Beit Rivka Geriatric Medical Center

Objectives: Because End of life (EOL) is becoming an increasingly long life stage, this paper aims to describe the delineation of EOL by reviewing studies which examine (a) terminal decline (TD), the timing of change in slope of decline in specific abilities; and (b) trajectories of decline in areas such as function, health care expenditures, and well-being according to cause of death. Methods: Studies were identified through Google Scholar, PsycNET, and PubMed. Results: TD was identified in diverse domains. Most findings focused on decline of cognitive abilities, and they reported this to occur 3-7 years prior to death. TD in wellbeing was found to begin 3-5 years prior to death. Trajectories by cause of death generally examined sudden death, terminal illness, organ failure, and frailty, and findings described differences in costs, function, and wellbeing, though examining a shorter predeath period than the TD literature. Discussion: Further research is needed to combine methods of investigation in order to assist the health care system in personalizing services to the trajectories of decline, and in enabling caregivers to prepare for the EOL experience.

Post-traumatic stress disorder may follow combat stress or civilian psychological traumata. In 25 retrospectively studied patients, symptoms were severe in terms of number of DSM-III items fulfilled, chronicity, and severity of psychosocial disability. Antidepressants had good or moderate results in 67% of cases treated, but major tranquilisers were much less effective; response to drug treatment was not clearly related to somatisation symptoms, significant depression, or panic attacks. Pharmacotherapy appeared to have had a positive impact on psychotherapy in 70% of cases.

Objective: To follow up six months post hip fracture and to compare functional gain of patients in different cognitive and functional groups. Design: Prospective longitudinal study of hip fracture patients with functional evaluation pre-fracture, prior to discharge from orthopaedic department and one, three and six months post fracture. Setting: Department of Orthopaedics, Rabin Medical Center, Golda Campus with follow-up at Beit-Rivka Geriatric Rehabilitation Hospital, both in Petach Tikvah, Israel, with a minority of patients followed at home or nursing home. Measurement: Cognition evaluated by Mini-Mental State Examination, prefracture functioning by Functional Independence Measure and Katz Index of ADL. Functional outcome assessed by Functional Independence Measure gain defined as the difference between Functional Independence Measure scores at six months and just prior to discharge from the Department of Orthopaedics. Results: Moderately cognitively impaired and normal patients had the same Functional Independence Measure – A (self-care) and Functional Independence Measure – B (motor) gains. Pre-fracture independent patients had significantly higher Functional Independence Measure – A and Functional Independence Measure – B gains. A multiple regression analysis examining age, sex, Mini-Mental State Examination score, Katz score, type of fracture, surgery versus conservative treatment and the pre-fracture Functional Independence Measure score showed that only the pre-fracture Functional Independence Measure – B scores and Katz scores are the independent variables for motor and self-care gains, respectively. Conclusions: Pre-fracture motor and not cognitive level has been the most important predictive factor for motor gain after hip fracture. Cognitively impaired hip fracture patients can achieve and maintain the same motor functional gain as normal patients, if they were mobile pre-fracture.

This paper is a report of the feasibility and outcome of using a low-cost, commercially available gaming system - Wii Fit - for balance training after stroke. The patient was an 86 year-old woman five weeks after stroke, who was unable to walk without close supervision, even with a walker, due to poor balance and a tendency to fall. In addition to standard physical therapy, the patient participated in four training sessions with the Wii Fit system; each training session included four different games. The outcome measures were Berg Balance Scale (BBS), the Functional Reach and Lateral Reach tests, Timed Up & Go test (TUG), computerized posturography, and the Short Feedback Questionnaire (SFQ). The tests were done before the intervention and on the last day of training. The SFQ was done during the third training session. The patient greatly enjoyed the training sessions and felt that she was receiving very dasiaup-to-datepsila treatment. She did not experience any discomfort such as nausea or dizziness while using the system. Following combined Wii and standard treatment, the patient demonstrated improved antero-posterior symmetry of stance, and there was a 10 second improvement in her TUG score. When released from hospital, she was able to walk with a walker with minimal supervision. This initial pilot study indicates that the Wii Fit gaming system has the potential to be used in clinical settings in order to improve balance. A full clinical trial is necessary in order to examine this premise.

