Dizziness-Trying to Prevent Falls and Accidents Among the Elderly
(3/2/19)- Falls are the leading cause of fatal and nonfatal injuries among older adults. An older person dies from a fall in this country.
More than a quarter of people age 65 and older fall each year, and falling once doubles their chances of falling again, according to the Centers for Disease Control and Prevention (CDC).
(1/15/18)-Almost 32,000 people die from falls, which is more than those killed by guns in the U.S. Fall injuries increase during the winter months, with deaths for those over 65 from falls, being highest in the states of Wisconsin and Minnesota, according to the April 2017 edition of the AARP Bulletin
The most common place for falls…. the homes. Falls are the number one cause of injury for those over 65, with about one in three of those over 65 falling each year.
(10/13/17)- Falls are a major health concern for older adults and a costly strain on the American health system, according to the researchers. More than 30 percent of adults aged 60 who live on their own—community dwelling—fall each year. The costs for falls in the older adult population is estimated at $23.3 billion. (From Futurity.com accessed 10/11/17)
8/18/17)- An analysis of 10 randomized trials studying the effects of the ancient Chinese martial art of tai chi that appeared in a recent edition of The Journal of the American Geriatric Society found that it reduced the incidence of falls by 43% in those followed for less than a year.
For those followed for more than a year, the incidence of falls was reduced by 13%.
Rafael Lomas-Vega of the University of Jaen in Spain was the lead author for the study.
Tai chi involves a series of graceful movements followed by deep breathing and mental focus that slowly move the center of balance from one leg to the other.
(5/16/16)- Antihypertensive-drug side effects that could potentially lead to falls include postural hypotension, problems with balance and walking, dizziness, and electrolyte abnormalities.
In 11 states and the District of Columbia, more than half of older adults (ages 65 and up) with vision impairment reported falling in the past year, and in 30 more states 40-49 percent reported falling. The report finds that about 1.3 million older persons with severe vision impairment reported falls in the past year. Although states reported a wide variation in rates of falls—from 30.8 percent in Hawaii to 59.1 percent in California, the percentage of people with severe vision impairment who fell was consistently higher than among people without impairment.
(2/2/16)- About 30-50% of falls in the elderly result in minor injuries, including bruises, abrasions, and lacerations, but an estimated 10% of all falls in the elderly cause major injuries, including intracranial injuries (ICIs) and fractures.
percent of all falls in this population result in hip fractures, which pose a
significant risk for post fall morbidity and mortality. In addition, according
to the Centers for Disease Control and Prevention (CDC), between 2006 and 2010,
falls were the leading cause of traumatic brain injury-related deaths in
persons aged 65 or older.
The aging process, illness or physical injury to the inner ear canal (which is known as the vestibular canal in each ear) can cause decrease in the sense of balance which may also lead to falling. The nerve ending in the vestibular canal send signals to the brain, so it can determine exactly where the body is standing.’
When damaged, the result is a decrease in the sense of balance
(11/4/14)- The number of people over 65 who died from a fall was almost 24,000 in 2012 (the latest year for which this data was available), according to the Centers for Disease Control and Prevention. This was almost double the number 10 years earlier.
The same source estimated that more than 2.4 million people over 65 were treated in emergency rooms for injuries from falls in 2012, an increase of 50% over a decade.
In the decade from 2002-2012, more than 200,000 Americans over 65 died after falls. As we pointed out in the item dated 9/26/13 below, falls are the number one cause of injury related deaths in the over 65 age category.
Vitamin D supplementation has been suggested to improve function in frail elderly patients at risk for falls, as well as individuals with myasthenia gravis and Parkinson's
(9/26/13)- Falls are the number one cause of death and injury among people age 65and older, according to the Centers for Disease Control and Prevention (CDC). More than two million older people went to an emergency room in 2010 because of a fall according to the CDC.
Researchers at the Fraser University, in Burnally, British Columbia determined that incorrect weight shifting accounted for 41% of the falls for people over 65. Tripping caused 20% of the falls.
Other less frequent causes of falling among the elderly included loss of support with an external object like a walker, or bumping into something.
(5/29/13)- As we continue to monitor the research literature on falls in the elderly, it becomes clearer that the society is dealing with an increasingly serious situation that will only grow worse as the U.S. population ages.
