Hospital Care Efficiency - Measuring Lipid Profile During Hospitalization

Background

Lipid profile measurement in order to identify patients with elevated low-density lipoprotein cholesterol (LDL-C) is clearly recommended for all age groups. However, the value of screening patients for elevated LDL-C during hospitalization has not been determined. The aim of this study was to investigate the value of lipid screening tests in patients admitted to internal medicine wards, and as part of our efforts to promote a more intelligent and efficient use of laboratory and imaging tests during hospital care.

Methods

We conducted this retrospective, observational study, in which medical charts of patients for whom at least one lipid profile measurement was performed during hospitalization were reviewed. The patients were categorized into 5 groups according to admission diagnosis, and for each patient, we looked if the lipid profile was mentioned or referred to, based on guidelines, in the discharge summary.

Results

Lipid profile taken during hospitalization was referred to in the discharge letter in only 38.7% of patients, and even in the case of a need to consider according to guidelines, only a 45.7% consideration rate was found.

Conclusion

This study highlights the need for a more efficient and focused approach to the use of lipid profile measurement during hospitalization.

Medical choices regarding feeding tubes in patients with end-stage dementia in Israel: nasogastric vs. percutaneous endoscopic gastrostomy

A previous study conducted more than 15 years ago in Israel found a high overall use of tube-feeding for institutionalized end-stage dementia patients (52%) and a proportionally higher use (2:1) of naso-gastric tube (NG) over Percutaneous Endoscopic Gastrostomy (PEG) tubes for enteral feeding. This rate was markedly higher than that observed in other western countries (4.9-34%), and did not conform with clinical guidelines preferring spoon-feeding over tube-feeding for these patients, and PEG over NG for those in whom tube-feeding was initiated in long-term care. Over the past decade, the Israeli Ministry of Health conducted a policy reform to neutralize the administrative incentives presumed to be responsible for this situation. Further administrative and legislative developments followed suit. Despite these, we found no significant reduction in the prevalence of tube-feeding over spoon-feeding. However, we did observe a reduction in the proportional use of NG over PEG.

Tale of two countries: attitudes towards older persons in Italy and Israel during the COVID-19 pandemic as seen through the looking-glass of the media

The COVID-19 pandemic has exposed the many challenges and difficulties of healthcare systems caring for older frail people. This public health crisis has indeed jeopardised the concept of the welfare state, in particular the right of older people to uncompromised healthcare. Together with the clinical challenges facing the geriatric patient and the organisational difficulties of the healthcare systems, sociocultural factors may have also played a substantial role in the strategies that countries have applied in coping with the pandemic. In this opinion article, we report attitudes towards the older populations of two countries, Italy and Israel, during the COVID-19 pandemic as viewed through the looking-glass of the media.

Secondary Prevention of Osteoporosis: If Not Now, When?

EDITORIAL: The time has come for us to work together in a concerted effort to decrease the related suffering and consequences of osteoporotic fractures. And if not now, when?

Age and Ageing During the COVID-19 Pandemic; Challenges to Public Health and to the Health of the Public

The distribution of the SARS-CoV-2 virus has reached pandemic proportions. While COVID-19 can affect anyone, it is particularly hazardous for those with "co-morbidities." Older age is an especially strong and independent risk factor for hospital and ICU admission, mechanical ventilation and death. Health systems must protect persons at any age while paying particular attention to those with risk factors. However, essential freedoms must be respected and social/psychological needs met for those shielded. The example of the older population in Israel may provide interesting public health lessons. Relatively speaking, Israel is a demographically young country, with only 11.5% of its population 65 years and older as compared with the OECD average of >17%. As well, a lower proportion of older persons is in long-term institutions in Israel than in most other OECD countries. The initiation of a national program to protect older residents of nursing homes and more latterly, a successful vaccine program has resulted in relatively low rates of serious COVID-19 related disease and mortality in Israel. However, the global situation remains unstable and the older population remains at risk. The rollout of efficacious vaccines is in progress but it will probably take years to cover the world's population, especially those living in low- and middle-income countries. Every effort must be made not to leave these poorer countries behind. Marrying the principles of public health (care of the population) with those of geriatric medicine (care of the older individual) offers the best way forward.

Loneliness, Depression, and Anxiety Experienced by the Israeli Population During the First COVID-19 Lockdown: A Cross-sectional Survey

This research letter presents our study, which sought to evaluate the differences in the prevalence of self-reported symptoms of depression, anxiety, and loneliness between younger and older generations at the time of the COVID-19 pandemic. Since the younger generation is generally less accustomed to facing and dealing with adversity and illness, we hypothesized that adolescents and younger adults would have a higher prevalence of depression, anxiety, and loneliness as compared to the older generation. It must be emphasized that this survey was conducted during the first COVID-19 lockdown that occurred in Israel from mid-March 2020 to early May 2020. This was a time when businesses were closed, individuals and families were isolated at home with very limited social contact, and feelings of fear and panic were fueled by the electronic media.

Mechanical ventilation for older medical patients in a large tertiary medical care center

Aim

The aim of the study is to determine the factors influencing the outcomes of older ventilated medical patients in a large tertiary medical center.

