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Biomedical subjects

David B Reuben

Publications and source records attributed to David B Reuben.

49 records · Page 3Linked to original sources
PubMed2003

Organizational issues in establishing geriatrics interdisciplinary team training.

The John A. Hartford Foundation-supported geriatrics interdisciplinary team training (GITT) initiative was a bold attempt to create a new educational agenda for the health professions. Although some components of GITT were previously in place at the eight institutions that participated in the Hartford initiative and at other institutions (e.g., Department of Veterans Affairs), never before has geriatrics interdisciplinary team training been so systematically planned, implemented, or evaluated. This paper focuses on four organizational factors essential to the establishment of a geriatrics interdisciplinary team training program: (1) organizational readiness to implement GITT, including the needs and existing resources of the organization; (2) partnerships, specifically the relationships between academic and clinical organizations; (3) institutional support, the tangible and intangible sources of support necessary at multiple levels within the organization; and (4) structure, the administrative and organizational requirements for team training programs. An analysis of these four factors and the influences upon them can help facilitate the successful implementation of interdisciplinary training programs at institutions considering this educational approach.

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PubMed2002

Peripheral blood markers of inflammation predict mortality and functional decline in high-functioning community-dwelling older persons.

OBJECTIVES: Several peripheral blood markers of inflammation have demonstrated prognostic ability, but the value of combining multiple markers as a measure of inflammatory burden remains unknown. The objective of this study was to determine the prognostic value of combining four peripheral blood measures of inflammation in healthy older persons. DESIGN: Inception cohort study with 7 years of follow-up. SETTING: Three communities. PARTICIPANTS: Eight hundred seventy high-functioning subjects aged 70 to 79 who had serum albumin, cholesterol, interleukin (IL)-6, and C-reactive protein (CRP) levels measured at baseline. MEASUREMENTS: Three- and 7-year mortality and Rosow- Breslau functional decline. RESULTS: A summary score was created that assigned one point each for the following blood levels: albumin <3.8 g/dL, cholesterol <170 mg/dL (bottom decile), IL-6>3.8 pg/mL (top tertile), and CRP>2.65 mg/L (top tertile). By 3 years, 6% of subjects had died, and, by 7 years, 23% had died. In subjects with three or four markers of inflammation, the adjusted odds ratios (AORs) for 3- and 7-year mortality were 6.6 and 3.2, respectively, compared with those who had no abnormal markers. Subjects with one or two markers were at more moderate and statistically insignificant increased risk of 3- and 7-year mortality with AORs of 1.5 and 1.3, respectively. The risks for functional decline at 3- and 7-years were generally small (AOR = 1.1-1.9) and not statistically significant. CONCLUSIONS: In high-functioning older persons, a measure of inflammation can identify those at a much higher risk of mortality and a possibly higher risk of functional decline. Whether therapies directed at reducing inflammation can attenuate such risk remains to be determined.

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PubMed2002

Are there differences between older persons who screen positive on the CAGE questionnaire and the Short Michigan Alcoholism Screening Test-Geriatric Version?

OBJECTIVES: To determine (1) the extent of agreement between the CAGE (acronym for cut down, annoyed by criticism, guilty about drinking, eye-opener drinks) and the Short Michigan Alcoholism Screening Test-Geriatric Version (SMAST-G) in identifying older persons who may have possible alcohol use disorders (AUDs) and (2) whether persons identified as having possible AUDs by each of these screening measures differ in their drinking, demographic, or health-related characteristics. DESIGN: Secondary analysis of a cross-sectional study using data from a self-administered mailed survey sample. SETTING: Three organizations were surveyed: (1) members of the American Association of Retired Persons and, in southern California, (2) managed care enrollees in a large medical group and (3) attendees of a community-based senior health center. PARTICIPANTS: One thousand eight hundred eighty-nine persons aged 55 and older completing a health risk appraisal for older persons (Health Risk Appraisal for the Elderly (HRA-E)). MEASUREMENTS: The HRA-E included items on drinking behaviors (including amount of alcohol use, the CAGE, and the SMAST-G) and health and demographic characteristics. RESULTS: Twenty-six percent of all persons screened positive on the CAGE or the SMAST-G. Fewer than half of all persons screening positive on either the CAGE or the SMAST-G, screened positive on both measures. Among current drinkers, persons screening positive on the SMAST-G alone drank less than persons screening positive on the CAGE alone, and these persons drank less than those screening positive on both the SMAST-G and the CAGE. More men screened positive on the CAGE alone than on the SMAST-G alone. CONCLUSION: Fewer than half of persons screening positive on either the CAGE or the SMAST-G screened positive on both measures, suggesting that these instruments may be capturing different aspects of unsafe drinking. A screening strategy employing both brief measures may identify more AUDs among older persons having differing demographic and health characteristics.

