the attitude towards the elderly

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THE ATTITUDE TOWARDS THE ELDERLY “Thou shalt rise up before the hoary head, and honour the face of the old man...” (Leviticus 19:32)

A Downton Lace Maker. Bertha Newcombe.

Unique Medical Research in Biblical Times from the Viewpoint of Contemporary Perspective Examination of Passages from the Bible, Exactly as Written

Liubov Ben-Nun, M.D., M.S. Professor Emeritus at Ben Gurion University of the Negev, Faculty of Health Sciences, Beer-Sheva, Israel.

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Aging is a multidimensional and multidirectional process. What is the Biblical attitude towards the elderly? What is a contemporary attitude towards the elderly? What is pacing of time? Autonomy of the elderly? Patients' integrity? Geriatric rehabilitation? What are the attitudes towards various diseases? Is the Biblical attitude implemented in our society? Are there negative attitudes towards the elderly? Contemporary interpretation of currently available ancient literature on the older people is important since it allows us to better understand the roots of modern geriatrics. By studying this literature, modern physicians can expand their knowledge and thus improve their professional skills. The present research examines these issues in Biblical Times from the Viewpoint of contemporary perspective.

Author: Dr. Liubov Ben-Nun, Specialist of Family Medicine, Professor Emeritus at Ben Gurion University of the Negev, Faculty of Health Sciences, Beer-Sheva, Israel.

95th Book Published by : B.N. Publication House. Israel. 2017. E-Mail: [email protected] Technical Assistance: Ilana siskal All rights reserved

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CONTENTS FOREWORD INTRODUCTION THE BIBLICAL DESCRIPTION PACING OF AGING AUTONOMY OF ELDERLY PATIENT'S INTEGRITY GERIATRIC REHABILITATION CARDIAC REHABILITATION STROKE/POSTSTROKE RECOVERY MUSCULOSKELETAL DISORDES FRACTURES AMPUTATIONS ELDERLY MISTREATMENT AND ABUSE ATTITUDES TOWARDS THE ELDERLY MEDICAL CONDITIONS ISCHEMIC HEART DISEASE PREVENTION HYPERTENSION DIABETES RESUSCITATION OSTEOARTHRITIS URINARY INCONTINENCE DEPRESSION DEMENTIA TERMINALLY ILL PATIENTS PAIN MANAGEMENT MEDICAL PROFESSIONS PHYSICIANS' AND NURSES' VIEWS STUDENTS' AND RESIDENTS' PERCEPTIONS GERIATRIC EDUCATION CHOOSING A CARRIER IN GERIATRICS SUMMARY

6 8 10 10 13 17 23 25 34 37 39 43 46 54 54 54 57 60 67 71 73 76 80 85 94 97 101 101 109 119 131 134

ABBREVIATIONS ACE ACGME ACP ACS ADL AHR AMSTAR AOR ASD BI BMI BMS BP CAD CBG CGA CHD CHF CI CMS CPPSCG CR CRP C-V DBP DM DONs DSM DVT ED EM EMS EPESE FIM FSA GCSD GDS GeMS GNPs GNRI GP GS HbA1c HCP HF HR HTN IADLs ICC

Angiotensin-converting enzyme Accreditation Council for Graduate Medical Education Advance care planning Acute coronary syndrome Activities of daily living Adjusted hazard ratio Assessment of multiple systematic reviews Adjusted odds ratio Aging Semantic Differential Barthel Index Body mass index Bladder management score Blood pressure Coronary artery disease Cochrane Back Group Comprehensive geriatric assessment Coronary heart disease Congestive heart failure Confidence intervals Centers for Medicare and Medicaid Services Cochrane the Pain, Palliative and Supportive Care Group Cardiac rehabilitation Cardio pulmonary resuscitation Cardiovascular Diastolic blood pressure Diabetes mellitus Directors of nursing and other nurses in administrative positions Diabetes self-management Deep venous thrombosis Emergency department Emergency medicine Emergency medical services Established Population for the Epidemiologic Study of the Elderly Functional Independence Measurement Fraboni's Scale of Ageism Geriatric Clinical Skills Day Geriatric Depression Scale Good Care of the Elderly Geriatric nurse practitioners Geriatric Nutritional Risk Index General practitioner Geriatric syndromes Glycosylated haemoglobin Healthcare provider/professional Heart failure Hazard ratio Hypertension Instrumental activities of daily living Intraclass Correlation Coefficient

