[THE CHALLENGE OF HEALTHY AGING WITH DIABETES: THE ISRAELI NATIONAL DIABETES COUNCIL GUIDELINES FOR TREATING OLDER PEOPLE].

INTRODUCTION: The prevalence of diabetes increases with age. Diabetes is a risk factor for many complications such as cardiovascular disease, kidney failure, stroke, neuropathy, and retinopathy. Data from recent years indicate that it is also a risk factor for cognitive impairment, dementia, functional disability and frailty. Diabetes is a disease that requires complex self-care capabilities; the individuals with diabetes are required to take medications on time, examine their feet, exercise, maintain a balance diet, preform daily glucose monitoring, cope with hypoglycemia and understand how differing life situations may effect glucose levels. All of these require intact cognitive and functional abilities. Thus, treatment plans should take into consideration the person's cognitive/functional state. Indeed, in the last several years many professional organizations such as the American Diabetes Association, the International Diabetes Federation, and the American Endocrinology Society have published guidelines for treating older people with diabetes. The Israeli National Diabetes Council, headed by Prof. Itamar Raz, in collaboration with other physician unions and other national councils, have recently authorized the Israeli guidelines for treating older people with diabetes. The Israeli guidelines include categorization of older adults with diabetes in relation to their functional status in order to reach determined treatment targets. According to the Israeli guidelines and in accordance with international guidelines, the treatment targets of the elderly person with diabetes should not be determined by the chronological age of the individuals but rather by their risk for functional deterioration. Older people with diabetes are categorized into three groups according to their risk for functional deterioration. Each category has unique glucose, blood pressure and lipid targets. The guidelines offer valid and reliable tools that, in addition to personal acquaintance with the patient, can help determine the level of risk of functional decline.

Identifying Risk Factors for Elder Falls in Geriatric Rehabilitation in Israel.

PURPOSE: To identify risk factors for elder falls in a geriatric rehabilitation center in Israel. DESIGN: Retrospective chart review study. METHODS: Four hundred and twelve medical records of inpatients in geriatric rehabilitation were retrospectively analyzed to compare between elders who sustained falls and those who did not. FINDINGS: Of elders hospitalized during this year, 14% sustained falls. Fallers included a high proportion of males, with little comorbidity, not obese, and cardiovascular patients. Falls occurred frequently during patients' first week at the facility, mostly during the daytime. The falls occurred frequently in patients' rooms, and a common scenario was a fall during transition. CONCLUSIONS: The research findings single out patients who are allegedly at a lower risk of falls than more complex patients. CLINICAL RELEVANCE: Caregivers in geriatric rehabilitation settings should pay attention to patients who are allegedly at a lower risk of falls than more complex patients, and to cardiovascular patients in particular.

Reporting adverse events at geriatric facilities: categorization by type of adverse event and function of reporting personnel.

PURPOSE: Adverse events and patient care-related adverse events are a challenging universal problem, among elder residents of geriatric facilities. The aim of this study was to examine which types of adverse events are characteristic of the geriatric center studied and which of the nursing staff reported this event. DESIGN/METHODOLOGY/APPROACH: Data were retrieved from the computerized adverse event management system at a large geriatric center in central Israel, and all adverse events reported over the past three years were examined. FINDINGS: The study findings indicate that the most common type of adverse event was falls. Older nurses with greater seniority in the facility show a higher tendency to report adverse events. In addition, registered nurses were found to report more often than practical nurses. PRACTICAL IMPLICATIONS: This study highlights the important role that nurses can play in reporting and reducing adverse events. The role of the nurse is becoming increasingly complex, especially in geriatric facilities, which serve people with complex mental and physical states who are more susceptible to adverse events to begin with. ORIGINALITY/VALUE: Despite the large number of adverse events, few studies have been undertaken on adverse events in geriatrics in general, and in nursing homes and long-term facilities in particular. Answers to these questions will enable improvement in the quality of care provided and ensure a safe care environment for residents. Systematically examining types of adverse events and the characteristics of those who do and do not report them, can contribute to improvement of processes in the healthcare system in general, and in the facility in particular. Additionally, efficient investigation can improve the behavior of those who enable adverse events.

Wandering in a dementia special care unit: behavioral aspects and the risk of falling.

BACKGROUND: Wandering is a common phenomenon among patients with dementia. While traditionally considered to be a behavioral problem, it also includes fundamental aspects of motor performance (e.g., gait and falls). OBJECTIVES: To examine the difference in motor function and behavioral symptoms between patients with severe dementia who wander and those who do not. METHODS: We conducted a retrospective study reviewing the medical records of 72 patients with severe dementia, all residents of a dementia special care unit. Motor and behavioral aspects were compared between "wanderers" and "non-wanderers." RESULTS: No difference was found in motor performance including the occurrence of falls between the wanderers and non-wanderers. A significant difference was found in aggressiveness and sleep disturbances, which were more frequent among the wanderers. There was no preference to wandering at a certain period of the day among the patients with sleep disturbances who wander. CONCLUSIONS: In a protected environment wandering is not a risk factor for falls. Sleep disturbances and wandering co-occur, but there is no circumstantial association between the two symptoms.

