Effects of Ai-Chi Practice on Balance and Left Cerebellar Activation during High Working Memory Load Task in Older People: A Controlled Pilot Trial.

BACKGROUND: Normal aging is associated with balance and working memory decline. From a neurobiological standpoint, changes in cerebellar functional plasticity may mediate the decline in balance and working memory for older adults. Mounting evidence suggests that physical activity is beneficial for decreasing aging effects. Previous studies have focused on land-based physical activity and research concerning the aquatic environment is scarce. This study investigated the effectiveness of Ai-Chi on balance abilities and cerebral activation during a high working memory load task among community-dwelling older people. METHODS: A total of 19 people aged 65-86 years were allocated to receive Ai-Chi practice (n = 6), structured on-land Ai-Chi practice (n = 7) or guided-imagery of Ai-Chi practice (n = 6) for a bi-weekly, 30-min exercise session for 12 weeks. Balance was measured by the Tinetti balance sub-test and working memory was measured by the N-back test during functional-MRI scan. RESULTS: The Ai-Chi practice group presented a significant change in balance between pre and post intervention (balance t = -4.8, p < 0.01). In the whole-brain analysis, during high working memory load task, the Ai-Chi practice group presented a decrease in left cerebellar activation. Region of interest analyses yielded similar results by which pre-cerebellar activation was higher than post-intervention (t = 2.77, p < 0.05). CONCLUSIONS: Ai-Chi is an available, non-invasive intervention method that may serve as a tool to improve cerebellar activation that in turn might improve balance. In addition, our findings may provide new insights into the neuronal mechanisms that underlie both motor and cognitive abilities.

Effects of aquatic physical intervention on fall risk, working memory and hazard-perception as pedestrians in older people: a pilot trial.

BACKGROUND: Normal aging is associated with balance, mobility and working memory decline that increase fall risk and influence activity of daily living functions. Mounting evidence suggests that physical activity is beneficial for decreasing aging effects. Previous studies have focused on land-based physical activity. Research concerning the aquatic environment is scarce. The primary objectives of this three arm intervention pilot study were to examine the effects of an aquatic physical intervention program on balance, gait, fall risk and working memory among community-dwelling older individuals. The secondary objective was to examine the effects of an aquatic physical intervention program on safety of street-crossing among community-dwelling older individuals. METHODS: Forty-two healthy participants aged 65 or older were enrolled into one of three intervention groups: aquatic physical intervention (API) (N = 13), on-land physical intervention (OLPI) (N = 14) or non-physical intervention (NPI) (N = 15). The intervention took place from 2018 until 2019 at Tel-Aviv University, Sheba medical center and Reich Center. The protocol included 30-min sessions twice a week for 12 weeks. Balance, gait and fall risk were assessed by the Tinneti test, working memory abilities were assessed by digit span and Corsi blocks tests and simulated safe streets-crossing was assessed by the hazard perception test for pedestrians. Testing and data collection was conducted at baseline, after six weeks and 12 weeks of intervention. All members of the professional team involved in evaluating participants were blind to the intervention group to which participants were allocated. RESULTS: The differences in Tinetti balance (F (2, 39)=10.03, p < 0.01), fall risk (F (2, 39)=5.62, p0 > .05), digit span forward (F (2, 39)=8.85, p < 0.01) and Corsi blocks forward (F (2, 39)=3.54, p < 0.05) and backward (F (2, 39)=6.50, p < 0.05) scores after 12 weeks between the groups were significant. The API group showed improved scores. The differences in hazard perception test for pedestrians scores after 12 weeks of intervention between the groups were marginally significant (F (2, 39)=3.13, p = 0.055). The API group showed improved scores. CONCLUSIONS: These findings may affect experts working with the elderly population when making decisions concerning therapeutic prevention interventions for the deficiencies of elderly patients. Older adults practicing aquatic physical activity could contribute to their increased safety. TRIAL REGISTRATION: Trial registration number: ClinicalTrials.gov Registry NCT03510377. Date of registration: 10/31/2017.

VIRTUAL ORTHOPEDIC-REHABILITATION-METABOLIC COLLABORATION FOR TREATING OSTEOPOROTIC HIP FRACTURES.