Robertson and Gillespie report (JAMA, April 3, 2013-Vol. 309, No. 13) that "[A]proximately 30% of older community dwelling people fall each year". They then went and pooled results of 159 random trials of studies from 1990 to 2011 involving treatment of falls in the elderly.
This involved 79,193 participants, 70% being women, 30% men. The mean age of this population was 75 years and it contained populations in 25 countries. The bottom line results of their study indicated "[F]all prevention exercise programs, usually including muscle strengthening and balance retraining, were associated with lower fall rates in community-dwelling older people whether or not individuals were selected on the basis of fall risk.
Home safety interventions, vitamin D supplementation in people with lower vitamin D levels, and individually targeted multifactorial interventions were associated with fewer falls in community-dwelling people with risk factor for falling."
Seemingly, this is good news, but the study notes that it does not apply to people with dementia or people who suffered from strokes and Parkinson's disease.
This brings us to the study by Kannus et al, (JAMA, May 8, 2013-Vol 309, No.18) Finnish researchers who examined fall-induced traumatic brain injury (TBI) in the entire Finnish population from 1970 to 2011, using The Finnish National Hospital Discharge Registry data.
The population they studied was 80 years and older. The definition of TBI was "a head injury that occurred as a consequence of a fall from a standing position of 1 m or less and resulted in hospitalization", and results were expressed as the number of cases per 100,000 adults aged 80 years or older per year.
Summarizing their results, Kannus et. al. state" [O]ur 40 year follow-up shows that the number and age-adjusted incidence of fall-induced TBI in Finnish men and women aged 80 years or older increased considerably between 1970 and 2011."
What the study did not determine was the reasons for the "considerable increase" in falls resulting in TBI. Could it relate to the fact that people are living longer and as they age, they become frail or show sensory neuropathy? Or is there some unknown factor that results in people falling more often these days? Could it be the result of the polypharmacy found among the elderly? or alcoholism?
There is no doubt that further studies are needed too better understand the reason(s) for the increase in falls in our society so that effective interventions for falls can be tailored to the individual. We also need methods to initiate injury prevention techniques.
(9/27/12)- At least one third of community-dwelling adults older than 65 years experience one or more falls at home per year, and approximately one in every five of these falls requires medical care.
Falls are associated with higher morbidity and mortality risks, and they trail only motor vehicle crashes in the economic costs of injuries among older adults. Wrist and hip fractures are the most particularly costly injuries among older adults. Resistance and balance training can reduce the risk for falls among older adults, but less than 10% of these individuals perform such exercises.
(9/28/10)-NYC Health Department reports that more than 1 million New Yorkers are now 65 or older, up from 605,000 in 1950. Falls, being the leading cause of fatal injuries for older adults, The Department of Health designated September 23 as Fall Prevention Awareness Day.
They suggest modifying medicines, improving vision, promoting physical activity and reducing trip-and-fall hazards in the home and community as steps to be taken to reduce incidence of falls.
Supplementation with ergocalciferol (vitamin D2) and calcium reduced the risk for falls in elderly women by 19%, according to the results of a randomized controlled trial reported in the January 14, 2008 issue of the Archives of Internal Medicine.
(11/11/08)-According to the Centers for Disease Control and Prevention, there are, on average, 1.8 million Americans over the age of 65 who fall and injure themselves every year.
In 2005, the last year for which statistics are available, there were about 433,000 people over the age of 65 who were admitted to hospitals after falling, and 15,800 who died as a direct result of their fall.
One in five hip fracture patients, over the age of 65, die within a year of their surgery, according to the CDC. These same statistics show that one four of those over 65, who fall, have to spend a year or more in a nursing home.
(10/7/07) The September 21, 2007 issue of Advanced Data: From Vital And Health Statistics, No. 392 entitled "Fall Injury Episodes among Non-institutionalized Old Adults: United States, 2001-2003" reveals some challenging statistics about health care utilization. "This report presents national estimates of nonfatal medically attended fall injury episodes for non-institutionalized adults aged 65 and over based on data from the National Health Interview Survey for 2001-2003. The NHIS is one of the major data collection systems of the Center for Health Statistics (NCHS) and is a continuous survey of a nationally representative sample of the U. S. civilian non-institutionalized household population. The following facts were cited in this survey:
(6/5/07)- The latest CDC Morbidity and Mortality Weekly Report on falls in the elderly indicated that more than 13,700 persons older than 65 died as result of falls in 2003, a whopping 55% increase from 1993.
