Jochanan Stessman

Physical activity, function, and longevity among the very old.

BACKGROUNDnRecommendations encouraging physical activity (PA) set no upper age limit, yet evidence supporting the benefits of PA among the very old is sparse. We examined the effects of continuing, increasing, or decreasing PA levels on survival, function, and health status among the very old.nnnMETHODSnMortality data from ages 70 to 88 years and health, comorbidity, and functional status at ages 70, 78, and 85 years were assessed through the Jerusalem Longitudinal Cohort Study (1990-2008). A representative sample of 1861 people born in 1920 and 1921 enrolled in this prospective study, resulting in 17 109 person-years of follow-up for all-cause mortality.nnnRESULTSnAmong physically active vs sedentary participants, respectively, at age 70, the 8-year mortality was 15.2% vs 27.2% (P < .001); at age 78, the 8-year mortality was 26.1% vs 40.8% (P <.001); and at age 85 years, the 3-year mortality was 6.8% vs 24.4% (P < .001). In Cox proportional-hazards models adjusting for mortality risk factors, lower mortality was associated with PA level at ages 70 (hazard ratio, 0.61; 95% confidence interval, 0.38-0.96), 78 (0.69; 0.48-0.98), and 85 (0.42; 0.25-0.68). A significant survival benefit was associated with initiating PA between ages 70 and 78 years (P = .04) and ages 78 and 85 years (P < .001). Participation in higher levels of PA, compared with being sedentary, did not show a dose-dependent association with mortality. The PA level at age 78 was associated with remaining independent while performing activities of daily living at age 85 (odds ratio, 1.92; 95% confidence interval, 1.11-3.33).nnnCONCLUSIONSnAmong the very old, not only continuing but also initiating PA was associated with better survival and function. This finding supports the encouragement of PA into advanced old age.

Maggot therapy for the treatment of intractable wounds

Background Fly maggots have been known for centuries to help debride and heal wounds. Maggot therapy was first introduced in the USA in 1931 and was routinely used there until the mid‐1940s in over 300 hospitals. With the advent of antimicrobiols, maggot therapy became rare until the early 1990s, when it was re‐introduced in the USA, UK, and Israel. The objective of this study was to assess the efficacy of maggot therapy for the treatment of intractable, chronic wounds and ulcers in long‐term hospitalized patients in Israel.

Chronic back pain among the elderly: prevalence, associations, and predictors.

Study Design. A longitudinal age homogeneous cohort study. Objective. To describe the prevalence, nature, and predictors of chronic back pain (CBP) in older people. Summary of Background Data. CBP is a growing source of morbidity among the elderly. Few longitudinal studies exist, and its time course and predictors are largely undefined. Methods. The Jerusalem Longitudinal Study assessed 277 subjects aged 70 years at baseline and 77 years at follow-up. Data collection included back pain symptoms, psychosocial, functional, and physical domains. Results. The prevalence of CBP increased from 44% to 58% at ages 70 and 77 years, respectively, while frequency and severity decreased. CBP was associated with female gender, economic difficulties, loneliness, fatigue, poor self-rated health, dependence in activities of daily living, joint pain, and obesity. Depression was associated at age 70 years, and unemployment, not leaving the house for leisure, poor sleep satisfaction, hypertension, and osteoporosis were at age 77 years. Predictors of CBP at age 77 years were female gender, loneliness, joint pain, hypertension, and preexisting CBP. Unemployment and not leaving the house for leisure showed a trend toward significance. Conclusion. CBP is increasingly common in the elderly. Psychosocial factors, female gender, hypertension, and existing joint pain identify individuals most at risk.

The impact of visual impairment on health, function and mortality

Background and aims: Our aim was to determine the impact of visual impairment on self-rated health, function and mortality amongst a community-dwelling elderly cohort. Methods: The study design was prospective and longitudinal, subjects being taken from an age-homogeneous, community-dwelling cohort comprising 452 subjects aged 70 in 1990 and 839 subjects aged 77 in 1998. Comprehensive data were collected by structured interviews and medical examinations carried out during home visits. Data included each subject’s demographic and socio-economic profile, medical history, physical findings, functional status and self-rated health status. Visual acuity was measured using a Snellen chart and visual impairment was defined as best-eye corrected visual acuity of 20/40 or worse on Snellen chart testing. Results: Measured and self-reported visual impairment correlated closely, and were significantly more prevalent amongst subjects with low education and poor financial status. Visually impaired subjects showed significantly greater dependence in ADL and IADL, poor self-rated health, less ability to rely on friends, increased loneliness and, in men aged 77, increased visits to the emergency room and hospital admissions. Visual impairment at age 70 significantly predicted poor self-rated health (p=0.029, OR 2.36, 95% CI 1.09–5.10), dependence in ADL (p=0.007, OR 2.91, 95% CI 1.34–6.33), general tiredness (p=0.037, OR 2.40, 95% CI 1.06–5.44), and mortality, with a two-and-a-half-fold increase in risk of death at seven years (p=0.0017,OR 2.84, 95% CI 1.48–5.46). Conclusions: Visual impairment in the elderly increases the risk of social, functional and medical decline.

Effect of Exercise on Ease in Performing Activities of Daily Living and Instrumental Activities of Daily Living From Age 70 to 77: The Jerusalem Longitudinal Study

OBJECTIVES: To determine the prevalence of independence and ease of performance in activities of daily living (ADLs) and instrumental activities of daily living (IADLs) at ages 70 and 77 in a well‐characterized cohort and to measure the effect of regular exercise at age 70 on independence and ease of performance 7 years later.