Objective: To evaluate the effectiveness of a virtual, closed-loop protocol that treated hip fracture patients without formal clinic visits. Methods: In this prospective cohort study, an intervention group of 85 hip fracture patients (33.6%) with vitamin D levels ≥65 nmol/L who received recommendations for osteoporosis treatment, was compared to a nonintervention group of 168 (66.4%), with vitamin D <65 nmol/L. Treatment included vitamin D loading in orthopedic and rehabilitation departments for patients from both groups, and virtual, osteoporosis treatment recommendations by Metabolic Clinic physicians to patients from the intervention group upon achieving a vitamin D level ≥65 nmol/L. Recommendations were given without requiring clinic visits. Osteoporosis drug recommendations were relayed to primary care physicians. The primary endpoint was patients receiving osteoporosis drugs within 12-months post-surgery. Secondary endpoints were patients issued drugs within 3- and 6-months post-surgery, and 1-year post-fracture mortality rates. Results: Among 253 hip fracture patients (81.3 ± 10.7 years-of-age, 68.8% women), the postintervention osteoporosis medication issue rate was higher than in the nonintervention group (48.2% versus 22.0%, respectively; P<.001). More intervention group patients received drugs 3 months (18.8% versus 2.9%; P<.001) and 6 months after surgery (40% versus 5.9%; P<.001). One-year mortality was lower among patients who received any osteoporosis medications (either through our intervention or from community physicians) than among untreated patients (5.1% versus 26.3%; P<.001). Conclusion: Virtual orthopedic-rehabilitation-metabolic collaboration increased osteoporosis treatment rates post-hip fracture. Yet, treatment rates remained <50%. Additional research is required to increase treatment rates further, such as providing drug therapy shortly after surgery, perhaps during rehabilitation, or lowering the vita-min D threshold. Abbreviations: CHS = Clalit Health Services; FLS = Fracture liaison service; HMO = Health Maintenance Organization; MMC = Meir Medical Center; PCP = primary care physician.

Gastrostomy Tube Placement by Radiological Methods for Older Patients Requiring Enteral Nutrition: Not to be Forgotten.

Background: The use of gastrostomy tubes for long-term nutritional support in older patients is frequent. Percutaneous gastrostomy tube placement may be performed using various techniques, including endoscopic, surgical, and radiologically-guided methods. While percutaneous endoscopic gastrostomy (PEG) placement is the most widely used and accepted approach, experience with the use of percutaneous radiological gastrostomy (PRG) is more limited. Objective: To evaluate the safety and short-term outcomes of PRG in older patients requiring long-term enteral feeding. Method: We performed a prospective study involving all patients aged 65 years and older who underwent PRG insertion at the Laniado hospital over a period of 2 years. Adverse events related to the gastrostomy tube insertion were recorded over a period of 3 months following the procedure. Results: A total of 58 patients were included with a mean age of 78.1 years, and 48% were women. The most frequent indications for enteral feeding were stroke (47%) and dementia (41%). The technical success rate was 100% with no immediate procedure-related mortality or morbidity. One-month mortality was 3%, and overall mortality at 3-month follow-up was 16%. Complications were reported in 39 (67%) of patients, with 17 (29%) experiencing more than 1 complication. While most complications (88%) were minor, major complications occurred in 19 (33%) of the patients. Peritonitis was the cause of death in 2 patients, and tube dislodgment occurred in 17 subjects. During the follow-up period 17 (29%) of patients were re-admitted to hospital, with the cause for re-hospitalization being unrelated to the PRG in half of the cases. Neither bleeding nor deep wound infection was detected in the study group. Conclusions: PRG is relatively safe and effective for gastrostomy placement in older patients, and this technique may be of value in patients with oral infections and those receiving anti-thrombotic therapy.

Severe central obesity or diabetes can replace weight loss in the detection of frailty in obese younger elderly - a preliminary study.