ICU IHD INPEA IPMP KEMS KOPS LOS MCS MCW MI MMSE MPHS 6MWT NAs NF NPT OA OR OSCE OSVE PCS PGY POPS PRM QOL RACFs RCT SBP SD SF-36 SPI SPPB SST STEMI TFA TTA TUG UCLA-GAS UI WHO

Intensive care unit Ischemic heart disease International Network for the Prevention of Elder Abuse Integrated pain management program Knee extensor muscle strength Kogan's Old People Scale Length of stay Mental composite scale Medical College of Wisconsin Myocardial infarction Mini-Mental State Examination Multi-purpose health service 6-minute walk test Nursing assistants Nursing facility Normalization process theory Osteoarthritis Odds ratio Objective Structured Clinical Examination Objective Structured Video Examination Physical composite scale Post-graduate year Personality Outlook Profile Scale Physical and Rehabilitation Medicine Quality of life Residential aged care facilities Randomized controlled trial Systolic blood pressure Standard deviation Short Form Standardized patient instructor Short Physical Performance Battery Socioemotional Selectivity Theory ST-Elevation Myocardial Infarction Transfemoral amputation Transtibial amputation Timed Up and Go Test University of California Los Angeles-Geriatric Attitudes Scale Urinary incontinence World Health Organization

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FOREWORD Aging is a multidimensional and multidirectional process. From a life-span perspective successful development and aging in late adulthood and old age requires the accomplishment of different typical developmental tasks or the solution of the final psychosocial crisis postulated in Erikson's stage theory (ego-integrity versus despair). Some theories emphasize fundamental psychological processes of aging such as identify assimilation and identity accommodation, and processes stabilizing the self of the aging person (resilience). Negative images of aging and old age in the society may negatively influence the self-concept of elderly people and the way their needs are met by professionals and institutions (1). “Geriatric” refers to the medical care of older people, and is derived from the Greek word geron (old) and iatros (medical care). Geriatric medicine is practiced by a wide range of physicians involved in primary care and in other subspecialties (2). The British Geriatric Society describes geriatrics as the branch of general medicine concerned with the clinical, preventive, remedial and social aspects of illness in the elderly (3). Thus, contemporary geriatrics deals with various medical, psychosocial and supportive care services available for the aged people. Older people engage in social interaction less frequently than their younger counterparts. The change has been interpreted in largely negative terms. Yet when asked about their social relationships, older people describe them as satisfying, supportive, and fulfilling. Marriages are less negative and more positive. Close relationships with siblings are renewed, and relationships with children are better than ever before. Even though older people interact with others less frequently than younger people do, old age is not a time of misery, rigidity, or melancholy. Rather than it presents a paradox, decreasing rates of contact reflect a reorganization of the goal hierarchies that underlie motivation for social contact and lead to greater selectivity in social partners. The reorganization does not occur haphazardly. Self-definition, information seeking, and emotion regulation are ranked differently depending not only on past experiences, but on place in the life cycle and concomitant expectations about the future. The emphasis on

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emotion in old age results from a recognition of the finality of life. In most people's lives this does not appear suddenly in old age but occurs gradually across adulthood. At times, however, life events conspire to bring about endings more quickly. Whether as benign as a geographical relocation or as sinister as a fatal disease, endings heighten the salience of surrounding emotions. When each interaction with a grandchild or good-bye kiss to a spouse may be the last, a sense of poignancy may permeate even the most casual everyday experiences. When the regulation of emotion assumes greatest priority among social motives, social partners are carefully chosen. The most likely choices will be long-term friends and loved ones, because they are most likely to provide positive emotional experiences and affirm the self. Information seeking will motivate some social behavior, but this will require choices of social partners. Narrowing the range of social partners allows people to conserve physical and cognitive resources, freeing time and energy for selected social relationships (4). Aging is a multidimensional and multidirectional process. The elderly represents the significant part of each society. Older people perceive healthy ageing as an active achievement, created through individual, personal effort and supported through social ties despite the health, financial and social decline associated with growing older. References 1. Marcoen A. Psychosocial aspects of the aging process. Rev Belge Med Dent (1984). 1999;54(2):80-94. 2. Fundamental of Geriatric Medicine. In: Cape RDT, Coe RM, Rossman I (eds.). New York. 1983, pp. 9-15. 3. Hodkinson HM. What is Geriatrics? In: Hodkinson HM (ed.). An Outline of Geriatrics. London. 1981, p.1. 4. Carstensen LL. Motivation for social contact across the life span: a theory of socioemotional selectivity. Nebr Symp Motiv. 1992;40:209-54.

