Laurence Z. Rubenstein

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 de creased 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.

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.

The Sepulveda VA Geriatric Evaluation Unit: Data on Four-year Outcomes and Predictors of Improved Patient Outcomes

Data from its first four operating years indicate that the Sepulveda VA Geriatric Evaluation Unit is having consistent beneficial effects on patient care. These benefits include improved diagnostic accuracy, reduced use of drugs, improved functional status, and improved placement location. However, not all patients benefit equally, and differences between patient responses highlight the need to select those who will benefit most from relatively costly Geriatric Evaluation Unit services. Discriminant and regression analyses were performed on 98 consecutive patients to determine which patients admitted to the Geriatric Evaluation Unit would show greatest improvement in terms of placement, functional status, one‐year survival, and living location, and which patients would be treated most efficiently in terms of length of stay. Patient characteristics on admission significantly associated with discharge home included a relatively high functional and cognitive status, the absence of an unstable medical problem, and not being expected to need nursing home placement by the referring physician. The latter two factors alone predicted actual placement location on the next 101 patients admitted to the Geriatric Evaluation Unit with high predictive accuracy (88.5 per cent). Factors predictive of patients whose functional status would improve on the Geriatric Evaluation Unit included absence of an unstable medical problem and being over 75 years old (predictive accuracy was 82.5 per cent). Two major factors associated with long patient stays on the Geriatric Evaluation Unit were low functional status scores and not living in own home or with family. These analyses indicate criteria that may be useful in selecting patients for inpatient geriatric evaluation and rehabilitation programs.

Improved Care for Patients on a New Geriatric Evaluation Unit

ABSTRACT: An analysis is presented of a geriatric evaluation unit (GEU) established at the Sepulveda VA Medical Center in 1979 to provide comprehensive interdisciplinary assessment and treatment of geriatric inpatients. The data on 74 patients admitted during the first year show that major improvements can occur in several outcome areas. Placement location was improved over expectations in 48.4 percent of patients, thus permitting a higher level of independence with a lower level of care requirements. Functional status (Katz ADL scale) improved in two‐thirds of the patients who could have shown improvement. An average of almost four new treatable disorders not noted by previous physicians were diagnosed per patient. The mean daily number of prescribed drugs was reduced by 32 percent per patient, and the total number of drug doses by 43 percent. Though limited by the unique aspects of the VA situation and by lack of a control group, the findings lend support to the efficacy and value of the GEU concept. (A randomized controlled study is in progress.)

Improving care in the nursing home : comprehensive reviews of clinical research

Introduction - Laurence Z Rubenstein and Darryl Wieland Clinical Research in the Nursing Home Rehabilitation in the Nursing Facility - Catherine Gill, Janet A Howells and Elizabeth H Hoffman Improving Medication Use in the Nursing Home - Bradley R Williams, John F Thompson and Kenneth V Brummel-Smith Infections and Infection Control - Santiago D Toledo et al Pressure Ulcers in the Nursing Home - Dan R Berlowitz and Spencer van B Wilking Assessment, Treatment, and Management of Urinary Incontinence in the Nursing Home - Joseph G Ouslander and John F Schnelle A Review of Research on Common Bowel Problems in the Nursing Home - Cathy Alessi, Karen Linderborn and Cynthia T Henderson Nutritional Problems in the Nursing Home Population - Adil A Abbasi et al Opportunities for Clinical Interventions Clinical Research on Falls in the Nursing Home - Laurence Z Rubenstein and Karen R Josephson The Assessment and Control of Pain in the Nursing Home - Bruce Ferrell The Management of Depression in the Nursing Home - James R Mervis, Steven Ganzell and Kenneth Cole Assessment and Management of Behavior Problems in the Nursing Home - Jiska Cohen-Mansfield et al Managing Nurse Aides to Promote Quality of Care in Nursing Homes - John F Schnelle et al

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% us 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. (Aging 3: 63-72,1991)