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Chapter 4
Mental disorders among the
elderly population in Israel
Perla Werner
In Israel, as in other countries, the proportion of elderly persons in the population is growing. According to estimates of the Central Bureau of Statistics, the proportion of the population
aged 65 and over will rise from 10% in 2005 to 12.3% in 2025 (1). This increase will be
accompanied by a sharp rise in the number of those aged 65 and older with mental disorders.
This expected increase has been labeled as an emergent crisis (2) requiring proper attention.
Although no specific data are available about the costs of mental illness in later life, it is clear that
this is becoming a serious public health concern due to the effects on the individual, family and
society. Societal effects include an increasing load on the healthcare and social services
systems, accompanied by increasing economic costs. Other effects include disability, poorer
health outcomes and mortality risk. Finally, psychological effects include stigma, isolation,
decreased quality of life and psychological dysfunction such as diminished self-esteem.
Israel’s mental health system is not yet prepared to face these prospects. Despite the fact that
the percentage of elderly persons who are hospitalized is 16%, only 10% of all hospital units are
defined as psychogeriatric units (3). Moreover, only four of 114 community-based mental health
clinics in Israel are totally dedicated to the psychogeriatric population (4). Approximately another
25 of the community-based mental health clinics have specialized memory clinics, but most of
them work on a partial schedule (5).
Israel is also lagging behind in the training of professional caregivers. While it is estimated that
one professional is needed for every 800 to 1,000 persons aged 65 and over (6), in Israel there
are only about 110 registered psychogeriatricians, reflecting a ratio of one professional for every
6,000 persons aged 65 and over (3). Moreover, although Israel is in the process of reforming its
mental health system (7), limited attention is being given to the elderly population, with its special
characteristics and needs.
This chapter presents an overview of the epidemiologic research being conducted on the most
prevalent mental health disorders among the Israeli elderly population – including depression,
anxiety, dementia and late schizophrenia. Recommendations for future research and action are
also presented.
• Depression
According to the Diagnostic and Statistical Manual of Mental Disorders – Fourth Edition Revised
(DSM-iv-R) (8), the criteria for major depression include five of the following symptoms present
for a period of two weeks – depressed mood, loss of pleasure in most activities, weight loss or
gain, insomnia or hypersomnia, psychomotor agitation, fatigue, feelings of worthlessness, guilt,
impaired concentration, and suicidal ideation. Symptoms of minor depression include depressed
mood during most days for a period of two years and at least two of the following symptoms: poor
appetite or overeating, insomnia or hypersomnia, low energy or fatigue, low self-esteem, poor
concentration and feelings of hopelessness.
Depression is the most common late-life mood disorder, and although it is similar in both older
and younger populations among the elderly it is often hidden in somatic symptoms. Also,
depression is characterized by its comorbidity with other medical illnesses (9–10).
Overall, studies in other countries reported that the prevalence of major depression in persons
aged 65 and over ranges between .9% and 9.4% in the community-dwelling elderly; between
14% and 42% among the institutionalized elderly; and between 1% and 16% among the elderly
PDF created with pdfFactory trial version living in private households or in institutions (11). As noted, those prevalence studies show great
variations, due mainly to the use of varied diagnostic criteria and research methods.
Although there is limited local epidemiological research purported to assess the prevalence of
late-life depression, some studies have examined the prevalence rates in specific populations
and their risk factors for depression. Results of these studies are summarized below together with
an overview of the depression assessment instruments validated in Hebrew.
Depression and depressive symptoms in selected populations
In a study assessing the rate and correlates of depressive symptoms in a sample of 1200
community-dwelling oldest-old (aged 75–94) Jewish residents, Ruskin et al. (12) found an
estimated 43% rate of depressive symptoms. A lower prevalence of depressive symptoms,
16.8%, was found in a prospective study examining the association between falls and depression
among 283 persons aged 60 and over in the city of Beersheba (13). Finally, Geulayov et al. (14),
in a review article on depression in primary care, summarized prevalence rates cited by several
studies that included patients aged 18 to 75. However, no specific rates for the population
samples aged 60 and over were given in those studies.
Most research on the topic of depression in the elderly has focused on unique populations, such
as immigrants, the Arab-Israeli sector, Holocaust survivors and kibbutz members.