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INTRODUCTION A variety of chronic pathologies often comes along with the aging process and is experienced by many patients in late adulthood. EMS providers must be aware of the various challenges of transporting the geriatric population. Although an emphasis is often placed on the physical and medical issues associated with this population, it is imperative to look at the whole picture to help prevent issues before they become an emergent problem. Being vigilant for elder abuse and neglect, as well as potential home hazards including fall potentials and maintaining colder home temperatures and dangerous cost-cutting measures, such as sharing medications. Prevention is key to helping older patients to avoid potentially devastating situations, such as falls, medication errors and urban hyperthermia. But when those situations happen and providers are called to care for an older patient, compassion and demeanor are necessary to make this vulnerable patient population comfortable and safe (1). The notion of identity with regard to the process of aging is examined from various approaches in social sciences. Continuity or transformation of identity is challenged in advanced age according to the place reserved in the society for the elderly subjects and their social age groups. Changes of identity among elderly subjects appear to proceed in two ways. In the first, called "rebirth", they establish a new self. In the second, termed "turning point", better strategy for coping with the aging effects is obtained by revealing untapped dimensions of the self (2). With the demographic aging, the older adults' needs for assistance and care will inevitably increase. Therefore, it is important to explore the beliefs and attitudes of the HCPs toward the elderly. The notion of ageism and its paradoxes in health care practices for the elderly are evaluated. First, the concept of ageism is defined through its cognitive, affective and behavioral components. Second, on the basis of the literature review, different "age biases" induced by ageism are described, which can influence the assessment of health condition of the elderly, the treatment decisions, and the attitudes of the HCPs with out-patients as with institutionalized subjects. Third, the potential negative effects of ageist stereotypes on the health status and psychological well-being of the elderly are

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evaluated. Finally, some propositions are made to oppose ageism in health care practices for the elderly, including continuing education, better knowledge of the diversity of aging processes, reflexion on professionals' own prejudices, values and beliefs, promotion of relational attitudes which sustain autonomy (3). My previous research deals with the Biblical approach to the old age described in this verse: "Cast me not off in the time of old age; forsake me not when my strength faileth " (Psalm 71:9). Here an old person calls for help in his distress. He begs not to be abandoned in old age because of his/her diminished or absent strength (4). With the improvement of medical care and hygienic conditions, there is a tremendous increase in human lifespan. The bulk of research on the elderly points to the fact that we have to cope with numerous problems related to aging. Each society has to face this problem and provide appropriate health care services for this segment of the population. There is a range of strategies that should be applied in different medical situations. The Biblical words are the road map indicating that the elderly should be respected and not neglected. This precept should be implemented fully (4). Contemporary interpretation of currently available ancient literature on the older people is important since it allows us to better understand the roots of modern geriatrics. By studying this literature, modern physicians can expand their knowledge and thus improve their professional skills. The present research is an additional study of one Biblical verse concerning attitudes towards the elderly. The Biblical texts were examined and one verse relating to the attitude towards a geriatric person was studied from a contemporary viewpoint. References 1. Widmeier K. Respect your elders. Special considerations for EMS response to geriatric patients. JEMS. 2013;38(8):36-41. 2. Danko M, Arnaud C, Gély-Nargeot MC. Identity and aging: psychosocial approaches. Psychol Neuropsychiatr Vieil. 2009;7(4):231-42. 3. Masse M, Meire P. Is ageism a relevant concept for health care practice in the elderly? Geriatr Psychol Neuropsychiatr Vieil. 2012;10(3):333-41. 4. Ben-Nun L. In: Ben-Nun L (ed.). Approach to the Elderly. B.N. Publication House. Israel. 2017. Available at Liubov Ben-Noun (Nun) https:// www.researchgate.net.

