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Biomedical subjects

David B Reuben

Publications and source records attributed to David B Reuben.

At least 37 records · Page 2Linked to original sources
PubMed2004

Cumulative biological risk and socio-economic differences in mortality: MacArthur studies of successful aging.

Previous research has suggested that socio-economic status (SES) differences in mortality are only partially explained by differences in life-style, psychological and social factors. Seven year mortality data (1988-1995) from the MacArthur Study of Successful Aging, a longitudinal study of adults, aged 70-79, from New Haven, CT; East Boston, MA; and Durham, NC; were used to test the hypothesis that a cumulative measure of biological dysregulation ("allostatic load"), reflecting multiple regulatory systems, would serve as a further mediator of SES differences in mortality. Logistic regression analyses revealed that a cumulative index of biological risk explained 35.4% of the difference in mortality risk between those with higher versus lower SES (as measured by less than high school education versus high school or greater educational attainment). Importantly, the cumulative index provided independent explanatory power, over and above a measure of doctor-diagnosed disease, though the latter also contributed to education-related variation in mortality risks. The summary measure of biological risk also accounted for more variance than individual biological parameters, suggesting the potential value of a multi-systems view of biological pathways through which SES ultimately affects morbidity and mortality.

Adaptation, Physiological↗
PubMed2004

Refining the categorization of physical functional status: the added value of combining self-reported and performance-based measures.

BACKGROUND: When considered individually, self-reported functional status and performance-based functional status predict functional status decline and mortality. However, what additional prognostic information is gained by combining these approaches remains unknown. METHODS: The authors used three waves of three sites (5138 participants) of the Established Populations for Epidemiologic Studies of the Elderly to determine the prognostic value of individual and combined approaches. Baseline self-reported (mobility and activities of daily living [ADL] items) and performance-based (Physical Performance Score) functional status information was classified into three and four hierarchical categories, respectively. RESULTS: Based on self-reported information alone, at 1 year, 73% participants had not changed, 15% declined, 6% improved, and 6% died. At 4 years, 53% had not changed, 24% declined, 2% improved, and 22% died. Based on performance-based assessment alone, at 4 years, 33% of the sample remained stable, 37% declined, 6% improved, and 24% died. In the top two self-reported categories, functioning on the performance-based assessment varied widely. Among those who were independent in all self-reported functioning, approximately 40% scored in each of the top two performance-based categories. Among persons in the top two self-reported categories, poorer performance was associated with progressively higher 1-year and 4-year mortality rates. Among persons with impaired mobility and at least 1 ADL dependency, the mortality rate was high and was not influenced by performance-based score. CONCLUSIONS: Combining self-reported and performance-based measurements can refine prognostic information, particularly among older persons with high self-reported functioning. However, if ADL dependency is present, performance-based measures do not add prognostic value regarding mortality.

Activities of Daily Living↗
PubMed2004

The effects of serum beta-carotene concentration and burden of inflammation on all-cause mortality risk in high-functioning older persons: MacArthur studies of successful aging.

BACKGROUND: It remains unclear to what extent the associations between low serum beta-carotene concentration and increased risk for cardiovascular disease and cancers are attributable to inflammation. The objective of this study was to evaluate simultaneously the effects of serum beta-carotene concentration and inflammation on the subsequent all-cause mortality risk in high-functioning older persons. METHODS: The authors conducted a prospective cohort study using information from 672 participants from the MacArthur Studies of Successful Aging. Baseline information was obtained for serum concentrations of beta-carotene, C-reactive protein, interleukin-6, cholesterols, and albumin; body mass index; waist:hip ratio; prevalent medical conditions; health behaviors; and medications. Sex-specific univariate and multivariate logistic regression analyses were used to study the effects of low beta-carotene, high inflammation burden, or both on 7-year all-cause mortality rates while adjusting for other confounders. RESULTS: The serum beta-carotene concentration was inversely associated with C-reactive protein and interleukin-6 levels. After adjustment for inflammation markers and other covariates, the relative risks for low beta-carotene for the 7-year all-cause mortality risk were 2.30 (95% confidence interval [CI], 1.23 to 4.31) in men and 0.85 (95% CI, 0.42 to 1.75) in women. Compared with men with high beta-carotene levels and low inflammation, the multiply adjusted relative risk for low beta-carotene and high inflammation burden was 3.78 (95% CI, 1.69 to 8.47) in men. CONCLUSIONS: Low levels of serum beta-carotene are independently associated with an increased all-cause mortality risk in older men, even after adjustment for the effects of inflammation and other risk factors. In men, but not women, a synergistic effect occurs between low beta-carotene concentration and high inflammation burden in predicting higher mortality rates.