PURPOSE: Unwanted weight loss is one of the established criteria for the diagnosis of frailty. However, the relevance of this criterion to detect frailty in obese older adults has not been assessed. In particular, with the exception of malignancy, unwanted weight loss is not commonly seen in older obese subjects. Therefore, we tested the possibility that some obesity phenotypes and/or diabetes might be more useful in the detection of frailty in this setting. PATIENTS AND METHODS: A preliminary cross-sectional study of 50 consecutive subjects was conducted at The Institute of Endocrinology, Metabolism and Hypertension, Tel-Aviv Sourasky Medical Center. Inclusion criteria were: young elderly (aged 65-75 years), with general and/or abdominal obesity, without cancer. Frailty was assessed directly using the Fried model, the five-item fatigue, resistance, ambulation, illnesses, and loss of weight (FRAIL) scale. Eventually, in the assessment of frailty, the weight loss criterion was replaced by one or several of obesity/diabetes-related variables each time: severity of obesity by body mass index, waist circumference (and their interaction), body fat, and diabetes. The receiver operating characteristic curves for functional impairment indices were plotted to compare the usefulness of the frailty accepted and adjusted models. RESULTS: The prevalence of frailty and pre-frailty in this cohort were 7/50 (14%) and 27/50 (54%), respectively, but unwanted weight loss was seen in three subjects (6%) only. The level of abdominal obesity had the strongest correlation with functional score (r=0.292, P<0.05). Frailty models which included either severe abdominal obesity or diabetes in lieu of unwanted weight loss had good sensitivity rates per each frailty score as compared with the original Fried model. CONCLUSION: For detecting and/or screening for the frailty syndrome in obese young elderly, the level of abdominal obesity or diabetes may provide a useful marker.

Cognitive impairment and the association between frailty and functional deficits are linked to abdominal obesity in the elderly.

OBJECTIVE: To evaluate whether specific obesity phenotypes in community-dwelling elderly: (a) affect differently the relationship between frailty and functional impairment and (b) are related to cognitive impairment. STUDY DESIGN: A post-hoc cross-sectional analysis of the last Israeli national health and nutrition survey of the elderly (≥ 65 yrs.; n = 1619). MAIN OUTCOME MEASURES: We implemented a previously validated frailty model based on frailty-related variables that were obtained in the survey. Mild cognitive impairment was defined using the Mini-Mental State Examination (a score <24 and >17). The Katz's scale of activities of daily living was used for functional assessment. Data were clustered according to different obesity phenotypes using measured body mass index (BMI) and waist circumference (WC). RESULTS: The link between frailty and disability was most prominent in subjects with abdominal obesity who were non-obese by BMI: compared with non-obese subjects as defined by WC and BMI, the odds ratio (OR) for functional limitations in this phenotype was 8.34 (95 % CI, 2.14-32.48) for pre-frail subjects and 69.26 (10.58-453.55) for frail subjects. The rate of cognitive impairment was 3.3 times higher (p = .023) in women who were obese by WC but not by BMI. CONCLUSIONS: In elderly people with a large WC and BMI < 30 kg/m2, disability is more tightly linked to frailty than for any other form of obesity. Cognitive impairment was more prominent in women with central obesity and BMI < 30 kg/m2 than in the other anthropometric phenotypes. WC should be used for early detection of individuals at risk of progression of frailty to functional incapacity.

[PATIENT ORIENTED CARE IN CHRONIC CONDITIONS].

INTRODUCTION: The physician as well as the health care system, are both facing the challenge of chronic conditions. Multi-morbidity is very common in many of the patients with chronic conditions (defined by the WHO as a disease with the duration of more than twelve months). Most of these patients are elderly with deterioration in their physiological systems' reserves. The clinical research in chronic diseases is trying to separate the disease from other conditions in order to achieve specific therapeutic conclusions for the disease. According to research results, guidelines are established for the treatment of the diseases. In recent years, new approaches to patients with chronic multi-morbidity have been developed. These approaches use individual approaches to the patient, establishing the goals of care according to the patient's view concerning his/her capacities to carry the workload that is associated with the treatment regime. Minimal Disruptive Medicine-MDM is an approach which originated in American Medicine. The aim of this paper is to introduce the different aspects of this approach, their origin and basis and its benefit to the chronic patient today. This approach encourages the patient and his physician to optimize the quality of care.