With the high rate of immigration to Israel, particularly in recent decades, research attention
focused on the elderly immigrant population has grown accordingly. In a clinical study using an
abbreviated version of the Composite International Diagnostic Interview (CIDI-S) (15),
Zilber et al. examined the prevalence rates of depression among a group of 116 elderly subjects
from the former Soviet Union (FSU), 86 of them aged 65 or younger and 30 aged over 65 (16).
Their findings showed a higher prevalence rate of major depression in the older as compared to
the younger group, 4.8% and 2.0%, respectively. In contrast, rates of dysthymia were closer,
3.7% and 2.9% for the younger and older participants, respectively. The authors also reported
that before immigration the incidence of depression was lower in the elderly group, while the
reverse was observed in the younger group. These findings suggest that immigration leads to an
increase in the incidence of depressive disorders, especially among elderly persons.
Section I: Psychiatric and Behavioral Disorders in Population Groups
Arab Israelis are a significant minority group. High rates of depressive symptoms, based on DSM-
iv criteria, were found in a population-based study of elderly Arabs from Wadi Ara who were
diagnosed with dementia of both Alzheimer’s (AD) type (n = 168) and vascular type
(n = 49) (17). Prevalence rates of depressive symptoms were higher among the latter than
among those with AD, 85% and 57% respectively.
Although not directly examining depression, Shemesh et al. reported high scores of emotional
distress among 824 Arabs aged 60 and above residing in the community (18). Prevalence rates,
obtained after establishing suitable cutting points, were especially high for Muslim Arabs (43.4%),
followed by Christian Arabs (37%) and Druze (17%). The same study showed a prevalence rate
of 21.4% among the 4,231 Jews surveyed.
Holocaust survivors represent another unique population in Israeli society. Several studies have
examined depression rates among them, but their results were inconsistent. In a study assessing
relationships among hopelessness, depression and suicidality among 464 elderly community
dwellers attending five senior-citizen centers near the city of Haifa, Ron reported that Holocaust
survivors – who comprised 45% of the study sample – expressed lower levels of depression on
the Beck Depression Inventory (19) as compared to those without such an experience (mean
scores 1.7 and 2.1 respectively) (19). Those findings were a reversal of the results obtained in a
previous study by the same author (20) conducted among a mixed sample of 227 elderly persons
residing in the community and 91 in nursing homes, also using the Beck Depression Inventory. In
this study, elderly Holocaust survivors reported higher levels of depression scores than elderly
PDF created with pdfFactory trial version people residing in the community (2.7 and 1.3 respectively). Similarly, a study conducted in a
long-stay psychiatric setting using the Structured Clinical Interview (SCID) found that 22 of 44
patients who were Holocaust survivors had a diagnosis of affective disorder, compared to five of
30 patients in the comparison group (21). The discrepancy between the studies might stem from
methodological differences as well as from different coping mechanisms used by the Holocaust
survivors.
Finally, Landau and Litwin (22) compared psychological and somatic symptoms associated with
depression – measured by the Zung Self-rating Depression Scale – in a community-based
sample of 91 Holocaust survivors and 103 elderly persons aged 75 and above who did not
experience the Holocaust. Although they found no statistically significant differences in
depression rates between the two groups, those who had experienced the Holocaust reported
slightly higher rates of depressive symptoms.
Lastly, elderly persons residing in kibbutzim have also been the focus of research in this area.
Blumstein et al. (23) compared the depression levels of elderly persons residing in kibbutzim with
a suitable national sample. Using the Center for Epidemiological Studies Depression
Scale (CES-D), lower depression scores were found among elderly female kibbutz members as
compared to elderly women living in other communities.
In sum, the study of depression in special populations of elderly persons in Israel has attracted
much research. However, most studies have concentrated on depression symptoms and not on
depressive disorders.
Factors associated with depression in the elderly population
Several studies have examined factors associated with depression and depressive symptoms in
the elderly population. Among the main factors reported were female gender; widowhood
(19); vascular dementia and Alzheimer’s disease (17, 24); anxiety (25); poor self-rated health;
poor cognitive status; impaired Activities of Daily Living (ADL); and frequent visits to a physician
(13). In a recent review on suicide in the elderly, mood disorders (and especially bipolar disorder)
were reported to be one of the main mental disorders associated with suicide in the elderly
population in studies in Israel and abroad (26). In Israel, a retrospective, matched, case-
controlled evaluation over a 10-year period of elderly bipolar patients showed a greater index of
suicide among persons with mood disorder than among those without (27).