Men were more prone to fall than women. Emergency department treatment for nonfatal injuries caused by falls among the elderly reached 1.8 million visits in 2003.
The report refers to a journal article by Hausdorff JM, Rios DA, Edelberg HK. Gait variability and fall risk in community-living older adults: a 1-year prospective study. Arch Phys Med Rehabil 2001; 82:1050--6 that reported falls affect approximately 30% of persons aged >65 years each year .
The CDC recommends the following to help prevent falls; exercise regularly, review medications with treating physician to reduce adverse effects of the medications. check eyes at least once per year, and eliminate fall hazards in homes.
(1/17/07) A community-based study of 2587 older men aged 65 to 99 years indicated that fall risk was higher in men with lower bioavailable testosterone levels (sex steroid) even when adjusted for physical performance. The study appears in the Archives of Internal Medicine 2006; 166:2124-2131 and followed the cohort group of men for four years. Incident falls were ascertained every 4 months.
It is well known that gonadal steroid levels decline with age. In general, this study indicated that lower testosterone levels were associated with more falls. (Fifty-six percent of the men reported at least one fall; many fell frequently.) However, in men 80 years and older, falls were not associated with testosterone levels. This suggested that the effect of fall risk may be mediated by other androgen actions.
Falls continue to be a serious issue with the elderly, with more research needed to focus on etiological factors that can be validated and proper adjustments made to correct this common age-related disorder.
(1/4/07)- The fatality rate from falls rose by more than 55% from 1993 to 2003, the latest year for which statistics are available. As a matter of fact, death rates have risen faster than injury rates from falls, in part because people are now living to ages when frailty raises the risk that a fall will be fatal.
As people age their bones become more brittle. Brittle and weakened bones are more likely to break. Statistics indicate that about one woman in four, and one male in 15 over the age of 50 will suffer at least one fractured bone over the latter period of their life.
(5/3/06)- Some of the initial data that was released about the Women's Health Initiative indicated that there was no significant benefit for bone health for postmenopausal women in taking calcium pills. The study, which followed 36,000 postmenopausal women for 10 years, cast a shadow on the federal guideline that recommended 1,200 mgs of daily calcium.
WHI researchers now say that the data may have been incorrectly interpreted because it did not take into account women who did not adhere to a strict regimen of taking their calcium pills. By the end of the study only 59% of the women were consistently taking their calcium pills.
Women over the age of 60 in the calcium group were 21% less likely to suffer a hip fracture than were women in the placebo group. When all age groups were taken into consideration, women who strictly adhered to their calcium regimen were at a 29% less of a risk of suffering a hip fracture. The study found that the biggest negative risk from taking the calcium pill was a 17% higher risk of developing kidney stones.
A recent Australian study of 1,400 women older than 70 years of age found there was a 34% overall reduction in fracture risk in the group of women who strictly adhered to their calcium regimen than there was in the placebo group. It turned out that there were only 57% of the women who adhered to their calcium pill program.
The WHI study also concluded that menopausal hormones lowered hip-fracture risk by 33% among users of estrogen and progestin, and by 40% among women taking estrogen alone.
(2/9/02)- The National Safety Council report for the year 1999 was released on April 26, 2000. It indicated that the number of accidental deaths in homes and public places increased 31 % from the 1992 figures. According to the report, the figure could be partially accounted for by the absolute increase in the elderly population, with accidental deaths increasing at a greater rate than population growth.
According to one study, one-third of those ever the age of 65 in a community living facility fall each year, and more than half of them suffer multiple falls during the year. Falling and instability are one of the major contributing reasons for nursing home admissions.
Here are some hints to help the elderly in trying to prevent falls in the home:
Since this trend of an increased elderly population is expected to continue in the next century, the report also laid out potential plans to reduce accidental deaths. Noting that falls had risen to 15,900 deaths in 1999 from 12,100 in 1992, the Council has joined with AARP to form the Coalition on Residential Fall Prevention whose goal is to reduce the amount of falls and related deaths.
The Council spokesman indicated that this would be achieved through enhancing building codes, making it mandatory to have nonskid bathroom floors and more handles in the bathroom for the elderly to hold on to when taking a shower or bath. They also hope to pursue more prominent labeling on medicines commonly used by the elderly, especially those that have dizziness as a side effect.
