Adherence to resistance training and hypocaloric diet among persons near retirement age - A secondary data analysis of three randomized controlled trials.

OBJECTIVES: Adherence to lifestyle interventions is crucial for the treatment of obesity. However, there is little research about adherence to lifestyle interventions in persons around retirement age. The objectives of this study are (1) to identify factors associated with the adherence to resistance training and a hypocaloric diet and (2) to describe the association between adherence and changes in body composition outcome parameters. DESIGN: This secondary data analysis included three randomized controlled trials. SETTING & PARTICIPANTS: The inclusion criteria of the participants were an age of 55-75 years, a BMI ≥ 25 kg/m2 and receiving both a hypocaloric diet and resistance training. All participants were residing in the community. MEASUREMENTS: Adherence to hypocaloric diet was measured through the mean dietary intake on the basis of a 3-day dietary record. If the participant consumed at least 600 kcal less than the individual caloric requirements, they were considered adherent. Adherence to resistance training was achieved if ≥67% of the recommended training sessions were attended over the course of the study periods. RESULTS: 232 participants were included, 47.0% female, mean age 64.0 (±5.5) years. 80.2% adhered to resistance training and 51.3% adhered to a hypocaloric diet. Older age (Beta 0.41; 95% CI 0.05, 0.78; p = 0.028) and male sex (Beta 7.7; 95% CI 3.6, 11; p < 0.001) were associated with higher resistance training adherence. A higher BMI at baseline (Beta 6.4; 95% CI 3.6, 9.2; p < 0.001) and male sex (Beta 65; 95% CI 41, 88; p < 0.001) were associated with higher adherence to hypocaloric diet. CONCLUSION: We identified several associated factors (sex, age and BMI at baseline) that should be considered to promote adherence in future lifestyle intervention studies in persons around retirement age. We recommend including behavior change techniques in lifestyle interventions and consider sex-specific interventions to improve the adherence of women.

Identification of factors associated with sarcopenic obesity development: Literature review and expert panel voting.

Sarcopenic obesity (SO) is defined as the combination of excess fat mass (obesity) and low skeletal muscle mass and function (sarcopenia). The identification and classification of factors related to SO would favor better prevention and diagnosis. The present article aimed to (i) define a list of factors related with SO based on literature analysis, (ii) identify clinical conditions linked with SO development from literature search and (iii) evaluate their relevance and the potential research gaps by consulting an expert panel. From 4746 articles screened, 240 articles were selected for extraction of the factors associated with SO. Factors were classified according to their frequency in the literature. Clinical conditions were also recorded. Then, they were evaluated by a panel of expert for evaluation of their relevance in SO development. Experts also suggested additional factors. Thirty-nine unique factors were extracted from the papers and additional eleven factors suggested by a panel of experts in the SO field. The frequency in the literature showed insulin resistance, dyslipidemia, lack of exercise training, inflammation and hypertension as the most frequent factors associated with SO whereas experts ranked low spontaneous physical activity, protein and energy intakes, low exercise training and aging as the most important. Although literature and expert panel presented some differences, this first list of associated factors could help to identify patients at risk of SO. Further work is needed to confirm the contribution of factors associated with SO among the population overtime or in randomized controlled trials to demonstrate causality.

A European survey of older peoples' preferences, and perceived barriers and facilitators to inform development of a medication-related fall-prevention patient portal.

PURPOSE: Falls are a major and growing health care problem in older adults. A patient portal has the potential to provide older adults with fall-prevention advice to reduce fall-risk. However, to date, the needs and preferences regarding a patient portal in older people who have experienced falls have not been explored. This study assesses content preferences, potential barriers and facilitators with regard to using a patient portal, as perceived by older people who have experienced falls, and explores regional differences between European participants. METHODS: We conducted a survey of older adults attending an outpatient clinic due to a fall or fall-related injury, to explore their content preferences, perceived barriers, and facilitators with respect to a fall-prevention patient portal. Older adults (N = 121, 69.4% female, mean age: 77.9) were recruited from seven European countries. RESULTS: Almost two-thirds of respondents indicated they would use a fall-prevention patient portal. The portal would preferably include information on Fall-Risk-Increasing Drugs (FRIDs), and ways to manage other related/relevant medical conditions. Facilitators included a user-friendly portal, with easily accessible information and physician recommendations to use the portal. The most-commonly-selected barriers were privacy issues and usage fees. A family member's recommendation to use the portal was seemingly more important for Southern and Eastern European participants compared to the other regions. CONCLUSION: The majority of older people with lived falls experience expressed an interest in a fall-prevention patient portal providing personalized treatment advice to prevent further falls. The results will be used to inform the development of a fall-prevention patient portal. The fall-prevention patient portal is intended to be used in addition to a consultation with a physician. Future research is needed to explore how to prevent falls in older patients who are not interested in a fall-prevention patient portal.

