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Biomedical subjects

L Z Rubenstein

Publications and source records attributed to L Z Rubenstein.

At least 91 records · Page 5Linked to original sources
PubMed1989

The value of Holter monitoring in evaluating the elderly patient who falls.

Ambulatory cardiac (Holter) monitoring is often recommended in the routine evaluation of patients who fall; however, the prevalence of arrhythmias in old people is high, and the usefulness of such monitoring is unproven. As part of a large study of institutionalized elderly fallers, we compared Holter findings of fallers (N = 51) with a group of nonfallers (N = 27) having similar medical and demographic characteristics. Prevalence of ventricular arrhythmias was 82% in each group, and all patients had supraventricular arrhythmias. The mean number of ventricular and supraventricular couplets and runs did not differ between groups. There was no difference in severity of arrhythmias between fallers and nonfallers; in fact, fallers had slightly fewer Lown 4B arrhythmias than nonfallers (10% vs 18%, NS). Prevalence of heart disease was 78% in both groups and was associated with increased ventricular ectopy in the form of runs and couplets (P less than .05). No symptoms were reported during the Holter monitoring. We conclude that Holter monitoring should not be a routine part of the work-up of the patient who falls.

Accident Prevention↗
PubMed1989

Effect of timing and number of baseline blood pressure determinations on postural blood pressure response.

We hypothesized that the blood pressure response to standing may depend on the method of establishing baseline blood pressure. Three hundred elderly subjects previously completed a postural blood pressure protocol with three supine baseline blood pressure readings obtained two minutes apart prior to standing. Comparison of the readings showed a significant drop between the first and the second (P less than .001) but not between the second and third supine systolic blood pressures. The difference between the first supine systolic blood pressure and the one minute standing blood pressure was significantly greater than that between the third supine systolic blood pressure and the one minute standing blood pressure (P less than .001). A second group was prospectively studied to determine whether the change in blood pressure after standing was greater if only a single baseline reading was taken rather than multiple readings, and whether the decline in blood pressure over three readings was related to duration supine or to the number of blood pressures taken. This group also demonstrated a decline in systolic blood pressure with three serial readings. We conclude that supine blood pressure declines significantly between the first and second readings taken two minutes apart and is secondary to the repetition of readings and not the duration supine. However, this change in supine blood pressure does not significantly alter the blood pressure response to standing. Thus, it appears that a single baseline supine blood pressure measurement is adequate for determining the postural blood pressure response, and that pooling of multiple baseline readings may not be appropriate.

Aged↗
PubMed1989

Predictors of falls among elderly people. Results of two population-based studies.

A study was performed to identify and rank risk factors for falling among populations of institutionalized (fallers, N = 79, nonfallers, N = 70) and noninstitutionalized (fallers, N = 34, nonfallers, N = 34) elderly persons. Fallers were matched by age, sex, and living location to nonfaller control subjects. A nurse practitioner performed a comprehensive physical assessment in all subjects using a standardized protocol and physician consultation. Fallers in both populations were significantly more physically and functionally impaired than control subjects. Logistic regression identified hip weakness, poor balance, and number of prescribed medications as factors most strongly associated with falling among institutionalized subjects. A fall prediction model was developed from these findings yielding 76% overall predictive accuracy (89% sensitivity, 60% specificity). Using the model, the predicted 1-year risk of falling ranged from 12% for persons with none of the three risk factors to 100% for persons with all three risk factors. Findings among noninstitutionalized subjects were similar. These data support the concept of performing focused fall risk assessments to identify elderly patients at high risk for falling.

Accidental Falls↗
PubMed1988

Improved survival for frail elderly inpatients on a geriatric evaluation unit (GEU): who benefits?