Findings

Of 554 older patients (mean age 79 years) who underwent mechanical ventilation for the first time during the study period in-hospital mortality was 64.1% and overall 6-months survival was 26%. A combination of age 85 years and older, poor functional status prior to ventilation, and associated morbidity were the strongest negative predictors of survival after discharge from the hospital.

Message

The identification of factors predicting poor survival of mechanical ventilation will assist policy makers in clinical decision-making particularly at times of limited health resources.

Background

The development of technologies for the prolongation of life has resulted in an increase in the number of older ventilated patients in internal medicine and chronic care wards. Our study aimed to determine the factors influencing the outcomes of older ventilated medical patients in a large tertiary medical center.

Methods

We performed a prospective observational cohort study including all newly ventilated medical patients aged 65 years and older over a period of 18 months. Data were acquired from computerized medical records and from an interview of the medical personnel initiating mechanical ventilation.

Results

A total of 554 patients underwent mechanical ventilation for the first time during the study period. The average age was 79 years, and 80% resided at home. Following mechanical ventilation, 8% died in the emergency room, and the majority of patients (351; 63%) were hospitalized in internal medicine wards. In-hospital mortality was 64.1%, with 48% dying during the first week of hospitalization. Overall 6-months survival was 26%. We found that a combination of age 85 years and older, functional status prior to ventilation, and associated morbidity (diabetes with target organ injury and/or oncological solid organ disease) were the strongest negative predictors of survival after discharge from the hospital.

Conclusion

Mechanical ventilation at older age is associated with poor survival and it is possible to identify factors predicting survival. In the midst of the COVID-19 pandemic, the findings of this study may help in the decision-making process regarding mechanical ventilation for older people.

CogTale: an online platform for the evaluation, synthesis, and dissemination of evidence from cognitive interventions studies

Systematic reviews and meta-analyses are critical in health-related decision-making, and are considered the gold standard in research synthesis methods. However, with new trials being regularly published and with the development of increasingly rigorous standards of data synthesis, systematic reviews often require much expertise and long periods of time to be completed. Automation of some of the steps of evidence synthesis productions is a promising improvement in the field, capable of reducing the time and costs associated with the process.This article describes the development and main characteristics of a novel online repository of cognitive intervention studies entitled Cognitive Treatments Article Library and Evaluation (CogTale). The platform is currently in a Beta Release phase, as it is still under development. However, it already contains over 70 studies, and the CogTale team is continuously coding and uploading new studies into the repository. Key features include advanced search options, the capability to generate meta-analyses, and an up-to-date display of relevant published studies.

Assessment of Global Health Education: The Role of Multiple-Choice Questions

Introduction: The standardization of global health education and assessment remains a significant issue among global health educators. This paper explores the role of multiple choice questions (MCQs) in global health education: whether MCQs are appropriate in written assessment of what may be perceived to be a broad curriculum packed with fewer facts than biomedical science curricula; what form the MCQs might take; what we want to test; how to select the most appropriate question format; the challenge of quality item-writing; and, which aspects of the curriculum MCQs may be used to assess.

Materials and Methods: The Medical School for International Health (MSIH) global health curriculum was blue-printed by content experts and course teachers. A 30-question, 1-h examination was produced after exhaustive item writing and revision by teachers of the course. Reliability, difficulty index and discrimination were calculated and examination results were analyzed using SPSS software.

Results: Twenty-nine students sat the 1-h examination. All students passed (scores above 67% - in accordance with University criteria). Twenty-three (77%) questions were found to be easy, 4 (14%) of moderate difficulty, and 3 (9%) difficult (using examinations department difficulty index calculations). Eight questions (27%) were considered discriminatory and 20 (67%) were non-discriminatory according to examinations department calculations and criteria. The reliability score was 0.27.

Discussion: Our experience shows that there may be a role for single-best-option (SBO) MCQ assessment in global health education. MCQs may be written that cover the majority of the curriculum. Aspects of the curriculum may be better addressed by non-SBO format MCQs. MCQ assessment might usefully complement other forms of assessment that assess skills, attitude and behavior. Preparation of effective MCQs is an exhaustive process, but high quality MCQs in global health may serve as an important driver of learning.

Mild Cognitive Impairment and Neurofeedback: A Randomized Controlled Trial

Background and Objectives: Mild cognitive impairment (MCI) is often a precursor of dementia, and in particular of Alzheimer's Disease (AD) which is the most common cause of dementia. Individuals with amnestic MCI are several-fold more likely to develop AD than the general population. Therefore, MCI comprises a well-detectable, early stage time-point for therapeutic intervention and strategic prevention. Based on common electroencephalographical (EEG) pattern changes seen in individuals with MCI, we postulated that EEG-based neurofeedback could help improve the memory performance of patients with MCI. Memory performance is of particular importance in these patients, since memory decline is the most prominent symptom in most patients with MCI, and is the most predictive symptom for cognitive deterioration and the development of AD.

Methods: In order to improve the memory performance of patients with MCI we used a system of EEG-based neurofeedback in an attempt to reverse alterations of the EEG that are known to be common in patients with MCI. Our protocol comprised the provision of positive feedback in order to enhance the activity level of the upper alpha band. Participants were divided to two groups receiving either neurofeedback training to enhance the upper alpha frequency (Experimental group) or random feedbacks (Sham group)

Results: We witnessed a significant improvement in memory performance in subjects in the experimental group compared to those in the sham group. This improvement was maintained for at least 1 month.