BACKGROUND: Hip fracture is a frequent injury in the elderly, and is associated with a high incidence of functional impairment, complications and mortality. OBJECTIVE: To determine kinetics of C-reactive protein (CRP), fibrinogen and erythrocyte sedimentation rate (ESR) in hip-fractured patients over a 1-month post-operative period; to examine the relationship of these parameters to cognition, operation type, post-operational complications, functional level 1 month post-operatively and 6-month mortality. METHODS AND SUBJECTS: 32 aged patients operated on for hip fracture were prospectively followed-up for 6 months. Fracture, type of operation and anesthetic risk were recorded. Cognition was evaluated by the Mini-Mental State Examination and pre-fracture functional level evaluated by the Katz Index of ADL. Follow-up included complications, mortality and functional outcome. CRP, fibrinogen and ESR were assessed during the first 10 h post-fracture; 48-60 h, and 7 and 30 days post-operatively, respectively. RESULTS: Only CRP kinetics were found to differ in patients with complications vs. those without, as a group (p = 0.006), and in patients suffering infections, delirium and cardiovascular complication vs. patients with no complications (p = 0.06, 0.03, 0.02, respectively). Mean (+/-SEM) CRP 48-60 h post-operatively was 20.9 +/- 2.1 and 13.1 +/- 1.6 mg/dl in complicated and uncomplicated patients, respectively (p = 0.002). The mean CRP 48-60 h post-operatively was highly correlated with the CRP area under the curve, R = 0.88 (p < 0.001). A cut-off level of 15 mg/dl for CRP, 48- 60 h post-operatively, was calculated for patients with complications (sensitivity 93%, specificity 65%, p = 0.003). CRP, fibrinogen and ESR were not related to fracture or type of operation, cognition, anesthetic risk, 1-month post-operative functioning and 6-month mortality. CONCLUSIONS: CRP measurement in elderly patients operated for hip fracture may be valuable in assessing and monitoring complications.

Aspiration pneumonias are frequent complications of cerebrovascular accidents (CVA). They occur mainly in patients suffering from swallowing disorders following the CVA. These patients can be diagnosed using a bedside swallowing evaluation. This evaluation is based on observation of some components of the oral and pharyngeal stages of the swallowing process and on a drinking test of 50 ml3 of clear liquids. Changing the mode of swallowing and the consistency of the diet according to the swallowing evaluation following CVA can reduce significantly the frequency of aspiration pneumonias. In our patient cohort, consisting of 180 patients admitted for stroke rehabilitation, aspiration pneumonias occurred in 10% and swallowing disorders were found in 28%. The administration of a structured swallowing evaluation was associated with a gradual reduction of frequency of pneumonia from 16% in the first group of 60 patients to 3% in the last group of 60 patients or, if considering only patients suffering from dysphagia, from 27% in the first group of patients to none in the last group of patients.

Fifty-six consecutive elderly ( > or = 65 years) patients, admitted for acute stroke to a geriatric department were included in the study and underwent CT scanning. Functional status was graded according to the modified Rankin scale. Three patients had primary intra-cerebral haemorrhage, 22 deep hemispheric infarct, 17 had anterior circulation cortical infarcts, five had posterior circulation infarcts and in nine the CT scan was normal. Stroke risk factors were equally distributed among the different CT scan groups, and all three larger groups had similar rates of non-neurological major complications including death (41%). However, independence in ADL (Rankin 0-2) was observed in 72% of deep infarct survivors, but only 15% of the cortical infarct group (p = 0.00018). For the normal scan group, functional recovery was intermediate. In the cortical infarct group patients with an infarct of > or = 50 mm mean diameter (five cases) should worse functional recovery than did eight patients with small infarcts. The mean difference between pre- and post-stroke Rankin score (DR) was 3.4 for the larger infarct patients and 1.9 for the smaller infarct group (p = 0.027). Pearson correlation revealed a direct relationship between the infarction size and DR (p = 0.039). Such a relationship was not observed for the deep hemispheric group.

