Improving Care in the Nursing Home: Comprehensive Reviews of Clinical Research
In recent years, the nursing home has emerged as the dominant health-related institution in U.S. health care. Yet, the knowledge base regarding nursing home patients, care, and outcomes is underdeveloped compared to that of acute and ambulatory care. Improving Care in the Nursing Home provides systematic reviews of the state of clinical and health services research in patient-care problem areas pertinent to nursing homes. Each chapter defines progress on a specific clinical nursing home problem and provides a critical synthesis and review of research information. Topics covered include medication use, infection control, pressure ulcers, falls, urinary incontinence, and behavior problems. This volume also includes sections on managing nurse aides, clinical interventions for nutritional problems, and clinical research on falls in nursing homes. Improving Care in ...
- Front Matter
- Back Matter
- Subject Index
- Chapter 1: Rehabilitation in the Nursing Facility
- Chapter 2: Improving Medication Use in the Nursing Home
- Chapter 3: Infections and Infection Control
- Chapter 4: Pressure Ulcers in the Nursing Home
- Chapter 5: Assessment, Treatment, and Management of Urinary Incontinence in the Nursing Home
- Chapter 6: A Review of Research on Common Bowel Problems in the Nursing Home
- Chapter 7: Nutritional Problems in the Nursing Home Population: Opportunities for Clinical Interventions
- Chapter 8: Clinical Research on Falls in the Nursing Home
- Chapter 9: The Assessment and Control of Pain in the Nursing Home
- Chapter 10: The Management of Depression in the Nursing Home
- Chapter 11: Assessment and Management of Behavior Problems in the Nursing Home
- Chapter 12: Managing Nurse Aides to Promote Quality of Care in the Nursing Home
Copyright © 1993 by Sage Publications, Inc.
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Library of Congress Cataloging-in-Publication Data
Main entry under title:
Improving care in the nursing home : comprehensive reviews of clinical research / [edited by] Laurence Z. Rubenstein, Darryl Wieland.
Includes bibliographical references and index.
ISBN 0-8039-4306-7 (cloth). — ISBN 0-8039-4307-5 (pbk.)
1. Nursing home care. I. Rubenstein, Laurence Z. II. Wieland, Darryl.
[DNLM: 1. Nursing Homes—organization & administration—United States. 2. Homes for the Aged—organization & administration —United States. 3. Health Services for the Aged—United States. WT 27 AA1 13 1993]
for Library of Congress
93 94 95 96 10 9 8 7 6 5 4 3 2 1
Sage Production Editor: Rebecca Holland
We, the editors, are grateful for the small grant from the Health Services Research and Development Service of the Department of Veterans Affairs (HSR&D #87098) that allowed us to pursue this project. James W. Davis, M.D., Elizabeth Clark, Ph.D., and Karen R. Josephson, M.P.H., were all part of the original study group leading to the planning of the book. We thank Christine Smedley of Sage for her valuable editorial assistance and Wendy Barnett, Beverley Phil-brook, and Mae Homestead, who assisted with manuscript preparation. Thanks also to Adina Katz, GRECC Administrative Officer, for helping us keep our oars in the water. Finally, we thank our uncomplaining families for supporting us through this and a multitude of other labors.
Introduction: Clinical Research in the Nursing Home[Page viii]
The size and scope of nursing home (NH) care has increased dramatically in the past 40 years. Since 1950, the number of persons living in U.S. NHs at any one time has grown more than fivefold—from under 300,000 in 1950 to over 15,000,000 in 1990 (1,2). Currently, over 20% of health care expenditures for persons age 65 years and over goes for NH care, about half coming from government sources, primarily Medicaid (2).
This growth has been spurred by increasing numbers and longer survival of elderly disabled people, changing demographics and family structures that have left more of these disabled elders to fend for themselves outside traditional family care environments, and financial incentives from governmental programs that have encouraged the growth of the NH industry.
Not uncharacteristically for health services, this growth has preceded the existence of clinical research to guide its structures, function, and direction. Much of how NH care is structured and delivered is determined by tradition or has been developed empirically rather than based upon a logical progression of what has been shown to be scientifically effective. As in many areas of health care, research into the effectiveness of an intervention generally comes after general deployment of the services.