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THE BIBLICAL DESCRIPTION The Biblical attitude is shown in the subsequent verse “Thou shalt rise up before the hoary head, and honour the face of the old man...” (Leviticus 19:32). What does the phrase “..the hoary head..” mean? These words indicate the gray or white hair which characterizes the older people or geriatric person. These words show a respectful attitude towards the old man. There is a great wisdom behind these Biblical words. What is pacing of time? Autonomy of the elderly? Patients' integrity? Geriatric rehabilitation? What is the contemporary attitude towards the elderly? What are the attitudes towards various diseases? Is the Biblical attitude implemented in our society? Are there negative attitudes towards the elderly? The present research examines these issues from a contemporary viewpoint. References 1. Fundamental of Geriatric Medicine. In: Cape RDT, Coe RM, Rossman I (eds.). New York. 1983, pp. 9-15. 2. Hodkinson HM. What is Geriatrics? In: Hodkinson HM (ed.). An Outline of Geriatrics. London. 1981, p.1.

PACING OF AGING Aging is a lifelong process. It does not begin at any specific time, such as at age 60 or 70, but is rather a developmental process that starts at the very outset of life (1). The pace of aging is dictated by genetic makeup and, to a lesser degree, by environmental factors. For these reasons, there are people who are already aged and frail in their sixties, while others show little evidence of the degenerative processes of biosenescence even in their eighties. Therefore it is difficult to identify a specific age at which people become “geriatric patients.” Nevertheless, the age 65 is generally regarded as the entry point to the latter part of life. From the clinical standpoint, this is certainly too soon, since the majority of individuals come under the care of geriatric physicians when they are over the age of 75 (2). What is the age of geriatric person in the Biblical passage described

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above? Since biblical text refers to “... the face of the old man...”, it can be assumed that such an old man would be at least 65 years old. The elderly population is increasing steadily, both in number and in proportion to the total population. In the U.S., in 1900 approximately 4% out of 76 million people were aged 65 and over. By 1950 the proportion had increased to 8% (12.4 million), in 1980 to 11% (24 million), and by 2020 the proportion is projected to be about 16% of the total population (3). The rapid increase in the very old (those aged 75 and over) is of key importance, since this age group, including many of the frail elderly, is characterized by a disproportionately high prevalence of chronic diseases and disabilities, which require various health services (4). Poor health and disability are not inherent to the aging process, because the majority of older people at any given time are fit and free of major illness. However, the statistical risk for illness and functional disability increases more rapidly with advancing age (5). At the same time, the older people generally have fewer economic, social, or psychological resources to meet their needs. Everybody should “..honour the face of the old man...” (Leviticus 19:32), and this certainly includes geriatric patient. In other words, maximal efforts are required to provide the appropriate medical, social, and psychological services to the older people (6). Though many changes occur with aging, under normal or resting conditions, there is usually little functionally that is diminished solely on the basis of aging. The net effects are reductions in reserve capacity and placing geriatric patients at higher risk for adverse consequences related to medications and diseases. Interactions between lifestyle factors, such as exercise, diet, and environmental exposures, have a large impact on aging and lead to great individual variability. The interplay between these environmental factors, aging, and development of chronic diseases multiply the amount of variation seen as individual's age (7). The global population is currently undergoing an upward shift in its age structure due to decreasing fertility rates and increasing life expectancy. As a result, clinicians worldwide will be required to manage an increasing number of spinal disorders specific to the elderly and the aging of the spine. Elderly individuals pose unique challenges to health care systems and to spinal physicians as these

