[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.

[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.

Gender differences influence the outcome of geriatric rehabilitation following hip fracture.

Hip fracture represents the most dramatic expression of the disease, in terms of morbidity, medical cost and mortality. The incidence of hip fracture increases substantially with age. The purpose of this study was to evaluate the association between gender and geriatric rehabilitation outcome after traumatic hip fracture. Ninety-nine community-dwelling elderly patients (older than 65 years), 64 women and 35 men, who were admitted to geriatric rehabilitation after operated hip fracture were studied. We assessed the patients' clinical and demographic data, preoperative risk (ASA), type of fracture and orthopedic repair, pain intensity (VAS), cognitive (MMSE), mood (Zung IDS), and functional status (FIM) on admission and at the end of geriatric rehabilitation. Men had higher mean number of comorbid conditions at the time of the fracture. Men recovered more from depressed mood in comparison with women during the rehabilitation. Significant improvement in FIM motor subscore on discharge was found in both groups. The FIM motor subscore gain was higher in men (24.47) in comparison with women (19.22, p=0.036). Those differences were demonstrated in mean subscores of transfers (p=0.004), and locomotion (p=0.019). Women were more functionally dependent in locomotion, transfers and sphincter control. There were no differences between the groups by duration on rehabilitation stay. Recovery after hip fracture depends in large part on the pre-fracture health and functional ability of the patient. Gender differences in functional recovery may affect therapeutic and rehabilitative decision making. Functional recovery after traumatic hip fracture was better in men in comparison with women.

Detection of urinary tract infection (UTI) in long-term care setting: Is the multireagent strip an adequate diagnostic tool?

Urinary tract infection (UTI) is one of the most commonly diagnosed and treated infection in elderly residents of long-term care (LTC) setting, and most of them are asymptomatic. Early diagnosis and treatment especially in this group of patients is very important because even a brief delay contributes to mortality as well as to reduce functional and cognitive decline. The purpose of the present study was to determine the validity of multireagent strips (Multistix 10 SG, Bayer, UK) compared with standard urinalysis for the early detection of UTI in LTC elderly patients. Urine specimens were examined for the presence of leukocyte esterase (LE) activity as an indicator of pyuria, nitrite production as an indicator of bacteriuria, erythrocytes (RBC), and protein. The sensitivity, specificity, predictive value, kappa agreement, and likelihood ration were determined for each of the four dipstick parameters measurement separately, and in four combinations were calculated against the urine culture for the diagnosis of UTI and asymptomatic bacteriuria. Ninety-six patients aged 65 years and older with symptomatic UTI were compared with similar number, age, sex and comorbidity status matched patients with asymptomatic bacteriuria. In both groups, urinary culture results were compared with the results of multireagent strips. The multireagent strips results were evaluated for the presence of LE activity as an indicator of pyuria, nitrite production as an indicator of bacteriuria, RBC, and protein. All positive sticks results were evaluated as single parameter and in combination of them. Positive urine cultures were found in 71% (68/96) of the patients with symptomatic and in 60% (58/96; p>0.05) of patients with asymptomatic UTI. In patients with UTI, using multireagent strips kappa agreement for LE was 0.53, for nitrite was 0.14, and in combination of them was 0.31. Similar results were reported in patients with asymptomatic bacteriuria, 0.35, 0.23, and 0.35m. The detection of RBC and protein, as single parameter or in combination with other parameters, decreases accuracy of the tests. Positive dipstick tests for LE and/or nitrite are not specific indicators of UTI, and are not suitable for screening of LTC inpatients for UTI because of high false-negative rates of the LE and nitrite.

Evaluation of the benefits of enteral nutrition in long-term care elderly patients.

BACKGROUND: Demented patients may refuse to eat as they come closer to the end of their lives. We evaluated the effectiveness of enteral nutrition in the improvement of survival and nutritional and functional status in very dependent and demented long-term care (LTC) elderly patients and its correlation with the nutritional parameters. MATERIAL AND METHODS: Fifty-seven elderly patients, aged 60 years and older, who received nutrition by the enteral route (enteral nutrition group, ENG), were compared with 110 age-, sex-, comorbibity-, cognitive-, and dependent-matched subjects (control group, CG). Indications for enteral nutrition, type of tube; weight status subsequent to enteral nutrition; cognitive, functional, and pressure sore status; and complete clinical, complete blood count, and biochemical profile were recorded for each subject on initiation and conclusion of the study. RESULTS: Enteral nutrition was associated with improvement in blood count (hemoglobin and lymphocyte count), in renal function tests and electrolytes (BUN, creatinine, BUN/creatinine ratio, sodium and potassium), hydration status, serum osmolarity, and in serum proteins (total protein, albumin, and transferrin), but not in serum cholesterol and CRP levels. Decline in functional and in cognitive status was higher in CG than in ENG (Delta changes; respectively P = .24 and P < .001). ENG had a higher Norton scale than CG (Delta changes; P < .001). Mortality rate was higher in ENG (42%) than in CG (27%, P > .05). Complication rate related to nutrition was higher in ENG than in CG (61% and 34%, respectively; P < .001). CONCLUSION: Enteral nutrition does not have an advantage over oral nutrition in prolonging life or preventing pressure sore development in an LTC setting.