Two peptides, based on the sequences of the complementarity-determining regions (CDR) 1 and 3 of a pathogenic murine monoclonal anti-DNA autoatibody that bears the 16/6 idiotype (Id), were shown to either prevent or treat an already established systemic lupus erythematosus (SLE) in two murine models of lupus. Two additional peptides based on the human monoclonal anti-DNA, 16/6 Id were synthesized. This study was undertaken in order to investigate the ability of the CDR-based peptides to immunomodulate SLE-associated responses of peripheral blood lymphocytes (PBL) of SLE patients. PBL of 24 of the 62 SLE patients tested proliferated in vitro following stimulation with the human 16/6 Id. Peptides based on the CDRs of both the human and murine anti-DNA autoantibodies inhibited efficiently and specifically the 16/6 Id-induced proliferation and IL-2 production. The latter inhibitions correlated with an up-regulated production (by 2.5-3.5-fold) of the immunosuppressive cytokine, TGF-beta. Overall, the results of our study demonstrate that the CDR-based peptides are capable of down-regulating in vitro autoreactive T cell responses of PBL of SLE patients. Thus, these peptides are potential candidates for a novel specific treatment of SLE patients.

PURPOSE: To characterize the lower-limb elderly amputee patients admitted to a post-acute rehabilitation program, assess their 1-year survival rate, estimate rate of prosthetic fit and report rate and factors associated with 1-year post-discharge prosthetic use. METHODS: A cohort study performed in a post-acute rehabilitation department. Patients were evaluated by the Functional Independence Measure (FIM), motor FIM (mFIM), rate of prosthesis fit, length of stay (LOS), 1-year survival rate and long-term prosthetic use. RESULTS: One-hundred and seventeen lower limb elderly amputee patients consecutively admitted from January 2004 to June 2010 were enrolled in the study. Mean age was 74.7 ± 8.1; 56 patients (47.9%) had transtibial amputation (TTA); 46 (39.3%) transfemoral amputation (TFA) and 15 (12.8%) bilateral amputation. The main cause for amputation was diabetic foot (60.7%). Fifty-four (46.2%) patients died during first year post-admission. Twenty-seven patients (23.1%) were fitted with a prosthesis. When the bilateral amputees were considered separately, the rate of prosthetic fit among unilateral amputees was 24.5% (25/102) whereas among bilateral amputees it was 20% (3/15). Patients with prosthesis rehabilitation had a higher rate of TTA (p = 0.027), better metabolic status (p < 0.001), higher functional and cognitive levels (p < 0.001), and longer LOS (p < 0.001) compared with patients who received wheelchair rehabilitation. Twenty patients were contacted 1 year later: eight (40.0%) reported continuous functional prosthesis use, eight - partial prosthesis use and four (20%) did not use the prosthesis at all. The patient group with 1-year post-discharge prosthesis use had a significantly higher rate of TTA (p = 0.032), lower rate of congestive heart failure (CHF) (p = 0.014) and higher score changes on the FIM and mFIM (p = 0.043). CONCLUSIONS: Rehabilitation efforts should best be targeted depending on need. Rehabilitation professionals should make an educated estimate of outcomes at the beginning of rehabilitation based on the characteristics of the patients (level of amputation and functional level on admission).

Nurses working in a long-term care facility could be at risk of developing compassion fatigue due to the nature of their work. In this descriptive, cross-sectional survey, we explored the level of compassion fatigue among nurses working in a long-term care facility, as well as the associated sociodemographic and occupational factors. In total, 103 nurses employed in various departments of a long-term care facility in central Israel completed the Hebrew version of the Professional Quality of Life Scale R-IV. Nurses scored moderate-high on the compassion fatigue (mean = 3.6, standard deviation = .5), burnout (mean = 3.5, standard deviation = .5), and compassion satisfaction (mean = 3.8, standard deviation = .5) scales. Older nurses scored lower on compassion fatigue, while nurses with higher qualifications scored higher on compassion satisfaction. In this study, we implicate that it is necessary to raise awareness about compassion fatigue, both in nursing education and training and in long-term care organizations. It is necessary to improve understanding of this phenomenon in order to help nurses acquire appropriate coping skills to address this critical issue.

