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Barenholtz Levy H.,HbL PharmaConsulting | Marcus E.-L.,Herzog Hospital
Annals of Pharmacotherapy | Year: 2016

The 2 most widely used explicit criteria regarding inappropriate medication use in older adults are the American Geriatrics Society’s Beers Criteria and the Screening Tool of Older People’s Prescriptions/Screening Tool to Alert to Right Treatment (STOPP/START). Both documents were updated recently. They are important educational tools that highlight medications for which risks of use may often exceed benefits in older adults and situations in which potentially appropriate medications should be considered for use. The application of these tools has the potential to significantly affect patient care. Thus, it is important for clinicians to be familiar with both documents. © 2016, © The Author(s) 2016.


Jaul E.,Herzog Hospital | Jaul E.,Hebrew University of Jerusalem
Drugs and Aging | Year: 2010

Pressure ulcers (pressure sores) continue to be a common health problem, particularly among the physically limited or bedridden elderly. The problem exists within the entire health framework, including hospitals, clinics, long-term care facilities and private homes.For many elderly patients, pressure ulcers may become chronic for no apparent reason and remain so for prolonged periods, even for the remainder of the patients lifetime. A large number of grade 3 and 4 pressure ulcers become chronic wounds, and the afflicted patient may even die from an ulcer complication (sepsis or osteomyelitis).The presence of a pressure ulcer constitutes a geriatric syndrome consisting of multifactorial pathological conditions. The accumulated effects of impairment due to immobility, nutritional deficiency and chronic diseases involving multiple systems predispose the aging skin of the elderly person to increasing vulnerability.The assessment and management of a pressure ulcer requires a comprehensive and multidisciplinary approach in order to understand the patient with the ulcer. Factors to consider include the patients underlying pathologies (such as obstructive lung disease or peripheral vascular disease), severity of his or her primary illness (such as an infection or hip fracture), co-morbidities (such as dementia or diabetes mellitus), functional state (activities of daily living), nutritional status (swallowing difficulties), and degree of social and emotional support; focusing on just the wound itself is not enough. An understanding of the physiological and pathological processes of aging skin throws light on the aetiology and pathogenesis of the development of pressure ulcers in the elderly.Each health discipline (nursing staff, aides, physician, dietitian, occupational and physical therapists, and social worker) has its own role to play in the assessment and management of the patient with a pressure ulcer. The goals of treating a pressure ulcer include avoiding any preventable contributing circumstances, such as immobilization after a hip fracture or acute infection. Once a pressure ulcer has developed, however, the goal is to heal it by optimizing regional blood flow (by use of a stent or vascular bypass surgery), managing underlying illnesses (such as diabetes, hypothyroidism or congestive heart failure) and providing adequate caloric and protein intake (whether through use of dietary supplements by mouth or by use of tube feeding). If the ulcer has become chronic, the ultimate goal changes from healing the wound to controlling symptoms (such as foul odour, pain, discomfort and infection) and preventing complications, thereby contributing to the patients overall well-being; providing support for the patients family is also important. Recent advances in wound dressings allow for greater control of symptoms and prevention of complications, and have also enabled the affected patient to be integrated more readily into the family setting and in the community at large. Ethical and end-of-life issues must also be addressed soon after the wound has become chronic.This article discusses the pathogenesis of pressure ulcer development in the elderly in relation to concomitant diseases, risk factor assessment and the management of such ulcers. © 2010 Adis Data Information BV. All rights reserved.


Weinstock M.,Hebrew University of Jerusalem | Luques L.,Hebrew University of Jerusalem | Poltyrev T.,Hebrew University of Jerusalem | Bejar C.,Hebrew University of Jerusalem | Shoham S.,Herzog Hospital
Neurobiology of Aging | Year: 2011

Oxidative stress and glial activation occur in the aging brain. Ladostigil is a new monoamine oxidase (MAO) and acetylcholinesterase (AChE) inhibitor designed for the treatment of Alzheimer's disease. It has neuroprotective and antioxidant activities in cellular models at much lower concentrations than those inhibiting MAO or AChE. When ladostigil (1 mg/kg/day) was given for 6 months to 16-month-old rats it prevented the age-related increase in activated astrocytes and microglia in several hippocampal and white matter regions and increased proNGF immunoreactivity in the hippocampus towards the levels in young rats. Ladostigil also prevented the age-related reduction in cortical AChE activity and the increase in butyrylcholinesterase activity in the hippocampus, in association with the reduction in gliosis. The immunological and enzymatic changes in aged rats were associated with improved spatial memory. Ladostigil treatment had no effect on memory, glial or proNGF immunoreactivity in young rats. Early treatment with ladostigil could slow disease progression in conditions like Alzheimer's disease in which oxidative stress and inflammatory processes are present. © 2009 Elsevier Inc.