Assessment instruments
The following are the most common instruments used for the assessment of depression in the
elderly population; they are available in Hebrew and have been validated locally.
The Hamilton Depression Scale (HDS or HAMD) (28) measures the severity of depressive
symptoms in individuals, often in people who have already been diagnosed as having a
depressive disorder. It is sometimes known as the Hamilton Rating Scale for Depression (HRSD)
or the Hamilton Depression Rating Scale (HDRS). Depending on the version used, there are
either 17 or 21 items for which an interviewer provides ratings. These include overall depression;
guilt; suicide; insomnia; problems related to work; psychomotor retardation; agitation; anxiety;
gastrointestinal and other physical symptoms; loss of libido; hypochondriasis; loss of insight; and
loss of weight.
The HDS has been widely used in local studies. It was validated by Kertzman et al. (29) in a
study of elderly patients, including 50 with primary degenerative dementia and 50 with vascular
dementia. Study findings showed the Hebrew version of the HDS to have good criterion validity in
the evaluation of depression in patients with dementia.
The Geriatric Depression Scale (GDS) (30), which originally included 30 items but whose shorter
form with 15 items (GDS-S) was developed later and shown to have adequate validity in many
PDF created with pdfFactory trial version languages (31), was specially developed for the assessment of depression in geriatric
populations.
The GDS-S has been widely used in local studies (13, 32). Its Hebrew version was validated by
Zalsman et al. in a study including 27 inpatients (M age = 73.3 years) with a diagnosis of major
depression, according to the DSM-iv criteria and 21 healthy volunteers (M age = 70.3 years) (33).
The Hebrew version of the GDS-S has proven to be a valid and reliable instrument for the
detection of depression among the geriatric population. It showed high correlation scores with the
HAMD (Pearson’s correlation = .79, p < .005), as well as high sensitivity for differentiating even
mild depression. High Kappa values were reported for inter-rater and test-retest reliability
(Kappa = 1.0 and .88, respectively).
The Beck Depression Inventory (BDI) is the most commonly used measure to assess depression
(34). It consists of 21 items describing various depressive manifestations, such as sadness, loss
of pleasure and pessimism. Total scores range between 0 and 63, with higher scores indicating
more severe depression. Although no specific study has examined the validity and reliability of
the Hebrew version, the BDI has been used in several studies in the local elderly population and
has shown good to excellent internal reliability-consistency, Cronbach’s alpha ranging from .82 to
.88 (19, 20 ).
The Zung Self-Rating Depression Scale consists of 22 statements that describe the way people
sometimes feel (35). An index score is calculated by dividing the total score by 40 and multiplying
it by 100. A score of ≥ 70 or greater is considered to indicate depression (36). This screening
instrument was translated into Hebrew and showed good internal reliability-consistency in a study
with elderly persons, Cronbach’s alpha = .87 (22).
The Short Zung Interview-Assisted Depression Rating Scale is a modified version including
10 questions on the frequency of symptoms which are rated on a Likert-type scale ranging from 1
= never to 4 = always. Translated into Hebrew and subsequently validated (25), it has shown
excellent sensitivity, 71.1%, and specificity, 88.3%, as well as positive and negative predictive
value (90.1%) in studies assessing depression in the Israeli elderly (37).
The Center for Epidemiologic Studies – Depression Scale (CES-D) is a 20-item scale designed to
measure depressive symptoms experienced in the past week (38). Responses range from 0 to
3 – and the total score, ranging from 0 to 60 – is calculated by adding the scores of all items (after
reversing four of them). A score of 16 or greater has been suggested as the cut-off point
indicative of probable clinical depression. The CES-D has been translated into Hebrew and has
shown excellent internal reliability, Cronbach’s alpha = .88, in several epidemiological studies (23,
39, 40).
• Anxiety disorders
These disorders are characterized by anxious over-concern and include several types, among
them generalized anxiety disorder (GAD), panic disorders and obsessive-compulsive disorder
(OCD). They are frequently associated with somatic complaints (41) as well as with the following
array of symptoms: overwhelming feelings of panic and fear; uncontrollable obsessive thoughts;
painful, intrusive memories; recurring nightmares; nausea; sweating; and muscle tension (42)
(see chapter 12).