The purpose of this study was to analyze and describe circumstances and clinical aspects of pectoralis major rupture in elderly patients compared with younger patients. Eleven patients were nursing home residents and two were community residents. All had severe pain with a large pectoral ecchymosis extending to the lateral chest wall and arm. Twelve patients experienced substantial blood loss (average, 2.3 g/dL hemoglobin), which resulted in hemodynamic decompensation in two of the patients, necessitating a blood transfusion. The most probable mechanism of injury was indirect, caused by a brisk tearing movement applied to stiff, atrophic muscle during commonly used nursing procedures for transferring, positioning, and dressing the patients. The authors suspect this injury to be more common than reported. Although surgical repair is not required in the elderly, a proper diagnosis is imperative because the injury has a severe clinical impact necessitating care and followup.

PURPOSE: To assess whether and to what extent cognitive status affects functional gain in mobility and extended activities of daily living (ADL) in patients admitted to a geriatric day hospital. METHODS: During 2003, 135 older patients admitted to a rehabilitation day hospital were evaluated by the Mini Mental State Examination (MMSE) and the Cognitive Functional Independence Measure (FIM). On admission and at discharge, they were assessed by the Nottingham Extended ADL Index (NEAI) and the Timed Get Up and Go test (TUG). RESULTS: Orthopedic and stroke patients achieved significant functional gain in mobility regardless of their cognitive status. Nevertheless, cognitively intact stroke patients achieved higher admission and discharge NEAI scores, manifesting greater absolute functional gain than cognitively impaired patients. The patients' ability to extract their rehabilitation potential was significantly better. CONCLUSIONS: Cognitively impaired patients can improve in mobility and performance of extended ADL during day hospital rehabilitation. Evaluation of the patients' cognitive status may enable the multidisciplinary team to develop suitable individual programs and better allocate resources. Cognitively intact stroke patients may benefit from extended rehabilitation treatment compared to impaired stroke patients as they are more capable of utilizing their potential to achieve independence in daily tasks.

BACKGROUND: Motor imagery practice refers to the mental rehearsal of motor acts in the absence of actual movement production. PURPOSE: To evaluate the effect of motor imagery practice on the performance of sit to stand (STS) and reaching to grasp in subjects with post stroke chronic hemiparesis. METHOD: The study was designed as a crossover intervention. Participants were 13 individuals (mean age, 68.9 [±4.9] years) with chronic hemiparesis enrolled in a day center at the Bet-Rivka Rehabilitation Hospital in Petach Tikvah, Israel. Following 1 week of baseline measurements of the performance of STS and reaching to grasp, these functions were mentally practiced for 15 minutes 3 times a week for 4 weeks. Half of the subjects mentally practiced STS, while the other half practiced the reaching imagery protocol. Subsequently, the participants in each group crossed over to practice the second function for the next 4 weeks. All practice sessions were performed according to a pre-established protocol under supervision. Measurements of real performance took place twice before and twice immediately following each practice session. For STS, the Tetrax Balance System was used to measure the speed of performance and weight distribution between the legs. Reaching to grasp was appraised via a "kinematic" glove and included speed variables of the hand. RESULTS: A significant decrease was found in the values of STS duration. Weight distribution between the legs was not affected by the intervention. For reaching to grasp, a significant improvement was found in the mean and the maximum reaching velocity. CONCLUSIONS: In individuals with chronic hemiparesis, the imagery practice of meaningful motor tasks can positively affect real performance.