Estimated frailty prevalence among Israeli elderly - results from a cross sectional national survey.

BACKGROUND: Increasing longevity presents new social and medical challenges in developed countries. The prevalence of frailty is of interest because of its association with health prognosis and outcomes, but so far there is no single best diagnostic tool for this entity. Therefore, estimated prevalence of frailty in countries varies considerably and ranges between 5% and 58%. In Israel, the nation-wide prevalence of frailty in the elderly population is presently unknown. The objective of our study was to assess the rate of the frailty in elderly Israelis. METHODS: A post-hoc analysis based on the results of a national Health and Nutrition Survey in Israeli elderly (MABAT Zahav). A non-direct model to estimate frailty was based on five components that were most similar to the common frailty assessment suggested by Morley et al. The frailty state was then reclassified according to different explanatory variables. RESULTS: Data collected from 1619 subjects (F/M = 52.9/47.1%) with an average age of 74.6 years were analyzed. Estimated frailty prevalence in the elderly population was 4.9%. Frail people were more likely to have a lower income, be unemployed and have a lower education level. Frailty rates were higher in women, in Jews and in subjects more prone to low physical function. CONCLUSIONS: The estimated frailty prevalence in the Israeli elderly population, while relatively low, is comparable to some of the rates suggested in the literature. The factors associated with frailty in the Israeli population are in accordance with the existing literature. The suggested model may be helpful in identifying frailty in Israeli elderly.

Two-Year Follow-Up of Fall Prediction Among Older Adults in an Independent-Living Community.

Adults over the age of 70 are at risk of falls. Early detection of risk of falls can suggest early interventions. In this study, we attempted to determine valid clinical tests that can differentiate older individuals who are at risk of falling. Older adults from an independent-living community volunteered to participate in this descriptive, cohort study. They were administered the Berg Balance Scale (BBS), Zur Balance Scale (ZBS), Head Shaking Nystagmus Head Impulse Test, Dynamic Visual Acuity, and the Hallpike maneuver for evaluating benign paroxysmal positional vertigo (BPPV); a questionnaire including sociodemographics and a health characteristics survey. Multivariate analysis indicated that a ZBS score < 51, previous fall, and number of medications strongly predict falls in older adults. ZBS score, BBS score, Hallpike maneuver, number of medications, deficit of vestibular ocular reflex, along with positive ZBS score and past fall differentiate between fallers and non-fallers. ZBS <51, taking >6 medications, and history of falls were a benchmark for high-risk of falling.

The Need for Medication Reconciliation Increases with Age.

BACKGROUND: Medication reconciliation (MR) at hospital admission, transfer, and discharge has been designated as a required hospital practice to reduce adverse drug events. OBJECTIVES: To perform MR among elderly patients admitted to the hospital and to determine factors that influence differences between the various lists of prescribed drugs as well as their actual consumption. METHODS: We studied patients aged 65 years and older who had been admitted to the hospital and were taking at least one prescription drug. RESULTS: The medication evaluation and recording was performed within 24 hours of admission (94%). The mean number of medications was 7.8 per patients, 86% consumed 5 or more medications. Mismatching between medication prescribed by a primary care physician (PCP) and by real medication use (RMU) was found in 82% of patients. In PCP the most common mismatched medications were cardiovascular drugs (39%) followed by those affecting the alimentary tract, metabolism (24%), and the nervous (12%) system. In RMU, the most commonly mismatched medications were those affecting the alimentary tract and metabolism (36%). Among all causes of mismatched medications, discrepancies in one drug were found in 67%, in two drugs in 21%, and in three drugs in 13%. The mismatching was more common in females (85%) than in males (46%, P = 0.042). CONCLUSIONS: This study provided evidence in a small sample of patients on differences of drug prescription and their use on admission and on discharge from hospital. MR processes have a high potential to identify clinically important discrepancies for all patients.

Circuit resistance training is an effective means to enhance muscle strength in older and middle aged adults: A systematic review and meta-analysis.