Aged↗
PubMed2004

The effect of self-reported and performance-based functional impairment on future hospital costs of community-dwelling older persons.

PURPOSE: We determined the prognostic value of self-reported and performance-based measurement of function, including functional transitions and combining different measurement approaches, on utilization. DESIGN AND METHODS: Our cohort study used the 6th, 7th, and 10th waves of three sites of the Established Populations for Epidemiologic Studies of the Elderly, linked to 1- and 4-year Medicare Part A hospital costs. We examined mean hospital expenditures based on (a) 1- and 4-year transitions in self-reported functional status; (b) 4-year transitions in performance-based functional status; (c) combined baseline self-reported and performance-based functional status; and (d) poorest self-reported and performance-based functional status during a 4-year period. RESULTS: Even modest declines in self-reported or performance-based functional status were associated with increased expenditures. When baseline self-reported and performance-based assessments were combined, mean 1- and 4-year adjusted costs were higher with progressively worse performance-based scores, even among those who were independent in self-reported function. When the poorest 4-year self-reported and performance-based functions were examined, self-reported functioning was the most important determinant of hospital costs, but within each self-reported functional level, poorer performance-based function was associated with progressively higher costs. IMPLICATIONS: The costs associated with even modest functional decline are high. Combining self-reported and performance-based measurements can provide more precise estimates of future hospital costs.

Activities of Daily Living↗
PubMed2004

Increases in serum non-high-density lipoprotein cholesterol may be beneficial in some high-functioning older adults: MacArthur studies of successful aging.

UNLABELLED: objectives: To examine the association between changes in serum non-high-density lipoprotein cholesterol (non-HDL-C) over a 2.5-year period and risk of adverse health outcomes in the following 4.5 years in high-functioning older adults. DESIGN: Prospective cohort, established in 1988, with a follow-up in 1991 and 1995. SETTING: Population-based, community-dwelling men and women. PARTICIPANTS: A random sample (n=267) from the MacArthur cohort (N=1,189). The cohort represented the highest-functioning tertile of 4,030 screened candidates aged 70 to 79. MEASUREMENTS: Change in non-HDL-C between 1988 and 1991 was measured as a predictor of health outcomes between 1991 and 1995, including all-cause mortality, and among survivors, incident heart attack or stroke, development of new disability in basic activities of daily living, and decline in performance on the Short Portable Mental Status Questionnaire. RESULTS: More-positive change in non-HDL-C between 1988 and 1991 was associated with fewer adverse outcomes between 1991 and 1995. In individuals whose total cholesterol at baseline was in the middle two quartiles (195-244 mg/dL), each 10-mg/dL increase in the 1988-to-1991 change in non-HDL-C was associated with an adjusted mortality odds ratio (OR) of 0.67 (95% confidence interval (CI)=0.51-0.88). In individuals without cardiovascular disease at baseline, the adjusted OR for new physical disability was 0.79 (95% CI=0.65-0.95) and for cognitive decline was 0.81 (95% CI=0.67-0.98). CONCLUSION: Increases in cholesterol over time have beneficial associations in some older adults. The role of cholesterol changes in the health of older individuals needs further exploration.

Activities of Daily Living↗
PubMed2004

Predictors of varying levels of nonadherence to mammography screening in older women.