This paper reports the outcome and feasibility of using a novel virtual reality system, SeeMe, for the assessment and treatment of unilateral spatial neglect following stroke in a recovered post-stroke subject with residual symptoms of unilateral spatial neglect (USN). The subject received 8 weekly treatment sessions. Outcome measures included the Short Feedback Questionnaire, standard paper and pencil tests and the assessment procedure of the SeeMe system itself. The tests were done on the first and last treatment days. The paper and pencil tests were normal while the SeeMe system showed a clear difference between movement times in the right and left hemispace. Following treatment, the subject showed improved movement times to the left hemispace and also showed functional gains. The subject did not experience any discomfort such as nausea or dizziness while using the system. This initial pilot study indicates that the SeeMe virtual reality system has the potential to be used in clinical settings in order to assess and treat USN. A full clinical trial is necessary in order to examine this premise.

OBJECTIVE: Primary generalized osteoarthritis (OA), the most prevalent joint disease, is usually symmetric. Sporadic case reports mention decreased OA manifestations in limbs in which there are neurologic deficits, but no systematic research has been published. The aim of the present study was to examine these observations in a planned and controlled survey in a group of patients with OA. METHODS: Seventy-five geriatric patients with a history of stroke and hemiparalysis were studied clinically and radiographically (hand radiographs; graded according to a modified Altman method) for the presence and the degree of OA in the hands. Detailed clinical and radiologic scores were calculated for each hand. Demographic, occupational, and neurologic data were collected. Patients with other joint or neurologic conditions were excluded. A group of 55 elderly patients without stroke were similarly studied (controls). Scores in the paralyzed hand were compared with those in the nonparalyzed hand in the stroke patients and subgroups (by Student's paired t-test and Wilcoxon test). Scores in the dominant hands were compared with those in the nondominant hands in stroke patients and control subjects (by Student's paired t-test and Mann-Whitney test). Correlation between the degree of neurologic damage and OA asymmetry (Pearson's correlation coefficient) was also sought. RESULTS: Paralyzed hands showed significantly fewer OA changes than nonparalyzed hands, both clinically and radiologically. This trend, accentuated in patients with more severe paralysis, disappeared in those with mild residual paresis. Asymmetry of OA was more pronounced in patients with flaccid, compared with spastic, paralysis. The degree of paralysis and loss of muscle strength correlated with the degree of OA asymmetry. Women had significantly higher OA scores than men. In the control group, dominant hands had higher OA scores, but this finding was concealed among hemiparalyzed patients. Lifetime gross occupational load and present grip strength did not correlate with the degree of OA. CONCLUSION: In elderly patients, hemiparalysis reduces ipsilateral hand expression of OA, while OA is accentuated (or increased) in the dominant hand of patients without paralysis. This first systematic study confirms the findings of previous case reports and lends support to the role of biomechanical factors in the development of OA.

a Beit Rivka Geriatric Rehabilitation Center, Israel b Research Center for the Health Professions, Ono Academic College, Kiryat Ono, Israel

Background: As the population lives longer, end of life (EOL) is emerging as a distinct life phase, about which there is still limited understanding. Characterizing this important period is vital for clarifying issues regarding trajectory and decline at EOL and for health service planning on an institutional, communal, and societal level. In this article, we aim to characterize the EOL period, examining the duration and number of EOL stages, as well as functional, attitudinal, and emotional trajectories. Methods: In this cross-sectional study, 70 primary caregivers of deceased persons were interviewed. Standardized rates of functional, attitudinal, and emotional change across the EOL period were calculated. Frequencies were compared using the McNemar statistical test. Results: EOL period was found to have a median length of 3.25 years, and an average of approximately three progressive stages. The duration of EOL stages tended to decrease as death approached. Unexpected events (eg new medical diagnosis/accident) served as the precipitating event for the EOL period for approximately half of the deceased persons, and changes in existing conditions (eg health status/cognitive state) were also reported to precipitate EOL for a similar proportion. Reports of functionality across stages found the steepest decline in the "physical" domain and the most moderate decline in the "social" domain. With each stage, positive indicators, such as "will to live," showed a progressive decline, whereas negative indicators, including "suffering" and "dependence level," progressively increased. Conclusions: Results help characterize EOL trajectories and should inform care planning and decision making at various levels. In addition, they suggest a methodology for better understanding EOL.