BACKGROUND: Physical exercise, particularly resistance training (RT), is proven treatment to reduce the accelerated decline in muscle strength exhibited by older adults, but its effect is hindered by low adherence rate, even under well-structured programs. OBJECTIVE AND DATA SOURCES: We investigated the efficacy of circuit resistance training (CRT) on muscle strength, lean mass and aerobic capacity in older adults based on report in MEDLINE, EMBASE, ClinicalTrials.gov and Cochrane electronic (through 8/2016). STUDY ELIGIBILITY CRITERIA: middle and older aged men and/or women who followed a structured program, assigned to CRT. STUDY APPRAISAL AND SYNTHESIS METHODS: Out of 237 originally identified articles, 10 articles were included with a total of 362 patients with mean: age -64.5±7.4 years; 3±1.15 sessions/week; session duration 41.8±15.9min. RESULTS: Upper body strength modestly increased, by 1.14kg (95% CI; 0.28-2.00), whereas larger increment was seen in lower body strength (11.99; 2.92-21.06). Higher program volume (>24 sessions) positively influenced upper body strength and aerobic capacity. LIMITATIONS: (1) variability in the studies' validity; (2) relatively low number of studies. CONCLUSION: CRT is a valid alternative to conventional RT. Its shorter duration and lower intensity relative to traditional RT, may increase adherence to training in older adults.

Crystal-Induced Arthropathy in Elderly Patients Hospitalized for Acute Conditions.

BACKGROUND: Arthritis and arthralgia are painful symptoms experienced by many elderly patients during hospitalization. Crystal-induced arthritis (CIA) is one of the most common causes of arthritis worldwide and represents the most common cause of acute arthritis in the elderly. OBJECTIVES: To determine the incidence of both acute new onset or acute exacerbation of CIA among elderly patients hospitalized due to an acute medical illness. METHODS: This study comprised 85 patients. Patients aged 70 years and older who complained of any articular pain were included in the study. Exclusion criteria were signs of septic arthritis, chronic use of steroids or non-steroidal anti-inflammatory drugs, or admission to the hospital due to an acute attack of CIA. RESULTS: RSynovial aspiration was performed in 76 patients (89%). Joint aspiration yielded a diagnosis in 67 of them (79%). The predominant type of crystal was calcium pyrophosphate dehydrate (68%) followed by monosodium urate (20%). The main causes of hospitalization were acute infectious disease (57%) followed by neurologic and cardiac diseases, 14% and 9% respectively, and orthopedic problems (6%). Among patients with acute infectious disease, the main causes were pulmonary (57%) and gastrointestinal (22%) infections. In 9 patients (12%) who underwent synovial aspiration, visible crystals were identified without a definite diagnosis. CONCLUSIONS: Our study showed that hospitalization could be a risk factor for the development of CIA, and the time to diagnose CIA is during hospitalization for other acute illnesses.

Muscle function and fat content in relation to sarcopenia, obesity and frailty of old age--An overview.

BACKGROUND AND AIM: In western countries, the proportion of people over age 60 is increasing faster than any other group. This is linked to higher rates of obesity. Older age, co-morbidities and obesity are all associated with frailty syndrome. In the core of both frailty and sarcopenia there are dysfunction and deterioration of the muscle and the fat tissues. This overview interlinks the phenotypes presented in older adults such as sarcopenia and frailty-alone and with relation to obesity, muscle function and fat tissue accumulation. RECENT FINDINGS: Observational studies have well described the loss of muscle mass and strength through the years of adult life, both components of frailty and sarcopenia. They have shown that these changes are associated with dysmetabolism and functional deterioration, independent of common explanatory variables. In the metabolic mechanism core of this link, insulin resistance and higher ectopic fat accumulation may play a role. Basic experiments have partially validated this hypothesis. Whether there is a synergistic effect of obesity and frailty phenotype on morbidity risk is still questionable and currently under investigation; however, few cohort studies have shown that the frail-obese or sarcopenic-obese group have higher probability for metabolic complications. SUMMARY: Muscle mass loss and fat accumulation in the muscle in the elderly, with or without the presence of obesity, may explain some of the functional and metabolic defects shown in the frail, sarcopenic population.

Anxiety among individuals with visual vertigo and vestibulopathy.