OBJECTIVES: To identify predictors of varying levels of nonadherence to mammography screening in older women. DESIGN: Cross-sectional survey. SETTING: Sixty community-based sites where seniors gather. PARTICIPANTS: Consecutive volunteer sample of 499 women aged 60 to 84 who had not received a mammogram within the previous year. MEASUREMENTS: Three levels of nonadherence (never had a mammogram (never), mammogram more than 2 years before (lapsed), and mammogram in the past 1 to 2 years (due/reference group)). These were based on a Transtheoretical Model and incorporated into the Adherence Model. Bivariate and multivariate multinomial logistic regression analysis was used for variables obtained. RESULTS: Two risk factors, having difficulty getting to a facility and not intending to ask a health provider for a mammogram, were predictive of the never and lapsed levels. Distinct risk factors for being in the never compared with the due level of nonadherence included being concerned about pain, not being enrolled in a health maintenance organization, not getting preventive checkups, and being only somewhat (versus very) likely to ask a physician for mammogram. In contrast, distinct risk factors for the lapsed compared with the due level of nonadherence included perceiving that no friends have routine mammograms and not having a provider referral. CONCLUSION: Some risk factors for not being up to date with mammography vary by the level of nonadherence. Interventions should be individualized to women's level of nonadherence and include common core strategies that encourage women to ask for a mammogram and to lessen the difficulty of getting to a screening facility.

Age Factors↗
PubMed2004

Development and validation of a geriatric knowledge test for medical students.

OBJECTIVES: To assesses the reliability and validity of a geriatrics knowledge test designed for medical students. DESIGN: Cross-sectional studies. SETTING: An academic medical center. PARTICIPANTS: A total of 343 (86% of those sampled) medical students participated in the initial study, including 137 (76%) first-year, 163 (96%) third-year, and 43 (86% of those sampled) fourth-year students in the 2000-2001 academic year. To cross-validate the instrument, another 165 (92%) third-year and 137 (76%) first-year students participated in the study in the 2001-2002 academic year. MEASUREMENTS: An 18-item geriatrics knowledge test was developed. The items were selected from a pool of 23 items. An established instrument assessing the clinical skills of medical students was included in the validation procedure. RESULTS: The instrument demonstrated good reliability (Cronbach alpha=0.80) and known-groups and concurrent validity. Geriatrics knowledge scores increased progressively with the higher level of medical training (mean percentage correct=31.3, 65.3, and 66.5 for the first-year, third-year, and fourth-year classes, respectively, P<.001). A significant (P<.01) relationship was found between the third-year students' geriatrics knowledge and their clinical skills. Similar results, except the relationship between knowledge and clinical skills, were found in the cross-validation study, supporting the reliability and known-groups validity of the test. CONCLUSION: The 18-item geriatrics knowledge test demonstrated sound reliability and validity. The average scores of the student groups indicated substantial room for growth. The relationship between geriatrics knowledge and overall clinical skills needs further investigation.

Education, Medical, Undergraduate↗
PubMed2004

Disciplinary split: a threat to geriatrics interdisciplinary team training.

In 1995, the John A. Hartford Foundation launched an initiative to strengthen geriatric interdisciplinary team training (GITT) for advanced practice nursing and masters-level social work students and residents in internal medicine and family practice. As part of the national evaluation of the initiative, case-study and cross-case designs were employed using quantitative and qualitative data to examine the influence of cultures, regulations, and attitudes of individual disciplines on interdisciplinary training efforts at the first eight GITT programs. This evaluation found that attitudinal and cultural traditions of the different health professions faculty and students (disciplinary split) remain as important obstacles to creating an optimal interdisciplinary team-training experience. In general, physician trainees participated least enthusiastically in GITT. In part, this lower level of enthusiasm may have been the result of inconsistent medicine faculty support of the program. At all but one program, physician trainees also had shorter GITT training experiences than other disciplines. In addition, the disparity in level of training by discipline of GITT participants may have contributed to attitudinal barriers to interdisciplinary training. Discipline-specific regulatory and accreditation barriers also impede interdisciplinary training. Nevertheless, GITT experiences at some clinical sites, especially home visits, appeared to promote interdisciplinary training. Some barriers to creating and implementing GITT programs may be best approached at the level of accrediting agencies and certifying organizations. Others will require local and national efforts of leaders in the different disciplines to model and support good team care.

Aged↗
PubMed2004

Physician recognition of cognitive impairment: evaluating the need for improvement.