There has also been a tremendous growth in areas of clinical research in the NH over the past two decades. Research has been of diverse types (e.g., medical, psychosocial, epidemiologic, health services), from many disciplines (e.g., medicine, nursing, social work, psychology, anthropology, pharmacy), covering a multitude of topics (e.g., drug use, infections, rehabilitation, quality of life). The [Page ix]present volume is a concerted effort to bring together and synthesize the major parts of this expanding body of clinical research, particularly research examining the effectiveness of clinical interventions. It is hoped that this will be both a useful chronicle of research progress as well as a clinically helpful compendium of current knowledge.
The volume is organized by chapters into the major topic areas of NH research. In most cases, the chapters are intended to include the vast majority of published clinical research studies pertaining to the topic. We have tried to include chapters representing each of the major active areas of clinical NH research. However, we acknowledge that some areas of research relevant to NH care have been left out—mostly because the published body of knowledge in those areas was relatively small.
Although much of NH care has evolved without the benefit of research, substantial progress has been made in NH care in a number of major areas directly as a result of and proportional to the intensity of the research devoted there. The chapters in this volume reflect this progress in practice as well as the progress in research productivity per se. For example, much has improved in the past two decades in the care of persons with common problems such as behavior disorders, incontinence, depression, and deconditioning. As well, we have learned much about what causes falls and how to assess and control the quality of care. Although we still have much to learn, we have learned a great deal about the epidemiology of pain, infections, and pressure sores in NHs, and research in these areas is extremely active.
The chapters are heterogeneous and have been organized in a rather arbitrary sequence, beginning with research on rehabilitation and proceeding with research on medication use, medical syndromes (infections, pressure sores, incontinence, bowel problems, nutritional problems, falls, pain), psychologic issues (depression, behavior problems), and ending with research on quality of care. The format of the review chapters, building around detailed tables of the research literature, was designed to make maximum use of space. The accompanying text is intended to provide summary narrative of the specific data in the tables and put the information into context, rather than repeat the tables.
Some chapters are more extensive than others, reflecting the variability in size of the research bodies themselves. Similarly, the depth and quality of the research data are quite variable—some areas are still fairly primitive and limited to descriptive studies and case series, whereas others are fairly well matured and include large randomized trials.[Page x]
All these areas are still very much in progress, and this volume can do little more than review the state of the art as of this point in time. Our anticipation is that in a short time, all of these chapters will need to be extensively revised and new chapters written to account for the continuing substantial progress in NH research. We hope that this effort to compile and synthesize clinical research in NHs will be a positive step in accelerating this research effort toward further clinical progress.References1. 1985). The long term care marketplace: An overview. In Healthcare Financial Management Association (HFMA) (Ed.), Long-term care: Challenges and opportunities. Oak Brook, IL: Author., & (2. U.S. Senate Special Committee on Aging. (1987). Aging America: Trends and projections (LR 3377-188-D12198). Washington, DC: U.S. Department of Health and Human Services.
About the Contributors[Page 338]
Adil A. Abbasi, M.D., is Assistant Professor in the Department of Medicine at the Medical College of Wisconsin in Milwaukee. He also holds an appointment at the Medical Service of the VA Medical Center in Milwaukee. His research interests include nutritional, metabolic, and endocrine problems associated with aging, and he is currently working on the following research projects: the prevalence, causes, and management of protein calorie undernutrition in the elderly; the effects of endogenous and exogenous growth hormone on renal status in old age; and insulinlike growth factor II and aging.
Mark E. N. Agnew, M.D., is a citizen of Great Britain. He was educated at Bedford School and entered the School of Physic at Trinity College Dublin in 1960, graduating in 1966. After graduation, he joined the house staff at Dudley Road Hospital in Birmingham, England, holding a series of appointments there followed by a residency in general practice with special responsibilities for a hospice. In 1972, he moved to Anchorage, Alaska, where he was instrumental in founding Hospice of Anchorage, a community-based program for the terminally ill. An interest in the problems of the frail elderly led to appointments as Medical Director to three long-term care facilities, one of which was recently given the 1991 Order of Excellence Award by Bill Publication of New York. His current areas of clinical interest include nutritional and pharmacologic strategies to reduce the incidence of aspiration pneumonia, anorexia and feeding refusal in the elderly, new pharmacologic approaches to the management of aggressive and agitated behavior in dementia, and use of graphic systems to display clinical data.
