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L Z Rubenstein

Publications and source records attributed to L Z Rubenstein.

At least 55 records · Page 3Linked to original sources
PubMed1995

Meta-analytic methods for health services research--an example from geriatrics.

The authors recently published a meta-analysis of controlled trials of comprehensive geriatric assessment (CGA). The results supported the view that efficacy of CGA is strongly related to the patients, objectives, and basic design of CGA programs, and that particular program models and design features are associated with important health outcome improvements (e.g., survival, living at home, and functional improvement at follow-up). Present objectives include the outline of methods and how they were developed given the condition of the trial database and scientific context. Aspects of the approach, such as (a) survey of primary trialists to recover unpublished information and standardize data, (b) development of a program typology to guide the principal analysis, and (c) incorporation of program design features as covariates where statistical heterogeneity was detected, proved extremely useful, and have implications for other systematic reviews of similarly complex primary trials of new health care technologies, health services, and organizational interventions.

Aged↗
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↗
PubMed1994

A home-based geriatric assessment, follow-up and health promotion program: design, methods, and baseline findings from a 3-year randomized clinical trial.

Controlled trials in a number of countries have documented benefits from different types of in-home assessment and treatment programs for various subgroups of elderly persons. We have developed a program to test, using a randomized controlled design, the concepts of in-home comprehensive geriatric assessment (CGA) coupled with follow-up, health education, and preventive care in an urban United States community. The intervention includes yearly in-home CGA by geriatric nurse practitioners (GNPs), who provide, following discussions with physician geriatricians, lists of specific recommendations for health and well-being enhancement. The GNPs provide follow-up visits quarterly and regular telephone contacts to improve compliance. We recruited for our trial 414 home-living subjects aged 75 years and over, 215 randomized to the intervention group and 199 to the control group. Subjects were generally representative of the overall elderly population of the city of Santa Monica, a seaside suburb of Los Angeles. Extensive baseline data (medical, functional, psychosocial and environmental) were collected from subjects prior to randomization, using validated instruments whenever possible. Follow-up data were collected from each subject every 4 months by trained research assistants throughout the 3-year intervention follow-up period. Our study was designed to assess effects of the intervention on the hypothesized outcomes of health status, functional status, psychosocial parameters, and service utilization. Careful documentation of the intervention will enhance our ability to make process-outcome comparisons. Preliminary analysis reveals that the in-home CGA uncovered many important health deficits for most subjects resulting in a number of substantial recommendations. We are confident that when it is completed, this study will succeed in answering important remaining questions about the feasibility and effectiveness of establishing a geriatric in-home prevention and health promotion program in the United States based on principles of CGA.

Aged↗
PubMed1994

Inpatient geriatric evaluation and management units (GEMs) in the veterans health system: diamonds in the rough?

BACKGROUND: Research suggests that inpatient geriatric evaluation and management units (GEMs), which undertake interdisciplinary diagnosis to improve the health of frail elderly patients, are effective. The Department of Veterans Affairs (VA) helped pioneer U.S. GEMs and mandates that every facility shall have a GEM by 1996. We conducted a population survey of VA GEMs in 1991 to assess their dissemination. METHODS: Various organizational and performance characteristics of GEMs were entered in a data base derived from a piloted questionnaire and administrative records. Basic criteria from consensus reports were used to classify and compare "standard" and "nonstandard" GEMs. The criteria covered performance of assessment, team structure, patient selection, GEM location, and treatment functions. We analyzed the effect of GEM type and other factors on length of stay and placement. Reasons for closure of GEMs inactive in 1991 were recovered, and GEMs active in 1991 but later closed are described. RESULTS: As of 1991, 41 of 73 GEMs were classified as standard, and 32 nonstandard. Standard compared to nonstandard GEMs had shorter stays (25.4 vs 69.9 days; p < .001), higher home discharge rates (63.4% vs 40%; p < .001), and lower nursing home placement rates (19.1% vs 40.3%; p < .001). Eleven hospitals had closed their programs by 1991. By 1993, 6 additional GEMs had closed; all were nonstandard in 1991. CONCLUSIONS: Most VA GEMs are organized according to basic consensus standards, and appear to be discharging most patients back to the community after reasonably short stays. However, various resource constraints are common, apparently reflected in nonstandard organization and GEM closure. Additional work is needed to monitor GEM proliferation, implementation, and performance in and out of the VA system.

Aged↗
PubMed1994

Medicare: challenges and future directions in a changing health care environment.

In this GSA-sponsored Congressional Briefing Seminar, authorities from several disciplines summarize the history, rationale, strengths, weaknesses, and future challenges of the Medicare program. In the current arena of health care reform, the role of Medicare is far from certain, and it is crucial to understand and confront a multitude of issues, many of which are raised in this briefing.

Aged↗
PubMed1994

Inpatient geriatric evaluation and management units: organization and care patterns in the Department of Veterans Affairs.