The Impact of Delirium on Recovery in Geriatric Rehabilitation after Acute Infection.

OBJECTIVES: Delirium is common during acute infection in older patients and is associated with functional decline. Geriatric rehabilitation (GR) can help older patients to return to their premorbid functional level. It is unknown whether delirium affects GR outcomes in patients with acute infection. We evaluated whether delirium affects trajectories of activities of daily living (ADL) and quality of life (QoL) recovery in GR after COVID-19 infection. DESIGN: This study was part of the EU-COGER study, a multicenter cohort study conducted between October 2020 and October 2021. SETTING AND PARTICIPANTS: Participants were recruited after COVID-19 infection from 59 GR centers in 10 European countries. METHODS: Data were collected at GR admission, discharge, and at the 6-week and 6-month follow-ups. Trajectories of ADL [using the Barthel index (BI)] and QoL [using the EuroQol-5 Dimensions-5 Level (EQ-5D-5L)] recovery were examined using linear mixed models. RESULTS: Of the 723 patients included (mean age 75.5 ± 9.9 years; 52.4% male), 28.9% had delirium before or during GR admission. Participants with delirium recovered in ADL at approximately the same rate as those without (linear slope effect = -0.13, SE 0.16, P = .427) up to an estimated BI score of 16.1 at 6 months. Similarly, participants with delirium recovered in QoL at approximately the same rate as those without (linear slope effect = -0.017, SE 0.015, P = .248), up to an estimated EQ-5D-5L score of 0.8 at 6 months. CONCLUSIONS AND IMPLICATIONS: Presence of delirium during the acute phase of infection or subsequent GR did not influence the recovery trajectory of ADL functioning and QoL.

[The "Short Physical Performance Battery" in the Czech Republic -  the pilot and validation study in older persons]. / "Krátká baterie pro testování fyzické zdatnosti senioru" -  pilotní studie a validizace testu u starsích osob v Ceské republice.

INTRODUCTION: Population ageing increases number of seniors with decline of physical capabilities and functional deficits. Targeted interventions to maintain or increase physical performance are most effective before the development of full frailty, in so-called "prefrail" period. One of the assessment tools for evaluation of the physical performance and/ or frailty in older persons is the "Short Physical Performance Battery" -  SPPB. The aim of the study was to introduce the assessment battery to clinical practice in the CR and to evaluate its selected psychometric properties. METHOD: Original English SPPB was translated into Czech language and back translated to ensure linguistic accuracy. SPPB was applied in the selected sample of older persons and validated against other performance tools for cognition, self- care and nutrition status used in CR and selected psychometric properties evaluated. RESULTS: We examined 145 older persons (108 women, i.e. 74.48 % and 37 men, i.e. 25.52 %) mean age 80.38 years (54- 101 years, SD ± 8,47). We found good physical performance in 35 (24.1 %) older persons (SPPB 10- 12 points), 21 (14.5 %) were identified as prefrail (SPPB 7- 9 points) and 89 (61.4 %) as frail in high risk of future disability or already disabled (SPPB 6 points). We found statistically significant correlation of global SPPB score with nutritional status (MNA- Short Form), activities of daily living performance (ADL) and cognitive performance (MMSE) -  (Spearman correlation ρ = 0.51; 0.53 and 0.38 respectively). The Cronbachs a for SPPB variables scored 0.821, which is consistent with good internal consistency of SPPB battery. When evaluating 3 age groups [ 75 years (n = 41), 76- 85 (n = 62) and 86- 101 years (n = 42)] the most significant correlations were found between SPPB and MNA, ADL and MMSE in the young elderly (ρ = 0.74, 0.79 and 0.64 respectively) and they diminished with increasing age. CONCLUSION: We confirmed significant correlations between SPPB and self care activities, cognitive performance and nutritional status and good internal consistency of the battery. SPPB test is simple, easy to perform, with low time and cost requirements. It could be recommended for clinical practice in both community and hospitalized older patients to evaluate their overall physical performance and identify persons at risk of frailty and disability who may profit from targeted interventions.