Age Factors↗
PubMed2002

Predicting cognitive impairment in high-functioning community-dwelling older persons: MacArthur Studies of Successful Aging.

OBJECTIVES: To examine whether simple cognitive tests, when applied to cognitively intact older persons, are useful predictors of cognitive impairment 7 years later. DESIGN: Cohort study. SETTING: Durham, North Carolina; East Boston, Massachusetts; and New Haven, Connecticut, areas that are part of the National Institute on Aging Established Populations for Epidemiological Studies of the Elderly. PARTICIPANTS: Participants, aged 70 to 79, from three community-based studies, who were in the top third of this age group, based on physical and cognitive functional status. MEASUREMENTS: New onset of cognitive impairment as defined by a score of less than 7 on the Short Portable Mental Status Questionnaire (SPMSQ) in 1995. RESULTS: At 7 years, 21.8% (149 of 684 subjects) scored lower than 7 on the SPMSQ. Using multivariate logistic regression, three baseline (1988) cognitive tests predicted impairment in 1995. These included two simple tests of delayed recall-the ability to remember up to six items from a short story and up to 18 words from recall of Boston Naming Test items. For each story item missed, the adjusted odds ratio (AOR) for cognitive impairment was 1.44 (95% confidence interval (CI) = 1.16-1.78, P <.001). For each missed item from the word list, the AOR was 1.20 (95% CI = 1.09-1.31, P <.001). The Delayed Recognition Span, which assesses nonverbal memory, also predicted cognitive impairment, albeit less strongly (odds ratio = 1.06 per each missed answer, 95% CI = 1.003-1.13, P =.04). CONCLUSIONS: This study identifies measures of delayed recall and recognition as significant early predictors of subsequent cognitive decline in high-functioning older persons. Future efforts to identify those at greatest risk of cognitive impairment may benefit by including these measures.

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PubMed2002

Implementation of consultative geriatric recommendations: the role of patient-primary care physician concordance.

OBJECTIVES: To examine the effect on primary care physicians' implementation and their patients' adherence behaviors of patient-physician concordance about recommended geriatric health care. DESIGN: Case-series, independent interviews of patients and their physicians about their perceptions of the patients' health and the comprehensive geriatric assessment (CGA). SETTING: Community. PARTICIPANTS: Community-dwelling older patients (n = 111) who received consultative outpatient CGA and their primary care physicians. MEASUREMENTS: Concordance variables were generated using physician and patient responses to 10 questions on health- and CGA-related perceptions. An overall concordance score was generated by summing the total number of items on which patients and physicians agreed. Measures of the two dependent variables (physician implementation of and patient adherence to CGA recommendations) were by self-report. RESULTS: In multiple logistic regression analyses, overall concordance between patient and physician proved to be a significant and powerful predictor of physician implementation of (adjusted odds ratio (OR) = 2.7, 95% confidence interval (CI) = 1.6-4.6, P <.001) and patient adherence to (OR = 2.7, 95% CI = 1.7-4.2, P <.001) CGA recommendations, controlling for patient and physician gender and age, patients' functional status, duration of the patient-physician relationship, and frequency of visits in the previous year. Further analysis revealed that mutual patient-physician concordance on health-related perceptions was a significant predictor of these outcomes, whereas individual patient or physician perceptions were not. CONCLUSION: Concordance between older patients and their primary care physicians is a powerful predictor of physician implementation of and patient adherence to outpatient consultative CGA recommendations. Future research should focus on ways physicians can assess and negotiate patient-physician agreement on geriatric healthcare recommendations.

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PubMed2002

Organizational interventions to improve health outcomes of older persons.

