[in Japanese]

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Aim: The purpose of this study was to investigate the role of geriatric physicians in end-of-life care through surveying elderly patients, their families, and health-care providers including physicians, nurses, and other caregivers, in order to determine what comprises good end-of-life care.
Methods: The survey respondents comprised 148 elderly patients, 76 members of their families, 105 physicians, 784 nurses, and 193 other caregivers. The survey asked respondents to rate the importance of (a) indicators of end-of-life in the elderly and (b) 17 aspects of quality of end-of-life care.
Results: With respect to indicators of end-of-life in the elderly, a patient being consistently critically ill was rated highly by all health-care providers (>70% responded that this indicated end-of-life). Being unable to perform the activities of daily life was considered an indicator of end-of-life by 36% of patients and 45% of their family members, but only by 23% of physicians, 8% of nurses, and 24% of other caregivers. For quality of end-of-life care, four items were rated as being important by all groups (>70% in each group): palliation of pain, freedom from anxiety regarding death, ability to spend time with close friends or family, and being respected. However, respecting the patient's principles and lifestyle was thought to be less important by patients (16.1%) and family members (28.2%) than it was by physicians (63.8%). Death at home was also thought to be less important by patients (21.0%) and family members (7.1%) than by physicians (37.5%).
Conclusion: Elderly patients and their families have different views from their health-care providers on matters related to good end-of-life care. Geriatric physicians should pay attention to not only the care of patients' physical needs, but also other needs of the patients and their families.

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Aim: This study examined the factors associated with burdens on the primary caregivers of community-dwelling disabled people.
Methods: Participants were 78 disabled people (40 men, 38 women; mean age 77.8±11.5 years) who received home-based physical therapy and/or occupational therapy, and their 78 caregivers (20 men, 58 women; mean age 66.8±10.2 years). The caregiver burden was assessed using the short version of the Japanese version of the Zarit Caregiver Burden Interview (J-ZBI_8). In addition, the primary caregivers completed questionnaires about burdens arising from supporting the activities of daily living (ADL) using a visual analogue scale, available social support, subjective well-being, and the Motor Fitness Scale. The performance of the disabled subjects was assessed using the Bedside Mobility Scale and the Barthel Index. The disabled subjects and the caregivers were divided into higher burden (J-ZBI_8 score, 10 points and over) and lower burden groups (J-ZBI_8 score, 9 points and under) to compare the group differences in the measurements.
Results: The disabled participants in the lower burden group (n=41) showed significantly higher Bedside Mobility Scale scores and Barthel Index scores than those in the higher burden group (n=37). The primary caregivers in the higher burden group showed significantly higher burden due to supporting the ADL, lower subjective well-being, and lower social support as compared to those in the lower-burden group.
Conclusion: The burden levels of the primary caregivers relating to the mobility and ADL of their recipients were assessed. The caregivers with higher burden showed less social support and low subjective well-being.

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Aim: Dementia Care Mapping is a behavior evaluation tool that can be used to measure and improve the quality of life of elderly patients with dementia. However, the reliability and validity of the Dementia Care Mapping-Japanese version (DCM-J) has not yet been established. Therefore, the purpose of this research was to clarify the reliability and validity of the Well-being and Ill-being (WIB) value of the DCM-J as a method for evaluating quality of life.
Methods: The study was conducted from April 1, 2005 to June 30, 2006. The participants included 130 elderly patients (men 31, women 99, average age 82.65±7.69 years) who were given a diagnosis of dementia. We established inter-rater reliability during a parallel observation method and also used test-retest for reliability. The correlation between the WIB value of the DCM-J and the Japanese Quality of Life Inventory for Elderly with Dementia (QOL-D) was used to establish criterion-related validity.
Results: Forty-nine (37.7%) subjects were given a diagnosis of dementia of Alzheimer's type, 80 (61.5%) had vascular dementia and 1 (0.8%) had dementia with Lewy bodies. The results showed correlation between the WIB value and social withdrawal measured by the behavioral category code (BCC) on the DCM-J and the three subscales of QOL-D: "interacting with surroundings", "expressing self", and "experiencing minimum negative behaviors". There was good internal consistency among these items. The interclass correlation coefficient was 82.32 (±5.85) for the WIB value of the DCM-J. The correlation coefficient of the retest, administered one week later, was 0.836 (p=0.001). The WIB value was significantly correlated with three sub-scales of QOL-D, and the correlation coefficient was greater than 0.53.
Conclusion: We demonstrated that the WIB value of the DCM-J has good inter-rater reliability and test re-test reliability and criterion-related validity. In this study, the WIB value was shown to have similar reliability to the WIB value of the original DCM. Furthermore, our results suggest that the DCM-J could be useful for evaluating quality of life among elderly Japanese patients with dementia.