EuGMS Task and Finish group on Fall-Risk-Increasing Drugs (FRIDs): Position on Knowledge Dissemination, Management, and Future Research.

Falls are a major public health concern in the older population, and certain medication classes are a significant risk factor for falls. However, knowledge is lacking among both physicians and older people, including caregivers, concerning the role of medication as a risk factor. In the present statement, the European Geriatric Medicine Society (EuGMS) Task and Finish group on fall-risk-increasing drugs (FRIDs), in collaboration with the EuGMS Special Interest group on Pharmacology and the European Union of Medical Specialists (UEMS) Geriatric Medicine Section, outlines its position regarding knowledge dissemination on medication-related falls in older people across Europe. The EuGMS Task and Finish group is developing educational materials to facilitate knowledge dissemination for healthcare professionals and older people. In addition, steps in primary prevention through judicious prescribing, deprescribing of FRIDs (withdrawal and dose reduction), and gaps in current research are outlined in this position paper.

EuGMS Task and Finish group on Fall-Risk-Increasing Drugs (FRIDs): Position on Knowledge Dissemination, Management, and Future Research.

Falls are a major public health concern in the older population, and certain medication classes are a significant risk factor for falls. However, knowledge is lacking among both physicians and older people, including caregivers, concerning the role of medication as a risk factor. In the present statement, the European Geriatric Medicine Society (EuGMS) Task and Finish group on fall-risk-increasing drugs (FRIDs), in collaboration with the EuGMS Special Interest group on Pharmacology and the European Union of Medical Specialists (UEMS) Geriatric Medicine Section, outlines its position regarding knowledge dissemination on medication-related falls in older people across Europe. The EuGMS Task and Finish group is developing educational materials to facilitate knowledge dissemination for healthcare professionals and older people. In addition, steps in primary prevention through judicious prescribing, deprescribing of FRIDs (withdrawal and dose reduction), and gaps in current research are outlined in this position paper.

Unintended weight loss in the elderly living at home: the aged in Home Care Project (AdHOC).

OBJECTIVE: To describe associations between unintended weight loss (UWL) and characteristics of nutritional status. DESIGN: A comparative cross-sectional assessment study at 11 sites in Europe. The target population was a stratified random sample of 4,455 recipients of home care (405 in each random sample from 11 urban areas) aged 65 years and older. MEASUREMENTS: the Resident Assessment Instrument for Home Care, version 2.0. Epidemiological and medical characteristics of clients and service utilisation were recorded in a standardized, comparative manner. UWL was defined as information of 5% or more weight loss in the last 30 days (or 10% or more in the last 180 days). RESULTS: The final sample consisted of 4,010 persons; 74% were female. The mean ages were 80.9 +/- 7.5 years (males) and 82.8 +/- 7.3 years (females). No associations were found between single diagnoses and UWL, except for cancer. Cancer patients were excluded from further analyses. Persons with a Cognitive Performance Scale value (CPS) superior 3 (impaired) had increased risk of UWL (OR = 2.0) compared with those scoring inferior or egal 3 (less impaired). Only in the oldest group did we find a significant association between UWL and reduction in ADL and IADL functions, comparing those who scored 3 or less with those who scored more than 3 (disabled). A binary logistic regression model explained 26% of UWL: less than one meal/day, reduced appetite, malnutrition, reduced social activity, experiencing a flare-up of a recurrent or chronic problem, and hospitalisation were important indicators. CONCLUSION: We recommend a regular comprehensive assessment in home care to identify clients with potential risk factors for weight loss and malnutrition, in particular those discharged from hospital, and those with physical dependency or cognitive problems. This study may provide incentives to create tailored preventive strategies.

[New evidence-based criteria for evaluating the appropriateness of drug regimen in seniors. Criteria STOPP (screening tool of older person's prescriptions) and START (screening tool to alert doctors to right treatment)]. / Nová evidence-based kritéria pro posouzení vhodnosti lékového rezimu u senioru. Kritéria STOPP (Screening Tool of Older Person's Prescriptions) a START (Screening Tool to Alert doctors to Right Treatment).

