Identifying the Elderly at Risk for Falling 

D. Galinsky, V. Fried, A. Biderman, J. Cwikel, Y. Ben Moshe

Geriatric Dept., Soroka University Hospital and Depts. of Family Medicine and of Social Work, Faculty of Health Sciences, Ben-Gurion University of the Negev; and ESHEL, Beer Sheba

Falling is one of the main problems affecting the health of the elderly. A community project was carried out to detect elderly people at high risk for falls. One of its aims was also to develop tools allowing primary care professionals to detect the elderly at risk for falling. Such a screening test in the community-dwelling elderly (EFST) and a protocol for diagnosis and treatment of the elderly at risk for falls is presented.

Infective Endocarditis Presenting as Polyarticular Septic Arthritis

Abraham Yaretzky, Jacob Feldman, Carola Vigder

Geriatric Dept., Meir Hospital, Kfar-Saba and Sackler Faculty of Medicine, Tel Aviv University

We report acute polyarthritis in an 86-year-old man which was initially considered to be an exacerbation of osteoarthritis. After a delay of a few days a diagnosis of septic polyarthritis as an initial symptom of infective endocarditis was made. Although rheumatic manifestations in infective endocarditis are common, septic polyarthritis is rarely seen. In our patient the course of the disease was rapidly fatal.

Prevalence of Medical Complaints in the Community-Dwelling Elderly

J. Gindin, M. Geitzn, M. Dushenat, H. Siboni, D. Goldstein, Z. Shapira, N. Konstantin, A. Wurm, A. Goldsmid, E. Hay-Am

Geriatric Institute of Education and Research, Kaplan Medical Center, Rehovot; Pharmacology Dept., Kupat Holim Klalit, Tel Aviv and Central District; and Kupat Holim Klalit, Rishon LeZion

We assessed the prevalence of self-reported medical complaints among the community-dwelling elderly receiving regular medication, and determined associations between health and sociodemographic variables, and the prevalence of complaints.

The study included 170 patients, 60-90 years of age, living at home. Participants were recruited from the 3 main primary care clinics in Rishon LeZion. All were receiving chronic medication and were followed-up utilizing a long-term medication card. Data were gathered in interviews held in patients' homes using a structured questionnaire which included sociodemographics, diseases and medication, mental state assessment by Katzman's score, and a list of 15 medical complaints common among the aged. Relations to age, gender, education, living arrangements, number of diseases and number of medications per patient were determined.

Mean age of participants was 73.2±6.0 years and they suffered an average of 4.07±2.16 diseases and took 5.10±2.83 types of drugs. The most prevalent complaints were: weakness and fatigue (65.0%), agitation and restlessness (56.4%), dry mouth (45.6%), constipation (43.6%) and dizziness (43.2%). The number of diseases, gender, education and age had the strongest associations with the prevalence of specific complaints, as well as their total number. The association between number of medications and mean number of complaints was of borderline significance.

Clinical, Social and Economic Aspects of Comprehensive Geriatric Assessment

Jacob Feldman, Liora Peleg, Abraham Yaretzky

Geriatric Dept., Sapir Medical Center, Kfar Saba, and Sackler Faculty of Medicine, Tel Aviv University

It is well known that maelderly patients are referred to nursing homes because of "functional decline" without being thoroughly in. We studied 9 elderly patients, all referred to hospital due to functional decline and diagnosed as follows: spinal stenosis - 2 cases, depression - 3, thyrotoxicosis -1, Parkinson -1, polypharmacy and congestive heart failure -1 patient each. Proper diagnosis and appropriate treatment prevent unnecessary hospitalization in nursing homes. Our study is meant to draw attention to this crucial aspect of geriatric medicine.

Sacral Insufficiency Fractures - A Frequent Cause of Low Back Pain in Elderly Women

H. Semo, Z. Zwas, A. Goshen, S. Levenkrohn, A. Adunsky

Depts. of Geriatric Medicine and Nuclear Medicine, Sheba Medical Center, Tel Hashomer

Sudden low back pain is common in elderly women. It causes physical and mental stress, and results in deterioration of functional movement and in activities of daily living. Awareness of possible sacral insufficiency fracture is important; they may be demonstrated by imaging modalities, mainly radionuclide bone scan. Prognosis is good and accurate diagnosis serves to exclude malignancy and relieve fear of chronic pain and disability. We describe 4 women, aged 84, 82, 71 and 77 who illustrating the clinical and imaging findings of this disorder.

