עמירם כ"ץ, יאיר שפירא

המח' לשיקום ד', ביה"ח "לוינשטיין", רעננה, ביה"ח "אסותא", תל-אביב

לאדם, כמו ליונקים אחרים, מנגנון ויסות-טמפרטורה שנועד לשמר את טמפרטורת הגוף בטווח המאפשר פעילות פיזיולוגית תקינה. בגיל הזיקנה, משתבש מנגנון זה ואיננו יעיל כמו בגיל צעיר. לשיבוש זה סיבות אפשריות אחדות, וקיימים חילוקי דעות בין החוקרים על המשמעות של חלק מהן.

אפרים אייזן

המרכז הגריאטרי שיקומי פלימן, חיפה הפקולטה לרפואה, הטכניון, חיפה

נפילות מהוות את אחת מבעיות הבריאות הקשות והשכיחות ביותר בקרב קשישים. נפילות נישנות בקרב קשישים מהוות סימן לתשישות, הפרעות בתנועה ומחלות כרוניות וחדות. נפילות כשלעצמן עלולות להחמיר קשיים בתיפקוד בקשיש כתוצאה מפציעות, הגבלות פעילות, פחד מנפילות ואיבוד תנועתיות ועצמיות, תופעה זו היא הגורם השכיח ביותר לפציעות בלתי מכוונות ולשברים בקרב קשישים.

נפילה מוגדרת כאירוע שבעיקבותיו האדם מוצא עצמו באופן לא מכוון על מישטח אחר, הנמצא נמוך ממקום הימצאו הקודם. נפילות המתרחשות עקב הפעלת כוח חיצוני רב (לדוגמה, תאונת דרכים), פעילות ספורטיבית או תקיפה, אינן נכללות בדרך כלל במסגרת האמורה. הגורמים וגורמי הסיכון לפנילות אלה בדרך כלל שונים ומהווים נושא נפרד.

אביטל פורטר, אלכסנדר בטלר, דוד חסדאי

המערך לקרדיולוגיה, מרכז רפואי רבין, קמפוס בילינסון, פתח תקוה

מחלת לב כלילית מהווה את הגורם העיקרי לתמותה בעולם המערבי בכלל ובאוכלוסיית הקשישים בפרט. באופן כללי, הטיפול הניתן לחולה הקשיש הלוקה בתיסמונת כלילית חדה, הן בשלב החד והן כטיפול ממושך, נרחב פחות ופולשני פחות מזה הניתן לחולה הצעיר ואינו תואם את ההנחיות המקובלות.

חריגויות אלה מבטאות כנראה את תחושת הרופאים, שסיכויי הצלחת הטיפול נמוכים בחולה הקשיש, נוכח מחלות רקע רבות, שכיחות גבוהה של מחלה כלילית רב-כלית, וזמן ממושך יותר, יחסית לצעירים, עד קבלת סיוע רפואי.

המטרות בסקירה זו הן: 1) לבחון את הידוע כיום בספרות אודות טיפול תרופתי ופולשני בחולה הקשיש הלוקה בתיסמונת כלילית חדה; 2) לנסות לענות על השאלה, האם גיל צריך להוות שיקול בגיבוש העמדה הטיפול בתיסמונות כליליות חדות.

Heart Rate Variability with Spells of Unconsciousness in the Elderly

H. Semo, S. Feldman, A. Adunsky

Dept. of Geriatric Medicine and Neufeld Institute of Cardiology, Sheba Medical Center, Tel Hashomer

Presyncope, syncope and falls in undetermined circumstances are frequent among the elderly. They may be caused by orthostatic hypotension secondary to autonomic insufficiency. Tilt-tests and determination of catecholamines in serum and urine may establish the diagnosis, but often may not be feasible in these patients.

A simple, indirect, noninvasive technique to assess autonomic insufficiency is analysis of heart rate variability during Holter-monitoring. We present 5 cases in which it proved useful in the investigation of spells of unconsciousness.
 

זאב פילדמן¹, זאב קורשון¹, זאב ארינזון¹, רינת פרידמן²

¹מרכז רפואי לגריאטריה, נתניה, ²"נופי השרון", דיור מוגן, נתניה

התלונה על נדודי שינה אופיינית לקשישים ובד"כ מתמידה. שכיחותה עולה עם הגיל ומדווחת אצל נשים, גרושים או אלמנים, המתגוררים לבד, ומשתייכים למעמד חברתי-כלכלי הנמוך. נדודי שינה יכולים להופיע כמחלה בפני עצמה או כביטוי להפרעות פסיכיאטריות, פיזיולוגיות, או על רקע טיפול תרופתי.

המטרה בסקירה: להרחיב את המודעות לנושא נדודי השינה בקרב קשישים ולהרחיב את הנושא, בעיקר בנוגע לשינויים הפיזיולוגיים ולגישה הטיפולית.
 