[Geriatric medicine--between the blessing of modern medicine and the curse of aging].

The proportion of the elderly in the general population is increasing. The elderly are frail as a result of biological and physiological changes with aging. Therefore, the elderly consume more medical services. The law of patient's rights promises equality and equity in medical service. The law pays no attention to age, as an inequality factor. Elderly receive most of their acute medical care in the departments of Internal Medicine, General Surgery and Orthopedic Surgery in the general hospitals and their chronic care in the family practitioners' clinics in the community. In recent years, the elderly have chosen to receive their medical services as part of the general population. Therefore, the coming decade placed several goals for Geriatric Medicine in the general hospitals in Israel. In every general hospital, at least one department of Internal Medicine should be headed by a specialist in Internal Medicine and Geriatric Medicine, and one of the seniors in every department also has to be a geriatrician by education. Sub-acute care has to be affiliated to the general hospitals and Geriatric Medicine consultation service has to be established and communication and continuity maintained with community services. Treatment of the elderly in the general hospital as part of the general treatment is our duty as physicians and our obligation to the elderly as part of our society.

Infection-related hypoglycemia in institutionalized demented patients: a comparative study of diabetic and nondiabetic patients.

Hypoglycemia is common in elderly community dwelling patients and may accompany episodes of acute infection. We analyzed the interrelations of clinical variables with infection-related hypoglycemia (IRH) and its outcome in institutionalized demented elderly patients, with and without diabetes mellitus (DM). This is a retrospective cohort study involving residents of a large long term-care facility. We measured demographic, clinical, functional, nutritional and cognitive data as well as blood counts and chemistry analysis. We identified 65 elderly patients with IRH and compared data of 33 diabetic patients with 32 nondiabetic patients. Mean age of patients was 77.7 years and mean Mini-Mental score of 1.8. Diabetic patients were younger, more cognitively impaired, had a lower functional score (nonsignificant differences), but presented with more comorbidities, compared with nondiabetics (p=0.004). Mean blood glucose levels in diabetics and nondiabetics were 53.2 and 54.3 mg/dl, respectively. Only 22% of the patients showed clinical signs indicating hypoglycemia. Multivariate analysis showed that, in groups, comorbidity and functional status, creatinine, albumin, C-reactive protein (CRP) and total cholesterol were all associated with IRH. During a 6 months period, 58% (38/65) of the patients died, out of whom 47% (18/38) died within one month following the documentation of IRH. There were no statistically significant differences in short and late mortality rates between patients with and without DM. we conclude that asymptomatic IRH in institutionalized demented elderly is frequently associated with common respiratory and urinary infections, in both diabetic and nondiabetic patients. IRH seems to indicate a poor general health status rather than being the cause of death. Blood glucose needs to be screened in this population during common infections, also in nondiabetics, to identify patients at high risk.

Drug use in a geriatric long-term care setting: comparison between newly admitted and institutionalised patients.