PURPOSE: Visual vertigo (VV) is a type of dizziness triggered by visual stimuli. Despite a high incidence, its relationship with anxiety is not well-defined or understood. This study evaluated anxiety levels in subjects with VV compared to vestibulopathic subjects without VV and healthy individuals. METHODS: A cross-sectional study to evaluate anxiety among individuals with VV was conducted twice. The first study included 72 participants (66 to 83 years of age) from senior residential centers. The second included 31 participants from a vestibular rehabilitation program (age range 35-82 years). Study 1 also used the Activities-Specific Balance Confidence (ABC) scale and study 2 the Dizziness Handicap Inventory (DHI). RESULTS: Subjects were classified as VV positive (27 in study 1, 10 in study 2) or vestibulopathic without VV (30 in study 1, 11 in study 2) based on Head Impulse or Dynamic Visual Acuity Tests and the Dizziness Questionnaire. The remaining were age-matched healthy controls. The outcome of each study demonstrated significantly higher anxiety levels (p = 0.0001) in the VV group compared to the other groups. The results of the ABC test demonstrated that subjects in the VV group had significantly lower self-confidence (p = 0.001) than those in the Vest and Cont groups and performed fewer balance-related activities of daily life. DHI results showed that VV group expressed higher (p < 0.001) mean scores for self-perceived feelings of dizziness and imbalance (54%), compared to the Vest (9%) and Cont groups (1%). CONCLUSIONS: Anxiety related to VV requires special attention when assessing and managing vestibulopathy, regardless of patient age. IMPLICATIONS FOR REHABILITATION: Anxiety is a characteristic of subjects with visual vertigo (VV) and vestibulopathy. Anxiety in subjects with VV is not related to age. VV should be considered when subjects with anxiety complain of imbalance. Anxiety and vestibulopathy are often interrelated and should be considered in diagnostic evaluations.

Clinical presentation of urinary tract infection (UTI) differs with aging in women.

Uncomplicated UTI is among the most common health problems seen in general practice and typically affects immunocompetent, anatomically normal women. The aim of this study was to explore the difference in clinical presentation in acute, uncomplicated UTI in otherwise healthy community dwelling, premenopausal (Pre-M) and postmenopausal (Post-M) women. A UTI was defined as uropathogen of more than 10(3)cfu/ml in midstream urine culture. Symptoms of UTI were divided to three: during voiding, local symptoms, and generalized symptoms. A total of 196 women aged a minimum of 45 years with diagnosis of UTI were studied. The patients were divided into two groups: Pre-M (n=102, mean age 48.14 years) and Post-M (n=94, mean age 69.21 years). The predominant complaints in Pre-M women were local symptoms. The clinical presentations showed more severity in the Post-M group than in Pre-M women, predominantly generalized unspecific symptoms and storage symptoms. Advanced age positively correlated with urgency of urination, painful voiding, urinary incontinence, sexual activity, low-back pain, lower abdominal pain and negatively correlated with frequency, painful and burning of urination and bladder pain. Our study showed that clinical presentation of UTI in Pre-M and Post-M women is different. The differences are presented not only by the voiding itself and by local symptoms but also by unspecified generalized symptoms that is especially important in elderly patients.

[The challenge of geriatric medicine in the twenty-first century].