Geriatric evaluation and management units (GEMs) are designed to improve the functional health and placement of frail elderly hospital inpatients. We surveyed Department of Veterans Affairs (VA) GEMs to describe their care patterns and organization. GEMs meeting consensus standards (n = 46) varied considerably. Hospital, GEM, and patient-admission factors (e.g., hospital psychiatric mix, GEM location, proportion of GEM admissions from nursing homes) predicted length-of-stay, readmission rate, and discharge status. Ongoing monitoring may improve the effectiveness of VA GEMs systemwide.

Aged↗
PubMed1994

Are older pedestrians allowed enough time to cross intersections safely?

OBJECTIVE: To describe the pedestrian traffic flow at a busy urban intersection and determine the percentage of older pedestrians at risk for injury as a result of reduced walking speeds. DESIGN: Observational study. SETTING: The intersection of Third Street and Fairfax Avenue in Los Angeles, California. PARTICIPANTS: All pedestrians who started to cross the intersection during the legally acceptable parts of the traffic cycle during three days of observation (n = 1229) and a subsequent sample of 100 consecutive younger and 100 consecutive older crossers. MEASUREMENTS: The ability of all subjects to cross the intersection in the allotted time was measured. A questionnaire was administered to pedestrians who were unable to cross the intersection in time. In addition, we measured the actual gait speed of a subsequent consecutive sample of 100 younger and 100 older pedestrians. RESULTS: Of the 592 older pedestrians observed, 27% were unable to reach the opposite curb before the light changed to allow cross traffic to enter the intersection, and one-fourth of this group were stranded by at least a full traffic lane away from safety. All younger pedestrians were able to cross in the allotted time. Older pedestrians took significantly longer than younger pedestrians to cross the street (P < 0.0001). The mean walking velocity +/- 1 SD for older and younger pedestrians was 0.86 +/- 0.17 and 1.27 +/- 0.17 m per second, respectively. Fifty-three percent of those older pedestrians unable to cross in time were willing to be surveyed. Mean age was 77 years, 74% considered the intersection to be "dangerous", and 63% stated they cross the street at least once daily. City traffic reports revealed that over the preceding 5 years about one older pedestrian per year had been hit in this intersection, and 165 such injuries had occurred city-wide per year. CONCLUSION: The timing of this pedestrian signal does not allow adequate time for many older pedestrians to cross and puts them at potential risk. Providing more crossing time may reduce pedestrian injuries and allow for an increased feeling of independence and confidence by older citizens.

Accident Prevention↗
PubMed1994

Rationale and design of a multi-center randomized trial of comprehensive geriatric assessment consultation for hospitalized patients in an HMO.

OBJECTIVE: To describe the evaluation of an interdisciplinary comprehensive geriatric assessment (CGA) consultation program for targeted hospitalized patients. DESIGN: Multi-center randomized clinical trial (RCT) at four hospitals where patients were randomly assigned to CGA consultation or usual care by the attending physician, and a non-equivalent control group (NCG) at two hospitals. SETTING: Six hospitals in a multi-specialty group practice model health maintenance organization (HMO). PARTICIPANTS: 3593 patients age 65 years or older meeting at least one of 13 inclusionary criteria at admission. INTERVENTION: Screening by hospital staff and standardized CGA consultation conducted by a nurse practitioner, social worker, and geriatrician at the four RCT hospitals. MAIN OUTCOME MEASURES: Functional and health status, mortality, rehospitalization, and cost-effectiveness of the CGA program at 1 year post-randomization; validation of targeting (inclusionary) criteria that identify subgroups of patients deriving benefit from CGA; and physician contamination (learning from CGA and changing treatment provided to control patients). CONCLUSIONS: A number of methodological issues need to be considered when conducting effectiveness trials of CGA. The concurrent design of a multi-center RCT, coupled with the NCG to determine physician contamination, is an innovative approach intended to determine more precisely the cost-effectiveness of CGA for frail hospitalized elderly persons. The large and heterogeneous patient population and the broad array of inclusionary criteria will permit the evaluation of the benefit of CGA for subgroups. All these features are intended to enhance the generalizability of study results.

Aged↗
PubMed1994

An in-home preventive assessment program for independent older adults: a randomized controlled trial.