Previously reported data from a randomized controlled trial showed that admission to the geriatric evaluation unit (GEU) and follow-up clinic at the Sepulveda VA Medical Center leads to significantly improved outcomes for frail elderly hospital patients--including a 50% reduction of one-year mortality (p less than 0.005). In the present paper, two-year survival curves for GEU and control groups are reported. In addition, we subdivided the population by potential baseline risk factors (both patient- and treatment-related) and examined one-year survival using 12-month survival curves and odds ratios. There is evidence for GEU-related survival effects in specific subgroups of patients (e.g. patients with heart and pulmonary disease, patients with low baseline scores in functional status and mental status, and patients with high baseline morale scores). Finally, employing stepwise logistic regression, we determined the predictors of one-year survival in the pooled study population. These factors were: assignment to the GEU (adjusted odds ratio = 2.45; p less than 0.001); not having a heart diagnosis (2.24; p less than 0.001); and having primarily "geriatric/rehabilitation" problems (1.95; p less than 0.005). A predictive model derived from the regression defines patient subgroups likely to survive only when assigned to the GEU: cardiac patients with primarily "geriatric" or "rehabilitation" problems, and non-cardiac patients whose problems are primarily "medical". The dramatic effect of the GEU on survival appears to be concentrated on certain identifiable subgroups of patients who might be targeted to maximize program cost-effectiveness.

Activities of Daily Living↗
PubMed1988

Effect of age and posture on human lymphocyte adenylate cyclase activity.

1. A number of age-related changes have been reported in the catecholamine-adrenoceptor-adenylate cyclase system. Most of the data available on these alterations come from resting subjects; the response to acute stress may provide additional insights into the age effect on these responses. 2. We measured supine and 10 min upright plasma noradrenaline and lymphocyte adenylate cyclase activity in ten healthy elderly subjects (age 66-80 years) and seven healthy young subjects (age 27-34 years). 3. Isoprenaline stimulation of lymphocyte adenylate cyclase activity was not significantly different between supine and upright positions or between elderly and young subjects. There was a marked increase in forskolin-stimulated adenylate cyclase activity in the upright posture in both elderly and young subjects. The increment over supine levels was 70% in the elderly (P less than 0.025) and 73% in the young (P less than 0.05). This enhanced forskolin activity was not seen in two young subjects who became syncopal. 4. These data suggest that enhanced forskolin-stimulated adenylate cyclase activity occurs after 10 min of upright posture in both elderly and young subjects, and may be relevant to immediate blood pressure regulation. We were unable to demonstrate any age-related differences in these acute adrenergic responses.

Adenylyl Cyclases↗
PubMed1988

Predictors of immediate and 6-month outcomes in hospitalized elderly patients. The importance of functional status.

This article presents results of a prospective multivariate study of hospitalized elderly patients at an acute-care Veterans Administration (VA) hospital to identify factors on hospital admission predictive of several short- and long-term outcomes: in-hospital and 6-month mortality, immediate and delayed nursing home admission, length of hospital stay, and 6-month rehospitalization. All patients aged 70 years and over admitted to acute-care beds on the medical service wards during a 1-year period were included in the study (N = 396). Factors most predictive of 6-month mortality (using logistic regression) were decreased functional status, admitting diagnosis, and decreased mental status. Factors most predictive of nursing home admission were decreased functional status, living location, and decreased mental status. Functional status was a stronger predictor of length of stay, mortality, and nursing home placement than was principal admitting diagnosis--of relevance to the current emphasis on diagnosis-related groups (DRGs). These data may be helpful in improving discharge planning, in resource allocation, and in targeting patients for different specialized geriatric programs.

Activities of Daily Living↗
PubMed1988

New issues in geriatric care.

The rapid growth of the elderly population has increased the need for improved geriatric care and prevention of disability. For example, the prevalence and severity of osteoporosis can be reduced significantly by the use of estrogen, with or without added progestin, in postmenopausal women. A common and devastating problem of frail elderly persons is urinary incontinence, most cases of which can be classified without referral for urologic services. Appropriate treatment can improve nearly half of all cases of persistent incontinence. Comprehensive geriatric assessment is effective in guiding the treatment of frail elderly patients and leads to significantly improved outcomes under appropriate conditions. The advent of the teaching nursing home has shed light on the medical problems of elderly residents of nursing homes, including malnutrition, dysregulation of water and electrolyte balance, falling, cognitive and affective illnesses, behavior disturbances, infections, and pathogenic drug use. The future application of advanced technology may revolutionize nursing home care.

Aged↗
PubMed1988

Dynamics and clinical implications of the nursing home-hospital interface.

Nursing homes and hospitals are dynamically interrelated, and there is much that the clinician can do to optimize patient transitions between institutions. This article approaches this topic in three sections: epidemiology of movement between hospitals and nursing homes, impacts of policy changes and financial incentives on patient transfers, and clinical strategies to reduce unnecessary hospitalizations of nursing home patients.