Prevalence of APOE 4 Allele in Israeli Ethnic Groups

O. Hilkevich, J. Chapman, B-S. Bone, A.D. Korczyn

Neurology Dept., Tel Aviv Medical Center, and Depts. of Physiology, Pharmacology and Human Genetics, Sackler Faculty of Medicine, Tel Aviv University

The 4 allele of the APOE gene, coding for apo-lipoprotein E, is the most common genetic risk factor for Alzheimer's disease and a significant risk factor for coronary atherosclerosis. There is therefore much interest in studying its frequency in different ethnic groups.

We examined its frequency in Jews originating from Libya, Buchara and Ethiopia and in Jews of Sepharadi and Ashkenazi origins. Its frequency among Ethiopian immigrants was 0.27, significantly higher than in the other groups, in which the frequency was between 0.067 and 0.10. These differences in allele frequency may serve as a basis for future studies in Israel to assess the relative contributions of genetic and environmental factors to the incidence of dementia.

Reactive Increase in Blood Pressure on Immobilization, but not Hypertension, Prevents Pressure Ulcers

Vladimir Shats, Silvio Kozacov

Geriatric Dept., Rebecca Sieff Hospital, Safed

Of 135 geriatric patients immobilized for at least 2 days, 37 (27.4%) had pressure ulcers (PU). Those without PU were the control comparison group. Gender, length of immobilization, number of blood pressure determinations and proportion with hypertension were similar in those with and without PU. Those with PU were slightly older than those in the comparison group: 75.5±8.8 and 74.7±9.6 years, respectively (p>0.05).

Of 66 patients with acute ischemic stroke, reactive increase of systolic or diastolic blood pressure to 140/90 mm Hg or above following immobilization, was seen in 60.6% and 22.7% of patients, respectively, and there were PU in 12.1%. Of 17 with recurrent ischemic stroke, corresponding figures were: 41.2%, 23.5% (p>0.05), and 47.1% (p<0.01). In 7 patients with previous ischemic stroke corresponding figures were: 14.3% and 0% (p<0.01) and 100% (p<0.001). In 36 operated for fracture of the femur, corresponding figures were: 50%, 11.1% (p>0.05), and 27.8% (p>0.05). For 9 patients with severe infections, sepsis or pneumonia, the corresponding figures were: 22.2% and 0.0% (p>0.05), and 44.4% (p<0.04).

The proportion of patients with reactive increase in systolic blood pressure on immobilization was lower in the PU group than in the controls, 27% vs 59.2%, (p<0.001). The corresponding figures for reactive increase in diastolic blood pressure were similar, 8.1% and 20.4%, respectively (p>0.05).

The mean systolic blood pressure on immobilization was higher in the control than in the PU group, 145.4±21.7 and 130.8±14.9 mm Hg, respectively (p<0.001). The corresponding figures for the mean diastolic blood pressure were similar, 81.2±10.5 and 75.7±8.9 mm Hg, respectively (p<0.01). An increase in systolic blood pressure on immobilization reduced the risk of developing PU (p<0.05).

There was no significant statistical relation between diagnosis of hypertension and proportion of patients with PU (p>0.05). Of 67 patients with hypertension, in 23.9% and 74.6% of them there was no increase in systolic or diastolic blood pressure, respectively. Statistical difference between lack of diastolic or systolic response was very significant (p<0.001).

Reactive increase of blood pressure, but not hypertension, predicts reduced risk of PU on immobilization in the hospitalized elderly. Diminished reactive increase of blood pressure in response to stress of any kind may be a criterion of frailty and reduced physiological reserves. Efforts to reduce elevated blood pressure when a patient is immobilized appear irrational.

Geriatric Rehabilitation in Israel: Assessment of Needs and In-Patient Services

J. Gindin, M.A. Clarfield, Z. Haklai, P. Zedaka, J. Brodesky, M. Davis

Geriatric Division, Kaplan-Hartzfeld Hospitals, Rehovot; Geriatric Wing, and Health Information and Computer Service, Israel Ministry of Health; Central Bureau of Statistics, Prime Minister's Office; Brookdale Institute, Jerusalem; and Health of the Elderly, Israel Center for Disease Control

Geriatric rehabilitation (GR) in Israel, which has not been thoroughly investigated, was examined by a subcommittee of the Committee on Health of the Elderly, in the Israel Center for Disease Control.