BACKGROUND: With the reorganization of the financing of health care and creation of systems of care, it is possible to design and implement organizational interventions to improve the care of older persons beyond the services that can be provided by an individual provider. OBJECTIVES: To review the effectiveness of organizational interventions for older persons, describe barriers to dissemination of success models into practice settings, and identify future directions for such interventions. METHODS: Selective review of organizational interventions that have been aimed primarily at the geriatric population and have been formally evaluated using conventional research designs, usually randomized clinical trials. RESULTS: Organizational interventions can be classified into two groups: component models and systems changes. The former can be superimposed upon an intact system but do not fundamentally change the system of care whereas the latter modify the basic structure of primary care. A variety of organizational interventions have been implemented in diverse settings, but the evidence supporting the effectiveness of these interventions is inconsistent. Even when such interventions have been effective in research settings, these interventions rarely reduce health care costs. Moreover, there have been formidable barriers to implementation of successful interventions into practice. CONCLUSIONS: Organizational interventions are potentially powerful methods to influence health care and maintain health status of older persons. Nevertheless, gaps between knowledge and practice and unanswered questions about the effectiveness of organizational interventions currently limit the potential value of this approach to improving health care of older persons.

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PubMed2002

Effects of managed care on the length of time that elderly patients spend with physicians during ambulatory visits: National Ambulatory Medical Care Survey.

OBJECTIVES: To examine the factors related to the length of time that elderly patients spend with physicians during ambulatory visits and explore specifically the association between managed care and visit duration. DESIGN: Cross-sectional analysis of the 1998 National Ambulatory Medical Care Survey. SUBJECTS: Four thousand nine hundred sixty-four office visits to nonfederally employed physicians by elderly patients who had face-to-face contact with physicians and had complete information on variables related to managed care. MEASURES: Information was collected on the characteristics of patient, physician and clinic, visit duration, reasons for visit, diagnoses, clinical services performed, and medications ordered. Measures of managed care included patient's health maintenance organization (HMO) status, requirement of authorization, capitation, and HMO ownership of the clinic. RESULTS: The mean visit duration was 19.2 minutes for elderly patients (27.0 minutes for new patients and 18.3 minutes for established patients; P <0.001). In bivariate analyses, the patient's HMO status was not associated with visit duration, but office visits for patients seen at clinics owned by HMOs were 4.2 minutes shorter than those seen in other settings (P <0.001). In multivariate analyses with mixed-effect models, HMO-owned clinic was an independent predictor for shorter visit duration, after adjusting for other patient, physician, and clinic characteristics and type of service provided. CONCLUSIONS: The effects of managed care on the duration of ambulatory visits by elderly patients appear to be related to the structure of the managed care plan rather than managed care reimbursement per se.

Adult↗
PubMed2002

Development of a method to identify seniors at high risk for high hospital utilization.

BACKGROUND: A small percentage of older persons account for most Medicare costs. If persons at high risk for high health care utilization can be identified, resources can be directed to improve their health care and reduce utilization. OBJECTIVE: To develop an efficient and economical approach to identifying older persons at risk for high future health care utilization. DESIGN: Validation cohort. SETTING: Three communities. SUBJECTS: Five thousand one hundred thirty-eight community-dwelling persons aged 71 years or older. MAIN OUTCOME MEASURES: High utilization (defined as >or=11 hospital days during 3 years) and overall Part A Medicare hospital costs during 3 years. RESULTS: Predictive multivariable models were created that relied on prior hospitalization only, self-report only, and combined self-report and physical examination/lab data. Ten self-report items (hospitalizations in prior year and year before that, male gender, fair/poor health, not working, infrequent religious participation, needing help bathing, unable to walk 1/2 mile, diabetes, and taking loop diuretics) and two lab tests (low serum albumin and iron) remained as independent predictors of high utilization. Based upon these variables, approximately 1/4 of the population was identified as being at high risk (>or=0.28 probability) for high health care utilization and those identified accounted for approximately half of all Medicare Part A costs for the entire population. Finally, a two-phase strategy was developed in which tests are only administered to individuals whose risk cannot be adequately determined by self-report variables (approximately 1/4 of subjects). CONCLUSIONS: Simple questions and laboratory tests can accurately and efficiently identify seniors at high risk for high health care utilization.

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PubMed2002

Beyond alcoholism: identifying older, at-risk drinkers in primary care.