Changing Profile of Health and Function from Age 70 to 85 Years

Background: Old age has traditionally been considered to begin at age 65. The improving health and functional status observed among older people may necessitate reevaluation of this cut-off point. Objective: To present the changing prevalence of common geriatric syndromes, functional parameters, common disease status and health care utilization, at ages 70, 78 and 85, in order to help address the question of when does contemporary aging actually begin. Methods: Medical, psychosocial, cognitive, and functional status, and health service utilization at age 70, 78 and 85 were assessed through the Jerusalem Longitudinal Cohort Study (1990–2010), which prospectively followed a representative sample (born 1920–1921), of 1,861 people, all of whom underwent home-based comprehensive assessment. Results: At age 70, the cohort had good health, low comorbidity, preserved cognition, mobility and independence in basic and instrumental activities of daily activities (ADL). Rising comorbidity, declining cognitive status, increasing depression, and difficulty in ADLs were seen at 78. By age 85, compared to age 70, comorbidity had tripled, depression, hearing and visual impairment, falls, dizziness and mobility problems had doubled; 23% of subjects had cognitive impairment, 42.5% suffered urinary incontinence, and dependence in basic and instrumental ADLs was common (37.8 and 51.7%, respectively). Home care was 4.5, 10.1, and 24.6%, and hospitalization in the previous year occurred among 12.3, 18.8 and 27.8% at ages 70, 78 and 85, respectively. Conclusions: At age 70, the overall health profile was favorable, prevalence of geriatric syndromes was low, cognitive and functional status was preserved, and health service utilization was low. The progressive deterioration seen at ages 78 and more profoundly so at age 85, suggest that a cut-off point beyond age 70 years may serve to better define entry into old age.

MODELS OF GERIATRICS PRACTICE: Decreased Hospital Utilization By Older Adults Attributable to a Home Hospitalization Program

OBJECTIVE: To evaluate the cost effectiveness of a short‐term home health care program for older people, Home Hospitalization (HH), compared with the alternative of regular ambulatory care with general or geriatric hospitalization as necessary.

Sex Differences in the Effect of Heart Rate on Mortality in the Elderly

Objectives:u2002 To examine the association between heart rate and mortality risk in the elderly.

Strategies to enhance longevity and independent function: the Jerusalem Longitudinal Study

PURPOSEnTo analyze the impact of medical and social factors on survival and function from age 70 to 82 and point to possible genetic basis for differences.nnnMATERIALS AND METHODSnLongitudinal, cohort study of a representative sample of Jerusalem residents, born 1920-1921. At age 70, 463 subjects underwent a thorough interview eliciting social determinants as well as a medical history and examination and laboratory investigation. At age 77,265 of the survivors, 71%, were re-examined. In 2002, all death certificates in Israel were reviewed. End points were performance of basic and advanced tasks with ease at age 77 and survival to age 82 or life span in subjects who had succumbed. The independent influence of each factor was tested using logistic regression.nnnRESULTSn89.6% of women were alive after 6 years and 77.4% after 12. Survival for men was 79.9% and 59.8%, respectively. Social factors predominated in the correlation with longer life: financial security, p=.0004; volunteer activity, p=.0002; regular exercise, p=.0002; positive self-assessed health, p<.0001; and activities of daily living (ADL) independence, p<.0001. Less striking but significant correlation for longevity was noted for avoiding naps, p=.04 and instrumental activities of daily living (IADL) independence, p=.048. Medical conditions associated with increased mortality included diabetes, p<.0001; coronary artery disease, p=.0002; impaired vision, p=.0007; and renal insufficiency, p=.008. Anemia and disturbed sleep did not independently correlate with mortality while the association with hypertension did not reach statistical significance, p=.056. In a regression to determine the independent impact of medical and social factors on mortality, unimpaired renal function, good vision, avoiding afternoon naps, volunteer or compensated work, physical activity and IADL independence all correlated with improved survival. Moreover, good vision, volunteer work or work for pay and physical activity were independently associated with continued ADL independence after 7 years.nnnCONCLUSIONSnThese findings highlight the ability of social, economic and functional factors to modify genetic influence on survival and function. Increased physical and social activity is an important tool to lengthen the span of robust function. The role of heredity in determining function and mortality may be expressed through diverse pathways.

Home hospitalization in the spectrum of community geriatric care

The Home Hospitalization Programme was initiated in Jerusalem in 1991 to provide intensive medical care at home in order to prevent or shorten hospitalizations. The programme was based upon regular home visits by physicians, and nursing assessment to determine the need for regular nursing care. Primary-care physicians and nurses were renumerated by a global monthly fee, and were on 24-h call in addition to their periodic visits. Patients were recruited by senior geriatric physicians from acute hospital wards, as well as from the community, at the family doctors request. Ancillary services available to the home hospitalization team included laboratory and electrocardiographic testing, specialty consultations, physical occupational or speech therapy, social work and home help up to 3 h daily. Monthly visits by a senior physician provided oversight and further consultation. Home hospitalization grew out of the continuing care division of the Clalit Sick Fund, a health maintenance organization providing umbrella medical insurance and ambulatory care. The programme grew synergistically with the other facilities of continuing care to encompass a network of comprehensive services to acute, subacute and chronic patients both at home and in institutional settings. In 4 years this network succeeded in establishing the focus of subacute intensive care in the community, achieving high levels of patient and family satisfaction, as well as striking economic advantages. In its first 2 years of operation home hospitalization saved S4 million due to reduced hospital utilization, and preliminary data for the subsequent 2 years indicated that this trend continued. Home hospitalization became the hub of a far-reaching system of supportive, intensive and humane care in the community.