Edema of the paretic hand in elderly post-stroke nursing patients.

Post-stroke edema of the paretic hand constitutes an additional, functional, and esthetic nuisance for the patient. Although often encountered in daily practice, it is not even mentioned in the stroke chapters of the various textbooks. The phenomenon is far from being elucidated and various aspects are still obscure. In this study we tried to estimate the extent of post-stroke hand edema (PSHE) in a sample of elderly patients. The study group consisted of 188 elderly post-stroke nursing patients with hemi or only hand paresis. Seventy, age matched, non-paretic patients were examined as controls. The basis of comparison was the difference in circumference between the two arms at three sites: mid-finger, hand, and wrist as measured in the control group. Values above two standard deviations (S.D.) of the mean difference in circumference of the controls, at two or three sites, were considered as edema. Edema of the paretic hand was detected in 37% of post-stroke patients. Most (about three-quarters), could be classified as simple PSHE, while the rest may have had reflex sympathetic dystrophy (RSD).

Progressing stroke with neurological deterioration in a group of Israeli elderly.

Progressing stroke with neurological deterioration (PSND), i.e., neurological deterioration of patients during the first days following a stroke, although not an infrequent event, has hitherto been addressed only by few studies. This is the first investigation conducted in Israel with the aim to determine its prevalence and characteristics. Data regarding 140 patients with first ever stroke were collected prospectively between May 1999 and October 2000. All patients underwent a thorough daily neurological examination over the first 7 days, using the Canadian Neurological Scale. Most (90%), patients had hemiparesis, with dysarthria, aphasia and dysphagia being the most frequent associated neurological deficits. Thirty percent of the patients were on anti-aggregant therapy prior to the stroke. The prevalence of PSND was 23%. The 1-month in-hospital death rate of these PSND patients was 31%. Univariate analysis showed that previous anti-aggregant therapy, Parkinson's disease (PD), obesity, hyperlipidemia, and presence of aphasia were significantly more frequent in the PSND group. In addition, these patients arrived earlier to the emergency room. However, logistic regression analysis showed that only PD and obesity could possibly be considered as predictors for development of PSND. The prevalence as well as the death rate of PSND in this group of Israeli elderly is within the range reported in the literature. However, prior anti-aggregant treatment and PD, are here reported for the first time as associated conditions. Future research will possibly clarify the links between these entities and PSND.

Medical staff attitudes: views and positions regarding blood transfusion to terminally ill cancer patients.

Blood transfusion is a widely used supportive treatment of cancer patients, most of whom are anemic. In the particular subset of cancer patients that undergoes chemotherapy, blood transfusion is viewed as an essential part of supportive care. However, the place of blood transfusion in anemic terminally ill cancer patients is far less established. There are no well-defined blood transfusion guidelines ("transfusion trigger") for these patients. Hence, transfusion decisions are greatly influenced by the personal views of the medical team. Therefore, a mail survey of 500 physicians (from several specialties) and nurses was initiated to assess their personal opinions on this topic. The overall response rate was relatively high (70%). There was broad agreement that blood transfusions, as a rule, should not be withheld from terminal cancer patients. On the other hand, only nurses were of the opinion that these patients should be transfused "as usual." Significantly, there was but a slight majority (53% of participants) that was of the opinion that transfusions to these patients do not prolong suffering. There emerged a short list of agreed-on suggestions for blood transfusion--namely, Hb level < or = 7 mg/dL, active bleeding (acute and/or occult), functional deterioration of the patient, presence of anemia resulting from chemotherapy, anginal symptoms, dyspnea, and worsening congestive heart failure. The agreed-on suggestions for transfusions in terminally ill cancer patients may serve as a reasonable physician standard for this complex clinical, medical-legal, and emotional issue.

Management of adverse clinical events by duty physicians in a nursing home.

BACKGROUND AND AIMS: The nature of adverse clinical events (ACE) during duty hours (16:00-08:00 and holidays), as well as the way they are addressed by duty physicians (DP) in a nursing home (NH) are the subject of this study. METHODS: Data, including medical details concerning ACEs and the resultant referrals to hospital, were collected prospectively during 183 consecutive days in a 90-bed NH. RESULTS: Ninety-six residents experienced 370 ACEs, representing an average of one for every 44.5 patient days. The highest rate of events was during evening hours (18:00-21:00). The most prevalent ACE was fever (32%). Most cases (53%) were treated by the DPs on site. No intervention was needed in 19% of cases, whereas 28% of ACEs (104 cases) were referred to the Emergency Room (ER) of a general hospital. Sixty-six percent of these were actually admitted. The rate of ER referral of residents was one for every 158 patient days. About 40% of the referred patients had been discharged from hospital the previous week. High fever was the commonest cause for referral: 47%. During the working hours of the study period, the rate of referral by the staff physician was only 1 for every 915 patient days. Only 17% of these had high fever. CONCLUSIONS: Evening rounds by staff physicians, strengthening of working relations with hospital physicians, as well as fostering intravenous treatment in NHs, are suggested as means for reducing hospital transfers. A standardized method for the reporting of ACEs and referrals to hospitals should be adopted in order to facilitate comparisons between NHs and to evaluate its use as a quality indicator.