Conclusions: Neurofeedback may be a promising and affordable novel approach for treating the decline in memory witnessed in patients with MCI.

Methylphenidate for Mild Cognitive Impairment: An Exploratory 3-Day, Randomized, Double-Blind, Placebo-Controlled Trial

Background: To evaluate the efficacy, safety and tolerability of methylphenidate (MPH) for cognitive function in older patients with mild cognitive impairment (MCI).

Methods: Male and female subjects aged 65 years and older with a clinical diagnosis MCI were included in an exploratory randomized, double-blind, placebo-controlled trial. Eligible subjects were assigned to either treatment with immediate-release MPH or placebo. The active compound was administered in an increasing-dose stepwise fashion, namely 10 mg MPH on day 1, 20 mg on day 2, and 30 mg on day 3. Subjects remained under observation for 4 h following drug administration and were monitored for changes in blood pressure and for adverse events. Cognitive outcome measures included the Montreal Cognitive Assessment (MoCA) and the Neurotrax Mindstreams computerized cognitive assessment battery.

Results: Of 17 subjects enrolled, 15 subjects completed the study, 7 in the active MPH group and 8 in the placebo group. The average age of the participants was 76.1 ± 6.6 years and 10 (66.7%) were men. Following the final dose a significant benefit on memory (predominantly non-verbal memory) was found in the MPH group. While 12 adverse events were reported, they were all rated as mild to moderate.

Conclusions: Our finding of modest beneficial effects of MPH on memory tests in older subjects with MCI in this exploratory study is of interest and should be investigated in further studies.

Validating the Hebrew version of the Person-Centered Care of Older People with Cognitive Impairment in Acute Care scale

AIM

To validate the Hebrew version of the Person-Centered Care of Older People with Cognitive Impairment in the Acute Care scale.

BACKGROUND

The Person-Centered Care of Older People with Cognitive Impairment in Acute Care scale is a reliable and valid measure to assess the extent to which person-centred care among people with dementia is adopted in the acute care setting.

METHODS

A cross-sectional study using a self-reporting structured questionnaire was conducted with 678 professionals (69% nurses, 26% physicians, 5% other health care professionals) in five hospitals across Israel.

RESULTS

Similar to other languages, best results were obtained using 14 of the 15 items included in the original scale. Confirmatory factor analysis indicated the appropriateness of a three-factor structure for the Hebrew version of the scale. Cronbach's alpha scores for these factors were moderate to good.

CONCLUSIONS

The Hebrew version of the scale is a reliable and valid tool for assessing hospital professionals' perceptions of person-centred care.

IMPLICATIONS FOR NURSING MANAGEMENT

A new language validated version of the scale will allow nurse managers to learn from multiple countries' experience while conducting international comparisons. Such developments will improve and expand the implementation of the person-centred care among people with dementia in hospital settings.

Validation of the Russian Version of the MoCA Test as a Cognitive Screening Instrument in Cognitively Asymptomatic Older Individuals and Those With Mild Cognitive Impairment

Background: Cognitive impairment is a common condition in older people, and age-related cognitive symptoms may progress to Mild Cognitive Impairment and Dementia. Physical exercise and cognitive training may be useful in maintaining cognitive function, and those developing impaired cognitive function should be advised to plan for the future. The MoCA test is a useful cognitive screening instrument, but the Russian version of this test has not yet been validated. The aim of the present study was to validate the Russian version of the MoCA test.

Methods: The study population included 160 residents of Israel aged 65 years and older with Russian as their mother tongue, 80 of whom were cognitively asymptomatic (AC) and 80 with a clinical diagnosis of MCI. All participants underwent cognitive screening using the Russian version of the MoCA test (MoCA-Ru) as well as evaluation by means of a validated computerized cognitive assessment battery (Neurotrax).

Results: The mean age of the study population was 78 ± 6.6 years and 123 (76.9%) were women. The MoCA-Ru score was higher in the AC group than in those with MCI (24.3 ± 3.74 vs. 20.2 ± 3.07, P < 0.0001). At a cutoff value of ≥25, sensitivity was 0.99 and specificity 0.54, with area under the curve (AUC) of 0.81.

Conclusions: We found the Russian language version of the MoCA test to be a useful cognitive screening instrument for older people with mild cognitive impairment.

[GERIATRICS AT CENTER STAGE]

Demographic changes in the developed world have resulted in population aging. Although Israel has a relatively young population, the older population is aging at a rapid rate. This has placed significant strains on health services in the community, in acute care, rehabilitation and long-term care. Geriatric medicine stands at the forefront of providing high quality care to the older population. The recognition of the importance of the "Geriatric Giants", which include immobility, instability (falls), incontinence, intellectual impairment (dementia and delirium), and iatrogenesis (including polypharmacy), has resulted in the development of improved diagnosis, prevention and treatment of these syndromes. The knowledge and understanding of aging and age-related diseases, and the development of a multidisciplinary function-based approach to assessment and treatment, have resulted in geriatricians playing a central role in the health care of older people. The current issue of Harefuah presents an overview of topics and studies of interest to Israeli researchers.

Implementing a Practical Global Health Curriculum: The Benefits and Challenges of Patient-Based Learning in the Community

Background: A growing number of medical schools across the world have incorporated global health (GH) into their curricula. While several schools focus GH education on lecture-based courses, our premise is that global health education should embody a holistic approach to patient care and medical education in local communities. Medical students may learn global health by focusing on real patients, their families and communities as part of a practical curriculum.