The report concludes that falls are a leading cause of morbidity and mortality in persons over 65 years of age. When an individual falls frequently, even if there are no serious injuries, there is a heightened fear-of-falling usually accompanied by a loss of confidence or self-efficacy in their ability to get around. In most cases, the tendency is then to limit daily activities, which has the domino effect of reducing physical exercise and concomitantly leads to an increase in social isolation. The net effect is that the self-imposed restrictions on activity can lead to an increase in risk of falling and greater dependency on family members to help perform daily activities.
What is needed is an intervention program that manipulates the capabilities of the individual, the goals of the task to be performed and the environment in which these tasks are to be performed. Debra J. Rose and Sean Clark (Journal of the American Geriatric Society. 2000; 48:275-278) undertook such a study. Their goal was " to review evidence regarding the benefits of exercise in older adults and provide guidance about how to approach a sedentary patient and write an exercise prescription…and how to follow-up an activity to enhance exercise adherence".
They used a theory of perception and control of bodily orientation as the basis of their program. It was a psychoeducational program that taught patients problem solving techniques where movement is concerned. Patients explored different postural control strategies to solve different task goals involving balancing activities in different environmental constraints (e.g. slipping forward or backwards on a moving or stationary surface; walking up and down inclined surfaces). With repetition of the learning experience (exposure) the patient was "better able to quickly and accurately select and implement the appropriate movement strategies for the task being performed."
It remains to be seen whether this method can reduce the long-term incidence of falls in the elderly and whether this method can be taught in groups as opposed to individual sessions. In any case, it represents another way to try to reduce the incidence of falls.
Sixty percent of falls occur in the home and many of these falls are preventable if proper safety measures are taken. Dr. Mary Tinette, Director of Yale's Program on Aging, recommends two key measures to try and prevent falls from occurring.
One of the keys is to avoid side effects like dizziness caused by
medications. This is especially true for the elderly, since they may be taking
several medications at the same time. Sometimes reduced dosage will help
prevent a fall and at the same time not impair the beneficial effects of the
medication. Certain high blood pressure or heart ailment drugs can cause
dizziness as well, so the elderly who are on such medications should be watched
Dr.Tinette's other key suggestion involves physical exercise that increases physical strength and balance. The lifting of weights by hand or foot will also serve to increase bone mass and thus reduce the risk of fracture if a fall does take place. Tai chi for the elderly has been found to improve balance and thus decrease the risk of falling.
Dizziness may be a sign that there is a disturbance or a disease in the system that helps people maintain balance. This system is coordinated by the brain, which reacts to nerve impulses from the ears, the eyes, the neck and limb muscles, and the joints of the arms and legs. If any of these areas fail to function normally or if the brain fails to coordinate the many nerve impulses it receives, a person may feel dizzy. Today, both older and younger people with serious dizziness problems can be helped by a variety of techniques-from medications to surgery to balancing exercises.
The focal point within the Federal Government for research on the brain and central nervous system is the National Institute of Health. Within the NIH the National Institute of Neurological and Communicative Disorders and Stroke (NINCD) is the central point for studies on dizziness.
The vestibular labyrinth system enables the body to maintain a sense of balance through our daily twists and turns. This system is located behind the eardrum. It features a group of 3 semicircular canals or tubes that arise from a common base. At the base of the canals is a rounded chamber called the vestibule.
The 3 canals and the vestibule are hollow and contain a fluid called endolymph which moves in response to head movements. Within the vestibule and the canals are patches of special nerve cells called hair cells. Hair cells are also found in 2 fluid filled sacs, the utricle and saccule, located within the vestibule. Tiny calcium stones called otoconia are also located within the inner ear. When you move your head or stand up, the weight of the otoconia or movement of the endolymph bends the hair cells.
The bending of the hair cells transmits an electrical signal about head movement to the brain. This signal travels from the inner ear to the brain along the 8th cranial nerve-the nerve involved in balance and hearing. Sensory input from the eyes as well as from the muscles and joints are sent to the brain. The brain interprets this information and adjusts the muscles so that balance is maintained. Dizziness can occur when sensory information is distorted. Another form of dizziness occurs when we turn around in a circle quickly several times and then stop suddenly. The senses are also important in determining balance.