[Relatives' satisfaction with the care of elderly patients in skilled nursing wards].

BACKGROUND: Skilled Nursing Wards (SNW) in Israel are purposely equipped and staffed for treatment of patients that, in addition to functional dependence, suffer from active diseases which require close medical supervision. Patients' surveys on satisfaction with health care are increasingly accepted as an element of quality assessment. However, given the high rate of communication disorders present in these patients, this method is not feasible for use in SNWs. OBJECTIVE: We initiated a survey of patients' relatives--based on a questionnaire specifically designed to reflect their satisfaction with the level of care provided. METHODS: Respondents were asked to rank their level of satisfaction with medical, nursing and structural aspects of the care in the SNW on a 1-5 Likert Scale. RESULTS: Relatives of 147 SNW residents answered the questionnaire. The overall level of satisfaction was high, all components being ranked at 4.2 or above. Four point fifty-five was the average rating given to the medical component of the care, 4.39 to the nursing aspect and 4.32 to the structural section. Five points were awarded to the medical component by 60% of the participants, to the nursing element by 55% of respondents and to the structural section by 40% of respondents. No differences were observed between the rankings of frequent and less frequent visitors. All respondents were highly cooperative and expressed their appreciation of the initiative to perform a satisfaction survey. CONCLUSION: The results show that the families of the skilled nursing patients that participated in this study are satisfied with the health care provided to their relatives. Such surveys contribute to the quality of care and should be considered for routine/periodical use in long-term care settings.

Attitudes of relatives and nursing staff toward tuboenteral feeding in severely demented patients.

Elderly patients with advanced dementia present a challenge with respect to efficient nutrition and hydration because of oropharyngeal dysphagia and lack of patient cooperation. For increasing numbers of patients, long-term tuboenteral feeding (TEF) is an alternative for providing food and fluids, with the hope of reducing the risk of aspiration. The purpose of this study is to learn about the opinions and the attitudes of relatives and nursing staff regarding patients on TEF for at least one year. The study included all the demented patients on TEF in four skilled nursing facilities and four nursing wards. Researchers retrieved clinical data from patients' medical records and prepared a questionnaire to survey the opinions of relatives and staff members. The study included 111 patients: 89 on nasogastric tube (NGT) feeding and 22 on percutaneous endoscopic gastrostomy (PEG) feeding. The clinical condition of both groups was satisfactory, as reflected by albumin, hemoglobin, and Body Mass Index (BMI). Relatives of the demented patients as well as the staff members were ambivalent toward TEF. Although most of them called it an essential procedure for delivering food and fluids for life support, about the same number expressed concerns that TEF prolonged a life of suffering. Nevertheless, most relatives and staff members were resistant to the idea of withholding TEF. The data show that TEF does provide efficient nutrition and hydration to patients with advanced dementia, and it is used in accordance with the will of the relatives. Any change in the present approach regarding TEF in these patients should be preceded by discussions with their relatives.

Anemia, serum vitamin B12, and folic acid in patients with rheumatoid arthritis, psoriatic arthritis, and systemic lupus erythematosus.

OBJECTIVE: Although anemia is frequent in inflammatory rheumatic diseases, data regarding vitamin B12 status is scarce. The purpose of this study was to analyze the incidence and nature of B12 and folic acid (FA) deficiencies in a cohort of rheumatic patients with rheumatoid arthritis (RA), psoriatic arthritis (PsA), and systemic lupus erythematosus (SLE). METHODS: Levels of B12, FA, and parameters of anemia were recovered or examined in 276 outpatients. In those with recent findings of low serum B12 levels, further studies of serum homocysteine (Hcy) and urine methylmalonic acid (MMA) levels were performed. RESULTS: The incidence of anemia was high: 49%, 46%, and 35%, in RA, SLE, and PsA, respectively. Low levels of serum B12 were also frequent (24%), with almost similar occurrence in the three disease groups. Deficiency in FA was rare (<5%). Mean levels of both vitamins did not differ significantly among the three groups. No correlation between serum B12 levels and anemia was found. In the 15 patients with recently detected low B12 levels, Hcy and MMA were evaluated before and following B12 therapy. In ten of them, baseline Hcy levels were high, while MMA was increased in one patient only. Response to B12 administration, i.e., a decrease in Hcy and/or MMA levels, was noticed in four patients only, suggesting that only 26% of the low-serum-B12 patients had true B12 deficiency. CONCLUSIONS: The incidences of anemia and decreased serum B12 levels were high in these three groups of rheumatic patients. However, true tissue deficiency seems to be much rarer.