Drug prescribing in the old age is burdened by a significant number of prescribing errors often resulting in high rate of adverse drug events associated with increased morbidity, health care utilization and health costs. The revised 2003 Beers' Criteria represent the most widely used method for identification of high risk ("potentially inappropriate") medication in elderly persons. A standardized method for evaluating omission of potentially beneficial drugs has been lacking. The Beers' Criteria consist of the list of selected drugs with high potential of adverse drug events in old age and clinical conditions with relative contraindications of selected drugs (drug-disease interactions). Prescribing of these drugs should be avoided in older patients. However, several limitations prevent wider use of Beers' Criteria: several outdated drugs or drugs unavailable in Europe are listed, some controversial drugs with specific indications are on the list, drug-drug interaction and drug class duplications are not mentioned, and last but not least low user friendliness was criticized. To overcome these limitations, new STOPP and START Criteria were developed in 2007 to serve as a screening tool for comprehensive assessment of safety and quality of prescription in patients 65 years and older. In the current review article Czech version of both criteria are presented for the first time in the Czech literature. Using STOPP Criteria potentially inappropriate drugs are identified in drug regimen which could be stopped altogether or replaced by a safer drug alternative. Concomitant use of START Criteria will help the prescribing physician to consider the benefit of starting new drugs in selected clinical situations. Both screening tools represent a new method for improving quality of geriatric prescribing in clinical practice.

[Effectiveness of teaching gerontology and geriatrics in students of the 1st Faculty of Medicine, Charles University in Prague]. / Efektivita výuky teoretické i klinické gerontologie u studentu 1. lékarské fakulty UK v Praze.

BACKGROUND: Increasing number of seniors in the society requires more university-degree educated professionals--health care professionals, social care workers and managers with basic exposure to and knowledge of gerontology and geriatrics. The aim of our paper was to evaluate the effectiveness of undergraduate training of gerontology and geriatrics among students of the 1st Faculty of Medicine, Charles University in Prague. METHODS AND RESULTS: To get information about knowledge of medical students and students of ergotherapy and physiotherapy and about their attitudes towards senior citizens we conducted a survey using two anonymous questionnaires prepared in our department and piloted earlier. The survey ran during the academic year 2004/2005. Students completed identical questionnaires twice, first time before the start of the clinical rotation and second time after the training end (n=134). Evaluation of knowledge and attitudes confirmed that one to two weeks clinical rotation at Department of Geriatrics was effective and increased knowledge of students in the topic trained. The percentage of correct answers in all three evaluated training programmes increased after the completion of the clinical rotation and reached 83% and more. From 134 participating students, 54.5 % appreciated life experience and wisdom of seniors they met, 98.4 % of students were satisfied with the training programme and 67.2 % of students reported that after training they changed their attitude towards senior population. CONCLUSIONS: Our survey confirmed that clinical training in geriatric medicine at 1st Faculty of Medicine, Charles University in Prague, prepared in agreement with current European recommendations is sufficiently effective and well accepted by the students. Therefore we recommend introduction of formal geriatric training for students in all medical faculties in the Czech Republic.

[Cross-national comparison of drug compliance and non-compliance associated factors in the elderly with polypharmacotherapy]. / Mezinárodní srovnání lékové compliance a faktoru ovlivnujících non-complianci u senioru s polyfarmakoterapií.

BACKGROUND: Population of seniors in the Czech Republic consumes more than 35 % of all prescribed medications. Currently, Czech seniors take on the average 4-5 prescribed drugs. However, our knowledge about factors influencing drug compliance is scarce particularly in seniors with polypharmacotherapy. Non-compliance can contribute to treatment failure and increases the risk of adverse drug reactions. The aim of the study is to compare drug compliance in the elderly in 11 European countries and to assess the impact of demographic and drug-related factors on non-compliance to medication. METHODS AND RESULTS: Cross-sectional comparative study in 3881 elderly subjects living in the community receiving home-care services in 11 European countries participating in ADHOC (Aged in Home Care) study. In the sample of Czech subjects we performed in-depth analysis of causes and factors associated with non-compliance in patients with polypharmacotherapy. 12.5% (n=456) of European seniors were non-compliant with prescribed medication with significantly higher prevalence of non-compliance in the CR (33.5 %) and Germany (17.0 %). In the Czech sample following non-compliance risk factors have been identified: taking > or = 7 drugs per os (OR= 2.2), 10 single applications/day (OR= 2.5), more than twice daily dosing (OR= 2.4), problems with drug preparation (OR= 4.6), polypharmacotherapy 5 years and longer (OR= 5.5) and drug preparation without supervision or help (OR= 2.8). The highest prevalence of non-compliance was found for antidepressants (80 %), antiasthmatics (68 %), fibrates (60 %), nonsteroidal antiinflammatory drugs, vasodilatators, anticoagulants/antiplatelet drugs and nootropics (50 %). Among the most common causes, patients reported forgetting to take the drug (74.3 % patients), mistrust in drug effect (10.6%) and fear of taking "too many drugs" (8.6 %). CONCLUSIONS: Non-compliance to prescribed drug regimen is a prevalent problem in one third of the Czech seniors and was found to be the highest among 11 European countries. Doctors prescribing to older people have to monitor purposefully compliance and strenghten co-operation and motivation of the patient to adhere with prescribed drug regimen. Particularly in seniors with polypharmacotherapy it seems necessary to simplify drug regimen as much as possible. In elderly patients with physical disability, cognitive impairment or depression supervision and/or help of another person with drug preparation and application may improve drug compliance.