OBJECTIVE: To evaluate the effectiveness of in-home geriatric assessments as a means of providing preventive health care and improving health and functional status of community-living elderly veterans. DESIGN: Randomized controlled trial with 1-year follow-up. SETTING: Home visits performed in a suburb of Los Angeles. PARTICIPANTS: Community-living veterans 70 years and older not currently receiving health care at the Sepulveda VA Medical Center (n = 131 intervention; 123 controls). INTERVENTION: A home visit by a physician's assistant or nurse, to screen for medical, functional and psychosocial problems, followed by a letter describing findings and recommendations, and follow-up visits by trained volunteers at 4-month intervals for 1 year. Controls received only telephone interviews at 4-month intervals to collect outcome data. MEASUREMENTS: Compliance with recommendations was studied for the intervention group. Outcome comparisons between the two groups included: mortality, medication usage, functional status, immunization rates, and nursing home and hospital utilization. MAIN RESULTS: A mean of four new or suboptimally treated problems was identified for intervention subjects. Subjects complied with 76% of recommendations to see a physician or initiate a specific health practice. At 12-month follow-up, intervention subjects had significantly increased their immunization rates (P < 0.001) and had a significantly increased likelihood of having a primary care physician (P < 0.05). Twelve-month functional status (IADL) scores were significantly higher for intervention subjects than for controls; intervention subjects maintained their functional status, while controls experienced significant decline during the follow-up year (P < 0.05). Non-prescription drug use increased significantly among controls, but not among intervention subjects (P < 0.05). CONCLUSIONS: A brief geriatric screening assessment performed in the home can detect unrecognized and treatable problems, even among relatively healthy older adults. The use of trained volunteers is a feasible strategy for providing health education and follow-up contacts. These results support the concept that preventive gerontological approaches can help maintain important aspects of health and function.

Activities of Daily Living↗
PubMed1993

Comprehensive geriatric assessment: a meta-analysis of controlled trials.

There is disagreement on the usefulness of comprehensive geriatric assessment (CGA) due to conflicting results from individual trials. We did a meta-analysis on 28 controlled trials comprising 4959 subjects allocated to one of five CGA types and 4912 controls. Published data were supplemented with reanalysed data provided by the original investigators. We calculated combined odds ratios of important outcomes by pooling data from individual trials with multivariate logistic regression. Combined odds ratio (95% confidence interval) of living at home at follow-up was 1.68 (1.17-2.41) for geriatric evaluation and management units, 1.49 (1.12-1.98) for hospital-home assessment services, and 1.20 (1.05-1.37) for home assessment services. Covariate analysis showed that programmes with control over medical recommendations and extended ambulatory follow-up were more likely to be effective. Our analysis suggests that CGA programmes linking geriatric evaluation with strong long-term management are effective for improving survival and function in older persons.

Activities of Daily Living↗
PubMed1992

The use of targeting criteria in hospitalized HMO patients: results from the demonstration phase of the Hospitalized Older Persons Evaluation (HOPE) Study.

OBJECTIVE: To determine the yield of standardized targeting criteria for identifying hospitalized HMO patients who are at high risk for mortality and nursing home placement and, therefore, may be appropriate for comprehensive geriatric assessment. DESIGN: Prospective cohort study. SETTING: Four HMO (Southern California Kaiser-Permanente) hospitals. SUBJECTS: 3,697 patients 65 years of age or older admitted to any inpatient service from July 1 through September 30, 1990. MAIN OUTCOME MEASURES: Screening measures for standardized targeting criteria, administered 24-48 hours after admission. RESULTS: Overall, 35.1% of patients screened met at least one inclusionary criterion, which is considerably higher than other published reports. The most commonly met criteria were incontinence, impairment in performing activities of daily living, malnutrition, and immobility. The percentage of patients meeting at least one criterion and meeting each criterion varied considerably among hospitals. The vast majority of patients (83%) who were judged appropriate for assessment met at least three criteria. CONCLUSIONS: The yield of standardized criteria differs when applied to patients in different health care systems and to patients at different hospitals within a health care system, which may reflect differences in the populations being served and the practice styles of physicians and the delivery system. Because no single criterion identified more than approximately half of patients who were judged appropriate for assessment, it is likely that a battery of criteria will be necessary to identify these patients.

Activities of Daily Living↗
PubMed1991

Syncope: etiology, prognosis, and relationship to age.

Syncope is a common and particularly troublesome problem in the elderly population. In a series of 146 patients admitted for syncope to an acute care hospital in Chile during a 4-year period, 2/3 (68%) were aged 65 years and older. A specific etiology could be established in 62%, and 3/4 of these were cardiovascular in origin. Diagnosis was established entirely on history, physical examination, resting ECG, and 24-hour cardiac monitoring in most cases but in some, more sophisticated measures (i.e., echocardiography, electrophysiologic studies, blood tests, EEG) were needed, and mostly to confirm clinically suspected problems. In-hospital mortality was 2.1% and mortality at the end of the approximately 2-year follow-up period was 18.1%. Mortality was higher for persons over age 65 than for younger persons (23.9% vs 2.3%), and for persons with cardiovascular syncope than for persons with other kinds of syncope (28.3% vs 8.9%). This study confirms the particular lethality of syncope in the elderly population and outlines a relatively simple strategy with which most syncope patients can be diagnosed without resorting to expensive procedures.

Adult↗