OBJECTIVES: To assess physician recognition of dementia and cognitive impairment, compare recognition with documentation, and identify physician and patient factors associated with recognition. DESIGN: Survey of physicians and review of medical records. SETTING: Health maintenance organization in southern California. PARTICIPANTS: Seven hundred twenty-nine physicians who provided care for women participating in a cohort study of memory (Women's Memory Study). MEASUREMENTS: Percentage of patients with dementia or cognitive impairment (using the Telephone Interview of Cognitive Status supplemented by the Telephone Dementia Questionnaire) recognized by physicians. Relationship between physician recognition and patient characteristics and physician demographics, practice characteristics, training, knowledge, and attitudes about dementia. RESULTS: Physicians (n=365) correctly identified 81% of patients with dementia and 44% of patients with cognitive impairment without definite dementia. Medical records documented cognitive impairment in 83% of patients with dementia and 26% of patients with cognitive impairment without definite dementia. In a multivariable model, physicians with geriatric credentials (defined as geriatric fellowship experience and/or the certificate of added qualifications) recognized cognitive impairment more often than did those without (risk ratio (RR)=1.56, 95% confidence interval (CI)=1.04-1.66). Physicians were more likely to recognize cognitive impairment in patients with a history of depression treatment (RR=1.3, 95% CI=1.03-1.45) or stroke (RR=1.37, 95% CI=1.04-1.45) and less likely to recognize impairment in patients with cognitive impairment without definite dementia than in those with dementia (RR=0.46, 95% CI=0.23-0.72) and in patients with a prior hospitalization for myocardial infarction (RR=0.37, 95% CI=0.09-0.88) or cancer (RR=0.49, 95% CI=0.18-0.90). CONCLUSION: Medical record documentation reflects physician recognition of dementia, yet physicians are aware of, but have not documented, many patients with milder cognitive impairment. Physicians are unaware of cognitive impairment in more than 40% of their cognitively impaired patients. Additional geriatrics training may promote recognition, but systems solutions are needed to improve recognition critical to provision of emerging therapies for early dementia.

Aged↗
PubMed2004

Building academic geriatric capacity: an evaluation of the John A. Hartford Foundation Centers of Excellence initiative.

Almost 15 years ago, the John A. Hartford Foundation began its Centers of Excellence (CoE) program. In summer 2002, a quantitative and qualitative evaluation of the CoE program was conducted. The evaluation used previously collected quantitative data from surveys of program directors and graduates of fellowship programs, as well as interviews and surveys of currently funded CoEs. Since its inception, the CoE program has supported 163 geriatrics fellows, of whom 63% entered academic geriatrics. Almost half of these graduating fellows have gone to new academic institutions. CoEs have also supported 222 faculty, including some who were in disciplines other than geriatrics. The vast majority (82%) have remained in academics, and nearly two-thirds are currently in geriatrics. As the priorities and needs of the institutions and geriatrics programs changed, most centers shifted their CoE priorities. These changes predominantly took two forms: a refocus from one activity to another or an expansion of outreach or levels of support. Based upon this formal evaluation, the Hartford-supported CoE program has been successful in strengthening academic geriatrics, particularly in attracting, developing, and retaining geriatrics faculty.

California↗
PubMed2004

Cognitive decline in high-functioning older persons is associated with an increased risk of hospitalization.

