rating and the best-performing algorithm was 95%. Using rheumatologist's review as a standard, the sensitivity of the algorithm was 100%, specificity was 88%, and the positive predictive value was 91%. The validation of rheumatologist's review by medical record showed 81% sensitivity, 60% specificity, and 78% positive predictive value. CONCLUSION: Reliability of rheumatologists' assignment of a diagnosis of RA by using self-report data is good. Algorithms defining symptoms as either joint swelling or tenderness with symptom duration >or=4 weeks have a better agreement with rheumatologist's diagnosis than do ones relying on a longer symptom duration. RELEVANCE: These findings have important implications for health services research and quality improvement interventions pertinent to case finding for RA through self-report data.

Algorithms↗

PubMed2004

Development and evaluation of a patient self-report case-finding method for rheumatoid arthritis.

OBJECTIVE: To describe the development and evaluation of a patient self-report case-finding method for rheumatoid arthritis (RA) not dependent on direct contact with the treating physicians. METHODS: The American College of Rheumatology criteria for RA diagnosis were adapted for patient self-report using a questionnaire, and alternative scoring algorithms were evaluated to balance case-finding sensitivity and specificity. Positive rheumatoid factor tests were used to identify 1053 individuals in 2 large healthcare organizations; 440 agreed to receive study materials. Case-finding results were validated by medical record review (MRR) for a random sample of 90 patients. Three scoring algorithms were compared with MRR for likelihood of RA diagnosis. Cases not classifiable by algorithm were flagged and reviewed by 2 expert physicians for likelihood of RA diagnosis. RESULTS: Pilot testing demonstrated that patients comprehended the questionnaire and were willing to answer the questions. Completed questionnaires were returned by 265 (60%) of the 440 patients contacted. Following expert physician review of 16 flagged cases in the 90-patient MRR subsample, the most accurate scoring algorithm demonstrated 80% sensitivity, 67% specificity, 74% accuracy, and 77% positive predictive value for detecting early RA. CONCLUSION: The case-finding method represents a promising tool for identifying RA patients, with potential application in research and quality-assurance activities. RELEVANCE: This case-finding method should be useful in research and quality-assurance efforts requiring identification of RA patients treated by all types of providers in healthcare organizations in which centralized laboratory data are available.

Arthritis, Rheumatoid↗