Key words: Health System Model, Community-based care, Senior Citizen.

As we know in recent decades human societies have been faced with a great challenge, that is the unprecedented number of elderly people as a consequence of more healthy environments and the lowering of mortality rates. It is estimated that in 2020 one billion of the world's population will be older adults and 60% of this number would live in developing countries and unfortunately these societies are not prepared to encounter the aging phenomenon and its social, economic and medical repercussions.(Bartz, 1996) Today, the great challenge of health and social care delivery systems is how to optimize the health status of elders. (Eliopoulos, 1999 ) Delivery of effective and efficient nursing care to any group of clients depends on recognition of their uniqueness and conduction of comprehensive health care needs assessment. Nursing as an academic discipline has adopted a holistic approach to the clients; their environment and any other influencing factors.(ANA , 1982 ) Recently the philosophy in gerontological nursing has been changed dramatically and this discipline has adopted a health promotion and disease prevention orientation. As a result gerontological nursing has a great emphasis on active and healthy aging and autonomy and self dependency of elders.(Ebersol , 1990) In recent years a variety of system models for providing community based health care services to the elderly has been envisioned and implemented in developed countries, which meet the special care needs of different groups of elders. Day care centers, home health care services, skilled nursing care facilities, nursing homes, congregate housing and hospice care are some of these services.(Stone , 1999 ) On the other hand in Iran, a developing country, provision of specialized health and social services to elders in many extents has been ignored and only in the end stages of elders' life this issue goes under consideration by one of the following traditional ways: A) provision of informal home care by elder's relatives and lay caregivers B) signing a contract between the families and private home care agencies that in many cases don't have required licenses and primarily with profit incentives deliver their under standard services. C) transfer of dependent elder to a nursing home as last and worst resort due to exhaustion of limited resources in family caregivers. (Rastegarpour , 1999) Today it is strongly recommended that all needed health services to aging people should be provided to them in their residential places and in the community. The reasons for this emphasis are as follows: 1) It is known that elders are more comfortable and feel at ease while are in their homes; and 2) 2) many studies have showed that community based and home health care are the more cost beneficial than hospital based services. In Iran, there is a considerable percentage of old people 'living' in the society who need to receive specialized care and health services. In order to respond to these needs, planning and implementing health and social care systems with consideration of factors such as existing and available resources and facilities (financial and manpower); social and cultural issues and special characteristics of various groups of elders( physically fit, frails ,home bounds ) seems to be necessary. Self reliance and ability to continue independent living in their houses is very important to elders but many factors such as deteriorating health condition, declining economic status, dominant negative viewpoints in community about aging and aged people (e.g. ageism) and ever changing policies and practices of health care delivery systems discourage fulfillment of this ideal situation. Ageing in place is a term coined in gerontology to highlight the significance of capacity in elders to live independently in the community. It means that elders remain in their residential places as long as possible and receive appropriate health and social services (Kreuger1990). Aging in place means that instead of removing elders to nursing homes and residential institutions; they would remain in their homes and have their surroundings undergo modifications to respond to their changing health needs. Nowadays, organizations that are responsible for providing community based health care services are faced with a great challenge; that is the development and implementation of cost benefit service packages for elders which prolong the stay of elders in community and meanwhile ensure that their life quality remains at acceptable levels. Health systems in many countries implemented varieties of community based programs, which have been specifically developed for elders. Home care services, community based health care programs, respite care, day care, senior centers, home maintenance programs, home meal delivery; transport services are some of these programs. (Broadhead, 1983) Social support is the most important predictive variable that saves the elders from premature movement to residential facilities. Studies show that in almost all countries a large part of home health services and social support are provided to elders by their families and informal caregivers. To ensure that crippled and frail elders would receive necessary health and social services cooperation of these families as main resources of informal care giving, with local formal authorities, is crucial.( US Senate Special Committee on Aging , 1988 )

Nose bleeds are rare in infancy and common in childhood. Diagnosis and treatment depend on location and cause of bleeding.[1]

The differential diagnosis should include both local and systemic causes (Table 1).[2]

Leech infestation has not been mentioned as a cause of epistaxis in common textbooks.

Leeches are annelids or segmented worms. The bodies of all leeches are divided into the same number of segments (34), with a powerful clinging sucker at each end. The medicinal leech is amphibious, needing both land and water, and resides exclusively in fresh water.

Leeches usually have three jaws and make a Y-shaped incision. Leeches can vary in size from about 7 mm long to as much as 200 mm when extended.3 after a full meal of 10ml to 15 ml of blood. The medicinal leech may increase 8 to 11 times its initial body size.

Hirudo medicinalis is parasitic and the adults feed on the blood of mammals. It attaches to the host by means of its two suckers. Simultaneously, the leech injects an anaesthetic so that its presence is not detected, and an anticoagulant in order for the incision to remain open during the meal.[4]

Hirudin is the active anti-coagulant in Hirudo medicinalis, the common leech. LEPIRUDIN is the recombinant form of Hirudin recently approved for use as an anti-coagulant. The exact mechanism of action of Hirudin is not known. It acts independently of AT-III. It may, unlike heparin, inhibit thrombin that is already bound to fibrinogen in a forming clot, thus inhibiting fibrin and subsequent clot formation.[5]

Beside this class of molecules, factor Xa inhibitor, platelet aggregation inhibitors have also been isolated from leeches.[6]

Hirudin produces a dose dependent increase in the activated partial thromboplastin time, prothrombin time and thrombin time.[7]

Kruger25 report a 15 years old girl with leech infestation and fever (38.5)oc. Our patient was febrile too. This was possibly due to immunological reaction to Hirudin or other substances in the saliva of leeches but it needs more evidence .

Aquatic leeches have been described in sites like conjunctivae 8,.9, nose 10 mouth/pharynx/larynx 11,12,13,14,15,16,17,18 Trachea/bronchi19,20,15 oesophagus 21 vagina 22 bladder 23 and rectum24. Removal of the leech is curative.

Leech infestation should be considered in the differential diagnosis for epistaxis, particular in endemic areas. Every attempt should be made to locate the source of epistaxis that does not respond to simple compression.

If appropriate equipment such as a headlamp and a nasal speculum for optimal visualisation are not available, an otolaryngologist consultation should be performed.