Some people feel dizzy at great heights, partly because they can't focus on nearby objects to stabilize themselves. When an individual is on the ground it is normal to sway slightly while standing. A person maintains balance by adjusting the body's position to something close by. But when someone is standing high up, objects are too far away to use to adjust balance. The result can be confusion, insecurity, and dizziness.
A person suffering persistent dizziness should see a doctor. The doctor may try to determine which components of a patient's nervous system are out of kilter, looking for changes in blood pressure, heart rhythm or vision. Sometimes dizziness is caused by an ear disorder. The physician will also look for other neurological symptoms: difficulty in swallowing, talking or double vision. The patient may have a loss of hearing, discomfort form loud sounds, or constant noise in the ear, a disorder known as tinnitus.
The doctor in turn may refer the patient either to an ear specialist (otologist) or a nervous system specialist (neurologist). After the initial history taking and physical examination, the physician may deliberately try to make the patient feel dizzy. One widely used procedure is called the caloric test. The patient's eye movement is closely monitored while one ear at a time is irrigated with warm water or air and then with cold water or air.
Some patients who cannot tolerate the caloric test are given a rotary test. This test involves sitting in a rotating chair that spins around. Hearing tests are frequently given since loss of hearing is often associated with dizziness. Dizziness may also be the result of damage to the nerve cells in the brain stem, where the hearing and balance nerve relays signals to the brain.
To help detect this problem the physician may order a brain stem auditory evoked response test. If there is reason to suspect that the dizziness could result from a tumor or cyst a CT scan may be administered. Sometimes anxiety and stress may cause a person to feel dizzy. Once the cause of the dizziness is determined the physician may order medication or physical therapy to deal with the problem.
When these measures fail, and give them ample time to work, more drastic measures may have to be undertaken. Dizziness may be a sign of a "small stroke" or TIA in the brain stem. It may also be a symptom of diseases affecting other body parts. As you can see from the above only a competent physician can determine the cause of the dizziness. There are many other tests that the physician has available to get to the core of the problem.
The above tests will usually point to one or several causes for the patient's dizziness. Disorders responsible for dizziness can be categorized as:
Vertigo involves nerve cells in the inner ear sending confusing information about body movement to the brain. A well-known cause of vertigo is the peripheral vestibular disorder known as Meniere's disease, which is named after the French physician Prosper Meniere.
Inner ear problems with resulting dizziness can also be caused by certain anti-biotics used to fight life-threatening bacterial infections. Balance can also be affected by a cholesteatoma, a clump of cells from the eardrum that grow into the middle ear and accumulate there. Conditions in which dizziness results from damage to the brain stem or its associated nerves are called central causes of dizziness. One central cause of dizziness is a tumor called acoustic neuroma, which arises in the central auditory canal.
Dizziness can be a symptom of diseases affecting body parts other than the brain and central nervous system. Systemic conditions like anemia or high blood pressure decrease oxygen supplies to the brain; a physician eliminates the resulting dizziness by treating the underlying systemic illness.
The frailty of the elderly makes them particularly vulnerable when they fall. Oftentimes fractures, broken hips or other serious damage may be done to an individual afflicted with dizziness. It is imperative that you deal with this problem as soon as you are aware of it. Most nursing homes will require their unsteady residents to use walkers. The resident usually doesn't want to use a walker, but such usage should be encouraged to avoid problems down the road.
According to a study published in the April issue of The American Journal of Public Health, the most dangerous part of a house is the floor in the living rooms, bedrooms and hallways. Loose throw rugs, runners and mats; curled carpet edges; electrical cords and other small objects in pathways create the greatest danger. Dr. Thomas M. Gill headed the study group at the Yale School of Medicine. Uncarpeted slippery areas and wet spots on the floor were also main culprits in causing falls.
Stairways were another dangerous area that had to have safety improvements made. Night-lights should be installed to increase safety by decreasing the chance of falling. Steps should be repaired immediately if they are damaged and secure handrails should be in place the entire length of the staircase. Grab bars are especially helpful in preventing falls in the tub or shower. Non skid mats should be in place in the tub or shower.
A word most commonly associated with dizziness is vertigo. This is an illusion of rotation due to asymmetry of neural activity between the left and right vestibular nuclei in the ear. This condition is always temporary and is made worse by head movement in the same way that angina is made worse by exercise. It can create a lot of anxiety and possibly bring on panic attacks. You can bring on this condition by turning around in circles for 10 times and then stopping suddenly and throwing your head back.