Aged↗
PubMed1987

Yield of routine annual laboratory tests in a skilled nursing home population.

The yield of routinely performed annual panels of laboratory tests was examined among patients in the skilled nursing facility section of a large, multilevel, long-term-care institution. Of 9270 tests done as part of 336 annual panels in 121 patients over an eight-year period, 17% of the tests yielded abnormal results, and in 36% of the tests, abnormal results were new. Among the 336 panels, 56 (16.7%) had at least one abnormality that was believed to have resulted in some benefit to 30 (24.7%) of the patients. Many of the abnormalities that led to patient benefit could have been detected by periodic monitoring of chronic conditions and their treatment as opposed to true screening tests, and all such abnormalities could have been identified by a complete blood cell count, electrolyte determinations, renal and thyroid function tests, and a urinalysis. The results suggest that a modest panel of annual laboratory tests could limit the potential costs of screening and not result in the loss of potential benefits to patients in skilled nursing facilities.

California↗
PubMed1987

Low prevalence of postural hypotension among community-dwelling elderly.

Postural hypotension (PH) has a prevalence of about 20% in most large studies of elderly individuals; however, these studies do not exclude subjects with diseases and medications known to cause PH. We sought to determine the prevalence of PH in healthy, community-living, elderly individuals in contrast to those with known risk factors for the condition. We measured supine and one-minute standing blood pressures in 300 independently living elderly persons who visited a senior citizen health screening program. Subjects were divided into two groups: those with known risk factors (n = 175) and those without (n = 125). The prevalence of PH (systolic decrease, greater than or equal to 20 mm Hg) for for the entire population was 10.7%. In the group with risk factors, the prevalence was 13.7% (24/175), compared with 6.4% in the group without risk factors (8/125). Supine hypertension was associated with PH, but there was no relationship between the presence of PH and age, history of falls, symptoms on standing, or recent meal. These data suggest that PH is a relatively uncommon finding in healthy elderly, its prevalence is significantly related to risk factors, and its association with falls or symptoms may be less than previously reported.

Aged↗
PubMed1987

Incontinence among nursing home patients: clinical and functional correlates.

This study was undertaken to examine the association of specific medical and genitourinary conditions, medications, and functional disabilities with urinary incontinence (UI) in a nursing home (NH) population. Seventy-six incontinent and 38 continent patients in a Veterans Administration NH were studied. Incontinence was highly associated with each of the physical and mental functional disabilities we examined. However, with the exception of recurrent urinary tract infections and dementia, no specific clinical factors were significantly more common among incontinent than continent patients. Although precise causes for the UI were not determined, these data highlight the potential role of impairments of physical and/or mental function in the pathogenesis of UI among NH patients, and emphasize the need to address these impairments in future research on the assessment and treatment of UI in this population.

Aged↗
PubMed1987

Old people in the emergency room: age-related differences in emergency department use and care.

Little is known about how the care received in emergency departments (ED) by the elderly population differs from that received by younger people. We prospectively abstracted ED records of 1620 consecutive patients visiting a large community hospital ED over a 22-day period in 1984 for demographic and medical variables. Charts of patients presenting with five specific complaints (dyspnea, chest pain, abdominal pain, syncope, and motor vehicle accidents) were also analyzed for process of care variables and, for patients hospitalized, the accuracy of the ED diagnosis. Older people (ie, those greater than or equal to 65 years of age) do not seem to be overutilizers of the ED for minor complaints, in fact, they tend to be more acutely ill on presentation than younger people. Older people were more likely to be hospitalized (46% v 10%, P less than .001), to arrive by ambulance (35% v 10%, P less than .001), and to have an identified source of primary care (95% v 64%, P less than .01). Older people stayed longer in the ED than younger people if they were eventually released home but shorter if admitted to the hospital. Test ordering patterns for specific complaints varied by patient age (eg, older patients had more electrocardiograms performed for chest pain and fewer urinalyses for abdominal pain than younger patients). Therapy for specific complaints showed less age effect. Although generally more diagnostic tests were performed on older patients, the ED diagnosis tended to be more accurate for younger patients. Our data indicate that the process of ED care may be substantially different for the elderly population and have implications for future planning and financing of medical care.

Age Factors↗