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patients typically have an increased number of medical comorbidities, reduced bone density mass, more severe spinal degeneration and a greater propensity to falls. In anticipation of the aging of the population, this project is conducted to heighten physicians' awareness of age-related spinal disorders, including geriatric odontoid fractures, central cord syndrome, osteoporotic compression fractures, degenerative cervical myelopathy, lumbar spinal stenosis, and degenerative spinal deformity (8). A large twin study investigated the trajectories of change in five systems: C-V, respiratory, skeletal, morphometric, and metabolic. Longitudinal clinical data were collected on 3,508 female twins in the TwinsUK registry (complete pairs: 740 monozygotic, 986 dizygotic, mean age at entry 48.9 ± 10.4, range 18-75 years; mean follow-up 10.2 ± 2.8 years, range 4-17.8 years). Panel data on multiple agerelated variables were used to estimate biological ages for each individual at each time point, in linear mixed effects models. A weighted average approach was used to combine variables within predefined body system groups. Aging trajectories for each system in each individual were constructed using linear modeling. Multivariate structural equation modeling of these aging trajectories showed low genetic effects (heritability), ranging from 2% in metabolic aging to 22% in C-V aging. However, a significant effect of shared environmental factors was found on the variations in aging trajectories in C-V (54%), skeletal (34%), morphometric (53%), and metabolic systems (53%). The remainder was due to environmental factors unique to each individual plus error. Multivariate Cholesky decomposition showed that among aging trajectories for various body systems there were significant and substantial correlations between the unique environmental latent factors as well as shared environmental factors. However, there was no evidence for a single common factor for aging. The findings suggest that diverse organ systems share non-genetic sources of variance for aging trajectories. Confirmatory studies are needed using population-based twin cohorts and alternative methods of handling missing data (9). References 1. Rossman I. Anatomic and body composition with aging. In: Finch CE, Hayflick L (eds.). Handbook of Biology of Aging. New York. 1977, pp. 189-221 .

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2. Cape RDT. The Geriatric patient. In: Cape RDT, Coe R.M, Rossman I (eds.). Fundamental of Geriatric Medicine. New York. 1983, pp. 9-15. 3. U.S. Bureau of the Census. Current Population Reports. Series P-25. 1978. 4. Coe RM. Comprehensive Care of the Elderly. In: Cape RDT, Coe RM Rossman I (eds.). The Geriatric Patient. Fundamental of Geriatric Medicine. New York. 1983, pp. 3-7. 5. Greene VL, Monaham D, Coleman PD. Demographics. In: Ham RJ & Sloane PD (eds.). Primary Care Geriatrics: A Case-Based Approach. Mosby, St Louis. 1992, pp. 3-17. 6. Ben-Nun L. In: Ben-Nun L (ed.). Approach to the Elderly. B.N. Publication House. Israel. 2017. Available at Liubov Ben-Noun (Nun) https:// www.researchgate.net. 7. King M, Lipsky MS. Clinical implications of aging. Dis Mon. 2015;61(11):4678. Fehlings MG, Tetreault L, Nater A, et al. The Aging of the Global Population: The Changing Epidemiology of Disease and Spinal Disorders. Neurosurgery. 2015;77 Suppl 4:S1-5. 9. Moayyeri A, Hart DJ, Snieder H, et al. Aging trajectories in different body systems share common environmental etiology: the healthy aging twin study (HATS). Twin Res Hum Genet. 2016;19(1):27-34.

AUTONOMY OF ELDERLY Aging, viewed as an individual and social phenomenon, poses multiple challenges to HCPs who treat the elderly. The many physiological changes that come with aging modify habits, patterns of behavior limit autonomy and functionality. However, there are instances in which well-meaning relatives, physicians, and nurses underestimate the ability of elderly patients to make decisions regarding their own health and wellbeing, thus withholding information or disregarding patients’ opinions. The elderly patientHCP relationship has unique legal and ethical aspects that require deep reflection and special training. Care must be taken to avoid infringement of the elderly patient’s autonomy by limiting or distorting information given to the patient. The unique aspects of elderly patient care require effort and dedication, as well as scientific and appropriate ethical training (1). The aging process brings with it changes to biological, psychological and social level that hinders the maintenance of the autonomy of older people and, consequently, decreases their QOL. The progressive aging population, due to the health, social and