Cathy A. Alessi, M.D., is Assistant Professor in the Department of Medicine and the Multicampus Program in Geriatric Medicine and [Page 339]Gerontology at the University of California, Los Angeles, and Sepulveda VA Medical Center. She is a geriatrician in the Geriatric Research, Education and Clinical Center, and Chief of the Geriatric Evaluation and Management Unit at Sepulveda VA Medical Center. Her prior training included medical training at the University of Illinois School of Medicine in Chicago from 1980 to 1984, and residency in Internal Medicine at Michael Reese Medical Center, also in Chicago, from 1984 to 1987. She then held a 3-year fellowship in Geriatric Medicine at the University of Chicago from 1987 to 1990. She has been in the UCLA program and Sepulveda VA since 1990. Her current research topics include acute illness in the nursing home, the effects of nighttime sleep and medication on daytime behavior in impaired nursing home residents, and geriatric assessment. The topics of her most recent publications have been delirium, constipation in the nursing home, thyroid-function testing in the elderly, and the behavior problems of dementia. The topics of her most recent scientific abstracts have been methods to monitor mental status in the elderly, acute illness in the nursing home, and measuring mental status in the nursing home.
Luca Alverno, M.D., is Chief of Consultation/Liaison Service at the Clement Zablocki Veteran Affairs Medical Center in Milwaukee Wisconsin. He is Associate Professor of Psychiatry at the Medical College of Wisconsin and a member of the American Psychiatric Association and the American Association for Geriatric Psychiatry. His current research interests are health indicators and aggressive and hallucinatory behavior in chronically institutionalized psychiatric patients.
Ariane An, Pharm. D., was born in Saigon, Vietnam, in 1970. In 1978, her family immigrated to the United States as refugees. She attended the University of the Pacific in northern California and received a Doctor of Pharmacy degree in 1992. She is currently completing a residency in clinical geriatric pharmacy at the West Los Angeles VA Medical Center Geriatric Research, Education and Clinical Center (GRECC), after which she plans to enter a pharmacy fellowship program in infectious diseases. Her research interest is the use of antibiotics in the elderly.
Sailendra N. Basu, M.D., is Medical Director at the North Central Health Care Facilities in Wausau, Wisconsin. He has published a variety of papers in India, Europe, and the United States.[Page 340]
Dan R. Berlowitz, M.D., M.P.H., is currently on the staff of the Edith Nourse Rogers Memorial Veterans Hospital in Bedford, Massachusetts, and is Assistant Professor of Medicine at Boston University. Until recently, he served as Assistant Chief of Medicine for Extended Care. In this capacity, he was involved in all aspects of long-term care and maintained an active research program on the clinical epidemiology of pressure ulcers and the use of advanced directives in this setting. Specific projects included a prospective study to identify risk factors for pressure ulcer development and an analysis of the short-term outcome of pressure ulcer patients. Presently, he is the recipient of a Department of Veteran Affairs Research Associate Career Development Award through the Health Services Research and Development Field Program at Bedford. Active research interests center on quality assessment in ambulatory and long-term care settings, with one specific project using the incidence rate of pressure ulcer development as an outcome monitor of the quality of care.
Kenneth V. Brummel-Smith, M.D., is Associate Professor of Medicine and Family Medicine at Oregon Health Sciences University. He is also Program Director of the Geriatric Evaluation and Management Unit and the Geriatric Assessment Clinic at the Portland Veterans Affairs Medical Center in Portland, Oregon. He is coeditor of two textbooks in geriatrics, Geriatric Rehabilitation (published by Pro-Ed) and Ambulatory Geriatric Medicine (soon to be released by Mosby Year Book). He has written numerous chapters for other textbooks as well. Past research includes a large-scale community survey of the health care status and needs of Hispanic elderly in Los Angeles, the effect of a support group on caregivers of Alzheimer's patients, and methods for establishing the mobility status of community ambulators. His current research interests are in geriatric rehabilitation, late-life effects of postpolio and spinal chord injury, and ethics. He has served as invited reviewer for research grants and as a panelist for the National Consensus Conference on Geriatric Assessment for the National Institutes of Health. He also served on the committee to develop the first certification examination for geriatric physicians and on the Task Force in Geriatric Education for the Society of Teachers of Family Medicine. Prior to moving to Oregon, he served for 8 years as Co-Chief of the Clinical Gerontology Service at Rancho Los Amigos Medical Center in Downey, California, and as Director of the Section of Geriatrics, Department of Family Medicine at the University of Southern California School of Medicine.