Anxiety disorders may be the most common mental disorders in elderly persons; they can affect
twice as many older adults than does depression (43). However, little research has been
conducted worldwide and in Israel to assess the prevalence, correlates and treatment of anxiety
disorders among the elderly (44).
There are few local studies assessing anxiety in the elderly population. They were aimed at
examining the association between anxiety, depression and cognitive decline. Trying to elucidate
PDF created with pdfFactory trial version this relationship, Sinoff et al. (45) developed one of the few screening tests for the assessment of
anxiety in the elderly – the Short Anxiety Screening Test (SAST). The SAST was developed
based on DSM-iv criteria (8) and includes, among others, modifications of commonly recurring
questions found in other instruments and items exploring somatic symptoms. The instrument
includes 10 questions scored from 1 to 4; a total score is calculated by the sum of the scores. A
score of 24 or higher is considered as the cut-off point for the diagnosis of anxiety. The SAST
was validated in a study including 150 geriatric inpatients and outpatients, and was found to be a
valid screening test for detecting anxiety among the elderly (45). The internal consistency of the
SAST was Cronbach’s alpha = .70, and its inter-rater reliability, .80. Additionally, it showed a
sensitivity of 75%, a specificity of 79%, and a positive predictive value of 71%. SAST was later
used in studies to assess the associations between depression, anxiety, and cognitive
impairment (25, 37).
• Dementia and Alzheimer’s disease
Dementia is the progressive decline in cognitive functioning due to damage or disease of the
brain beyond what might be expected from normal aging. The functions particularly affected are
memory, attention, language and problem-solving. Alzheimer’s disease (AD) is the most common
cause for dementia, followed by vascular dementia (46).
The most important age-related disorder, dementia has attracted considerable amount of
research worldwide and in Israel. The results of the local studies examining dementia in general
and AD in particular are summarized below, together with an overview of the dementia
assessment instruments validated in Hebrew and studies assessing the consequences of
dementia.
Studies on the prevalence of dementia
The first comprehensive epidemiological study to assess the prevalence of dementia among
Jewish-Israeli elderly was conducted in 2002 by Wertman et al. on a random sample of 1624
community dwellers aged 65 and over and residing in Jerusalem (47). Following an initial
screening for suspected dementia and a further in-depth clinical examination using a clinical
protocol developed by the Neuro-Psychogeriatrics Department of Jerusalem’s Herzog Hospital in
accordance to the diagnostic criteria of DSM-iii-R and DSM-iv, a fifth of the participants (19.2%)
were diagnosed with different stages of dementia. When these rates were applied to data on the
total elderly community-dwelling population living in Israel by the end of 2002, the numbers
reached some 98,000 individuals.
The rate found was higher than those reported by Kahana et al. in their study conducted with a
population of 1,501 elderly persons over the age of 75 in the coastal city of Ashkelon
(48).The total prevalence of dementia in this study was 11%, with rates increasing from 5.9%
among those aged 76 up to 26.9% among those aged 90 and over. The difference between the
two studies can be explained by the different assessment methods used. In Jerusalem, it was
based on a physician examination, while in Ashkelon, on trained medical field workers (nurses or
social workers).
As might be expected, higher prevalence rates were found among residents of long-term care
geriatric institutions. In a cross-sectional survey of a representative sample of 11 wards in
34 long-term care institutions providing care for the elderly in Jerusalem, 49.9% of the sample
was diagnosed with dementia (49).
While these studies referred to all dementias, others have examined specific types of dementia in
specific cultural groups. Bowirrat et al. reported unusually high prevalence rates
(20.5%) of Alzheimer’s disease in an epidemiological study of 821 Arab Israelis aged 60 and over
residing in Wadi Ara (50). A prevalence rate of 6.0% of vascular dementia was found in the same
population (51). These findings are explained by the unique characteristics of this group, such as
PDF created with pdfFactory trial version rural living conditions, environmental hardships, cigarette smoking, and by their unique human
genome data (52).
Assessment instruments
A number of instruments are available for the screening of dementia (for a thorough recent review
of this topic, see ref. 53). They vary in length, mode of administration and psychometric
characteristics (for a review, see ref. 54; specific data are provided below). However, only few of
those instruments in their Hebrew version have been appropriately tested and validated.