The meanings of delusions in dementia: a preliminary study.

One of the common symptoms of dementia is delusions. Due to a biological conceptualization of the behaviors represented as delusions, these are classified as psychotic symptoms. This is a qualitative and quantitative study aiming to describe the delusions experienced by older persons with dementia and the context of occurrence, and to elucidate their etiology. Participants were 74 nursing home residents aged 65 and over, diagnosed with dementia, from nine nursing homes in Israel. Participants with delusions were found to have significantly more difficulties in performing ADLs, and poorer vision and hearing. Based on assessment using the BEHAVE-AD, six categories of delusions were examined: 1. One's house is not one's home, 2. Theft, 3. Danger, 4. Abandonment, 5. Misidentification, and 6. Other non-paranoid. Common themes appeared across delusions including reality, disorientation, re-experience of past events, loneliness and insecurity, boredom, and trigger. Current results suggest that delusions may not represent psychotic symptoms for most participants, because they sometimes represented reality, or were neither firm nor incontrovertible. Thus, utilizing the term delusion relegates the person's behavior to the domain of severe psychiatric phenomena and precludes understanding its true meaning.

The war against polypharmacy: a new cost-effective geriatric-palliative approach for improving drug therapy in disabled elderly people.

BACKGROUND: The extent of medical and financial problems of polypharmacy in the elderly is disturbing, particularly in nursing homes and nursing departments. OBJECTIVES: To improve drug therapy and minimize drug intake in nursing departments. METHODS: We introduced a geriatric-palliative approach and methodology to combat the problem of polypharmacy. The study group comprised 119 disabled patients in six geriatric nursing departments; the control group included 71 patients of comparable age, gender and co-morbidities in the same wards. After 12 months, we assessed whether any change in medications affected the death rate, referrals to acute care facility, and costs. RESULTS: A total of 332 different drugs were discontinued in 119 patients (average of 2.8 drugs per patient) and was not associated with significant adverse effects. The overall rate of drug discontinuation failure was 18% of all patients and 10% of all drugs. The 1 year mortality rate was 45% in the control group but only 21% in the study group (P < 0.001, chi-square test). The patients' annual referral rate to acute care facilities was 30% in the control group but only 11.8% in the study group (P < 0.002). The intervention was associated with a substantial decrease in the cost of drugs. CONCLUSIONS: Application of the geriatric-palliative methodology in the disabled elderly enables simultaneous discontinuation of several medications and yields a number of benefits: reduction in mortality rates and referrals to acute care facilities, lower costs, and improved quality of living.

[Utilization of external hip protectors in frail elderly residents of nursing homes].

Falls are common among the elderly and stem from multiple causes. Much attention has been given to the development of falls-prevention programs, mainly because of the substantial risk for hip fracture sustained after a fall. The population of frail elderly nursing home residents is a high-risk group for falls. The utilization of an external hip protector that covers the greater trochanter of the femur has been shown to reduce the incidence of hip fractures. However, low compliance remains a major obstacle in the effective use of hip protector systems.

Staphylococcus aureus carrier state among elderly residents of a long-term care facility.

INTRODUCTION: Methicillin-resistant Staphylococcus aureus (MRSA) infections have recently become a major concern in long-term care facilities (LTCF). Patients that have been colonized with MRSA in general hospitals may introduce the organisms into LTCF, and these can become reservoirs for the pathogen. Our objective was to evaluate the rate of colonization by S aureus, especially MRSA, in elderly residents of a large LTCF, and to find factors that predispose to it. METHODS: A nasal culture was obtained from randomly selected patients in an Israeli LTCF. Inclusion criteria were absence of active infection and no antibiotic treatment in the preceding month. The carrier state was defined when two consecutive cultures were positive for S aureus. RESULTS: The study population comprised 270 patients, aged 81 +/- 9.3 years and from all types of wards. Of these, 63 (23.3%) were carriers of S aureus and 17 of those (27%) had MRSA. From univariate analysis, the carrier state was associated with antibiotic treatment or an invasive procedure in the previous 3 months, and with a prior MRSA infection. Subacute LTCF departments had a higher carrier rate than the chronic care wards. CONCLUSIONS: In this large multilevel facility, 6.2% of the patients were MRSA carriers, and came predominantly from the subacute departments, suggesting an influx from general hospitals. This information and the identification of factors associated with MRSA infection permit the development of an institutional infection control program.

[Prevalence and etiology of anemia in an institutionalized geriatric population].