Jiska Cohen-Mansfield, Ph.D., founded the Research Institute of the Hebrew Home of Greater Washington in 1984. In addition to her role [Page 341]as Director of the institute, she is Director of Research at the Center on Aging and Professor of Psychiatry, both at Georgetown University. She received her Ph.D. in clinical psychology from the State University of New York at Stony Brook and completed a postdoctoral fellowship at New York University Institute of Rehabilitation Medicine. She also has a master's degree in statistics from the Hebrew University in Jerusalem. She has published numerous articles on the topic of agitation in the nursing home resident and also addressed important issues for the nursing home resident such as sleep, religious beliefs, elderly persons' decisions regarding life-sustaining treatments, and stress in nursing home caregivers. She is a member of many professional organizations, including the Gerontological Society of America, the Maryland Gerontological Association, the American Society on Aging, and the American Psychological Association. She has received grants from various institutions, including the National Institute of Mental Health, the National Institute on Aging, and the National Center for Health Services Research.
Kenneth D. Cole, Ph.D., received his doctorate in clinical psychology with a specialty in life span development from the University of Southern California in 1981. He has published articles and chapters in the areas of depressive and paranoid states in later life, interdisciplinary team development and maintenance, and health care professional relationships. For 7 years, he was Director of the Interdisciplinary Team Training Program at Sepulveda VA Medical Center, and since February 1991, he has been on staff at Long Beach VA Medical Center as a health psychologist providing consultation and liaison services to rehabilitation medicine and hematology/oncology. Since 1985, he has operated a private practice specializing in adult development, particularly at midlife and late in life. He has also consulted with health care organizations on issues of team development and geropsychology.
Valerie C. Crooks, D.S.W., is Research Associate at the Anna and Harry Borun Center for Gerontological Research and the Multicampus Program of Geriatric Medicine and Gerontology at the University of California at Los Angeles. She is also Associate Clinical Professor in the School of Medicine at UCLA. Her research interests have focused on evaluating the effect of geriatric clinical and educational programs on learning in a number of health care disciplines, as well as the impact of these programs on the elderly in community, acute, and long-term care settings. Her most recent research efforts have been directed at developing and refining geriatric assessment instruments to evaluate subjective quality of life in community-dwelling [Page 342]elderly. Her current research is targeted at determining and developing appropriate methods of care and training in the nursing home to aid in measuring resident outcomes. Along with articles on various geriatric patient assessment measures, she has publications in the areas of geriatric mental health and multidisciplinary training strategies in geriatrics.
Bruce A. Ferrell, M.D., is Associate Director for Clinical Programs for the Geriatric Research, Education and Clinical Center (GRECC) at the Sepulveda VA Medical Center and Assistant Professor of Medicine (Geriatrics) at the UCLA School of Medicine. He is also Medical Director of the Hospital-Based Home Care program and Director of the postdoctoral Geriatric Medicine Fellowship program at the Sepulveda GRECC. After receiving his medical degree (1979) and internal medicine training (1982) from the University of Oklahoma, he pursued geriatric medicine training at the UCLA Multicampus Division of Geriatric Medicine. He is board certified in internal medicine (1983) and geriatric medicine (1988). He is a member of the Gerontological Society of America (GSA), the American Geriatrics Society (AGS), the American College of Physicians (ACP), and the American Pain Society (APS). His research interest is applied clinical research. He has conducted studies and authored a number of research articles and book chapters in the areas of geriatric pain management, pressure sores, and geriatric home care.
Steven Lloyd Ganzell, Ph.D., is a neuropsychologist on the geropsychiatry multidisciplinary treatment team at the Sepulveda Veterans Affairs Medical Center. He received his Ph.D. in clinical psychology from Brigham Young University in Salt Lake City, Utah. He completed a postdoctoral fellowship in neuropsychology at the University of California, Los Angeles, in 1989.
Catherine Gill, M.S., M.H.A., P.T., is currently Director of Education and Research for Therapy Management Innovations, Inc. She was previously Research Associate at the Rehabilitation Research and Training Center on Aging, Rancho Los Amigos Medical Center, and practiced therapy in primarily long-term care and home health settings. She received her master of science in physical therapy from the University of Southern California and a master of health care administration from the University of La Verne. She is currently a member of the American Physical Therapy Association, American Geriatrics Society, Gerontological Society of America, and American Society on Aging and has presented on several research and clinical [Page 343]topics to these organizations. She has also presented numerous workshops and seminars to both professional and community groups.
