A. Mark Clarfield

The Identification of Frailty: A Systematic Literature Review

An operational definition of frailty is important for clinical care, research, and policy planning. The literature on the clinical definitions, screening tools, and severity measures of frailty were systematically reviewed as part of the Canadian Initiative on Frailty and Aging. Searches of MEDLINE from 1997 to 2009 were conducted, and reference lists of retrieved articles were pearled, to identify articles published in English and French on the identification of frailty in community‐dwelling people aged 65 and older. Two independent reviewers extracted descriptive information on study populations, frailty criteria, and outcomes from the selected papers, and quality rankings were assigned. Of 4,334 articles retrieved from the searches and 70 articles retrieved from the pearling, 22 met study inclusion criteria. In the 22 articles, physical function, gait speed, and cognition were the most commonly used identifying components of frailty, and death, disability, and institutionalization were common outcomes. The prevalence of frailty ranged from 5% to 58%. Despite significant work over the past decade, a clear consensus definition of frailty does not emerge from the literature. The definition and outcomes that best suit the unique needs of the researchers, clinicians, or policy‐makers conducting the screening determine the choice of a screening tool for frailty. Important areas for further research include whether disability should be considered a component or an outcome of frailty. In addition, the role of cognitive and mood elements in the frailty construct requires further clarification.

Fragmentation of Care for Frail Older People— an International Problem. Experience from Three Countries: Israel, Canada, and the United States

Cross‐national comparisons of healthcare systems can help us to better understand them and to offer possible solutions for problems identified within these jurisdictions. Because multiple discontinuities present in most healthcare systems interfere with the appropriate clinical care of frail older people, we were interested in comparing the situation in three countries with markedly different healthcare systems. At one end of the spectrum we find Canada, with an almost fully socialized system. At the other stands the United States, where market forces are allowed the freest rein in any developed nation. Israel offers an intermediate model with elements held in common with both the U.S. and Canadian systems.

Ethical Issues Relating to the Use of Antimicrobial Therapy in Older Adults

This article aims to review the literature relating to the ethics of antibiotic prescription decisions in older adults and to offer some suggestions as to how one might approach these difficult problems. According to many studies, most patients and their family members wish to receive antibiotics even when they are terminally ill or suffering from advanced dementia. Health care professionals are also frequently reluctant to deny the use of antibiotics in such situations. We suggest that the difficult decisions regarding whether one should withhold treatment can be based on consideration of the ethical principles of autonomy, beneficence, nonmaleficence, and justice. From the public health point of view, one should also take into account the need to avoid the emergence of antimicrobial resistance, keeping in mind the balance between the benefit to the specific patient and the cost to future patients. Infectious diseases consultants should actively participate in these ethical dilemmas.

Country Profile: Israel

srael, a small country situated at the eastern end of the I Mediterranean Sea, has a population of just over 6 million, nearly 80% of whom are Jews and the rest of whom are Arabs (Muslims, Christians, and Druze). Israel has witnessed a growth in its older population (age 65 and older) from less than 4% at independence in 1948 to almost 10% in 1999. In the Jewish population, 11.6% are aged 65 and older, whereas in the non-Jewish population, only 3.8% are 65 and older. Life expectancy at birth (as measured in 1997) is at a level similar to that in other developed nations: 80.1 years for women and 75.9 years for men. Approximately 21.5% of the women and 12.5% of the men who were born between 1993 and 1997 (assuming that mortality rates remain constant) will live to age 90. Comparing life expectancy rates with those of other countries, Israeli men do especially well, ranking fourth in the world (just below Sweden and better than American rates). For reasons not entirely understood to date, Israeli women are ranked only 18th in the world, although this is still higher than their American counterparts.2 Although relatively high fertility rates (3.0 children per woman in 1998) have ensured that Israel remains, with respect to its proportion of older citizens, one of the youngest of the developed countries, it has experienced a phenomenal increase in the absolute numbers of its older people, due to a combination of both immigration and natural growth. In the 50 years since the foundation of the state, the number of those aged 65 and older has increased by more than 1400%. Just within the last decade, the recent wave of immigration from the countries of the former Soviet Union has enlarged the older population considerably. Over the last decade alone, the population aged 65 and older increased in absolute terms by 45%, and nearly onefifth of these are new immigrants. In the next decade, the number of those 65 and older is expected to increase by a further 22%, and in the decade from 2010 to 2020, with the aging of Israeli baby boomers, the older population will once again grow by more than 40% in one decade. Clearly these large rates of increase have and will continue to strain the capacities of Israels health and social services.