Aims and Objectives: A unique GH curriculum was devised to compare student learning outcomes on a practical vs. lecture-based course. The premise was that learning from patients would result in a greater breadth of coverage of the global health syllabus as compared to that from a lecture-based course.

Methods: A teaching and learning program was developed over 3 years to provide medical students interaction with real patients in the community on a first-preclinical-year Introduction to Global Health and Medical Anthropology course. Learning outcomes on the practical vs. lecture-based course were compared using thematic analysis of the written assignments of both courses: global health case reports and literature reviews, respectively. All members of three cohorts of students undertaking the course in successive academic years were compared (Group A: literature review; Groups B and C: case reports; n = 87).

Results: Case reports provided evidence of a greater breadth of learning outcomes when compared to the literature review (p < 0.001). The writing of the case report was enhanced by completion of a field journal and family health needs assessment tool (p < 0.001). Students demonstrated a closeness to their patients that added depth, understanding and motivation to assist patients in health activities and advocate for their needs.

Discussion: Placements with patients in the community provided students with a rich learning environment and facilitated the formation of relationships with patients to better understand the social determinants of health and advocate for improvements in their living and working conditions and access to healthcare.

Conclusions: Global health may be better learned experientially by following patients rather than from frontal lectures. Patient-based learning inspires a commitment to the individual and facilitates medical schools in meeting their obligations to the communities they serve.

The design, evaluation, and reporting on non-pharmacological, cognition-oriented treatments for older adults: Results of a survey of experts

Introduction

Cognitive decline and dementia significantly affect independence and quality of life in older adults; therefore, it is critical to identify effective cognition-oriented treatments (COTs; eg, cognitive training, rehabilitation) that can help maintain or enhance cognitive functioning in older adults, as well as reduce dementia risk or alleviate symptoms associated with pathological processes.

Methods

The Cognitive Intervention Design Evaluation and Reporting (CIDER), a working group from the Non-Pharmacological Interventions Professional Interest Area (NPI-PIA) of the Alzheimer's Association conducted as survey in 2017 with experts in COTs worldwide. The survey's aims were three-fold: (1) determine the common attitudes, beliefs, and practices of experts involved in the COTs research targeting older people; (2) identify areas of relative agreement and disagreement among experts in the field; and (3) offer a critical review of the literature, including recommendations for future research.

Results

The survey identified several areas of agreements among experts on critical features of COTs, and on study design and outcome measures. Nevertheless, there were some areas with relative disagreement. Critically, expert opinions were not always supported by scientific evidence, suggesting that methodologic improvements are needed regarding design, implementation, and reporting of COTs. There was a clear consensus that COTs provide benefits and should be offered to cognitively unimpaired older adults, mild cognitive impairment (MCI), and mild dementia, but opinions differed for moderate and severe dementia. In addition, there is no consensus on the potential role of COTs in dementia prevention, indicating that future research should prioritize this aspect.

Discussion

Evidence of COTs in older adults is encouraging, but additional evidence is needed to enhance dementia prevention. Consensus building and guidelines in the field are critical to improve and accelerate the development of high-quality evidence for COTs in cognitively unimpaired older adults, and those with MCI and dementia.

Israel Ad Hoc COVID-19 Committee: Guidelines for Care of Older Persons During a Pandemic

Early on, geriatricians in Israel viewed with increasing alarm the spread of coronavirus disease 2019 (COVID‐19). It was clear that this viral disease exhibited a clear predilection for and danger to older persons. Informal contacts began with senior officials from the country's Ministry of Health, the Israel Medical Association, and the country's largest health fund; this was done to plan an approach to the possible coming storm. A group was formed, comprising three senior geriatricians, a former dean, a palliative care specialist, and a lawyer/ethicist. The members made every effort to ensure that their recommendations would be practical while at the same time taking into account the tenets of medical ethics. The committee's main task was to think through a workable approach because intensive care unit/ventilator resources may be far outstripped by those requiring such care. Recommendations included the approach to older persons both in the community and in long‐term care institutions, a triage instrument, and palliative care. Patient autonomy was emphasized, with a strong recommendation for people of all ages to update their advance directives or, if they did not have any, to quickly draw them up. Considering the value of distributive justice, with respect to triage, a “soft utilitarian” approach was advocated with the main criteria being function and comorbidity. Although chronological age was rejected as a sole criterion, in the case of an overwhelming crisis, “biological age” would enter into the triage considerations, but only in the case of distinguishing between people with equal non–age‐related deficits. The guideline emphasized that no matter what, in the spirit of beneficence, anyone who fell ill must receive active palliative care throughout the course of a COVD‐19 infection but especially at the end of life. Furthermore, in the spirit of nonmaleficence, the frail, very old, and severely demented would be actively protected from dying on ventilation. J Am Geriatr Soc 68:1370‐1375, 2020.