BACKGROUND AND OBJECTIVE: Advanced age, co-morbid diseases, functional dependence and frailty are associated with polypharmacy and overall high health expenditures. Polypharmacy is commonly defined as the concomitant ingestion of four or more medications, particularly in community-dwelling patients, but the number of drugs being taken by institutionalised and hospitalised patients may be as high as ten. The aim of this study was to compare drug use in newly admitted patients (AP) to a geriatric medical centre for long-term care (LTC) with that of institutionalised patients (IP) at the centre. METHODS: A cross-sectional study was conducted, between January 2001 and December 2002, in 324 functionally dependent and cognitively impaired elderly patients (> or = 65 years of age), consisting of 167 IP (127 females, 40 males) staying at the centre for > or = 3 months and 157 (117 females, 40 males) consecutive new admissions for LTC. All patients underwent a comprehensive geriatric assessment, which included a structured medical history, history of drug use, physical examination and functional and cognitive examinations. Overall drug use, drug categories and the basis of use (regular and/or as needed) were compared between the two groups of patients. The pattern of drug use was defined as use of drugs either on a 'regular' basis or on an 'as needed' basis at any time during the 3 weeks preceding the comprehensive geriatric assessment. RESULTS: IPs were younger, more dependent, more cognitively impaired, had more co-morbidity and had nonsignificantly higher overall drug use than APs. APs used drugs mainly on a 'regular' basis. All of the IPs and most (97%) of the APs were taking drugs according to regular regimens. However, advanced age in IPs was associated with lower overall drug use, predominantly of medications taken on a 'regular' basis, and higher use of drugs taken on an 'as needed' basis, whereas in APs, advanced age was associated with higher use of both types of medications. CONCLUSION: IPs used more drugs on an 'as needed' basis, probably because of closer medical supervision of these patients than those in the community. Better knowledge of the patient's medical condition and treatment, together with better monitoring in the community through patient caregiver instruction, on the one hand, and computerisation of medical data accessible to all healthcare providers, on the other hand, might reduce drug use on a regular basis and, consequently, the costly and adverse effects of polypharmacy.

Antiepileptic drug use and the occurrence of pressure ulcers among bedridden institutionalized elderly patients: a retrospective chart review.

BACKGROUND: Phenytoin (PH) is indicated primarily for the control of grand mal and psychomotor seizures. However, topical PH has been used for the treatment of various types of ulcers, including pressure ulcers. OBJECTIVE: The aim of this study was to investigate the possibility of a relationship between the use of oral PH and the prevalence of pressure ulcers among bedridden institutionalized elderly patients. METHODS: This retrospective chart review was conducted in a state-run urban geriatric medical center in Israel and involved long-term bedridden institutionalized patients who were receiving chronic antiepileptic medication during the 7-year period between January 1996 and December 2003. The prevalence of pressure ulcers in patients who received treatment with PH alone or in combination with other antiepileptic drugs was compared with that in patients who received antiepileptic agents other than PH. RESULTS: The study analyzed data from the medical charts of 153 patients, 72 of whom received PH alone or in combination with other antiepileptic drugs, and 81 of whom received antiepileptic agents other than PH. Patients' mean (SD) age was 78.5 (7.2) years; 106 (69.3%) were women. All patients were totally dependent with respect to activities of daily living (mean Katz score, 2.0 [2.0]) and had severe cognitive decline (mean Mini-Mental State Examination score, 3.5 [3.3]). Pressure ulcers occurred in 9.7% of PH recipients and 27.2% of non-PH recipients (P = 0.006; chi2 = 7.55). In PH recipients, 85.7% of pressure ulcers were of mild to moderate severity (stage I or II), compared with 59.1% of ulcers in non-PH recipients; the difference between groups was not statistically significant. Four (18.2%) non-PH recipients and no PH recipients had stage IV pressure ulcers. In the PH group, 71.4% of patients had a pressure ulcer in only 1 anatomic location, compared with 22.7% of the non-PH group (P = 0.023; chi2 = 5.13); 28.6% of PH recipients and 63.6% of non-PH recipients had pressure ulcers in 2 or 3 anatomic locations; and 3 (13.6%) non-PH recipients and no PH recipients had pressure ulcers in > or = 4 areas. CONCLUSIONS: In the long-term bedridden institutionalized patients studied, those who received PH had lower rates of pressure ulcers, as well as less severe ulcers. PH may be a useful anticonvulsive agent in frail elderly patients, who are at risk for the development of pressure ulcers.

Functional recovery after hip fracture in old-old elderly patients.

Hip fracture is epidemic and prevalence increased with advanced age. Impact of comorbid and cognitive status, gender, type of fracture, operative delay and pre-fracture ambulatory levels on functional outcome was shown in previous studies. We studied functional outcome after rehabilitation for hip fracture in old-old elderly (85 years and older) and compared it to young elderly (65-74 years) community-dwelling patients. Before the fracture, old-old elderly patients were more functional dependent, has had more comorbid diseases, and more of them live alone than young elderly. The waiting time to surgery and mean length of stay in orthopedic ward were longer than in young elderly. On admission to rehabilitation treatment, old-old patients presented with more depressed mood, were more cognitive impaired, and more suffer from pain. Old-old patients presented with laboratory data of malnutrition (decreased serum levels of albumin, cholesterol, hemoglobin, hematocrit, lymphocyte count) and inflammation (increased of transferrin and C-reactive protein). Improvement in Functional Independence Measurement (FIM) scale was found in both groups but significantly better in young elderly than in old-old elderly. The change in FIM during the rehabilitation period (DeltaFIM) were in FIM total and in those parts of FIM concerning locomotion. The mean duration of rehabilitation stay was significantly longer in old-old elderly patients. On discharge old-old elderly patients more suffer from pain and difference between the groups according to the laboratory and to the cognitive data increased. Age per se is indicator of frailty and determinate functional recovery after hip fracture.