Cynthia T. Henderson, M.D., M.P.H., F.A.C.N., is Chair of the Department of Geriatric Medicine and Chronic Diseases at Oak Forest Hospital, a 1,000-bed chronic disease hospital in Illinois. She also serves as Director of Nutrition Support Services and consultant in gastroenterology. She is board certified in internal medicine and gastroenterology and holds a certificate of added qualifications in geriatric medicine. She received her M.D. and a master's degree in public health from the University of Illinois and completed residency in internal medicine at Cook County Hospital. She completed fellowship training in gastroenterology and clinical nutrition at the University of Illinois.
Elizabeth H. Hoffman, O.T.R., is currently Corporate Director of Quality Improvement for Integrated Health Services, Hunt Valley, Maryland. Prior to this position, she was Rehabilitation Clinical Coordinator with Therapy Management Innovations. She has more than 20 years' experience in the area of geriatric occupation therapy. She graduated from the occupational therapy assistance program at Mount Aloysius College in Pennsylvania. She received a B.A. in human services from the College of Notre Dame of Maryland. She became licensed through the American Occupational Therapy Association Career Mobility Program. She is currently a master's degree candidate at Johns Hopkins University in administrative science.
Janet A. Howells, M.S., P.T., is Vice President for Therapy Management Innovations, Inc. In her current position, she provides overall program development and direction for the rehabilitation services of Integrated Health Services, Inc. She earned her bachelor's and master's degrees from The Ohio State University. She is a member of the American Physical Therapy Association, in which she has held many state and district offices. She has participated in several research studies and coauthored an article entitled “The Prospective Payment System: Its Realities and Opportunities,” which appeared in Clinical Management in Physical Therapy.
Karen R. Josephson, M.P.H., is Senior Health Services Researcher for the Geriatric Research, Education and Clinical Center (GRECC) at the Sepulveda VA Medical Center. After receiving her master's degree in public health from UCLA, she continued her training in health services research and gerontology at the Sepulveda VA GRECC and participated in the first randomized trial of a geriatric assessment unit. She coordinated several large health services research projects, [Page 344]including an evaluation of a preventative health screening clinic, a multisite falls intervention trial, and an analysis of quality of health care for elderly persons in the United States. Her current research interests include causes and prevention of falls, exercise among frail older adults, pain management, and ageism in children's literature. She is currently co-investigator on two randomized trials: an exercise intervention for fall-prone elderly veterans and nonpharmacologic pain management for older adults. She has authored a number of research articles and book chapters, especially on the topic of falls.
Karen M. Linderborn, M.S., R.N.-C., is a research nurse at the Geriatric Research, Education and Clinical Center (GRECC), Department of Veterans Affairs Medical Center, Sepulveda, California. She received her nursing degree and a master of science in administration/gerontology from the University of Maryland School of Nursing. She is certified in gerontology through the American Nurses' Association. She is currently involved in several research projects, including an exercise intervention for frail elderly veterans and a study of nursing indicators of acute illness in the nursing home. She was published in the Journal of Gerontological Nursing in 1989 and is currently awaiting the publication of several articles.
Steven Lipson, M.D., M.P.H., has been the Medical Director of the Hebrew Home of Greater Washington since 1984 and a full-time member of the faculty of Georgetown University School of Medicine since 1975. A graduate of Cornell University, New York University School of Medicine, and the Johns Hopkins School of Hygiene and Public Health, Dr. Lipson is a board certified specialist in Internal Medicine and in Public Health and General Preventive Medicine. He has extensive experience in medicine, medical administration, and medical education programs, as well as community educational programs. Research experience in the last decade has focused on long-term care of the elderly, including ethical aspects of long-term care decision making, the use of physical and chemical restraints, and the impact of infections in the aging population. He is a member of many national professional organizations, including the American Geriatrics Society, the Gerontological Society of America, the Society for Epidemiologic Research, and the American Society on Aging. He has participated in research projects funded by the National Institute of Mental Health, the National Institute on Aging, and the Retirement Research Foundation.