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Background: Recently, metabolic syndrome is increasing in Japan and it is thought to be the cause of coronary heart disease. In this study, we evaluated the metabolic syndrome and insulin resistance that is thought to be located in the upstream of metabolic syndrome in high age patients of coronary heart disease.
Patients and Methods: Coronary risk factors were examined and OGTT with measurement of plasma glucose and serum insulin was done to evaluate metabolic syndrome and insulin resistance in 214 patients who underwent coronary angiography; 102 patients were over 65 years old (high age group) and another 112 were young age group. We compared the two groups.
Results: The rate of hypertension was significantly high and that of obesity, LDL-cholesterol level and triglyceride level were significantly low in high age group compared with the young age group. There was no difference in the ratio of metabolic syndrome between the two groups. The frequency of insulin resistance confirmed by HOMA-R was significantly high in the young age group, however there was no difference confirmed by 2 hour serum insulin level after OGTT.
Conclusion: The influence of glucose metabolism and insulin resistance was equal between the two groups. The frequency of metabolic syndrome was the same, but the coronary risk factors were different between the two groups. Abnormal glucose metabolism and insulin resistance were common to both groups. To diagnose insulin resistance, 2 hour serum insulin level was more effective than HOMA-R.

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Aim: We previously investigated the relevant factors concerning each individual phenomenon related to the process of initiating dialysis in elderly patients with chronic renal failure. Background factors that were identified as relevant factors were significant in terms of enabling us to predict the outcome of each phenomenon in new patients. However, the significance of these factors in predicting the outcomes of subsequent phenomena at the stage of the initial phenomenon was unclear. This was attributed to the fact that the subjects with phenomena decreased in number and because of changes in characteristics (hereafter, changes in subjects) with the progression of the process of initiating dialysis. In the present study, we aimed to identify relevant factors for predicting the outcomes of subsequent phenomena at the stage of the initial phenomenon. For this purpose, we assumed that "progression of the process of initiating dialysis does not result in significant reductions in the number of cases and causes only minor changes in characteristics".
Methods: We studied a total of 152 patients with advanced chronic renal failure aged ≥60 years. Background factors were investigated in all patients. The following phenomena were analyzed: acceptance of dialysis, urgency of initiating dialysis, alleviation of disease, and returning home. In order to identify new relevant factors, we focused on the order and condition of the process by which each background factor was narrowed down during logistic regression analysis for each phenomenon. We determined which background factor to focus on for each phenomenon based on changes in background factors.
Results: Age and cognitive function were related to the urgency of initiating dialysis and alleviation of disease. Age, walking ability, and cognitive function were related to returning home. Age was eliminated at the final stage of logistic regression analysis for alleviation of disease and at the penultimate stage of logistic regression analysis for returning home.
Conclusion: We simulated the restoration of cases lost during the process of initiating dialysis in order to determine the relationship of age to alleviation of disease as well as returning home. Although age significantly affected alleviation of disease, its relationship to returning home was unclear. Age was thus identified as a new relevant factor for alleviation of disease. In addition, all relevant factors identified from investigation of each phenomenon enabled prediction of outcomes of subsequent phenomena at the stage of the initial phenomenon.