The care of patients with dementia: A modern jewish ethical perspective

Patients with dementia and their families can face many difficult and agonizing ethical dilemmas over the course of the illness. An awareness of the Jewish ethical response to some of these issues can help clinicians in treating patients of the Jewish faith and also serve as an example of how one ethical system addresses these questions. The Jewish response is grounded in a profound respect and value for human life in all its forms and mans responsibility to preserve it, but Judaism rejects unproven therapies and recognizes the limitations of modern medicine. Jewish law also codifies normative obligations that children have toward their elderly parents. With these principles in the forefront, this article analyzes a Jewish ethical response to various problems in the care of the demented patient such as truth telling, transfer to a nursing home, artificial nutrition, and end‐of‐life care, taking into account modern concepts of the doctor‐patient relationship and ancient Jewish tradition.

Rembrandt's Late Self-Portraits: Psychological and Medical Aspects

The Dutch painter Rembrandt (1606–1669) left behind the largest series of self-portraits in the history of art. These paintings were produced over a period of time from age 22 years until just a few months before Rembrandts death at age 63. This series gives us a unique opportunity to explore the development, maturity, and aging of the artist. The changes in Rembrandts face and expression from one self-portrait to the next may be attributable to any combination of the following factors: normal aging changes, modifications and developments of his artistic style, alterations in the way he viewed himself, and changes in the way Rembrandt wanted us to see him. In addition, the modifications may be attributed in part to some illnesses from which the artist may have suffered and/or to a decline in his eyesight that may have influenced both his ability to detect details and his ability to paint.

Recommendations of the Canadian Consensus Conference on Dementia - Dissemination, Implementation, and Evaluation of Impact

BACKGROUNDnSubsequent to the development of consensus statements on a clinical topic, it is vital to establish a plan for dissemination, implementation and evaluation of impact. Consensus statements can be used for both guiding continuing medical education (CME) and producing clinical practice guidelines (CPGs). Insufficient attention to dissemination can lead to a failure to change physician behaviour and improve patient outcomes.nnnMETHODSnA plan to disseminate the conclusions of the Canadian Consensus Conference on Dementia (CCCD) was developed. This plan was based on a literature review of CME and CPGs. A Medline search was performed on the dissemination and evaluation of the 1989 Canadian Consensus Conference on the Assessment of Dementia (CCCAD) and other published guides for physicians on dementia care. CCCD dissemination that has occurred to date (June, 2000) was reviewed in this paper.nnnRESULTSnLectures and unsolicited printed material are weak forms of CME. Small-group interactive CME that provides practice opportunities appears to be the most effective way to change physician behaviour. The ability of CPGs to change physician behaviour is uncertain. It appears that inadequate attention has been placed on CPG dissemination and implementation. The CCCAD had a modest impact on clinical practice in Canada. While dissemination of the conclusions of the CCCD has taken place, evaluation of the impact of the CCCD has yet to be done. Local initiatives utilizing the conclusions of the CCCD are on-going.nnnCONCLUSIONSnFurther work is needed on how to optimize the impact of consensus statements and CPGs. While dissemination of the CCCD has occurred, it is currently unknown whether it has led to any change in physician practices.

Same patients, different systems: clinical implications for the care of the elderly.

n the past several years, there has been increasing interest, on both sides of the border, in a comparI ison of the Canadian and American health care systems. For example, in the last 2 years, eight articles comparing the Canadian and American systems appeared in the New England Journal of Medicine alone.- In fact, this issue has become a central topic in political campaigns on both sides of the border. There are major differences in the two health care systems. The American system is based on private insurance for both medical care and hospitalization. The government reimburses most expenses for acute medical care and hospitalization for both the needy and the elderly. Nevertheless, at least 35 million Americans do not have any form of private or public coverage.7 Virtually all elderly citizens are insured by the federally regulated and financed Medicare program. However, Medicare pays for less than 5% of nursing home care, only in the cases of subacute illness requiring constant nursing observation or for rehabilitation when the patient is making progress towards a lower level of care. Although the availability of private longterm care insurance is growing, these policies tend to be expensive and restrictive in what they are prepared to cover. On a national basis, nursing home care is paid for approximately 50% out of pocket and 50% by Medicaid, a means-tested, state-administered medical welfare program. This has created the phenomenon known as spend down where families exhaust their assets in order to pay for nursing home care. When they are finally impoverished, they qualify for Medicaid assistance. The cornerstone of the Canadian system is universal hospitalization and medical care insurance. Although there are definite differences among provinces, the basic principles are the same across the country. The system is universal; it is comprehensive in that it covers all aspects of medical care and hospitalization; it is portable from one province to another, publicly administered, and financed through taxation. Most health care institutions, from acute care hos-

Agreement Between Older Subjects and Proxy Informants on History of Surgery and Childbirth

OBJECTIVES: To assess the agreement between proxy informants reports of history of surgery and childbirth and older index subjects own recall.