[Fever and its decrement in acute stroke].

Management of body temperature is considered crucial in the management of acute stroke patients. Hyperthermia exacerbates ischaemic neuronal injury and physiological dysfunction. Hypothermia has been suggested as the "gold standard" for neuroprotection to which new pharmacological therapies should be compared. This article reviews the literature on the predictive role of admission body temperature on the outcomes of patients with stroke. We also examined the derived effect of using hypothermic procedures and antipyretic agents as a treatment measure in acute stroke patients for improving outcomes. Immediate effective treatment of the fever, while simultaneously evaluating its origin, is found to be crucial in the acute stroke for improving outcomes. The hypothermic effect of acetaminophen as a preventive measure for all patients requires further evaluation.

Homocysteine effect on protein degradation rates.

OBJECTIVES: To show the effect of homocysteine (Hcy) on the degradation rates of proteins. DESIGN AND METHODS: Degradation rates of short-lived proteins in neutrophils were measured in in vivo human model of elevated plasma Hcy and lower vitamin status and in animal model of Hcy added in vitro to rat neutrophils. RESULTS: In the human study, we found significant coefficients of correlation between plasma total homocysteine (tHcy) and the degradation rates of 21 protein fractions. In the animal model, Hcy significantly increased degradation rates of 57 protein fractions. CONCLUSIONS: The increase in protein degradation rates, induced by Hcy, may provide a clue to our understanding of the mechanism of Hcy detrimental effects. Hcy may amplify the specific effect of cellular solutes on protein conformation, thereby monitor protein degradation rates to control enzyme activity. Consequently, the cell may lose its ability to maintain an efficient control of some crucial metabolic pathways, possibly leading to atherogenesis.

The effect of electric stimulation treatment on the functional rehabilitation of acute geriatric patients with stroke--a preliminary study.

The most common neurological damage in acute stroke/cerebrovascular accident (CVA) is a decline in the senso-motor capacities of both the upper and the lower extremities with a more severe injury in the upper ones. Motor improvement of the affected limb can be attained through frequent intensive exercise by electrical stimulation (ES). The objective of this study was to examine the effect of the ES treatment using Handmaster ES device on the functional rehabilitation of elderly patients after acute CVA. Twenty-two elderly with different levels of damage and partial movements in their upper limb joints underwent a 3-week treatment. Nine of them were treated for additional 3-weeks after a 3-week break. After the first 3-week treatment, significant improvements were observed, in all the subjects, in the active range of motion (ROM) of the shoulder and the wrist joints, on manual dexterity tests and on functional independence measure (FIM). After the two periods of treatment the nine subjects exhibited significant improvements in ROM and in manual dexterity. FIM score increased by the same rate after each of the three stages. This preliminary study has proven that the Handmaster treatment can improve the geriatric rehabilitation outcome of elderly patients with senso-motor deficit caused by acute CVA.

Triple task Clock Completion Test (CCT) as a predictor of functional outcome in geriatric rehabilitation.

Cognitive status is considered as a predictor of the rehabilitation outcome. The triple task Clock Completion Test (CCT), which evaluates visuospatial skill, has been demonstrated to be a sensitive predictor of functional capacity. The objective of the study was to test the predictive validity of the CCT for assessing functional outcome in geriatric rehabilitation. Functional evaluation using the Functional Independence Measure (FIM) and cognitive evaluation using the Mini Mental State Examination (MMSE) as well as the CCT, were performed in 77 elderly patients (35 men, 42 women, median age 81.5 years) on admission and discharge. Significant positive coefficients of correlation were found between the admission and discharge CCT scores, and negative coefficients, between CCT and FIM scores, both on admission and discharge. CCT and MMSE scores correlated significantly just on admission. The MMSE and the FIM scores were significantly higher among those who succeeded than in those who failed on the CCT in the task of setting the hour on admission and discharge, whereas in the task of reading the hour, just on admission. The triple task CCT is a sensitive tool for identifying cognitive impairment affecting the executive functions and an important functional outcome predictor.