Comprehensive clinical assessment in community setting: applicability of the MDS-HC.

OBJECTIVE: To describe the results of an international trial of the home care version of the MDS assessment and problem identification system (the MDS-HC), including reliability estimates, a comparison of MDS-HC reliabilities with reliabilities of the same items in the MDS 2.0 nursing home assessment instrument, and an examination of the types of problems found in home care clients using the MDS-HC. DESIGN: Independent, dual assessment of clients of home-care agencies by trained clinicians using a draft of the MDS-HC, with additional descriptive data regarding problem profiles for home care clients. SETTING AND PARTICIPANTS: Reliability data from dual assessments of 241 randomly selected clients of home care agencies in five countries, all of whom volunteered to test the MDS-HC. Also included are an expanded sample of 780 home care assessments from these countries and 187 dually assessed residents from 21 nursing homes in the United States. MEASUREMENTS: The array of MDS-HC assessment items included measures in the following areas: personal items, cognitive patterns, communication/hearing, vision, mood and behavior, social functioning, informal support services, physical functioning, continence, disease diagnoses health conditions and preventive health measures, nutrition/hydration, dental status, skin condition, environmental assessment, service utilization, and medications. RESULTS: Forty-seven percent of the functional, health status, social environment, and service items in the MDS-HC were taken from the MDS 2.0 for nursing homes. For this item set, it is estimated that the average weighted Kappa is .74 for the MDS-HC and .75 for the MDS 2.0. Similarly, high reliability values were found for items newly introduced in the MDS-HC (weighted Kappa = .70). Descriptive findings also characterize the problems of home care clients, with subanalyses within cognitive performance levels. CONCLUSION: Findings indicate that the core set of items in the MDS 2.0 work equally well in community and nursing home settings. New items are highly reliable. In tandem, these instruments can be used within the international community, assisting and planning care for older adults within a broad spectrum of service settings, including nursing homes and home care programs. With this community-based, second-generation problem and care plan-driven assessment instrument, disability assessment can be performed consistently across the world.

Is aging a preventable or curable disease?

The question of whether aging is a disease is old and controverted. Three possible positions are outlined: (i) aging is a natural event, not a disease; (ii) aging is a disease, to be combated by medical knowledge and skills; and (iii) aging, while natural, can be treated as if it is a disease and efforts made to lessen its undesirable impact. The last position seems, de facto, the one that is being pursued by contemporary medicine; however, in such a pursuit, important issues will be raised of intergenerational justice in paying for advances in medicine, and the need to balance the medical goals of care for aged people against other important social needs.

Cytogenetic examination of bone marrow cells and peripheral lymphocytes in rats exposed to cyclophosphamide.

The sensitivity of the peripheral lymphocytes and bone marrow cells to the induction of chromosome aberrations was studied in rats using a model mutagen Cyclophosphamide. In the acute-exposure experiment the rats were treated with CY by the intraperitoneal injection of 10, 20, and 40 mg.kg-1 b.w. A clear-cut dose-dependence was found in the frequency of aberrant cells as well as in the values of breaks per cell in both analysed cell types. In the chronic experimental series CY was administered to animals in drinking water for 28 days as 0.001%, 0.002%, 0.004%, and 0.008% CY. CY increased the frequency of aberrant metaphases and breaks per cell depending on its concentration identically in the peripheral lymphocytes and bone marrow cells. The results of acute and chronic exposures indicate that both somatic tissue cells are equally susceptible to the clastogenic action of CY.

The RAI-PC: an assessment instrument for palliative care in all settings.