OBJECTIVES: To examine hospital use for patients with evidence of cognitive decline indicative of early cognitive impairment. DESIGN: Medicare Part A hospital utilization data were linked to data from the MacArthur Research Network on Successful Aging Community Study to examine the association between baseline cognition and decline in cognitive function over a 3-year period and any hospitalization over that same period. SETTING: New Haven, Connecticut, and East Boston, Massachusetts. PARTICIPANTS: Subjects (N=598) were from two sites of the MacArthur Research Network on Successful Aging Community Study, a 7-year cohort study of community-dwelling older persons with high physical and cognitive functioning. MEASUREMENTS: Multivariate logistic regression was used to determine the association between any hospitalization over 3 years (1988-91) as the outcome variable and baseline cognitive function and decline in cognition over 3 years as primary predictor variables. Decline was based upon repeated (1988 and 1991) measures of delayed verbal recall and the Short Portable Mental Status Questionnaire (SPMSQ). RESULTS: Of 598 subjects, 48 died between 1988 and 1991. No baseline (1988) delayed recall scores or change in recall scores (1988-91) were associated with hospitalization. Although 48.2% declined on verbal memory scores, decline was not associated with risk of hospitalization. Of 494 subjects with complete 3-year data, 31.2% declined at least one point on the SPMSQ, and 4.7% declined more than two points. Among individuals aged 75 and older at baseline, the adjusted odds ratio for hospitalization for those who declined more than 2 points compared with those who declined less was 7.8 (95% confidence interval=2.0-30.8). CONCLUSION: Although specific memory tests were not associated with hospitalization, high-functioning older persons who experienced decline in overall cognitive function were more likely to be hospitalized. Variation in baseline cognitive function in this high-functioning cohort did not affect hospitalization, but additional research is needed to evaluate associations with other healthcare costs.

Activities of Daily Living↗
PubMed2003

Identification of risk for high hospital use: cost comparisons of four strategies and performance across subgroups.

OBJECTIVES: To determine the relative costs of four risk-identification strategies and compare their performance in predicting hospital use by different subgroups of older persons based on age, sex, and prior hospital use. DESIGN: Prospective validation study and cost-comparison analysis. SETTING: Community-based. PARTICIPANTS: Five thousand one hundred thirty-eight participants of the sixth wave of three sites of the Established Populations for Epidemiologic Studies of the Elderly. MEASUREMENTS: Four strategies (prior hospitalization data only, a 10-item self-report screen alone, self-report combined with two laboratory tests, and sequential self-report plus as-needed use of laboratory tests when the self-report screen is inconclusive) and 3-year Medicare Part A hospital cost data. RESULTS: Assuming that interventions based on screening would yield a total benefit of $1,000 per true-positive case and a cost of $400 for each false-positive case, the sequential strategy was slightly less expensive than the self-report only strategy; both were considerably less expensive than the combined or hospitalization-only strategies. Accuracy as measured by the area under the receiver operating characteristic curve for the sequential strategy was comparable for all subgroups (between 0.62 and 0.70) but was least accurate for those who had high prior use and for those aged 85 and older. CONCLUSION: A sequential screening strategy that administers laboratory tests selectively is slightly less expensive than one that uses only self-report items. This strategy is also accurate in both sexes, in those with various degrees of prior use, and in the oldest old.

Aged↗
PubMed2003

Does inflammation or undernutrition explain the low cholesterol-mortality association in high-functioning older persons? MacArthur studies of successful aging.

OBJECTIVES: To explore the effect of inflammation and undernutrition on the association between hypocholesterolemia and higher overall mortality in high-functioning older persons. DESIGN: Prospective cohort study. SETTING: Three U.S. communities. PARTICIPANTS: A cohort of 870 participants from the MacArthur Studies of Successful Aging. MEASUREMENTS: Baseline information was obtained for serum levels of cholesterol, C-reactive protein, interleukin-6, and albumin; body mass index; prevalent medical conditions; health behaviors; and medications. Crude and multivariate logistic regression analyses were used to examine the association between serum total cholesterol levels and 7-year all-cause mortality, while adjusting for potential confounders. RESULTS: In univariate analysis, the risk ratio of low serum total cholesterol level (<169 mg/dL) for 7-year total mortality was 1.90 (95% confidence interval (CI) = 1.18-3.07). The multiple adjusted risk ratios were 1.82 (95% CI = 1.10-3.00) after controlling for markers of inflammation and nutrition and 1.39 (95% CI = 0.80-2.40) after adjustment for additional cardiovascular risk factors. Sex was an important confounding variable that contributed to the observed inverse association between low serum cholesterol and overall mortality in univariate analysis. CONCLUSIONS: Hypocholesterolemia is not an independent risk factor for increased overall mortality in high-functioning community-dwelling older men and women. The association between low total cholesterol and high mortality observed in crude analysis is mainly confounded by common cardiovascular risk factors, rather than underlying inflammation or undernutrition.