Neurofeedback Improves Memory and Peak Alpha Frequency in Individuals with Mild Cognitive Impairment

Mild cognitive impairment (MCI) is a syndrome characterized by a decrease in cognitive abilities, while daily function is maintained. This condition, which is associated with an increased risk for the development of Alzheimer's disease, has no known definitive treatment at present. In this open-label pilot study we explored the possible benefits of neurofeedback for subjects with MCI. Eleven participants diagnosed with MCI were trained to increase the power of their individual upper alpha band of the electroencephalogram (EEG) signal over the central parietal region. This was achieved using an EEG-based neurofeedback training protocol. Training comprised ten 30-min sessions delivered over 5 weeks. Cognitive and electroencephalographic assessments were conducted before and after training and at 30 days following the last training session. A dose-dependent increase in peak alpha frequency was observed throughout the period of training. Memory performance also improved significantly following training, and this improvement was maintained at 30-day follow-up, while peak alpha frequency returned to baseline at this evaluation. Our findings suggest that neurofeedback may improve memory performance in subjects with mild cognitive impairment, and this benefit may be maintained beyond the training period.

Exceptionally Long-Lived Individuals (ELLI) Demonstrate Slower Aging Rate Calculated by DNA Methylation Clocks as Possible Modulators for Healthy Longevity

Exceptionally long-lived individuals (ELLI) who are the focus of many healthy longevity studies around the globe are now being studied in Israel. The Israeli Multi-Ethnic Centenarian Study (IMECS) cohort is utilized here for assessment of various DNA methylation clocks. Thorough phenotypic characterization and whole blood samples were obtained from ELLI, offspring of ELLI, and controls aged 53–87 with no familial exceptional longevity. DNA methylation was assessed using Illumina MethylationEPIC Beadchip and applied to DNAm age online tool for age and telomere length predictions. Relative telomere length was assessed using qPCR T/S (Telomere/Single copy gene) ratios. ELLI demonstrated juvenile performance in DNAm age clocks and overall methylation measurement, with preserved cognition and relative telomere length. Our findings suggest a favorable DNA methylation profile in ELLI enabling a slower rate of aging in those individuals in comparison to controls. It is possible that DNA methylation is a key modulator of the rate of aging and thus the ELLI DNAm profile promotes healthy longevity.

The Acute Effect of Exercise on Executive Function and Attention: Resistance Versus Aerobic Exercise

Acute aerobic exercise was shown to enhance such cognitive functions as executive function (EF) and attention. Acute resistance exercise was also shown to enhance cognitive functions, however, only few studies directly compared these two exercise modalities. The aim of this study was to evaluate the acute effect of a typical moderate intensity resistance exercise session as compared to a typical moderate intensity aerobic session, on executive function and attention. A counterbalanced repeated measures experimental design was applied. Forty physical education students (21 women; 19 men, age = 25.7±2.84 years) were tested before and after three sessions: aerobic, resistance, and control. Each session consisted of 30 minutes of exercise or a rest. Executive function and attention were assessed by components of the computerized Stroop Catch game and Go-NoGo cognitive tests. A two-way ANOVA showed a greater increase in attention scores after the resistance sessions (p < .05) compared to the control condition. Attention scores in the aerobic sessions showed a trend toward improvement but did not reach statistical significance. Scores of EF significantly increased, both after the resistance session and the aerobic session (p < .05), but not after rest in the control condition. Our findings show that an acute session of resistance exercise increased both Attention and EF test scores, while an aerobic exercise session improved only the EF scores.

Coming of age: health-care challenges of an ageing population in Israel

Although Israel is still young in years, with relatively high birth rates and older people (individuals aged 65 years or older) constituting only about 11% of its population, the absolute number of older people is growing rapidly. Life expectancy is high, and increasing numbers of people are living to advanced old age (older than 85 years). A wide spectrum of geriatric care is provided within a universal system providing health services to all citizens. Community and institutional care is available, and many innovative programmes are being developed. The unique demographic characteristics of the ageing society in Israel reflect cultural and multiethnic diversity, in addition to a high rate of immigration of older people. To meet the growing challenges, address disparities, and search for innovation will require planning and development of adequate services at the highest level.

The effects of a resistance vs. an aerobic single session on attention and executive functioning in adults

Evidence from recent studies showed that acute aerobic exercise results in improvements in different cognitive functions. The goal of this study was to assess the influence of acute bouts of aerobic versus resistance exercise on attention and executive function in adults. Thirty-nine physically active adults (age = 52±8 yr) served as participants. Each participant visited the laboratory four times: on the first visit participants performed a cognitive test (NeuroTrax) followed by an aerobic fitness assessment, as well as maximal strength test composed of six exercises. During visits 2-4, participants completed the cognitive test before and after the experimental condition, which consisted of either 25 min of aerobic exercise or resistance exercise, or watching a recorded interview show in a seated position (control condition). Findings indicated significantly higher changes in scores of attention after acute aerobic exercise (mean change 3.46, 95% CI -0.32, 7.27) than following the control condition (mean change -0.64, 95% CI -2.23, 0.96). The changes following resistance exercise (mean change -0.67, 95% CI -4.47, 3.13) were not significantly different from the changes following the control condition. Executive function scores showed a marginally significant improvement following acute aerobic (mean change 4.06, 95% CI 1.68, 6.44) and resistance exercise (mean change 3.69, 95% CI 0.78, 6.60), but not after control (mean change 0.91, 95% CI -1.21, 3.02). We suggest that adults should consider augmenting both modalities into their training routines, which may improve their cognition in addition to providing other physical benefits.