Nutritional Status and Vitamin B⁶ Supplementation in the Institutionalized Elderly

Felicia Stern, Yitshal N. Berner, Zeev Polyak, Sophya Bernadiner, Margarita Komarnitsky, Ben Ami Sela, Ram Doolman, Yoseph Dror

Institute of Biochemistry, Food Science, and Nutrition, Hebrew University of Jerusalem; Subacute Dept. and Clinical Nutrition, Hartzfeld Geriatric Hospital, Kaplan Medical Center, Gedera; and Institute of Chemical Pathology, Sheba Medical Center, Tel Hashomer

Nutritional status and vitamin B⁶ status were assessed in 18 men and 32 women, average age 84, living in a home for the aged. Average proportion of energy derived from protein was higher than the recommended; fiber intake was very low. Also low were intakes of calcium, magnesium, zinc, copper, vitamins D and E, thiamin, folic acid and vitamin B⁶.

Supplementation with vitamin B⁶ (10mg/d) for 28 days in those with the lowest B⁶ status assessed by B⁶ intake, activation coefficient of aspartate transaminase and plasma pyridoxamine concentrations led to improved B⁶ status (marked decrease in activation coefficient) and increased synthesis and decreased degradation of many short-lived neutrophil proteins. Though our elderly enjoy a variety of foods, some have marginal deficiencies that can be improved. Therefore, in the institutionalized elderly, micronutrient supplementation should be administered at a level low enough to be safe (below recommended upper level of intake) but high enough to be effective.

Mortality in Fractures of the Hip 

Y. Titiun, Z. Eshkol, Z. Horesh, M. Soudry

Dept. of Orthopedic Surgery, Beilinson Campus, Rabin Medical Center, Petah Tikva

Prevalence of hip fractures is increasing world-wide, as the mean age of populations increases. Despite advances in anesthesia, nursing care, and surgical techniques, hip fractures remain a significant cause of morbidity and mortality in the elderly.

We operated on 65 cases of hip fractures from 1995 to the end of 1997: average age was 82.9, 72% were women, average waiting time for operation was 1.6 days, perioperative mortality was 3.5% and postoperative mortality 26.2%.

Multiresistant Escherichia Coli from Elderly Patients

Ilana Slucky-Shraga, Moshe Wolk, Sofia Volis, Israel Vulikh, David Sompolinsky

Dept. of Medicine and Microbiology Laboratory, Mayanei Hayeshua Hospital, Bnei Brak; Central Laboratories, Ministry of Health, Jerusalem; and Faculty of Life Sciences, Bar Ilan University, Ramat Gan

We examined all ceftriaxone-resistant Escherichia coli isolates obtained from clinical samples during 16 months (1‚Dec. '97 - 31 Mar. '99). A total of 97 resistant isolates from 36 patients were obtained, mostly from urine specimens. Of these patients, 35/36 were over 75 years old, most lived in nursing homes, were dependent on nursing in their daily lives, and were incontinent and/or had indwelling catheters.

All 97 isolates had similar susceptibility profiles: resistant to ciprofloxacin, gentamicin, ampicillin, amoxycillin/clavulanate, tricarcillin/clavulanate, aztreonam, and cefuroxime; decreased susceptibility to ceftazidime and cefepime; and susceptible to imipenem and meropenem. Double-disc tests indicated that all strains produced extended spectrum beta-lactamase(s). All the isolates belonged to 1 of 3 E. coli serotypes: 79 were 0153:H31, 13 were 0142:H10, and 5 were 0102:H6.

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.

Left Ventricular Outflow Tract Obstruction without Left Ventric-Ular Hypertrophy Treated with Ace Inhibitors

Jacob Feldman, Irit Laxer, Abraham Yaretzky

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

We describe a very unusual case of sudden, severe worsening of congestive heart failure which was caused by ACE inhibitors. Diagnosis was made by echocardiogram showing a typical picture of dynamic, left ventricular outflow tract obstruction without left ventricular hypertrophy, which disappeared on discontinuing ACE inhibitors. This phenomenon has already been described as a complication of other drugs such as nitrates, commonly used as provocative tests for latent obstructive cardiomyopathy. To our knowledge ACE inhibihave not been described as a causative factor.

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.

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.

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.

Polyneuropathy in Critical Illness

M. Mouallem, A. Adunsky, H. Semo, M. Dolgopiat

Depts. of Medicine E, Geriatrics, and Neurological Rehabilitation, Sheba Medical Center, Tel Hashomer and Sackler School of Medicine, Tel Aviv University

Critical illness polyneuropathy developed in 8 patients aged 22-84 years in our intensive care units. This acute polyneuropathy, predominantly axonal and motor, develops in the setting of the systemic inflammatory response syndrome and multi-organ failure. It is found in about 50% of patients treated in intensive care units for more than 2 weeks. In those who survive, neurological and functional recovery is the rule.