Marcia S. Marx, Ph.D., who joined the Research Institute of the Hebrew Home of Greater Washington in June 1987, received her doctorate in [Page 345]experimental psychology from Tulane University in 1982. Dr. Marx has extensive experience in research involving the visual system. She worked with Dr. James May at the LSU Eye School of Medicine in New York City, where she studied visual problems in persons with glaucoma as well as in those suffering from Parkinson's disease and other dementing disorders. Since joining the Research Institute, she has developed a test for visual acuity estimation that is appropriate for all nursing home residents, regardless of their ability to communicate. Dr. Marx is a member of the Gerontological Society of America, the Association for Research in Vision and Ophthalmology, and the American Association for the Advancement of Science. She received support from a grant from the Radcliffe Morris and Marion W. Urquhart Memorial Foundation. In addition to her work in vision, Dr. Marx has participated extensively in research projects concerning the nursing home elderly and, in particular, agitation in nursing home residents. She is the principal investigator of a grant from the Alzheimer's Association to study outcome of cataract surgery in the nursing home.
M. Patrick McNees, Ph.D., serves as President of North Rim Systems. His work is directed toward translations of treatment and management protocols that have been validated in controlled (laboratory) settings into complete working systems for use in nursing homes and hospitals. He has a particular focus on incremental (continuous) quality improvement in health care settings. He was the recipient of the National Behavioral Engineering in Business Award. He has contributed numerous articles and chapters to the professional literature and currently serves on a federal grant panel for nursing research. He collaborated with Dr. John Schnelle on the development of an automated urinary incontinence management system for nursing homes and is Principal Investigator for a National Institute on Aging (SBIR Phase II) grant to test the system in nine nursing homes across the nation. He was a visiting researcher at the Mary Conrad Center (Anchorage, Alaska) during the period that Mary Conrad won the Contemporary Long-Term Care Award for Excellence. He currently is involved in nursing home projects in Alaska, Washington, and California.
James Randy Mervis, M.D., completed his psychiatric training at the State University of New York, Downstate Medical Center, in 1988. He currently is Ward Chief of the Geropsychiatry Assessment and Treatment Unit at the Sepulveda Veterans Affairs Medical Center. He has additional board qualifications in geropsychiatry. He is Assistant Clinical Professor at the UCLA School of Medicine, Department of [Page 346]Psychiatry and Biobehavioral Sciences. He is currently conducting research evaluating various pharmacologic approaches to controlling agitation in patients who are demented.
Dean C. Norman, M.D., was born in New York City in 1950, but moved in 1952 with his family to California, where his father became a faculty member of the Physics Division of the UCLA School of Medicine. He later attended UCLA and graduated in 1972 with a bachelor of science degree in physics. He then entered the UCLA School of Medicine and completed his medical studies in 1976. After graduation from medical school, he entered postgraduate residency training and completed 3 years of internal medicine residency at Los Angeles County-University of Southern California Medical Center. The residency training was followed by a 2-year fellowship in infectious diseases at Harbor General-UCLA Medical Center and then a 2-year fellowship in geriatric medicine at the VA/UCLA Multicampus Program of Geriatric Medicine and Gerontology. In 1980, he joined the faculty of the West Los Angeles VA Medical Center Geriatric Research, Education and Clinical Center (GRECC) and became Assistant Professor of Medicine at UCLA. Currently, he is Clinical Director of GRECC at the West Los Angeles VA Medical Center and Associate Professor of Medicine at UCLA. He has received his boards in internal medicine and infectious diseases and special certification in geriatric medicine. His research focus has been on the pathogenesis and treatment of infections in the elderly.
Joseph G. Ouslander, M.D., is Medical Director of the Eisenberg Village campus of the Jewish Home for the Aging of Greater Los Angeles and Associate Professor of Medicine in the Multicampus Program of Geriatric Medicine and Gerontology, UCLA School of Medicine. He also serves as Director of Research and Education at the Jewish Home, Associate Director of the Borun Center for Gerontological Research, and Director of the Continence Program and Urodynamic Laboratory at Encino Hospital. His primary area of interest has been urinary incontinence in the elderly. He also has begun research on the quality of medical care in nursing homes, initially focusing on improving physician drug prescribing. He is a coauthor of Essentials of Clinical Geriatrics and Medical Care in the Nursing Home. Currently, he serves on the board of directors of the American Geriatrics Society and the California Association of Medical Directors, and has served on the Geriatric Medicine Test Committee of the American Board of Internal Medicine/American Board of Family Practice. He has lectured extensively on incontinence and [Page 347]nursing home care at national and international meetings, including visiting professorships in Australia, Japan, and China.