[MEASURING THE EFFECT OF MULTI-SENSORY STIMULATION IN THE SNOEZELEN ROOM ON SLEEP QUALITY OF ALZHEIMER PATIENTS USING ACTIGRAPH]

BACKGROUND

The most common cause of dementia is Alzheimer's disease. The major manifestation of the disease is the cognitive impairment which appears at the onset of the disease. In addition to the cognitive impairment there are behavioral dysfunctions such as apathy, anxiety, depression and sleep disturbances. The treatment for the manifestations of Alzheimer is currently pharmacological and behavioral. One of the newest behavioral treatments for Alzheimer is the multi-sensory treatment using the Snoezelen room.

METHODS

The study group included 16 hospitalized Alzheimer patients. A device called the ActiGraph, which reads movement level, was placed on the subjects' non-dominant wrist. The measurements took place continually for five nights: two nights before snoezelen treatment, the day of treatment and two nights after the treatment. This protocol was repeated after a week of rest.

RESULTS

The results showed that snoezelen treatment has a positive effect on the quality of sleep during the first week but not on the second week.

CONCLUSIONS

Snoezelen treatment should be considered as part of the treatment regimen of Alzheimer patients, in addition to the pharmacological treatments in order to improve their quality of sleep and quality of life. Larger sample size and longer periods of time are needed to confirm the effectiveness of the treatment.

Acute aerobic activity enhances response inhibition for less than 30min

Acute exercise appears to facilitate certain aspects of cognitive processing. The possibility that exercise may lead to more efficient inhibitory processes is of particular interest, owing to the wide range of cognitive and motor functions that inhibition may underlie. The purpose of the present study was to examine the immediate and the delayed effect of acute aerobic exercise on response inhibition, motor planning, and eye-hand coordination in healthy active adults. Forty healthy and active participants (10 females) with a mean age of 51.88±8.46years performed the Go-NoGo test (response inhibition) and the Catch Game (motor planning and eye-hand coordination) before, immediately after, and following a 30-min recovery period in two conditions: a moderate-intensity aerobic session and a control session. In 2-way repeated measures ANOVAs (2 treatments×3 times) followed by contrast comparisons for post hoc analyses, significant pre-post interactions - indicating improvements immediately following exercise but not following the control condition - were observed in the Go-NoGo measures: Accuracy, Reaction Time, and Performance Index, but not in the Catch Game. In the post-follow-up interaction a deterioration was observed in Performance Index, and a trend of deterioration in Accuracy and Reaction Time. The conclusion was that a single session of moderate-intensity aerobic exercise facilitates response inhibition, but not motor planning or eye-hand coordination, in middle-aged healthy active adults. On the other hand, the improvement does not last 30min following a recovery period. Further studies are needed to examine the duration of the inhibitory control benefits and the accumulative effect of a series of acute exercise bouts, as well as to determine the brain networks and/or neurotransmitter systems most affected by the intervention.

Visual-spatial perception: a comparison between instruments frequently used in the primary care setting and a computerized cognitive assessment battery

BACKGROUND

The development of screening instruments will help the primary care team to determine when further comprehensive cognitive assessment is necessary.

DESIGN

A retrospective analysis based on medical records.

PATIENTS AND SETTING

Patients referred to a comprehensive geriatric assessment unit.

ANALYSIS

Cognitive screening and assessment included visual-spatial components: the Mini Mental State Examination, the Clock Drawing Test, the Montreal Cognitive Assessment Test, and the Neurotrax (Mindstreams) computerized cognitive assessment battery.

RESULTS

The average age of the 190 eligible patients was 81.09±5.42 years. Comparing the individual tests with that of the visual-spatial index of Neurotrax, we found the Trail Making B test to be most sensitive (72.4%) and the Cube Test to have the highest specificity (72.8%). A combination of tests resulted in higher sensitivity and lower specificity.

CONCLUSION

The use of a combination of visual-spatial tests for screening in neurocognitive disorders should be evaluated in further prospective studies.

Exposing some important barriers to health care access in the rural USA

OBJECTIVES

To review research published before and after the passage of the Patient Protection and Affordable Care Act (2010) examining barriers in seeking or accessing health care in rural populations in the USA.

STUDY DESIGN

This literature review was based on a comprehensive search for all literature researching rural health care provision and access in the USA.

METHODS

Pubmed, Proquest Allied Nursing and Health Literature, National Rural Health Association (NRHA) Resource Center and Google Scholar databases were searched using the Medical Subject Headings (MeSH) 'Rural Health Services' and 'Rural Health.' MeSH subtitle headings used were 'USA,' 'utilization,' 'trends' and 'supply and distribution.' Keywords added to the search parameters were 'access,' 'rural' and 'health care.' Searches in Google Scholar employed the phrases 'health care disparities in the USA,' inequalities in 'health care in the USA,' 'health care in rural USA' and 'access to health care in rural USA.' After eliminating non-relevant articles, 34 articles were included.

RESULTS

Significant differences in health care access between rural and urban areas exist. Reluctance to seek health care in rural areas was based on cultural and financial constraints, often compounded by a scarcity of services, a lack of trained physicians, insufficient public transport, and poor availability of broadband internet services. Rural residents were found to have poorer health, with rural areas having difficulty in attracting and retaining physicians, and maintaining health services on a par with their urban counterparts.