Paying with Interest for a High Interest in Screening

The interesting paper by Dale et al. 1 suggests that, despite clear lack of evidence of benefit, most members of a sample of adults drawn from two university-affiliated geriatrics outpatient clinics were interested in screening and treatment for mild cognitive impairment (MCI). This phenomenon is not restricted to cognitive decline. For example, Jotkowitz et al. found that elderly patients offered carotid artery ultrasound did not understand the potentially harmful implications of a positive screening test that they had agreed to undergo. Another study, using a population-based telephone survey, found that, despite the lack of firm evidence of efficacy for prostate cancer screening, more men availed themselves of prostate-specific antigen tests than colon cancer screening, although the evidence for the latter is much better. There are several aspects of this phenomenon that deserve comment. Let us begin with an eminent British editor’s two-pronged judgment about the suitability of publication of any manuscript submitted to him: Is it new? Is it true? With respect to ‘‘true,’’ given Dale’s methodology, there is no reason to think otherwise. If so, are these results generalizable? Probably not yetFat least according to the hard evidence. However, one cannot avoid a niggling suspicion that they would be if the authors extended their study to other and larger populations. In other words, a lot of older people (supported by their doctors) would likely seek out screening for MCI. With respect to ‘‘new,’’ in a society so medicalized and in which so many patients and practitioners believe in a ‘‘can do’’ kind of approach (or to use an earlier term, ‘‘heroic medicine’’), perhaps Dale et al.’s results will come as no surprise. However, as the authors point out, MCI does not meet most of the usual criteria for screening: that the condition must be common (it is); that there must be a valid, acceptable test to identify it (there is not); that there must be an efficacious treatment available (not yet); and finally, overall, that the benefits of screening, with resultant early diagnosis and subsequent treatment, must outweigh the harm in not offering this maneuver (probably not). Even for Alzheimer’s disease, for which MCI is arguably a precursor, no authoritative body of which I am aware recommends screening. So if there is no hard evidence for early detection, why would some patients want such a service, and what possible harm apart from a waste of resources could accrue even if screening is not beneficial? To begin with the first question, we in the medical profession are largely responsible for the present state of affairs. The history of screening goes back to at least the middle of the 19th century, when a British physician, Horace Dobell, proposed ‘‘as the only means by which to reach the evil and to obtain the good, that there should be instituted, as a custom, a system of periodical examination, to which all persons should submit themselves.’’ Relevant to, among other issues, screening for MCI, Han points out, that ‘‘Central to his [Dobell] thesis were the notion that diseases are preceded by ‘preexistent physiological states’ of ‘low health’ and the idea that therapeutic efforts are more effective at these earlier stages.’’ Other physicians and soon too the insurance industryFespecially but not exclusively in the United StatesF joined the crusade. Of interest (especially to geriatricians given the name of the organization he founded) will be the person of Eugene Lyman Fisk, who in 1913 opened the ‘‘Life Extension Institute,’’ devoted to performing periodic health examinations on behalf of life insurance companies. So, over the last 150 years, it appears that the professionals, with the more recent collusion of various interest groups (organizations as the Alzheimer’s societies and cancer associations) and an unusually uncritical media (scientific and popular) have sold the public a bill of goodsFthe value of which often remains questionable. There is no doubt that childhood immunizations and avoiding smoking are examples of efficacious preventive measures. And, most probably, the early diagnosis and treatment of conditions such as hypertension and hypercholesterolemia, at least in certain groups, are also beneficial. But in many cases, we in the profession and our patients as well have gone far beyond the evidence. Recommending screening for Alzheimer’s disease and especially for MCI are good examples of where magical thinking trumps scientific logic. Can such screening actually be harmful? In some conditions, yes. For example, where the criterion standard (gold standard) confirmation or resulting therapy has a high risk/benefit ratio, indeed overall, more harm than good can often result. In the field of dementia, a universal neuroimaging policy will result in some proportion of patients being harmed by surgery, in an often futile attempt to repair a rare case of normal-pressure hydrocephalus. Will these be fewer than the number cured? No one knows, but there is some evidence that more will be harmed than helped. Moving caudad down the human frame, an uncritical approach to prostate-specific antigen testing and the resultant surgery for a disease that many older men will die with rather than of often causes a great deal of harm to continenceFurinary and sexual, not to speak of sometimes causing death. DOI: 10.1111/j.1532-5415.2006.00885.x