The Mini-Mental State Examination (MMSE) (55) appears to be the most widely used test for the
screening and diagnosis of dementia. It is an 11-item instrument assessing cognitive functioning,
with scores ranging from 0 (total cognitive deterioration) to 30 (normal cognitive functioning). The
Hebrew version of the Mini Mental State Examination was administered to 36 and 19 elderly
persons with and without dementia, respectively. Test-retest reliability scores were calculated as
exact agreement rates and ranged from good to excellent for all the items. Strong convergent
validity, as measured by the correlation between the MMSE and the CAMCOG (see below, r =
.94) was found. Good predictive value was observed, as over three-quarters of the participants
were correctly classified as demented or non-demented (56, 57).
The Telephone Interview for Cognitive Status-Modified (TICS-m) is a short instrument, modeled
on the Mini-Mental State Examination with the aim of assessing cognitive status over the
telephone. The mental functions assessed include orientation, attention, memory, repetition,
comprehension and conceptual knowledge (58). Its validated Hebrew version (59) has shown
high internal reliability-consistency, Cronbach’s alpha = .98, as well as excellent convergent
validity and sensitivity.
The CAMCOG is a relatively brief neuropsychological battery which forms part of the Cambridge
Examination for Mental Disorders of the Elderly (CAMDEX) (60) and assesses a wide range of
cognitive functions. The CAMCOG ranges from 0 to 107, with scores lower than 79/80 indicating
cognitive impairment. The CAMCOG is the second most popular cognitive test used by Israeli
physicians. It was validated by Heinik et al. (61) and has shown excellent inter-rater agreement
scores, as well as strong convergent validity and predictive characteristics.
Other well-known instruments in use locally – but for which no reliability and validity data have
been published – include the Alzheimer’s Disease Assessment Scale (cognitive subscale)
(62), the Modified Mini-Mental State Examination (3MS) (48, 50), the Clock Drawing Test (63)
and the Brookdale Cognitive Screening Test (49, 52).
The recent emphasis on the need for early diagnosis of AD highlights the pressing need to
develop precise instruments that can be easily and objectively administered and will minimize
learning effects. Thus, Israeli researchers have recently been concentrating on the development
and validation of computerized tests for the assessment of dementia among the elderly
(64). Aharonson et al. reported the validity of a computerized method for the diagnosis of mild
cognitive impairment by assessing the recall of a pattern and digit symbol substitution (65).
Finally, the Mindstreams Mild Impairment Battery is an interactive cognitive test that assesses a
wide variety of cognitive domains, including memory; executive function; visual spatial skills;
verbal fluency; attention; information processing; and motor skills (66). Results of a Receiving
Operating Curve analysis measuring the ability of this instrument to discriminate mild cognitive
impairment from cognitively healthy elderly persons showed that the parameters estimated
discriminated significantly with an AUC ranging from .70 to .86.
Impact of dementia
The main impact of dementia have also been examined by local researchers. First, the direct and
indirect monetary costs associated with caring for persons with AD were examined in community-
dwelling and institutionalized patients (67, 68). Seventy-one AD patients who lived in the
community, 50 institutionalized AD patients and 50 healthy elderly subjects were interviewed.
PDF created with pdfFactory trial version The interviews covered information about the number of caregivers’ hours invested in caring for
the patient and amount of expenditures, such as in-house paid help and payment for day care.
The annual social cost of caring for a person with AD in Israel was approximately US $17,000,
whether the patient lived at home or in a nursing home. The cost components differed in the two
groups. For community-dwelling patients, 60% of the cost represented an imputed value of
unpaid indirect care compared with 12% for institutionalized patients. Also, in both residences,
the private cost was significantly higher than the public cost, i.e., more than 75% of the services
provided to patients were paid out-of-pocket. Cost of institutionalization was the major component
of the social cost. Additionally, the costs of the disease increased with functional and cognitive
deterioration and were especially high for the management of the associated behavioral and
psychological symptoms.
In addition, the stigmatic views of the lay public and professionals towards persons with
Alzheimer’s disease were examined (69. 70). These studies showed that despite anecdotal
beliefs regarding the stigma associated with Alzheimer’s disease, professionals as well as the lay
public reported more positive (such as concern – reported by 60% of the lay public, and desire to
help – reported by 72%) than negative emotional reactions (such as irritation – reported by 4% of
the lay public, and anger – reported by 10%).