Biochemical, immunological and enzymatic components of saliva in prolonged naso-gastric-fed elderly patients.

BACKGROUND AND AIMS: We have previously shown that naso-gastric tube (NGT)-fed patients harbor pathogenic flora in their oropharynx. The purpose of this study was to examine comparatively the biochemical, immunological and enzymatic components of the saliva of these patients with that of orally-fed counterparts. METHODS: The study group consisted of 19 elderly NGT-fed patients and 18 comparable patients on oral feeding. Unstimulated whole saliva was collected and analyzed according to accepted methods for sodium, potassium, chloride, uric acid, total protein, albumin, amylase, lysozyme, and immunoglobulins, IgM, IgG, IgA, as well as secretory IgA. RESULTS: None of the above tested salivary components significantly differed between the two groups. Only uric acid levels were significantly lower (50%, p < 0.05) in NGT-fed patients. CONCLUSIONS: Uric acid is the main antioxidant component of saliva and, as such, it may be related to pathogenic bacterial colonization of the oropharynx in NGT-fed patients, with the risk of aspiration pneumonia.

Geriatric medical education in Israel.

In this article we will focus on geriatric medical education in Israel and will review our experience in this field. A coordinated effort of the Ministry of Health and the Israeli Medical Association led to the establishment of a modern geriatric system and to the recognition of geriatrics as a medical specialty in the early 1980s. All four Israeli medical schools joined this effort by introducing geriatrics in the undergraduate studies. Several innovative models for teaching geriatrics to medical students and for postgraduate training have been developed and implemented. The growing body of skills and knowledge available, and their application for competent care of the elderly, constitute a compelling impetus for the further development of a high-quality geriatric medical education.

Satisfaction with the care of institutionalized psychogeriatric patients, as reflected by a survey of their relatives.

The patients' satisfaction is an important aspect of quality of care assessment in long-term care institutions. However, many psychogeriatric patients are institutionalized at an advanced stage of their disease, when they are unable to communicate properly and cannot be questioned about their satisfaction with the care received in these psychogeriatric settings. Therefore we initiated a survey of patients' relatives based on a questionnaire purposely designed, to evaluate their satisfaction with the medical, nursing and structural components of the institutional care. The relatives of 101 patients, representing 79% of the patients in four psychogeriatric wards, responded to the questionnaire. The level of satisfaction with the care was high, as reflected by the fact that over 75% of the respondents rated the overall question about satisfaction with the medical, nursing, and structural components with the maximum of five points. The high correlation between the summative and the overall satisfaction supports and even strengthens this view. Another finding was the reluctance of most relatives to be involved in the personal care of the patients. Our study concluded that the relatives do appreciate the efforts of the staff and understand the constraints imposed by the nature of the patients' condition. Moreover, both families and staff welcomed this study and mentioned its contribution in improving communication.

Early and late effects of low-dose aspirin on renal function in elderly patients.

BACKGROUND: Although low-dose aspirin is used by many elderly patients, monitoring of renal function is currently not recommended. We recently reported transient retention of uric acid and creatinine caused by aspirin in doses of 75 to 325 mg/d. We therefore evaluated the renal effects of aspirin (100 mg/d), including post-treatment effects. METHODS: We studied 83 stable geriatric patients in long-term care (aged 56 to 98 years) who were treated with low-dose aspirin (100 mg/d) for 2 weeks and 40 control patients. Other medications and diet were kept constant. Biochemical monitoring including blood samples and 24-hour urinary collections for creatinine and uric acid at baseline and weekly for a total of 5 weeks. RESULTS: After 2 weeks on aspirin, urinary excretion of creatinine decreased in 60 (72%) and excretion of uric acid decreased in 54 (65%) of the 83 patients, and their mean clearances decreased; during the same period, serum blood urea nitrogen, creatinine, and uric acid levels increased (P <0.05 for all). Deterioration from baseline levels was significantly greater (and more prevalent) in the aspirin-treated group than in the 40 control patients (P = 0.001 to 0.09). After withdrawal of aspirin these parameters improved. However, 3 weeks after stopping aspirin, 48% (35 of the 73 in whom this measurement was available) had a persistent decline in creatinine clearance from baseline, as compared with only 8% (3/36) controls (P <0.001). CONCLUSION: Short-term low-dose aspirin treatment may affect renal function in elderly patients. These effects persist 3 weeks after cessation of the drug in some of these patients.