The most common form of vertigo is called benign paroxysmal positioning vertigo (BPPV). The movement of stray otoconical particles within the duct of the posterior semicircular canal causes this condition. Your physician can check this condition out by simply having you lie down.He then has you turn on your side, move your head slightly off the table to allow movement of the otoconical particles.You then move your head to another position, further shifting the particles, reducing the pressure-stimulated neural activity brought on by the otoconical particles. If this does not work, then your physician may believe you do not have benign paroxysmal vertigo and may have to explore other possible sources of dizziness. The important thing to know is that the condition is treatable and if persistent, the otoconical particles can be surgically removed.
The following question was received from Jane and when we e-mailed the answer back to her we were unable to have same delivered to her e-mail address. We hope she reads the answer herein.
Question: Can Benign positional Vertigo or any kind of dizziness be found
on a MRI?
The nature of your question suggests that you have been reading the articles on our web site. We hope you will continue to read them and tell your colleagues/friends and others about the site.
In reference to your question about MRI and vertigo, the answer could be a reflection of the question. Why the need for an MRI when you already have a diagnosis?
MRI is an expensive diagnostic test. Some consider it an essential tool for the diagnosis of central nervous system disorders and it is used as a tool for the evaluation of a variety of diseases in other organ systems. It is a diagnostic test that bridges the gap between postmortem anatomical studies and in vivo measures of brain function. They have now come up with MRI which combines structural and functional in one technique with high temporal and spatial resolution Simply put, it can disclose not only structural but also functional abnormalities. It permits detailed view of various abnormalities in various anatomical planes and can identify accompanying anomalies. There are a few contraindications to MRI: presence of pace makers; implanted neurostimulators; cochlear implants and presence of any metal that might be displaced by the magnetic field in MRI.
Vertigo is defined as a hallucination of movement and may be described as a sensation as if the external world were turning around the individual or as if the individual were turning in place. Simply, it is similar to the experience after getting off a merry-go-round or after spinning in place for several minutes.
Medical textbooks suggest that vertigo is due to conditions affecting labyrinthine structures or the vestibular nerve (peripheral vertigo). They indicate that although these conditions are distressing and at times disabling, they are usually self-limited. However, in a small minority of cases vertigo can be a manifestation of progressive disease of the central nervous system or is a secondary manifestation of a systemic condition. A MRI may be in order in these cases.
The diagnosis of benign positional vertigo (BPV) falls in the class of peripheral causes of vertigo and is generally not suggestive of need for MRI. This type of vertigo is most common after 40 years of age. The pathological basis of BPV is not known. The episodes of vertigo are brief, usually lasting less than one minute, and they are always brought on with a change in head position. BVP is usually treated with positional exercises, with literature suggesting that individuals report improvement after doing these exercises for 2-3 weeks.
A study by the Insurance Institute for Highway Safety, a nonprofit research organization financed by the auto insurers, found that drivers ages 70 to 74 who had accidents were twice as likely to die as were drivers 30 to 59. If the driver is 80 or older and is involved in a car crash the chances of it resulting in the driver's fatality increases five-fold.
The institute further concluded that the auto industry could reduce the chance of injury to the elderly by making seat belts that are easier on the shoulders and ribs of the elderly. It also found that bigger lettering on the highway signs results in more elderly being able to read the signs and thus being better able to avoid an accident. One of the other major problems with highway signs continues to be how unclear and misleading the directions contained therein continue to be.
The study figured that by 2030, one-quarter of all road fatalities will involve drivers 65 and older. Despite the claim by many that older drivers should have to pass regular driving tests to keep their licenses, the tests were not accurate in determining who would be involved in an accident. Thus we feel that all drivers should be required to periodically pass driving tests in order to maintain their right to drive a car.
Some of the information for this article comes from the National Institutes of Health Publication No.86-76. We are deeply indebted to them for this information.
FOR AN INFORMATIVE AND PERSONAL ARTICLE ON PRACTICAL SUGGESTIONS WHEN SELECTING A NURSING HOME SEE OUR ARTICLE "Selecting a Nursing Home"
Harold Rubin, MS, ABD, CRC, Guest Lecturer
updated March 2, 2019