Abbas Parsa, M.D., is a faculty member of the Department of Medicine of the Medical College of Wisconsin and the Medical Service of the VA Medical Center, Milwaukee.
Laurence Z. Rubenstein, M.D., M.P.H., is Director of the Geriatric Research, Education and Clinical Center (GRECC) at the Sepulveda VA Medical Center and Associate Professor of Medicine (Geriatrics) at the UCLA School of Medicine. After receiving his M.D. in 1974 from Albert Einstein College of Medicine, he pursued further training in medicine, public health, health services research, and gerontology at Einstein and UCLA and was a UCLA Robert Wood Johnson Clinical Scholar. He is board certified in geriatric medicine (1988) as well as internal medicine (1978) and preventive medicine (1980). He has been on the UCLA geriatric medicine faculty at the Sepulveda GRECC since 1979. He is a GSA Fellow as well as a Fellow in the American Geriatrics Society and American College of Physicians. He serves on the GSA Public Policy Committee and was on the editorial board of the Journal of Gerontology (1983–1986). He is section editor of JAGS (Heath Services Research) and serves on several other editorial boards, review panels, and advisory boards. He has authored or coauthored more than 90 research articles, books, and book chapters. His primary area of research is geriatric health services, and he has conducted several major studies in the areas of geriatric assessment, long-term care, falls, and instability.
Daniel Rudman, M.D., is Professor of Medicine at the Medical College of Wisconsin and Associate Chief of Staff for Geriatrics and Extended Care at the VA Medical Center in Milwaukee.
John F. Schnelle, Ph.D., is Associate Director of the Borun Center for Gerontological Research and Professor in Residence, Multicampus Program of Geriatric Medicine and Gerontology, School of Medicine, University of California, Los Angeles. He is known for his role as principal investigator on several major clinical trial intervention grants designed to improve care and management in nursing homes and has received awards for his outstanding contributions to behavior therapy. Among his most notable contributions is his innovative work in incontinence care, comprehensively described in his newest book, Management of Urinary Incontinence Care in the Frail Elderly (1991). He has published extensively in the areas of quality control in institutional settings and quality of life issues in the frail elderly, with over 70 publications in [Page 348]professional books and journals. He currently serves on the board of editors of the Journal of Organizational Behavior Management.
Sandra F. Simmons, M.A., is Staff Research Associate at the Borun Center for Gerontological Research, Multicampus Program of Geriatric Medicine and Gerontology, School of Medicine, University of California, Los Angeles. Her primary focus is on management issues in long-term care, including staff management and related interventions, her most recent publications appear in the Gerontologist and the International Journal of Urogynecology, reporting research findings on restraint management and incontinence care, respectively. Recent presentations at professional meetings have concerned the effectiveness of exercise programs for frail and demented elderly. She currently serves as a consultant on a Small Business Innovative Research grant designed to disseminate incontinence management systems to nursing homes. She is a member of the Gerontological Society of America.
Fawn Takemoto, Pharm. D., was born in 1960 in Hilo on the island of Hawaii. She graduated from the University of Hawaii at Manoa with a bachelor of arts degree in biology and subsequently attended the University of Southern California, where she received a doctor of pharmacy in 1992. She is currently completing a residency in clinical geriatric pharmacy at the West Los Angeles VA Medical Center Geriatric Research, Education and Clinical Center (GRECC). After completion of residency training, she plans to continue practicing in an environment that combines research, teaching, and a health care team approach to caring for the elderly.
John F. Thompson, Pharm. D., graduated from the University of Southern California in 1973 with a Pharm. D. and did residency in clinical pharmacy at Wadsworth Veterans Administration Medical Center, Los Angeles, California. He became a USC faculty member in 1975 as Assistant Clinical Professor, teaching clinical therapeutics in geriatrics. He became Associate Professor of clinical pharmacy and clinical gerontology in 1991 and 1992, respectively. Currently, he holds the status of Fellow with the American College of Clinical Pharmacology. His research interests center on physician prescribing habits and the elderly, adverse drug reactions, and health services research.