Pseudomonas aeruginosa and the oropharyngeal ecosystem of tube-fed patients.

We evaluated whether elderly patients fed with nasogastric tubes (NGT) are predisposed to Pseudomonas aeruginosa colonization in the oropharynx. Fifty-three patients on NGT feeding and 50 orally fed controls with similar clinical characteristics were studied. The tongue dorsum was swabbed and cultured. P. aeruginosa was isolated in 18 (34%) of the NGT-fed group but in no controls (p<0.001). Other gram-negative bacteria were cultured from 34 (64%) of NGT-fed patients as compared with 4 (8%) of controls (p<0.001). Antibiotic susceptibility of the oropharyngeal P. aeruginosa isolates was compared with that of isolates from sputum cultures obtained from our hospital's bacteriologic laboratory. The oropharyngeal isolates showed a higher rate of resistance; differences were significant for amikacin (p<0.03). Scanning electron microscope studies showed a biofilm containing P. aeruginosa organisms. The pulsed-field gel electrophoresis profile of these organisms was similar to that of P. aeruginosa isolates from the oropharynx. NGT-fed patients may serve as vectors of resistant P. aeruginosa strains.

The relation between the clinical subtypes of delirium and the urinary level of 6-SMT.

Delirium is a common syndrome among hospitalized elderly patients. In humans, sleep and circadian rhythms are disturbed during delirium, and both are influenced by the hormone melatonin. This prompted us to investigate the relationship of the clinical subtypes of delirium: 1). hyperactive, 2). hypoactive, and 3). mixed, with melatonin, as reflected by a patient's urinary metabolite 6-SMT. Results support our hypothesis that urinary 6-SMT during delirium was higher in hypoactive and lower in hyperactive patients. Because this is the first time a biochemical parameter related to the clinical subtypes of delirium has been reported, further research on the link between melatonin and delirium is necessary.

Geriatrics in the new millennium, Israel.

Since the early 1980s demographic changes compelled Israel's health system to dedicate efforts to establish modern geriatric services. This task was performed with the help of governmental and non-governmental institutions and was coordinated by the Division of Geriatrics and Long-Term Care Diseases of the Ministry of Health. Today, 20 years later, as a result of those efforts, geriatrics and geriatric services in Israel are thriving. Qualified staff, including physicians who specialized in geriatrics, are working to maintain a high quality of care in various geriatric settings. However, more resources should be allocated for research in order to maintain and to continue to develop geriatric medicine in Israel.

Gender-associated findings in postmortem examinations of elderly patients: an increased rate of pulmonary embolism in women.

BACKGROUND: While age at death is on the rise, the number of postmortem examinations is declining and is disproportionately low among the elderly population. Research on, the subject of gender-associated pathology in the elderly is also scarce. OBJECTIVE: To seek eventual gender-related differences in autopsies of elderly patients. METHODS: We analyzed the data extracted from a published report on 93 PMEs performed at a geriatric hospital during the past 20 years. RESULTS: Ninety-three autopsies, representing 1.2% of the 8,101 deaths during these 20 years, were performed. Forty-five of the deceased were women and 48 were men. The incidence of pulmonary embolism was significantly higher in women (28%) than in men (10%) (P < 0.02). There was no significant difference in the gender distribution of the other diagnoses. CONCLUSION: Gender distribution of PME-based causes of death in elderly patients revealed a significant rate of pulmonary embolism in women. A thorough search of the medical literature revealed two previous studies with similar findings. Further research will determine whether pulmonary embolism is more frequent or whether it has a worse prognosis in frail elderly women.

Saliva secretion and oral flora in prolonged nasogastric tube-fed elderly patients.