OBJECTIVE: Anemia is a common problem in the elderly, but its etiology in this age group is not well known, nor is its correlation with the mental and functional states. The objectives of the present study were to determine the prevalence of anemia in a large institutionalized geriatric population, to diagnose the etiology, and to analyze the correlation of anemia with the nutritional, mental and functional status. METHODS: The study was performed in a 970 bed multilevel geriatric complex, from which 481 residents were randomly chosen. Their mean age was 81.4 +/- 8.7 years, and 46 of these residents were independent, 162 frail, and 273 nursing home patients. RESULTS: High prevalence of anemia (31.4%) was found, but, in more than half of the cases, the anemia was mild. The most common diagnosis was anemia of chronic disorders (65.6%), followed by anemia of chronic renal failure (13.2%). Anemia primarily due to iron, vitamin B12 or folate deficiency was found to be only 4%. In 15.9% of these cases the main cause of anemia could not be resolved. No correlation with the nutritional or cognitive states was found, but the functional state was highly and significantly inversely correlated with the presence of anemia. CONCLUSIONS: Anemia in institutionalized elderly is mostly the consequence of other chronic diseases. Further studies are required to determine whether a low functional state is an independent risk factor for anemia in old age.

Prevalence and correlates of cardiovascular medication use among nursing home residents with ischemic heart disease: results from the SHELTER study.

OBJECTIVES: Despite being the highest group of users of many medications, older individuals remain underrepresented in clinical trials. This leaves a gap in evidence to guide management of many conditions, such as ischemic heart disease (IHD), in this population. This study aimed to describe factors associated with IHD medication use among nursing home residents in 7 European countries and Israel to depict challenges facing disease management in this population. DESIGN: This study was a retrospective cohort analysis. SETTING AND PARTICIPANTS: The sample included 4156 nursing home residents in the SHELTER study. MEASUREMENT: All residents were assessed using the interRAI Long-Term Care Facility (LTCF) instrument. Use of angiotensin-converting enzyme inhibitor (ACEi) and/or angiotensin receptor blocker (ARB), beta-blocker (BB), antiaggregants (including acetylsalicylic acid [ASA]) and statins was analyzed. Based on the use of these medications, residents were classified into groups by medication use (as nonusers, 1-2 medications, or 3-4 medications). Generalized Estimation Equation modeling was used to explore predictors of medication use from items on the LTCF instrument as well as facility questionnaire. RESULTS: Of the 1050 residents with IHD, medication use was 77.7% overall, but only 16.9% were receiving 3 to 4 medications. Use of antiaggregants was highest at 51.7% and variations in medication use were observed by country (highest in France and lowest in Italy). Functional disability was the strongest predictor of medication use, reducing the likelihood of any or optimal management. Severe cognitive impairment also reduced the likelihood of optimal management, and comorbidity generally increased the likelihood of medication use. Polypharmacy reduced the likelihood of use of 3 to 4 medications for IHD. CONCLUSION: Optimal management of IHD in nursing home residents was low and varied by country. Individual characteristics seemed to predict IHD medication use, suggesting prescribing bias and an effect of population differences from clinical trial cohorts.

High efficacy for hip protectors in the prevention of hip fractures among elderly people with dementia.

OBJECTIVE: To evaluate the efficacy of hip protectors (HP) in preventing hip fractures (HF) in patients with dementia. DESIGN: A case-control study. SETTING: Four specialized dementia units. PARTICIPANTS: 206 physically independent patients with dementia. INTERVENTIONS: Beginning in January 2004, following the recommendation of the Israeli Ministry of Health, we recommended the use of HP (Hip Saver-nursing home type) to each family/guardian of all patients in these departments. MEASUREMENTS: The rate of falls and HF per falls in patients with and without HP. RESULTS: We achieved patient compliance of 70% to 80% for wearing the HP 24 hours a day; 106 patients were permanently wearing HP for a total period of 1905 months. Of those, subgroup B of 63 patients had been monitored prior to January 2004, before HP were introduced. One hundred patients of the same departments have never used HP; together with the months of follow-up before January 2004 in subgroup B, the follow-up period in patients not wearing HP, reached a total of 3136 months. There was no statistical difference between patients with/without HP regarding age, gender, comorbidities, routine laboratory findings, and medications. The rate of falls was not significantly different in patients with and without HP. However, there was a significant difference in the rate of hip fractures (HF): in patients not wearing HP there were 323 falls resulting in 14 HF, and in patients wearing HP, 260 falls but only 2 HF (4.3% versus 0.8%, respectively, P = .007, chi-square test, 95% confidence interval 1.3-24.6, NNT = 28). CONCLUSIONS: When appropriately introduced and used, hip protectors have high efficacy in preventing hip fractures in long-term care patients with dementia. The medical, social, and economic beneficial outcomes are substantial.