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economic development of recent times, generates new challenges to the professionals involved in the maintenance of the autonomy of this increasingly long-living population group. One of the fundamental strategies for the maintenance of the satisfaction of new needs that have arisen is the promotion of self-care. Nurses are the leading providers of care and have much of the responsibility to cope with the new demands of care demanded by the population aging (2). Autonomy is an important concept because it brings dignity to peoples' lives, regardless of physical circumstances. The United Nations Madrid International Plan of Action on Ageing emphasizes the need to include older adults in autonomous decision-making processes. However, many older people living in residential care find that their autonomy is curtailed. This is largely because autonomy for older people is poorly understood, and hence, nurses working with older people need to become clear about what autonomy is and how it can be facilitated (3). As the population ages, the expectations of consumers rise and future care provision for older people will demand that autonomy will be operationalized in residential care facilities. There are many factors which both facilitate and hinder the level of autonomy which older people experience in residential care. There are three most pertinent factors that are discussed repeatedly in the literature, and they are as follows: the organizations approach to care, personcentered care and life planning (4). The qualitative analysis of the role of family careers shows that supporting a family member losing his autonomy not only involves providing physical assistance and care but also, increasingly, adopts a role of coordinator. These activities can be a source of stress or they can be rewarding, depending on the shared history of the careerpatient relationship (5). Changes in the level of autonomy of the elderly admitted to the hospital at the entrance and at discharge in relation to a rehabilitation program were described. A prospective observational study was conducted at the Italian National Research Center on Aging Geriatric Hospital of Ancona. Patients aged 65 years and over, daily admitted to the Hospital between September and December 2010 were evaluated. Criteria for inclusion were age ≥65 years, LOS >24

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hours and signed informed consent. Patients admitted for less than 24 hours or in day hospital or day surgery were excluded from the beginning. A total of 1,266 elderly patients were recruited. From this sample, 74 people who died during hospitalization were excluded. At the time of hospitalization (within 24 hours) and at discharge, patients were evaluated with the BI, the Rankin scale, and a short assessment of cognitive status derived from the MMSE. Referring to 1,192 subjects who participated in the study, the mean age was 82.13 years ±7.39, age ranged between 65 and 100 years. The average BI was 56.6±36.16 (SD) (median value = 60) at admission and 63.84±34.7 (SD) (median value 70) at discharge. The average Rankin score at admission was 2.63±1.5 (SD) (median value 3). The data indicated that patients presented better score of the BI at discharge and this figure was associated with the implementation of a rehabilitation treatment. Hospitalization of the elderly patient in a suitable environment, such as a geriatric hospital, contrary to some theories highlighting only the negative aspects of removal from the living environment, can be a measure of benefit for the reduction of disability and the recovery of compromised activities along and after the acute event. The collection of data on the level of autonomy of the subjects before and after hospitalization can be a useful element for clinical evaluation in a geriatric hospital (6). In order to evaluate changes in the functional autonomy of elderly patients after a stay in a medical ICU, and the impact of post-ICU management in geriatric ward, 45 patients aged ≥75 years were included in a RCT. They were assessed for functional autonomy before ICU stay, just after ICU discharge, just after hospital discharge, and 6 months later. The patients were randomly divided into two post-ICU management groups: "geriatric ward" and "standard care". Autonomy was usually recovered rapidly, but the degree of recovery depended on the patient's previous autonomy (p13.5 s or inability to perform the test. After adjustment for several covariates, musculoskeletal pain remained independently associated with mobility limitation (OR 1.83, 95% CI 1.16-2.89). The risk of mobility limitation was highest among those who reported severe or moderate pain (OR 1.84, 95% CI 1.13-3.13) and among those who used analgesics (OR 2.37, 95% CI 1.37-4.11). The data show that musculoskeletal pain increases the risk for mobility limitation. The findings underline the importance of the careful assessment and pharmacological and nonpharmacological management of pain in promoting mobility in older age (2). Because the prevalence of chronic pain among the elderly in nursing homes is high and decreases their QOL, effective nonpharmacologic pain management should be promoted. The purpose of this quasiexperimental pretest and posttest control design was to enhance pain management in nursing homes via an IPMP for staff and residents. Nursing staff and residents from the experimental nursing home were invited to join the 8-week IPMP, whereas staff and residents from the control nursing home did not receive the IPMP. Baseline data were collected from nursing staff and residents in both groups before and after the IPMP. The IPMP consisted of eight lectures on pain assessment, drug knowledge, and nondrug strategies for the nursing staff, and 8 weeks of activities, including gardening therapy and physiotherapy exercise, for the residents. There were 48 and 42 older people in the experimental and control groups, respectively. Insignificant differences were found in their educational level, sleep quality, bowel habits, past and present health conditions, pain conditions and psychologic well-being parameters at baseline. After the IPMP, the experimental nursing staff showed a significant improvement in their knowledge and

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attitudes to pain management (p