To elucidate clinical profile and prognosis in elderly patients with chordal rupture, 19 patients (11 men and 8 women), who were diagnosed as having chordal rupture by echocaridography, were divided into two groups; i.e. (1) 12 elderly patients (60 years or older, 5 men and 7 women) and (2) 7 younger patients (59 years or younger, 6 men and one woman). Fifteen patients later underwent cardiac catheterization and 14 patients received surgical treatment. These two groups were compared in their clinical features and prognosis. Nine (75%) of 12 elderly patients had acute onset of symptoms, whereas 5 (71%) of 7 younger patients were without acute symptoms. All of the elderly patients were in heart failure (NYHA III∼IV) but only 2 (29%) of 7 younger patients were in heart failure. Prevalence of atrial flutter/fibrillation were 50% (6 of 12 patients) in the elderly and 14% (one of 7 patients) in the younger group. Site of chordal rupture was anterior in three and posterior in nine in the elderly patients, all of them with primary chordal rupture. There was no significant difference in the left atrial (LA) and left ventricular (LV) size in two groups, although LA and LV size were mildly enlarged in both groups. Systolic pulmonary artery pressure was significantly higher in the elderly (43±17mmHg) than that in the younger patients (27±18mmHg) (p<0.05). The LV-angiogram showed significant mitral regurgitation (III∼IV) in 8 of 9 elderly and 4 of 6 younger patients. In the elderly group, 9 patients underwent cardiac surgery (MVR or MV plasty). Eight of them had excellent results with good long-term prognosis although one of them died of post-operative complication. In contrast, two of 3 medically treated patients died of heart failure during the follow-up. In the younger group, prognosis of 5 surgically treated and 2 medically treated patients was both excellent without heart failure. Elderly patients with chordal rupture usually have acute onset of symptoms and are in heart failure secondary to severe mitral regurgitation, often associated with atrial flutter/fibrillation. When their heart failure cannot be controlled medically, they should undergo emergency surgery for MVR. Even when their heart failure can be controlled medically, surgical treatment (MVR) may be recommended in the elderly patients with severe mitral regurgitation, since prognosis of medically treated elderly patients with severe mitral regurgitation seems poor. Surgically treated elderly patients seem to do well as the younger patients.
Prevalence of depressive symptoms was determined for 1031 respondents who were of age 60 years and over. The responding rate was 75.6%. The respondents consisted of 384 males and 647 females including 4 community groups and 4 institutionalized groups. For the measurement of depressive symptoms the Zung Self-Rating Depression Scale (SDS) was used. The overall prevalence rate of depressive symptoms based on SDS point of 48 or higher was 11.1%. The prevalence rate was higher among females than males, but the difference was not of statistical significance. Persons who were of age 70-79 and 80-89 years showed significantly higher prevalence rate than other persons. After controlling the effects of age, prevalence rate of depressive symptoms among the institutionalized elderly was significantly higher than that among the other elderly. More attention should be paid on mental health services for the institutionalized aged people.
The circadian rhythm of heart rate was assessed using 24 hour electrocardiographic recordings in 88 hospitalized elderly patinets without any organic heart diseases. To investigate the factors influencing the diurnal variation of heart rate, patients were classified on the basis of dementia and physical disability into four groups. To determine if heart rate fluctuates rhythmically with a circadian period, mean hourly heart rate in 24 hour electrocardiographic recordings was used to fit cosine curves by the statistical technique of least squares, and three parameters of the rhythm -designated the mesor, amplitude, and acrophase- were estimated. 1) The cosine curves were fitted with a P value of 0.001 or less in all patients. 2) The mesor represented the rhythm-adjusted mean of heart rate. An analysis of the mesor revealed no significant difference in each group. 3) The amplitude values were derived from one half of the total diurnal variation of heart rate. The amplitude was significantly larger in patients without physical disability than in those with physical disability, regardless of accompanying dementia. This finding is a probable result of diminished autonomic nervous system activity, especially sympathetic nervous system activity in patients with physical disability. 4) The acrophase indicated the time when heart rates were at their peak above the mean. The acrophase showed a significant delay in patients with dementia, compared with that of patients without dementia. This result suggests that impaired central autonomic nervous system which regulates the acrophase of periodicity is present in patients with dementia.
