Robert Hammerman-Rozenberg

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

BACKGROUND Recommendations 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. METHODS Mortality 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. RESULTS Among 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). CONCLUSIONS Among 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.

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.

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.

Holocaust Survivors in Old Age: The Jerusalem Longitudinal Study

OBJECTIVES: To examine the hypothesis that Holocaust exposure during young adulthood negatively affects physical aging, causing greater morbidity, faster deterioration in health parameters, and shorter survival.

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

PURPOSE To 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. MATERIALS AND METHODS Longitudinal, 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. RESULTS 89.6% 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. CONCLUSIONS These 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.

Home hospital care.

To the Editor: In a recent review of the first issue of the ]ournal of the American Geriatrics Society, * I pointed out the existence of a phenomenon that I thought, by now, had died a natural and welcome death. When geriatrics was still in its pediatric stage, it was, perhaps, acceptable for research relating extensively to “older” patients to examine subjects in their 50s and 60s (even in their 40s). But to read in the pages ofJAGS today, as we enter the millennium, an otherwise fine study’ (and to be fair, it is not the only such miscreant) that examines two groups aged 63 ( 2 1) years and 58 ( 2 1) years seems to me to point to a certain lack of progress in our field. It is true that the age range of the patients included those aged 80 and that the study offered a 7.3-year average follow-up. However, in the data included, most of the patients were not even in the young-old category (65-74) much less in the old-old (75 + ) age group. Perhaps 50 years ago,]AGS could allow itself to publish research on subjects in middle age or the young-old (and I must admit that my own personal sensitivities to this issue might be because I am about to enter my sixth decade). But, given the development of our field, I believe that our present research should concentrate primarily, if not exclusively, on frail older people, most of whom are in the old-old age category. Others will investigate the middle-aged, but only geriatricians will focus their research efforts primarily on the very old. It is my contention that journals such as JAGS should reflect this need.