The needs of the elderly population for rehabilitational services were assessed and the existing services reviewed. A survey of GR beds, their geographic distribution, and the number of patients over 65 after CVA and hip fracture (the 2 main causes for GR need) was carried out. Data were gathered from records of the Ministry of Health and the Central Bureau of Statistics.

In 1994 there were 1,503 beds for active, long-term geriatric care in general and geriatric hospitals: 751 beds were assigned to rehabilitative geriatrics, and the rest to skilled-nursing geriatrics. A high concentration of beds was found in the geographical center of the country, in contrast to a small number in the periphery. Approximately 10,100 patients were hospitalized that year in rehabilitative geriatric and skilled-nursing wards.

There was considerable variation between services, as expressed in the wide range in average duration of hospitalization (from 12-269 days). Most of the beds for GR and skilled-nursing care beds were mixed in the geriatric wards together in the wards.

Limited services and public needs have led to the development of services outside the licensed and regulated settings, a process which has not yet been investigated. About 6,700 older patients were hospitalized during 1994 with a primary diagnosis of CVA. It has been estimated that 4,000 of them needed GR. 2,624 older patients died that year of CVA.

The increase in CVA prevalence between 1987 and 1994 was far greater than the increase in morbidity, in both the general and older populations. Nearly 4,000 elderly patients with a primary diagnosis of hip fracture, most of whom needed rehabilitation, were hospitalized in 1994. The total number of older patients who needed GR following CVA or hip fracture that year was set at 8,000. However, this figure is up to 30% lower than the actual rates, since the those 2 diagnoses include only 70% of total GR needs.

It is impossible to obtain a comprehensive picture of GR in Israel based only on currently available data. The subcommittee outlined areas to be thoroughly examined in-depth, including services and needs, as well as GR tools and processes and how to maintain the achievements of rehabilitation after discharge.

Community-Acquired Pneumonia in the Elderly: Guidelines for Hospitalization

Jacob Feldman, Abraham Yarezky, Carola Vigder

Geriatric. Dept., Meir Hospital, Kfar Saba and Sakler Faculty of Medicine, Tel Aviv University

A prospective study was carried out among elderly patients with community-acquired pneumonia to determine if there are any specific features that could help in deciding whether to hospitalize, or to treat in the community. We concluded that there is no correlation between clinical presentation of pneumonia and outcome, except for impairment of consciousness. Laboratory data showed a correlation between oxygen saturation in arterial blood, levels of hemoglobin and albumin, and outcome. Sputum culture was not helpful in deciding about diagnosis and treatment, which remain empiric. These patients should be treated at home if conditions permit. Recommendations are made for improving such conditions.

Nursing Home-Acquired Pneumonia: Guidelines for Hospitalization

A. Yaretzky, C. Vigder, I. Feldman

Geriatric Dept., Meir Hospital, Kfar Saba, and Sackler Faculty of Medicine, Tel Aviv University

To determine if there are any specific features of nursing-home acquired pneumonia we carried out a retrospective study in a nursing home between 1995-1996, based on clinical and laboratory data. We found no correlation between these findings and the severity of pneumonia, so it would be hazardous to determine rigid guidelines. These patients should be treated in the nursing home as long as conditions allow, in order to avoid hospitalization.

Pelvic Lytic Lesion and Osteoporosis-Related Fractures

Yaron Weisel, Ehud Rath, Nissim Ohana, Dan Atar

Orthopedic Dept., Soroka Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheba

Insufficiency fractures of the pelvis may be overlooked as a cause of hip or groin pain. These fractures occur in the elderly, usually those with pronounced osteopenia of the pelvis. Predisposing factors include corticosteroids, local irradiation and postmenopausal osteoporosis. These fractures are difficult to detect clinically and plain radiographs and other studies may be misleading, delaying diagnosis and treatment. A 65-year-old woman had left groin and hip pain for 2 months with no history of trauma. Plain radiographs showed lytic lesions in the left pubic rami. Bone scan revealed increased uptake in that region, suggesting metastatic bone disease. Computed tomography and magnetic resonance imaging demonstrated fractures in the left superior and inferior pubic rami, with callus formation with no involvement of soft tissues. Quantitative computed tomography indicated low calcium concentration, below fracture threshold. The diagnosis of insufficiency fractures of the pelvis was confirmed by the favorable clinical and radiographic outcome. It is therefore important to be familiar with the appearance and location of these fractures.