In order to elucidate the relationship between roentgenographic infiltrates and gas exchange disturbance in pneumonia of the aged, we investigated 48 subjects with pneumonia who had their chest roentgenogram and arterial blood gas examined simultaneously. The aged group consisted of 27 subjects (male:female=14:13, mean age=76.3 years) with the age of 65 years or above, while the young group consisted of 21 subjects (male:female=16:5, mean age=44.0 years). The area of total lung field (TL) and that of pneumonic infiltrates (PI) on a chest film of posterior-anterior view were measured using a digitizer (MITABLET-II, Graphtec Co.) and the size of pneumonic infiltrates (SI, SI=100×PI/TL (%)) was calculated. There was a significant correlation between SI and PaO2 (r=-0.499, p<0.01) in the aged as well as in the young. When the regression equation of the aged was compared with that of the young, PaO2 level of pneumonia among the elderly was much lower than that of the young for a given SI. With regard to the relationship between SI and AaDO2, significant correlation also existed both in the aged (r=0.476, p<0.01) and in the young. When the regression equations were applied to estimate the magnitude of gas exchange disturbance, AaDO2 level of pneumonia of the aged was higher than that of the young for a given SI. In order to verify the accuracy of SI measured with eyes, we examined correlation of measured area with eyes and a digitizer. The correlation was highly significant (r=0.963, p<0.01) to confirm the accuracy of measurement with eyes. In 21 subjects whose chest films were available both on posterior-anterior (PA) and lateral view, we compared the data obtained with unidirectional (SI on PA view) measurement with that of bidirectional (summed SI on PA and lateral view) measurement. The correlation was highly significant (r=0.983, p<0.01), so that little difference should be expected between both measurements except for a case with pneumonia of left lingular lobe. Through these observations, we conclude as follows. (1) In pneumonia of the aged, the most common disorder of gas exchange is deoxygenation accompanied by increase of AaDO2, which might be caused by ventilation-perfusion mismatching. (2) Early oxygen administration should be recommended in pneumonia of the elderly, considering the tendency that PaO2 level of pneumonia in the aged is much lower than that of the young for a given SI and that the aged patients are susceptible to respiratory failure.
In order to investigate the frequency of pseudohypertension in the elderly, intraarterial blood pressure was measured by inserting catheter into the brachial artery in 59 aged subjects more than 65 years old, and was compared with the simultaneously measured indirect cuff method. On average, systolic blood pressure of 161.5mmHg by cuff method was significantly lower than 169.2mmHg by direct method, although the significantly correlation was observed between both methods (y=0.93±19.3, r=0.94). A case that indirect cuff method overestimated systolic blood pressure more than 10mmHg, referred as pseudohypertension, was not observed in this study. Moreover, a significant difference of blood pressure between Osler positive's and netative's was neither observed in systolic nor diatolic. The present study showed that pseudohypertension was very rare phenomenon even in elderly subjects, in contrary with reports by some investigators.
A 32-year-old female was diagnosed as Acrogeria by the following clinical characteristics; 1) atrophy of the skin with pigmentation, most marked on the backs of the hands, fingers, feet and toes, extending over the distal parts of the forearms and legs, 2) blue veins clearly visible on the trunk, 3) easy bruisability with formation of ugly scars on the lower extremities, 4) small fingernails and onychogryphosis of the nails of both big toes, 5) peculiar wrinkles arranged in semicircles around the corners of the mouth extending to the outside of the eyes. Her maternal grandparents were cousins and her mother had the same characteristic appearance as the patient. The patient had experienced the rupture of the uterus during her first labor at full term when she was 30 years old. The histological examination of the uterus showed no abnormality as the pregnant uterus and the fetus, who had died immediately after the rupture, was also found to have no abnormality. In addition to this case, 35 reported cases of Acrogeria were reviewed, and the significance of the disease in relation to the premature aging syndrome was discussed.