Santiago Deleon Toledo, M.D., was born in Manila, Philippines, in 1959. After completing medical school at the State University of the Philippines, he completed a 3-year postgraduate internal medicine [Page 349]residency at the university-based Philippine General Hospital. In 1991, he completed 1 year of research training at the West Los Angeles VA Medical Center Geriatric Research, Education and Clinical Center (GRECC). Currently, he is enrolled in a 2-year fellowship in geriatric medicine at the VA/UCLA Multicampus Program of Geriatric Medicine and Gerontology. His research interest continues to be in the early detection and treatment of infections in nursing homes.
Perla Werner, M.A., a native of Argentina, received her bachelor's degree from the Hebrew University of Jerusalem, her master's degree from Bar Ilan University in Tel Aviv (in sociology and anthropology), and is a doctoral candidate at the University of Maryland. For 8 years she worked at the Research Department of the National Insurance Institute in Israel. Her research there focused on the evaluation and follow-up demonstration projects for the elderly, including home health care and support programs for the caregivers of disabled elderly in the community. Before joining the Research Institute of the Hebrew Home of Greater Washington, she was a research statistician at the National Institute on Aging, working on a project concerning sleep disturbances among elderly people. In December 1988, she came to the Research Institute where she has been involved in studies of agitation, sleep disturbances in nursing home residents, and other topics. Because of her expertise in data analysis (with both personal computers and mainframe computers), she is an active participant in studies at the Research Institute. Ms. Werner is a member of the Gerontological Society of America and the Southern Society of Aging. She is the recipient of a contract from the National Institute on Aging to study sleep patterns of elderly persons. She is also coprincipal investigator on grants from the Robert Wood Johnson Foundation and the American Society of Consultant Pharmacists Research and Education Foundation to study the effects of removal of physical restraints on psychotropic medication in the nursing home.
Darryl Wieland, Ph.D., is currently Senior Health Services Researcher for the Geriatric Research, Education and Clinical Center (GRECC) at the Sepulveda (California) VA Medical Center and Assistant Research Anthropologist in the Multicampus Program of Geriatric Medicine and Gerontology at the University of California, Los Angeles. He has served as Research Director of the Beverly Foundation, Pasadena, California, and Principal Investigator or Director on numerous research projects in geriatric health services, ranging from hospital-based geriatric assessment to teaching nursing homes and [Page 350]long-term care work force studies. He is also focusing on the implications of ethnic diversity for geriatric care. He has published in the Journal of the American Medical Association, Social Science and Medicine, and the Journal of Cross-Cultural Gerontology, among others. He was a coeditor of Anthropology and Aging: Comprehensive Reviews (1991).
Spencer Van B. Wilking, M.B., B.S., M.P.H., is currently Assistant Clinical Professor of Medicine in the Geriatrics Section of Boston University and Director of Medical Education at Jewish Memorial Hospital and Rehabilitation Center. He received his medical training in Great Britain with a specialty in geriatric medicine. His research interests include the management of pressure ulcers, developing a model for predictors of nursing home placement, and the epidemiology of isolated systolic hypertension in the elderly. He is Clinical Researcher at the Framingham Heart Study, where he is involved with data collection among elderly members of the original Framingham Heart Study cohort. He is actively involved in research and teaching at University Hospital and Jewish Memorial Hospital and Rehabilitation Center.
Bradley R. Williams, Pharm. D., is Associate Professor of Clinical Pharmacy and Clinical Gerontology at the University of Southern California School of Pharmacy and Andrus Gerontology Center and Clinical Pharmacist with the Geriatric Health, Education and Research Center at Rancho Los Amigos Medical Center in Downey, California. He currently is the preceptor for a clinical pharmacy clerkship in geriatrics at Rancho Los Amigos and also teaches a preclinical geriatrics course at the USC School of Pharmacy. His clinical practice includes drug therapy monitoring and management for elderly patients of the Clinical Gerontology Service at Rancho Los Amigos. His research interests focus on drug use evaluation and the appropriate use of medications by elderly patients. Topics of his recent publications include risks of NSAID-induced renal toxicity in institutionalized elderly and conducting drug use evaluation studies in long-term care facilities. He is also coeditor of Clinical Pharmacology and Nursing. He is completing a 3-year project investigating interventions of a clinical pharmacist to improve medication use and avoid inappropriate prescribing in residential care facilities for the elderly. This project, sponsored by the John A. Hartford Foundation, has used an educational strategy to improve physician prescribing and increase drug knowledge among staff and residents of rest homes.