Large numbers of persons in most types of healthcare settings have palliative care needs that have considerable impact on their quality of life. Therefore, InterRAI, a multinational consortium of researchers, clinicians, and regulators that uses assessment systems to improve the care of elderly and disabled persons, designed a standardized assessment tool, the Resident Assessment Instrument for Palliative Care (RAI-PC). The RAI-PC can be used for both the design of individual care plans and for case mix and outcomes research. Some elements of this instrument are taken from the resident assessment instrument (RAI) mandated for use in all nursing homes in the United States and widely used throughout the world. The RAI-PC can be used alone or in counjunction with the other assessment tools designed by the InterRAI collaboration: the RAI for homecare (RAI-HC), for acute care (RAI-AC), and for mental health care (RAI-MH). The objective of this study was to field test and carry out reliability studies on the RAI-PC. After appropriate approvals were obtained, the RAI-PC instrument was field tested on 151 persons in three countries in more than five types of settings. Data obtained from 144 of these individuals were analyzed for reliability. The reliability of the instrument was very good, with about 50 percent of the questions having kappa values of 0.8 or higher, and the average kappa value for each of the eight domains ranging from 0.76 to 0.95. The 54 men and 95 women had a mean age of 79 years. Thirty-four percent of individuals suffered pain daily. Eighty percent tired easily; 52 percent were breathless on exertion; and 19 to 53 percent had one or more other symptoms, including change in sleep pattern, dry mouth, nausea and vomiting, anorexia, breathlessness at rest, constipation, and diarrhea. The number of symptoms an individual reported increased as the estimated time until death declined. The "clinician friendly" RAI-PC can be used in multiple sites of care to facilitate both care planning and case mix and outcomes research.

Health care services for the elderly in Czech Republic: new trends and future development.

Old people over 65 are now the most rapidly growing segment of the population and represent 13% of all Czech inhabitants. Because of the high prevalence of morbidity and disability among the elderly they are the most important consumers of health care services, both extramural and intramural. They consume about 1/3 of the total expenditures on the health care, 40-50% of the general practitioner's time, 40% of prescribed drugs, and over 30% of all hospital days. An important additional consequence of population aging are the increasing needs and costs of long-term care. During the past 30 years, health services for the elderly have been developed and geriatric and chronic care medicine have become an integral part of the contemporary medical enterprise. The past few years of political and economical transformation have brought about significant changes in health and social care and they are having a great impact on the provision of services. In light of the demographic projections and steadily increasing costs of health care, what are the contemporary changes and what should be the future development of health care services for the elderly?

[Transformation of health care, the aged patient and the aging society]. / Transformace zdravotnictví, starý pacient a stárnoucí spolecnost.

Ageing of the population is associated with historically new social conflicts which have an immediate impact on the health services. The advances of the health care reform depend also on the fact whether the social and health policy will be able to foresee these conflicts and tackle them in advance. The most serious conflict is the increasing number of old people who require health and/or social care with recent medical advances as regards old age, and are confronted with final and restricted nation-wide and health resources resp. The author discusses possible solutions which in addition to a technical, organizational and economic aspect have a significant, although frequently omitted, moral, ethical and philosophical dimension.

[New trends in providing home care for elderly clients]. / Nové trendy pri poskytování péce v domácnosti (home care) u klientu vyssího veku.

A progressive form of long-term care of old people with reduced self-sufficiency is home care. It is an alternative of in-patient care and provides services in the client's home. It combines the advantages of lower cost with the possibility to remain in the domestic environment and keep up social contacts. The most important factors which will substantially increase the need of home care are demographic development, the declining availability of potential care providers and possibilities of the family to ensure care, economic pressure and clients' preference. The present state of home care provision does not meet the demands of society nor individual demands of clients. It is important to create a new model of home care which will form an integral part of the social and health care policy of the state. The author discusses in particular the main principles of this care based on principles of state regulated pluralism.

[Thoughts on ethical problems of long-term institutional care of chronically ill patients and the aged]. / Zamyslení nad etickými problémy dlouhodobé ústavní péce o chronicky nemocné a staré.

Long-term institutional care of dependent subjects is an integral part of chronic health and social care. Its importance will increase as a result of the increasing numbers of chronic patients and subjects depending on the care of others. The author reviews some serious problems associated with care provided in institutes of social care, pensioners' homes and long term care departments in our country and abroad. She discusses the cultural and historical aspect of care, the contemporary state and quality of care and investigates the causes of negative attitudes to these institutions and possibilities how to improve care and the quality of life of their inmates.