BACKGROUND: In a previous study we showed that prolonged nasogastric tube feeding is associated with pathogenic oral flora. OBJECTIVE: To reexamine the impact of prolonged nasogastric tube feeding on the oral microbiota and to explore the salivary flow and composition in elderly patients in long-term care. METHODS: We compared a group of elderly patients fed by nasogastric tube with a control group of elderly patients in long-term care who are fed orally. Bacteriologic studies were performed by culturing samples from the oropharynx. Saliva studies included quantitative and biochemical analysis of basal and stimulated salivary flow. RESULTS: Bacteriologic studies performed in 90 patients revealed a significantly higher prevalence of gram-negative bacteria in nasogastric tube-fed patients (73% vs. 13%, P < 0.001). It is emphasized that Pseudomonas aeruginosa and Klebsiella pneumoniae were commonly and exclusively isolated from the oral flora of the nasogastric tube-fed patients (P < 0.001, P < 0.05). In the saliva studies performed on 23 nasogastric tube-fed and 21 control patients, basal and stimulated salivary flow was not significantly different in the two groups, however the ratio of stimulated to basal flow was reduced in the nasogastric tube-fed group (P < 0.05). Significant differences were also found in the concentrations of sodium, amylase, phosphor and magnesium. Noteworthy was the concentration of uric acid, the main non-enzymatic antioxidant of saliva, which was significantly lower in nasogastric-tube fed patients (P < 0.002). CONCLUSIONS: These findings suggest that prolonged nasogastric tube feeding is associated with pathologic colonization of the oroparynx and with alterations in the saliva that are related to the risk of aspiration pneumonia. Further research is called for, as well as a thorough revision of the existing oral cleansing procedures in these patients.

Pathogenic colonization of oral flora in frail elderly patients fed by nasogastric tube or percutaneous enterogastric tube.

BACKGROUND: Aspiration of infected oropharyngeal content is the main cause of aspiration pneumonia. This complication, mainly related to gram-negative bacteria, threatens percutaneous enterogastric tube as well as nasogastric tube (NGT) fed patients. The objective of this study was to examine the oral microbiota of tuboenterally fed patients and compare it with that of orally fed counterparts. METHODS: Patients were recruited for this study from six nursing and skilled nursing facilities with an overall number of 845 beds. Enrolled were 215 patients: Group 1 consisted of 78 patients on NGT feeding, Group 2 consisted of 57 patients on percutaneous enterogastric tube feeding, and Group 3 consisted of 80 patients fed orally who were from the same facilities. Cultures were performed by sampling the oropharynx of each subject in order to identify gram-negative bacteria and Staphylococcus aureus. RESULTS: A high prevalence of potentially pathogenic isolations was found in tuboenterally fed patients: 81% in Group 1 and 51% in Group 2, as compared with only 17.5% in Group 3 (p <.0001). Pseudomonas aeruginosa was cultured from 31% of the subjects in Group 1 and 10% of Group 2, but in none of Group 3 (p <.001). Klebsiella and Proteus were isolated mainly from the NGT fed patients (p <.003). No correlation was found between the time duration on tube feeding or the presence of residual dentition and pathogenic microbiota. CONCLUSION: This study shows that tuboenteral feeding in elderly patients is associated with pathogenic colonization of the oropharynx. These findings are related to the risk of aspiration pneumonia and are compelling for the reevaluation of current oral cleansing procedures.

[Satisfaction with healthcare in long-term care settings].

Health consumers' satisfaction has become a factor of increasing importance for health care systems. It is dictated by modern management methods and also by the competition between health care providers. Survey of satisfaction with health care in long term care settings is challenging because of its complexity and the communication handicap of many of the patients. This subject is reviewed according to existing publications and we mention our own experience on the matter. Satisfaction surveys are not an inherent objective but an important lever for quality of care improvement and assurance.

Colonic transit time in diabetic and nondiabetic long-term care patients.

BACKGROUND: Constipation is a frequent health concern for elderly people. The increased incidence of constipation with age is mainly based on self-reported data. Only a few studies have examined this problem objectively and even fewer have carried this out in the special subpopulation of frail elderly patients. OBJECTIVE: The aim of this study was to examine colonic transit time (CTT) in frail elderly patients. We also attempted to compare CTT in diabetics and nondiabetics within this population. METHODS: 45 frail elderly patients, all immobile with and without diabetes mellitus, residing permanently in long-term geriatric departments were recruited for the study. All patients underwent segmental and total CTT studies using radiopaque markers. The segmental CTT was calculated separately for the four segments of the colon (ascending, transverse, descending, and rectosigmoid) and for the total transit time which was the sum of all four segments. RESULTS: The average CTT was extremely prolonged in all patients included in this study. In the diabetics the CTT was even longer with a mean total transit time of 200 +/- 144 h as compared with 143 +/- 95 h in the controls. The difference was not statistically significant. For each segment tested, the CTT was shorter in the control group, but these differences did not reach statistical significance. CONCLUSIONS: The CTT is prolonged in immobile frail elderly patients. No significant differences were noted between diabetic and nondiabetic patients.