Energy restriction controls aging through neuroendocrine signal transduction.

Since the work of McCay in 1935, demonstrating the effect of energy restricted diet on the lifespan of rats, many studies have confirmed these findings in different species. Several mechanisms have been suggested, including among others, growth retardation, diminished apoptosis, decreased oxidative damage, altered glucose utilization, changes in gene expression, enhanced stress responsiveness and hormesis. There is some evidence that energy restriction (ER) exerts important metabolic effects on the aging process and longevity through intra- and intercellular signal transduction transmitters, with several signaling pathways mediating its beneficial action.

Activities of antioxidant scavenger enzymes (superoxide dismutase and glutathione peroxidase) in erythrocytes in adult women with and without type II diabetes.

It is widely believed that oxidative stress plays an important role in the pathogenesis of type II diabetes. The present study was undertaken to examine the functioning of two antioxidant scavenger enzymes, superoxide dismutase (SOD) and glutathione peroxidase (GSH-Px), in erythrocytes in a population of healthy aging adult women compared with a similar population with type II diabetes. Blood samples were examined from 42 female adult healthy subjects at different ages and from 59 female patients with type II diabetes. A significant increase in SOD activities was correlated with aging in erythrocytes of the healthy control subjects (r =.550, P =.001); however, this correlation was not found in subjects with type II diabetes (r =.250, P <.07). A trend showing a reduction in glutathione peroxidase activities was demonstrated with aging (r = -.331, P =.228); however, this trend was not found in diabetic subjects (r =.031, P <.820). The results indicate a possible imbalance in the antioxidant system in erythrocytes of aging adult women, which is even more pronounced in cases of type II diabetes. This study may indicate possible therapeutic treatment or preventive measures to limit oxidative damage and reduce complications of diabetes.

[Vestibular function, falls and hip fracture in elderly--a relationship study].

BACKGROUND: Falling is the main reason for which people over 70 arrive at emergency rooms. Over 90% of hip fractures occur as a direct result of falling. PURPOSE: To examine the relationship between the function of the vestibular system and hip fractures following falls in elderly. SUBJECTS AND METHODS: The research group (n = 84) undergone hip surgery as a result of a fall and were then hospitalized in a rehabilitative geriatric care unit at the Meir Hospital in Kfar Sava. The control group (n = 85)--without any history of a hip fracture and living in a retirement home. Four clinical tests were given to each examinee in order to locate any impairment of the vestibular system. Three of the clinical examinations concentrated on testing the VOR while the fourth test was especially used to locate BPPV (Benign Paroxysmal Positional Vertigo). Sociodemographic status and medical history were taken. RESULTS: A significant difference was found between the two groups (those with a hip fracture and those without any hip fracture) with regard to the functioning of the VOR, age, endocrine disease and medications for treating diabetic. However, there was no significant difference found in the appearance of the BPPV. CONCLUSIONS: It is important to locate the elderly who are at risk of falling in nursing homes and the community at large by performing the four simple clinical tests. Correct diagnosis and early treatment of the vestibular impairment in elderly patient can prevent the next fall.

Hypodermoclysis (subcutaneous infusion) effective mode of treatment of dehydration in long-term care patients.

Dehydration is associated with morbidity and mortality in frail elderly patients. Intravenous fluid administration in these patients is sometimes hard, especially in agitated patients. The purpose of this study was to review of 57 long-termed care patients received hypodermoclysis infusion on 118 different occasions during the 9 months. Data collection included: demographic data, functional and mental status, indication hypodermoclysis, duration of the infusion, type of solution, laboratory data, adverse effects, and outcome. The main reasons for initiation of the hypodermoclysis were either dehydration (64%) or febrile illness (21%). The average duration of infusions was 15.9 days and average daily volume was 1161 ml per day. After hydration by hypodermoclysis, in 77% of the patients, clinical improvement occurred manifested as general improvement (88%), cognitive status improvement (84%), and improved oral intake (81%). During the course of the study, failure of the treatment was observed in 12% of the patients, mortality of 11% was observed. Nobody developed signs of fluid overload. Local complications were reported in 12% of patients: local swelling (6/57), complain of local pain at site (3/57) and local inflammation (2/57). Hypodermoclysis is a safe, effective and suitable alternative to intravenous re-hydration in long-term care patients.