However, one of the hardest consequences of the disease – the burden on the caregivers of the
persons with dementia (71, 72) – has attracted limited research attention in Israel. Lowenstein, in
a study examining the effects of demographic, ethnic, personal and familial resources on the well-
being of children caring for parents with Alzheimer’s disease, found that ethnicity and
intergenerational relationships were the main predictors of the caregivers’ mental health
(73). The need remains to expand this line of research locally.
• Schizophrenia in late life
Although schizophrenia is typical of young adults, it is clear today that it can also appear in or
extend into late life. Increased research attention has recently been devoted to schizophrenia in
elderly persons, with a special focus on similarities and differences between age groups (74).
Diagnostic criteria for schizophrenia in late life are similar to those of early life, and symptoms
include delusions; hallucinations; disorganized speech; affective flattening; alogia; and avolition.
Although no epidemiological data about the prevalence of late-life schizophrenia are available, a
recent Israeli review estimated rates ranging from .1% to 4% (75).
The results of Israeli studies in the area of late-life schizophrenia confirm those of studies
worldwide that patients with late-life and very-late-life schizophrenia present stable cognitive and
everyday functioning, as compared with younger patients (76); a relatively low base rate of
suicide (77); and lower levels of self-stigma than younger populations (78).
In terms of screening instruments, Israeli researchers rely on the Positive and Negative
Syndrome Scale (PANSS) (79). This is an interviewer-administered scale scored on the basis of
a clinical interview lasting 30 to 45 minutes. It consists of three subscales: positive syndrome
scale, negative syndrome scale and general psychopathology scale. The reliability and validity of
the PANSS in Hebrew have been established among both adult and elderly schizophrenia
patients (80).
• From epidemiology to mental health action
In view of the anticipated demographic changes worldwide, the number of elderly persons with
mental disorders will continue to increase, posing a considerable burden to individuals,
professionals and society at large. Importantly, Israel is in the process of undergoing a thorough
reform in the delivery of psychiatric care aimed at addressing this problem (7).
Given the relative high prevalence rates of elderly persons with mental disorders, there is an
urgent need to expand the research base, particularly in the following areas:
PDF created with pdfFactory trial version (a) Epidemiological studies assessing the incidence and prevalence of mental disorders among
the elderly population are needed, with special attention paid to unique groups, such as
Arab Israelis and new immigrants;
(b) Unique correlates of mental illness in the elderly should be identified, such as comorbidity,
populations at risk (e.g., elderly persons living alone);
(c) Data obtained through these studies should be geared to provide information and guidelines
with regard to the clear definition of policy and priorities that are specifically centered on the
needs and unique characteristics of elderly persons with mental disorders;
(d) Knowledge and attitudes regarding discrimination towards elderly persons with mental
disorders should be assessed, particularly in relation to the following questions: Are these
persons a target for double stigma? Do discriminatory behaviors prevent help seeking in this
population? Do professionals’ attitudes affect the care that elderly persons with mental disorders
receive?
(e) Studies on issues of clinical importance and related to the practice with elderly persons with
mental disorders are needed. For example, professionals’ knowledge and training regarding the
care of elderly persons with mental disorders should be examined and the effectiveness of multi-
professional care evaluated;
(f) Evaluation should be conducted of educational programs aimed at providing knowledge about
mental disorders among the elderly, specifically those geared to different population groups, such
as the lay public, elderly persons with mental disorders and their family members, professionals;
and
(g) Assessment of the efficacy of intervention programs for elderly persons with mental disorders
should be expanded.
In sum, the field of mental disorders in Israel’s elderly population is still in its developing stages.
Services geared to the unique needs of this population should be developed. These include
mental health services for the elderly in non-hospital-based outpatient settings, nursing homes
and community centers for the elderly. Training programs for professionals in the area of
psychogeriatrics should be developed. Special attention must be paid to an interdisciplinary
mental health care approach for the elderly with mental disorders that include the disciplines of
medicine, psychiatry, psychology, psychiatric nursing and clinical social work.
Although old age is not itself a risk factor for mental disorders, increasing numbers of elderly
persons will be developing a significant mental health disorder. Israeli society should be prepared
to deal with these developments adequately.
This work was partially funded by grant 483/05 from the Israel Science Foundation.

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