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We report an 82-year old man prescribed paroxetine who had hyponatremia and in whom the syndrome of inappropriate secretion of antidiuretic hormone was diagnosed. He had taken sulpiride for depressed mental status. However, he showed parkinsonism, which was an adverse effect from the treatment of sulpiride. Therefore sulpiride was changed to selective serotonin reuptake inhibitor, paroxetine 10mg daily. His depressed mental status deteriorated after paroxetine treatment started. His depression had not lessened after 12 days, and the dosage was increased to 20mg daily. On the 15th day after starting paroxetine, routine laboratory tests showed that his serum sodium level was 126mEq/l. We recognized that his confusion and loss of appetite were symptoms of hyponatremia, rather than of worsening depression. Laboratory data revealed hyponatremia, low serum osmolarity (242mOsm/kg) with a relatively high level of serum antidiuretic hormone, and concentrated urine (439mOsm/kg). We diagnosed the syndrome of inappropriate secretion of antidiuretic hormone (SIADH), associated with paroxetine. The dosage of paroxitine was reduced gradually and the serum sodium level returned to normal on day 2 after medication ceased completely. Paroxetine produces fewer adverse effects than other types of antidepressants. However, its use can be associated with inappropriate secretion of antidiuretic hormone in the body and may lead to SIADH, which is characterized by hyponatremia, a potentially fatal condition that is typically asymptomatic until it becomes severe. SIADH is more likely in some populations, including the elderly. Serum sodium levels should be monitored closely, especially in elderly patients.

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We report an elderly patient with maternally inherited diabetes with deafness (MIDD). A 69-year-old woman was found to be diabetic for the first time when she visited her local medical doctor for the symptoms of a common cold. Her casual plasma glucose level was 311mg/dl and HbA1c was 8.3%.She had been aware of muscle atrophy of the lower extremities and hearing disturbance since age 66. As for her family history, her mother, older sister and younger brother were diabetic with hearing difficulty and all of them had died suddenly in their middle age. Her 45-year-old daughter was also diabetic with some difficulty in hearing. Therefore, we suspected both the patient and her daughter had MIDD, and found alterations in mitochondrial DNA3243A-G. MIDD is a condition that needs to be diagnosed accurately and treated at an early stage, since diabetic complications can progress rapidly and could cause myocardial complications and mitochondrial encephalomyopathy, lactic acidosis and stroke-like episodes (MELAS). According to a report of 115 cases of MIDD in Japan, MIDD had been diagnosed at the age of 32.8 on average and our case was strikingly old for the age of onset of the disease.

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A 76 year-old man had had hypertension, diabetes mellitus and hyperlipidemia since 1985, and bruit in his left neck since 1993. He had abrupt decrease in left visual acuity on November 24, 2005, and visited an ophthalmologist. On November 28, his corrected visual acuity was 1.0 in the right and 0.1 in the left. The examination of optic fundi showed ear-side edema of the left optic disk. Fluorescence examination of the left optic fundus showed delay in early filling and later hyperfluorescence. Goldman visual field examination showed horizontal lower semiblindness. Since he did not complain of eye pain, his blood examination showed no reaction of inflammation, and he had hypertension, diabetes mellitus and hyperlipidemia, anterior ischemic optic neuropathy was diagnosed. The treatment with aspirin, alprostadil and prednisolone transiently improved the optic fundi and visual acuity, but his left visual acuity returned to 0.1. Carotid ultrasonography showed 95 percent stenosis in the left internal carotid artery. As there is no established treatment for ischemic optic neuropathy, the management of risk factors is most important.

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We report a 79-year-old Japanese man with histlogically-diagnosed Creutzfeldt-Jakob disease (CJD) with codon 129 polymorphism and codon 180 point mutation. At the time of the first examination, we diagnosed and treated as Alzheimer's disease with cerebrovascular disease because of laterality of cortex accumulation and an accumulation decrease of perforating branch areas at the SPECT (¹²³I-IMP). His status rapidly progressed to an apallic state and died of lung abscess 12 months later. None of the members of his family had neuromuscular disorders. EEG (electroencephalogram) did not reveal periodic synchronous discharges (PSD). Prion protein gene analysis showed Codon 129 polymorphism (Met/Val) and codon 180 point mutation (Val/Ile).
The autopsy findings revealed spongiform changes and numerous senile plaque formation in the cerebral cortex. The hippocampus and the cerebellar cortex were well preserved and did not show lacunar infarctions. CJD patients with combination of the codon180 point mutation and codon 129 polymorphism of the PrP gene have rarely been reported.

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