Gold A.,Herzog Hospital | Lichtenberg P.,Herzog Hospital | Lichtenberg P.,Hebrew University of Jerusalem
Journal of Medical Ethics | Year: 2014

Placebos are arguably the most commonly prescribed drug, across cultures and throughout history. Nevertheless, today many would consider their use in the clinic unethical, since placebo treatment involves deception and the violation of patients' autonomy. We examine the placebo's definition and its clinical efficacy from a biopsychosocial perspective, and argue that the intentional use of the placebo and placebo effect, in certain circumstances and under several conditions, may be morally acceptable. We highlight the role of a virtuebased ethical orientation and its implications for the beneficent use of the placebo. In addition, the definitions of lying and deception are discussed, clarified and applied to the clinical placebo dilemma. Lastly, we suggest that concerns about patient autonomy, when invoked as a further argument against administering placebos, are extended beyond their reasonable and coherent application.


Jaul E.,Herzog Hospital | Jaul E.,Hebrew University of Jerusalem
Ostomy Wound Management | Year: 2011

Local (extrinsic) and systemic (intrinsic) risk factors for the development of pressure ulcers over bony prominences such as the sacrum, coccyx, ischium, gluteal area, and leg area (heels) have been extensively studied and documented. Several case studies have described (but little is known about) pressure ulcers in atypical anatomical locations. A descriptive pilot study was conducted to document the occurrence, cause, prevention, assessment, and treatment of pressure ulcers in atypical anatomical locations. Thirty-two (32) patients (53% female) in a skilled geriatric long-term care nursing department participated in the 6-month study. All patients were immobile (100%) and most had feeding (91%) and neurological problems (80%). All care was provided by a multidisciplinary team. Twenty-six (26) new ulcers developed during the course of the study. Of those, 13 (40% occurrence rate) were in an atypical location and were found to have an uncommon pathogenesis. A review of the data showed that six (6) pressure ulcers were associated with medical devices (tubes, catheters, and tapes for affixation), four (4) with increased spasticity, and three (3) with bone deformity. The ulcers associated with medical devices (iatrogenic) were observed at the site of insertion or device placement; ulcers associated with spasticity or bone deformity were noted at the site of increased muscle tone and pressure. Using a multidisciplinary specialty and team approach, underlying risk factors were addressed as part of the wound care protocol. Although the study duration was short and the sample size small, these results suggest that the incidence of atypical pressure ulcers in immobile patients with multiple comorbidities may be underreported and underestimated. Additional studies are needed to increase awareness and understanding about the scope of this problem and to develop targeted approaches to prevention and care.


Greenberg D.,Herzog Hospital | Huppert J.D.,Hebrew University of Jerusalem
Current Psychiatry Reports | Year: 2010

The earliest descriptions of obsessive-compulsive disorder (OCD) were religious, as was the understanding of their origins. With the emancipation, religion in OCD was relegated to its status today: a less common symptom of OCD in most Western societies known as scrupulosity. The frequency of scrupulosity in OCD varies in the literature from 0% to 93% of cases, and this variability seems predicated on the importance of religious belief and observance in the community examined. Despite the similarities between religious ritual and compulsions, the evidence to date that religion increases the risk of the development of OCD is scarce. Scrupulosity is presented as a classic version of OCD, with obsessions and compulsions, distress, and diminished functioning similar to those of other forms of OCD. The differentiation between normal religiosity and scrupulosity is presented, and the unique aspects of cognitive-behavioral therapy in treating scrupulosity, especially in religious populations, are reviewed. © Springer Science+Business Media, LLC 2010.