During the last generation the population in Israel has doubled and the number of hospital beds per capita has declined to the lowest number in the OECD. This has implications on the number of physicians and nurses, as well as the nation's capacity to educate medical staff, while there are no increases in the infrastructure. Shortening the length of stay for acute medical conditions to an average of about three to four days is the main consequence of this situation. About 800,000 elderly people over 65 years of age are now living in Israel. Many of them suffer from acute conditions with complicating chronic morbidities. Currently, they are the main victims of the present crisis in medical services in Israel. Aging is accompanied by a decline in the physiological reserves leading to increased morbidity, decreases in function and a prolonged period for returning to normal function after trauma or acute disease. During the twentieth century, the science of medicine progressed rapidly. The pathogenesis of many conditions, either chronic or acute, was recognized, as well as the structure of the human genome and many pharmaceutical, as well as other technologies, were developed for the cure and care of diseases. Nevertheless, understanding the aging process remains a challenge. Geriatric medicine is a medical specialty that deals with a process--the process of aging, which is like pediatrics, and unlike other specialties that concentrate on systems (cardiovascular, gastroenterology, blood, immune system etc.). The added value of the geriatrician in medical practice is in the knowledge of the scientific background of aging, as well as the practical implications concerning physical and cognitive decline of function with aging and its accompanying morbidity. The practice of Geriatric Medicine is the art of connecting the biological and medical sciences to the function and the environment of the individual aging person. It requires dedicating a lot of time and patience on the part of the physician, to retrieve the information, to build confidence in the relationship with the patient and to lead the patient to continue living with an optimal quality of life in his remaining years. During the last decades, the number of geriatricians in Israel has doubled, obligatory clerkship in Geriatric Medicine is part of the medical schools' curriculum and Geriatric Medicine is part of the board curriculum in Internal Medicine and Family Medicine. Thus, Geriatric Medicine maintains the art of medical practice, using the recent knowledge in biology and medical sciences, and dealing with the population with the highest level of morbidity and lowest function. The Geriatric Medicine approach to the old person who needs medical help has to lead medical practice in the near future, so that we can preserve the great achievements of medicine during the twentieth century.

C-reactive protein (CRP): an important diagnostic and prognostic tool in nursing-home-associated pneumonia.

Pneumonia is the second most common infection in long term care (LTC) residents and is a leading cause of death from infection in those groups of patients. Atypical presentations and fewer presenting signs and symptoms in older patients complicate diagnosis and delay initiation of adequate treatment. The aim of this study was to compare laboratory CRP levels to pneumonia severity scores, in prediction of short-term death from pneumonia. Diagnosis of pneumonia was performed according to the criteria of McGeer for the identification of pneumonia at an LTC facility. The severities of pneumonia and mortality prediction were assessed by three indices: PSI (pneumonia severity index), Missouri study index and the nursing home associated pneumonia (NHAP) severity index. A strong positive correlation was found between CRP levels and PSI (r=0.445, p<0.001), Missouri study index (r=0.315, p<0.001) and NHAP severity index (r=0.246, p=0.002). The initial values of CRP were significantly higher in patients with short term mortality and positively correlated with rate of death (r=0.493, p<0.001). By multivariate regression analysis, the variables that were independently and significantly associated with the rate of death included presence and duration of fever, respiratory rate, serum CRP and albumin levels, lymphocyte count, number of comorbid diseases, CHF, and DM (the R2 was 0.711 and 0.685 when adjusted). Because presentation of nursing home acquired pneumonia is not specific, it is suggested that CRP should be performed in every patient with a suspicion of pneumonia.

Delirium in long-term care setting: indicator to severe morbidity.

We aimed to investigate the incidence and characterize predictors associated with delirium in elderly demented and functionally dependent LTC patients. Data collection included: demographic, clinical, functional, nutritional and cognitive data as well as blood counts and chemistry analysis. The tools used to detect delirium were the Confusion Assessment Method (CAM) and the Delirium Rating Scale (DRS), supported by clinical observation. The occurrence of delirium was 34%. The predominant primary etiologies for delirium were infections (58%), following by metabolic abnormalities (36%), and adverse drug effects (18%). The mean duration of delirium was 15.74 days (2-96 days). Independent predictors influencing duration of delirium were low plasma albumin level, high number of comorbid diseases, male gender, advanced age and presence of CVD. Complete resolution of the delirium was found in 33% (30/92), with persistence in 12% (11/92), and no change in 8% (7/92) of the patients. Forty-eight percent (44/92) of the patients died. Most deaths (50%) were in the first month. The main cause of death was infection related (70%), of which bronchopneumonia was predominant (39%), followed by sepsis (32%). Independent predictors of death were infection, advanced age, low plasma albumin level, dehydration and CHF. The early recognition, identification, correction and treatment of underlying conditions especially in very demented, uncooperative and functionally dependent patients may influence their outcome. Any changes in cognitive and functional status are critical in monitoring LTC patients.