CONCLUSIONS

Rural and urban health care disparities require an ongoing program of reform with the aim to improve the provision of services, promote recruitment, training and career development of rural health care professionals, increase comprehensive health insurance coverage and engage rural residents and healthcare providers in health promotion.

Teaching corner: an undergraduate medical education program comprehensively integrating global health and global health ethics as core curricula : student experiences of the medical school for international health in Israel

The Medical School for International Health (MSIH) was created in 1996 by the Faculty of Health Sciences at Ben-Gurion University of the Negev in affiliation with Columbia University's Health Sciences division. It is accredited by the New York State Board of Education. Students complete the first three years of the program on the Ben-Gurion University campus in Be'er-Sheva, Israel, while fourth-year electives are completed mainly in the United States (at Columbia University Medical Center and affiliates as well as other institutions) along with a two-month global health elective at one of numerous sites located around the world (including Canada, Ethiopia, India, Israel, Kenya, Nepal, Peru, the Philippines, Sri Lanka, Uganda, the United States, and Vietnam). The unique four-year, American-style curriculum is designed not only to prepare physicians who will be able to work at both an individual and community level but also at both of these levels anywhere in the world. In this way, it combines elements of medical and public health curricula not limited to an American perspective.

Feeding tubes for older people with advanced dementia living in the community in Israel

BACKGROUND

Feeding tubes to address eating problems of older people with advanced dementia (OPAD) has been studied primarily in nursing homes.

OBJECTIVES

To examine the prevalence of feeding tube use among OPAD living in the community; to evaluate the characteristics, quality of care, and the burden on caregivers.

METHODS

A cross-sectional survey of 117 caregivers of OPAD living in the community.

RESULTS

Of 117 patients, 26% had feeding tubes. Compared to nonusers, feeding tube users had more use of restraints, greater problems with swallowing, more emergency room visits, and were more likely to have a legal guardian. In addition, caregivers of feeding tube users were older and reported very heavy burden of care. Half of the caregivers reported that the medical team consulted them before insertion of the feeding tube.

CONCLUSION

Feeding tube use in OPAD in the community is associated with negative outcomes and increased caregiver burden.

Cardiovascular Fitness and Neurocognitive Performance among Older Adults in the Maintenance Stage of Cardiac Rehabilitation

BACKGROUND

Cardiovascular fitness is associated with cognition in advanced age. Cardiovascular disease (CVD) is a risk factor for cognitive decline beyond the normal aging process, thus we investigated this association in CVD patients.

METHOD

Patients in phase III of cardiac rehabilitation were divided into high and low cardiovascular fitness groups based on their predicted peak VO2. Cognition was assessed by a battery of neuropsychological tests examining memory, attention, visual spatial function, executive function and global cognitive score.

RESULTS

The two groups were similar on reported physical activity and on the Mini-Mental State Examination (MMSE). However, the high fitness group had significantly higher scores than the lower fitness group on attention and on the global cognitive score, and marginally significant scores on executive functioning.

LIMITATION

Due to the small sample size no differentiation was made among the various CVD conditions.

CONCLUSION

Higher cardiovascular fitness of CVD patients is associated with superior cognition - predominantly in attention and executive functioning.

Assessment of dementia in the primary care setting

The aging population of the developed world has led to a significant increase in the number of people suffering from dementia. Most of these patients are cared for in the community by primary care physicians and paramedical staff. However, the comprehensive assessment of cognitive changes in an elderly patient is time-consuming and requires skills that are often lacking in the primary care setting. This may lead to misdiagnosis and unnecessary delays in therapeutic intervention. In this review, the primary care physician is provided with a structured approach to the assessment of cognitive decline.

Dissociative symptoms as a consequence of traumatic experiences: the long-term effects of childhood sexual abuse

BACKGROUND

The purpose of this study was to assess the prevalence of dissociative symptoms and post-traumatic experiences in an ambulatory setting.

METHOD

The study was conducted in the ambulatory outpatient clinic of the Beersheva Mental Health Center. Over a period of six months new patients over 18 years of age were asked to participate in this survey. Patients completed questionnaires including the Dissociative experience Scale, trauma History Questionnaire, impact of event Scale, and Post-traumatic Diagnostic Scale.

RESULTS

A total of 505 patients were enrolled in the study, and 456 completed questionnaires were analyzed. of these, 442 (97%) participants reported at least one traumatic event during their lifetime. the traumatic events were experienced as meaningful and severe at the time of occurrence. the effects of sexual and childhood emotional abuse remained very intense throughout the victim's life and were viewed as powerful, significant experiences. on the other hand, traumatic experiences such as natural disasters and battle trauma were associated with longterm effects of relatively low intensity.

CONCLUSIONS

The presence of undiagnosed posttraumatic stress disorder (PtSD) among patients in outpatient mental health clinics suggests that screening and diagnostic procedures for this condition be more carefully defined. our most important finding is the large impact of childhood trauma, especially sexual abuse, on later life. thus the prevention, early detection and treatment of child abuse in preventing long term psychopathology must be emphasized.

A retrospective analysis of the sentence writing component of the Mini Mental State Examination: cognitive and affective aspects

BACKGROUND

One of the components of the Mini Mental State Examination (MMSE) is the request to write a sentence. We investigated the relationship between the characteristics of the written sentence of the MMSE and the cognitive and affective status of elderly patients.