Central Cord Syndrome in the Elderly Who Fall: a Diagnostic Trap

A. Adunsky, H. Semo, S. Levenkrohn

Geriatric Rehabilitation Dept., Chaim Sheba Medical Center, Tel Hashomer

Acute post-traumatic spinal injury is common and usually poses no diagnostic difficulties. Following a low-energy fall, the onset of acute central cord syndrome in the elderly is not common and is frequently misdiagnosed. Men aged 60 and 81, and a woman aged 75 are described, in whom central cord syndrome was overlooked. Awareness of this condition is important to avoid incorrect diagnosis and hazardous management.

Telling the Bad News: do the Elderly Want to Know Their Diagnoses and Participate in Medical Decision Making?

Sara Carmel, Alon Lazar

Sociology of Health Unit, Faculty of Health Sciences, and Dept. of Behavioral Sciences, Ben-Gurion University of the Negev, Beer Sheba

In view of reported changes in western countries in the preferred model of doctor-patient relations, we evaluated the wishes of elderly persons for open doctor-patient communication with regard to terminal disease. Data was collected in 1994 from 987 elderly persons (70+) by structured interviews. Most of respondents wanted open communication and wished to be involved in medical decisions regarding life-sustaining treatment. However, only a minority tell their physicians and/or family members of their wishes. This suggests that most of the elderly expect physicians to be the first to initiate discussions of these issues. The results also indicate that among the elderly, those more educated, less religious, and those living in Israel longer, are more likely to want open communication with their physicians. This is explained by the relationship of these characteristics with the dominant cultural values of this group, and its acceptable models of relations in other areas of life.

Should Physical Restraints be used in an Acute Geriatric Ward?

Svetlana Barazovski, Arnold Rosin

Geriatric Dept., Shaare Zedek Medical Center, Jerusalem

A prospective study was carried out in an acute geriatric ward to determine the incidence of the use of physical restraints, the reasons for using them and the consequences. Over a period of 8 months an independent observer documented all cases in which a restraint was used and followed them until it was removed. A questionnaire was submitted to the nurses as to why they applied the restraints. 16% of patients had some form of restraint applied, in 2/3 of them for up to half of their stay in the ward. In over 90% of those restrained, functional (Barthel) and cognitive (mini-mental) scores were between 0-5. In unrestrained patients, the functional score was 0-5 in 79% and the cognitive score 0-5 in 72%. The main reason for applying restraints, usually sheets or body binders, was to prevent the patient from falling out of, or slipping from chairs, rather than to stop them from rising out of them. Other important reasons, which overlapped, were to prevent the patient from interfering with nasogastric tubes, catheters, and IV cannulas, each in 1/3 of the group. Restraints were discarded when deterioration did not allow the patient to sit out of bed, to decrease agitation, to allow enteral or parenteral treatment, and in 12%, when there was supervision by the family. Of 33 families interviewed, none opposed application of restraints, and most left the decision to the responsible ward staff. We conclude that restraints cannot be avoided in some acutely ill, old patients with severe physical and mental dysfunction. However, ways should be sought to minimize their use, as recommended in the literature, by demanding from the staff a specific reason, signed agreement of a physician, close follow-up, and favorable environmental conditions such as suitable chairs, occupational activity, and staff cooperation in removing the restraints.

Hospitalization of the Elderly for Stroke Rehabilitation

D. Gottlieb, M. Kipnis, E. Sister, N. Lipkin, M. Medvedev, S. Brill

Stroke Rehabilitation Unit, Neurogeriatric Dept., Beit Rivka Geriatric Hospital, Petah Tikva

This is a descriptive, longitudinal study of 400 elderly patients admitted for stroke rehabilitation to a geriatric department dedicated to this purpose. We present the demographic, medical, and impairment and disability characteristics on admission, and the outcome of rehabilitation. Mean stay was 54 days and 2/3 became independent and returned home. Functional score on admission was the best predictor of outcome, but age and social support were also significant.