Levy H.B.,HbL PharmaConsulting | Marcus E.-L.,Herzog Hospital | Christen C.,University of Michigan
Annals of Pharmacotherapy | Year: 2010

OBJECTIVE: To provide a comparative overview of explicit criteria that have been developed since 2003 for inappropriate prescribing in older adults and to contrast these newer criteria with the most recent Beers criteria, published in 2003. DATA SOURCES: MEDLINE and Google Scholar searches were performed from 2003 through July 2010. Within MEDLINE, MeSH terms included aged, drug prescriptions, medication errors, and polypharmacy. Free-text search terms included elderly, guideline adherence, inappropriate prescribing, and medications. Related articles, as identified by MEDLINE, were used as well. Free-text search was performed on Google Scholar, using "potentially inappropriate prescribing elderly." Additional articles were identified in reference lists of key articles. STUDY SELECTION AND DATA EXTRACTION: Studies were selected if they were published after the most recent revision of the Beers criteria in 2003 and addressed the development and application of explicit criteria for the elderly. We independently reviewed pertinent literature to extract key information. DATA SYNTHESIS: The first explicit criteria published were the Beers criteria, and most research regarding inappropriate medication use applied these criteria. Criteria developed subsequent to the Beers criteria include the French Consensus Panel list, STOPP (Screening Tool of Older Persons' Prescription) and START (Screening Tool to Alert doctors to Right Treatment), the Australian Prescribing Indicators tool, and the Norwegian General Practice Criteria. Newer criteria offer several improvements on the Beers criteria, namely drug-drug interactions, omission of potentially beneficial therapy, and more broadly applicable criteria across international borders. CONCLUSIONS: Although no criteria may ever be globally applicable, STOPP and START make significant advances. Regional drug availability, economic considerations, and clinical practice patterns impact criteria selection. Research to validate the several newer criteria in various practice settings and to explore the effect of adhering to the guidelines on patient outcomes is warranted. Data from such research will aid practitioners in identifying preferred criteria.


Gold A.,Herzog Hospital
Journal of the American Academy of Psychiatry and the Law | Year: 2012

The historical origin of modern forensic psychiatry, as well as the circumstances of its evolution, may be defined and described from several vantage points. In this article I present a critical reading of Richard J. Bonnie's article, published in the Journal, in which he assigned the budding of modern forensic psychiatry to the 20th century. Although I concur with Bonnie's historical analysis, as well as with his underlying moral approach, I suggest that, to attain a broader view of the contribution of forensic psychiatry, it is important to be open to additional narratives of its development. The supplemental narrative that I offer highlights values other than those that were highlighted by Bonnie that are deeply rooted and equally inherent in the practice of forensic psychiatry. Thus, awareness of the two complementary narratives enables a stereoscopic view that encompasses the full picture regarding the roots of forensic psychiatry.


Jaul E.,Herzog Hospital
European Geriatric Medicine | Year: 2011

Pressure ulcers (PU) result from multi-factor causes and are prominent as a geriatric syndrome. Once a PU develops and is identified, the patient is entered into the medical system. The need for multidisciplinary assessment and treatment arises to determine preventability, systemic/acute problems, nutritional needs, disability, social/family resources (Jaul, 2010 [3]). Initially, PU grades 1-2 are treated at home by the local nurse or home care nurse. If the PU is grade 3-4, the patient is generally admitted to a general medical inpatient unit (acute problem), and from there, is transferred directly to the skilled nursing department (SND). A similar procedure is followed if the PU develops in a nursing home. The SND geriatric approach is to treat the patient as a whole, systemic and locally, and to provide quality of life for the patient and family by at least controlling the accompanying symptoms even if PU are not healing. © 2011 Elsevier Masson SAS and European Union Geriatric Medicine Society.


Hamama-Raz Y.,Ariel University | Zabari Y.,Herzog Hospital | Buchbinder E.,Haifa University
Qualitative Health Research | Year: 2013

In this study we examined the meaning of being the wife of a vegetative patient over time. The research was based on semistructured interviews with 12 wives of husbands who were diagnosed with persistent vegetative state between 1 year 2 months and 10 years prior to the interview. We found that there were two contradicting forces common to all of the wives across time. First, there was a process of finding significance in the situation based on acceptance of the husband's condition and focusing on positive emotions and values such as love, commitment, and loyalty. Second, the wives described an increase in negative emotions such as sadness, pain, loneliness, loss, and grief. These findings are discussed in the context of research and theoretical literature about coping processes and the meaning of caring for patients in a persistent vegetative state. © The Author(s) 2013.

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