METHODS

The characteristics of the sentence were compared to the total MMSE score, sociodemographic characteristics, tests evaluating cognition and affective status, and diagnoses.

RESULTS

The number of words was significantly associated with the degree of cognitive impairment, whereas the emotional polarity of sentences and concerns about health were associated with depression.

CONCLUSIONS

Characteristics of the MMSE sentence may provide important additional information regarding both cognition and affect when assessing older people.

[Five years experience at a community-based comprehensive geriatric assessment unit in southern Israel]

BACKGROUND

The health care of the growing number of older people in the population is predominantly provided by the family physician, who is usually faced with time limitations. A community-based Comprehensive Geriatric Assessment (CGA) unit has the potential to provide the family physician with the necessary support required in managing older patients.

OBJECTIVES

To describe and review the structure and clinical experience of a community-based CGA unit over a period of five years.

METHODS

The CGA unit comprises a multidisciplinary team that utilizes a comprehensive array of assessment instruments. Specific emphasis is placed on comorbidity, polypharmacy, cognitive and affective status, social support and daily function.

RESULTS

Over a period of five years, 456 older patients were evaluated. The mean age was 76.7 +/- 6.1 years and 36.2% were women. A total of 6.57 +/- 2.72 new diagnoses were made, the most common being dementia (60.1%), recurrent falls (43.9%) and social problems (32.5%). There were an average of 7 recommendations provided to the family physician, the majority relating to preventive medicine, fall prevention, improving mobility and social interventions. Based on a sample of files evaluated some six months later, we found that these recommendations had been carried out by family physicians to varying degrees. Prescriptions for new medications were provided for 55.6% of those recommended, 45.5% drugs were discontinued as suggested, and 44.4% investigations were performed. Preventive medicine recommendations were carried out in only 11.4% of patients.

Validation of the Hebrew version of the MoCA test as a screening instrument for the early detection of mild cognitive impairment in elderly individuals

INTRODUCTION

The English version of the Montreal Cognitive Assessment (MoCA) test has been shown to be reliable in screening for mild cognitive impairment (MCI). However, the sensitivity and specificity of the Hebrew version of this instrument are yet to be determined.

METHODS

The study population consisted of 2 groups of older individuals, 74 patients diagnosed with MCI and 80 patients who were cognitively asymptomatic. Cognitive evaluation included the Mini-Mental State Examination (MMSE), Mindstreams computerized cognitive assessment, and the MoCA test.

RESULTS

The Hebrew version of MoCA distinguished between cognitively asymptomatic older individuals and those with MCI, with a sensitivity of 94.6% and a specificity of 76.3%, using a cutoff of 26/30 points.

CONCLUSIONS

The Hebrew version of the MoCA test is effective for identifying MCI in older patients. As a screening instrument for MCI, its higher sensitivity makes it preferable o the MMSE, which is used extensively in the clinical setting.

Computerized testing of neurocognitive function in euthymic bipolar patients compared to those with mild cognitive impairment and cognitively healthy controls

OBJECTIVES

While neuropsychological impairment in bipolar disorder is well documented, the effect size of this impairment is rarely compared directly to that in other clinically familiar cognitive disorders. This study compares neuropsychological functioning of euthymic bipolar patients to those with mild cognitive impairment (MCI) as well as healthy controls.

METHODS

Following evaluation during regular follow-up in a mood disorders clinic, 58 euthymic adult bipolar subjects were administered a validated and fully computerized cognitive assessment (Mindstreams; NeuroTrax Corp., N.Y., USA). Study data were compared to existing data for MCI and cognitively healthy individuals tested with the same assessment.

RESULTS

Final analyses were based on 51 bipolar patients, 162 MCI patients and 495 healthy comparison subjects. Significant (p < 0.001) group effects were found for every parameter. Post hoc analysis revealed that the bipolar and MCI groups showed statistically equivalent functioning in memory, executive function, verbal function, and information processing speed. In the domains of visual-spatial processing, attention, and motor skills, the MCI group outperformed the bipolar group. In every domain, the healthy control group outperformed both the bipolar and the MCI groups.

CONCLUSIONS

The cognitive function of euthymic bipolar patients and those diagnosed with MCI was found to be similar in most but not all domains. Both groups performed significantly less well than the comparison group of healthy subjects. It may be helpful for clinicians to conceptualize the overall level of cognitive impairment in bipolar patients as similar to that in MCI.

Elevated serum homocysteine levels in male patients with PTSD

It has been suggested that an elevated serum or plasma homocysteine level may be a risk factor for neuropsychiatric conditions such as Alzheimer's disease, schizophrenia, and depression. Because depression is closely related to anxiety disorders, and because it has been suggested that stress may be associated with an elevated homocysteine level, we studied whether serum homocysteine levels are elevated in patients with posttraumatic stress disorder (PTSD). Total serum homocysteine levels in 28 male patients with PTSD were compared to those of 223 healthy controls. The effect of PTSD on the serum homocysteine level was significant (F=42.96, P<.0001). In a regression model for the PTSD patients, the duration of PTSD was found to predict serum homocysteine levels (t=2.228, P=.035). Our results suggest that elevated levels of homocysteine in male patients with PTSD may be related to pathophysiological aspects associated with the chronicity of this disorder.