Folate levels of serum and red blood cells (RBC) and vitamin B12 serum levels were investigated in 326 urban chronically ill elderly ambulatory patients and 41 healthy young control subjects. Two laboratory methods were used for investigating the folate levels, the microbiologic assay (MBA) with Lactobacillus casei and radioassay (RA). Serum and RBC samples of 326 patients were tested by the folate MBA and 270 of the same samples by the RIA methods. In the MBA 6.8% of the patients and 12.2% of controls had low levels of folate RBC (less than 200 ng/mL) and 1.8% of patients and 4.8% of controls had low serum folate levels (less than 5 ng/mL). All of the patients with the low folate levels had normal hematologic findings and no clinical symptoms of folate deficiency. In the RIA method, all of the patients and almost all of the control subjects (except one) had normal folate levels. Ten of the patients (3%) had low levels of serum vitamin B12 (less than 200 pg/mL). They were hematologically normal. They had normal Schilling tests and normal vitamin B12 dietary intake. Their RBC folate levels were normal and even somewhat higher. Forty percent of these patients had macular degeneration of the eyes. The data indicate the superiority of the RA method over the MBA and bring into question the accuracy of previous studies. The data furnish further evidence that a low vitamin B12 level in the elderly is not necessarily a true vitamin B12 deficiency and raise the possibility of an association between low B12 serum levels and macular degeneration of the eyes.

PURPOSE: The purpose of this study is to characterize hip-fractured patients who maintained or improved their functional ability, 1 year postdischarge from rehabilitation and to identify factors associated with functional achievement maintenance. METHODS: A retrospective study performed in a postacute geriatric rehabilitation center. Two hundred thirty-three hip-fractured patients admitted consecutively from January 2006 to September 2007 were enrolled in the study. The patients were evaluated at discharge from rehabilitation and after 1 year, they were classified into two groups: those who maintained or improved their motor Functional Independence Measure (mFIM) scores and those who deteriorated. The differences between the two patient groups relating to functional, clinical, demographic and fracture-related variables were assessed. RESULTS: One year postrehabilitation, 130 (55.8%) patients exhibited a decline in their mFIM score. Patients whose 1-year mFIM score had improved were discharged from rehabilitation with a less favorable mean mFIM score (50.7 ± 18.5 vs. 55.6 ± 15.2; p = 0.032), achieved a lower mean mFIM score gain during rehabilitation (12.0 ± 9.7 vs. 14.6 ± 8.1; p = 0.03), had a higher education level (p = 0.003) and had a lower rate of chronic lung disease (p = 0.020) compared with patients whose 1-year mFIM score had deteriorated. After 1 year, only 21 patients (9%) were functionally independent in activities of daily living and only 19 (8.2%) were able to walk unassisted. Only 13 patients (5.6%) perceived that they had regained their former functional level. CONCLUSIONS: A substantial decline in functional ability of hip-fractured patients occurred 1 year postdischarge from rehabilitation. Healthcare providers should be aware of the necessity for a long-term postrehabilitation physical training program to prevent functional decline. Further efforts should be invested in motivating their patients to exercise.

The objective of this study was to characterize (1) the severity of the proprioception deficit in the affected upper extremity on admission to rehabilitation and (2) the motor and functional recovery during the first six weeks of rehabilitation. Twenty patients who had sustained a hemispheric cerebral vascular accident (CVA) and had a proprioception deficit in addition to a motor deficit of their upper extremity participated in the study. Subjects were assessed for propriocep-tion loss and motor ability of the upper extremity four times (weeks 0, 2, 4, and 6) and for functional ability of the upper extremity and BADL (Basic Activities of Daily Living) on admission and after six weeks. On admission, eight of the patients suffered from a severe deficit, eight patients suffered from a moderate deficit, and four suffered from a mild deficit. By week 6, five patients had improved to the point where no deficit was discerned. Only two patients retained a severe deficit, whereas the remaining 13 patients retained moderate or mild deficits. In addition a significant improvement in the motor and functional ability of the upper extremity was found. Familiarity with these facts should help the clinician to establish more realistic therapeutic goals and to anticipate with greater accuracy the eventual treatment outcome.