OBJECTIVE: To evaluate the validity and reliability of two self-report instruments: the Alcohol-Related Problems Survey (ARPS) and its shorter version the Short ARPS (shARPS) that identify older persons whose use of alcohol alone or with their comorbidities may be placing them at risk for or causing them harm. METHOD: We compared the two measures against a "LEAD" (longitudinal evaluation done by experts employing all available data) standard among a sample of 166 drinkers aged 60 years and older in 10 internal medicine clinics. The LEAD standard included a medical record review, a clinical interview and a telephone interview with a collateral informant. We tabulated reasons the LEAD identified subjects as harmful or hazardous drinkers. We also compared the Alcohol Use Disorders Identification Test (AUDIT) and the Short Michigan Alcoholism Screening Test-Geriatric Version (SMAST-G) to the LEAD. RESULTS: Sensitivity and specificity of the ARPS and the shARPS as compared to the LEAD were 93% and 63%, and 92% and 51%, respectively. After minor changes were made in the scoring rules, specificity increased to 66% for both the ARPS and shARPS while sensitivity remained stable, 93% and 91%. Harmful and hazardous drinkers were most often identified because of alcohol use with comorbidities, symptoms, and medication use. Sensitivity and specificity of the AUDIT and the SMAST-G as compared to the LEAD were 28% and 100%, and 52% and 96%, respectively. CONCLUSIONS: The ARPS and shARPS are quite sensitive in identifying older drinkers with a spectrum of alcohol use disorders. They are more sensitive than the AUDIT and the SMAST-G in identifying older persons who may be at risk or experiencing harm as a result of their alcohol use and comorbidities. They also provide information on specific risks associated with alcohol use not obtained by other screening measures and may therefore facilitate interventions by busy clinicians to reduce such risks.

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PubMed2002

A randomized clinical trial to assess the benefit of offering on-site mobile mammography in addition to health education for older women.

OBJECTIVE: We conducted a cluster randomized clinical trial to compare the benefit of offering on-site mobile mammography in addition to an outreach program designed to increase mammography use by educating patients. SUBJECTS AND METHODS: We recruited a consecutive volunteer sample of 499 women ranging in age from 60 to 84 years who had not undergone mammography in the previous year to participate in a cluster randomized clinical trial about the benefit of on-site mobile mammography. Subjects were recruited from 60 community-based sites where seniors gather. The intervention included a structured on-site multicomponent educational program with or without available on-site mobile mammography. The primary outcome measure was self-reported receipt of mammography within 3 months of the intervention. RESULTS: Women in the group offered access to on-site mammography and health education were significantly more likely than those in the group offered health education only to undergo mammography within 3 months (55% vs 40%, p = 0.001; adjusted [for clustering] odds ratio, 1.83; 95% confidence interval, 1.22-2.74). Gains from offering on-site mammography were shown for several ethnic and sociodemographic subgroups and were especially large for Asian American women. CONCLUSION: Offering on-site mammography at community-based sites where older women gather is an effective method for increasing breast cancer screening rates among older women and may be particularly effective for some subgroups of women who traditionally have had low screening rates.

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PubMedDate not supplied

Interaction of serotonergic antidepressants and opioid analgesics: Is serotonin syndrome going undetected?

OBJECTIVES: To describe the potential for interaction between opioids and serotonergic antidepressants leading to the development of serotonin syndrome (SS), mechanism of the interaction, and the spectrum of SS in elderly residents of a long-term care facility. DESIGN: Case series. SETTING: Long-term care facility (LTCF) in California. PARTICIPANTS: Four elderly LTCF residents treated with serotonergic antidepressants including selective serotonin reuptake inhibitor (SSRI) or mirtazapine and opioids. MEASUREMENTS: Signs and symptoms suggestive of SS. RESULTS: We describe 4 cases of probable SS among elderly residents of a LTCF. The spectrum of serotonin toxicity ranged from visual hallucinations, muscle rigidity, myoclonus, or hypertension in patients taking an opiate with an SSRI to lethargy, hypotension, and hypoxia in a patient taking tramadol and mirtazapine. CONCLUSION: While many can benefit from coadministration of serotonergic antidepressants and opioids, it appears that some individuals are at increased risk for SS. Since SS is a clinical diagnosis, heightened clinician awareness of the possibility of SS among patients receiving SSRI or mirtazapine in combination with opioids may lead to earlier detection and avoidance of potentially lethal consequences.

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