Aged↗
PubMed2003

Quality of care for older persons at the dawn of the third millennium.

During the past quarter century, researchers, providers, insurers, and governmental agencies have devoted considerable effort to improving and standardizing the quality of health care provided to older persons. Because older persons differ from younger persons as a result of their life expectancy, disease prevalence and comorbidity, social resources, goals of treatment, and preferences for care, defining and measuring quality of care has been more difficult for this age group. Nevertheless, several decades of research have led to reliable, although imperfect, methods of measuring quality, including those for geriatric conditions. Using these measurement approaches, a variety of studies using different patient populations and sampling strategies have consistently identified deficiencies in quality of care provided to older persons. Moreover, efforts to improve quality of care for older persons have been difficult to design, implement, and sustain. Some have been successful, including having effects on outcome measures, but have not made the transition from research to clinical settings. Others have used quality improvement methods to improve the care of diseases (e.g., diabetes mellitus, congestive heart failure) that commonly affect older persons. However, the lack of alignment of incentives between providers and insurers for most older persons is a major barrier to this approach. In addition, there is no concerted effort among providers, regulatory agencies, and insurers to move the quality-of-care agenda for most Medicare recipients. Despite substantial progress in defining and measuring high-quality care for older persons, the goal of ensuring that older persons receiving such care remains a distant hope.

Aged↗
PubMed2003

The associations between physical activity and inflammatory markers in high-functioning older persons: MacArthur Studies of Successful Aging.

OBJECTIVES: To determine the relationships between recreational activity, house/yard work activity, work activity, and total physical activity and high levels of two peripheral blood markers of inflammation: interleukin-6 (IL-6) and C-reactive protein (CRP). DESIGN: Cross-sectional study. SETTING: Three communities (Durham, NC; New Haven, CT; and East Boston, MA). PARTICIPANTS: Eight hundred seventy persons aged 70 to 79 who were in the top third of community-dwelling older persons with respect to physical and cognitive functioning. MEASUREMENTS: Blood levels of IL-6 and CRP and self-reported recreational activity, house/yard work activity, work activity, and total physical activity. RESULTS: The adjusted odds ratios (AORs) for individuals with high levels of recreational activity to have values in the top tertiles of IL-6 and CRP were 0.65 (95% confidence interval (CI) = 0.48-0.87) and 0.70 (95% CI = 0.51-0.95), respectively. The AORs for those with a high level of house/yard work activity to have values in the top tertile of IL-6 and CRP were 0.90 (95% CI = 0.67-1.20) and 0.70 (95% CI = 0.50-0.96), respectively. High levels of house/yard work and recreational activity were independently associated with lower risk of high CRP. CONCLUSION: The association between high levels of recreational activity and lower levels of the inflammatory markers IL-6 and CRP suggests a mechanism for its protective effect and supports interventions that increase physical activity in older persons. Such potential benefits of increased physical activity on inflammatory markers will need to be confirmed in clinical trials.

Aged↗
PubMed2003

Restructuring primary care practices to manage geriatric syndromes: the ACOVE-2 intervention.

Despite evidence suggesting that primary care physicians do not address geriatric conditions adequately in practice, most efforts to change physicians' practice behaviors have been ineffective or too expensive to implement and sustain. In its second phase, the Assessing Care of the Vulnerable Elders (ACOVE-2) project has developed an intervention aimed at improving the care that primary care physicians provide for three geriatric conditions-falls, urinary incontinence, and cognitive impairment/dementia. The intervention addresses specific processes of care identified in the first phase of the ACOVE project (ACOVE-1) as important to the care of community-dwelling older persons. Beginning with case finding, the intervention uses a standardized multicomponent practice-change effort. The condition-specific intervention employs four methods of changing medical practice: efficient collection of condition-specific clinical data, medical record prompts to encourage performance of essential care processes, patient education materials and activation of the patient's role in follow-up, and physician decision support and physician education. Moreover, the costs of the intervention are low. The effectiveness of the intervention in improving the processes of care for these conditions and clinical outcomes will need to be evaluated in controlled trials.

Accidental Falls↗