Geriatrics in future will be most concerned with persons aged 80 years or more (very elderly) in Japan. Clinical and pathological features of very elderly patients were reported with comparison to the 65-79 age group. Many very elderly do not show clear-cut clinical signs and symptoms, but have serious underlying diseases. We propose here a concept of “clinical threshold”. On evaluating the laboratory data, we must consider the grades of “activity of daily living(ADL)” of the aged patients, because ADL may significantly modify the test results. Furthermore in clinical practice, we should pay attention to both the psychosocial states and physical findings of the patients. “The old age syndrome” proposed by Parker is useful in geriatric medicine. Extensive studies on dementia, especially of Alzheimer's type are required urgently. Molecular biologied approaches to this disease have shown great advances in geriatrics. To prevent geriatric disease, well-controlled exercise and diet are important as well as reasonable psychosocial integrity.
In order to clarify the clinical characteristics of the prehospital phase of acute myocardial infarction (AMI) in the elderly, we studied 92 elderly (65 years old or more) and 41 younger patients with first AMI. Fifty eight elderly (63.1%) and 30 younger (72.7%) patients had typical symptoms such as chest pain at onset. There were 5 elderly cases who had no symptom, although all of the younger had some symptoms at onset. More than 70% of the younger cases developed their symptoms either between 6 am and noon or between 6 pm and midnight, whereas the elderly showed no such tendency. Intervals between the onset of symptoms and hospital admission (admission time) averaged 6.8 hours (hr) in the younger and 7.7hr in the elderly. Approximately one half of the elderly and a quarter of the younger showed admission time more than 6hr, respectively. Elderly cases with atypical symptoms tended to have a longer admission time than younger cases (7.2 vs 3.1hr), although there was no significant difference between the elderly and the younger with typical symptoms (8.0 vs 7.9hr). Younger patients with heart failure had significantly shorter admission time than those without heart failure (3.6 vs 8.6hr). However, the elderly with heart failure showed a prolonged admission time (6.1hr). Although there was no difference on admission time between survivors and non-survivors within 28 days after admission in the elderly (7.5 vs 8.4hr), the elderly non-survivors with atypical symptoms had the longest admission time (13.0hr). The results show that the elderly with AMI tend to have atypical symptoms at onset and a prolonged admission time. This indicates that the delay of admission in elderly cases may be partially due to atypical symptoms. It is important to accelerate the early admission of the elderly with atypical symptoms to improve the immediate prognosis of elderly cases of AMI.
Changes of cerebral white matter on computed cranial tomography related to aging were studied in 70 subjects aged 30 to 94 years. The subjects had no histories of cerebrovascular accidents and no abnormalities in the central nervous system were shown by physical examinations nd CT scans. We measured the average attenuation values (CT numbers) of each elliptical region (165 pixels, 0.39cm2) in the bilateral thalamus and twelve areas of deep white matter. Multiple regression analysis was used to assess the effects of age, cranial size and cranial bone CT numbers on the brain CT numbers. We also studied the association between brain CT numbers and brain atrophy, hypertension, diabetes mellitus. CT numbers of frontal white matter surrounding anterior horns decreased with aging in 70 subjects aged 30 to 94 years. No significant correlation between age and brain CT numbers was found in any other region by multivariate analysis, because of the prominent effect of cranial bone CT numbers on brain CT numbers. Although no age-related changes of white matter CT numbers was found in 41 subjects aged 30 to 65 years, there were significant negative correlations between age and white matter CT numbers at all regions in 29 subjects aged 66 to 94 years. Brain atrophy was associated with brain CT numbers. No association was found for hypertension or diabetes mellitus. Brain CT numbers decreased with aging even in neurologically healthy persons in older age. Brain CT numbers also decreased as cerebral atrophy advanced.
We measured aortic pulse wave velocity (PWV) in 168 male adult cases of various arteriosclerotic diseases. In order to evaluate the effects of age, smoking habits, alcohol intake, and blood pressure, we applied the least median of squares (LMS) regression which was considered to be very useful for data analysis. The results showed that PWV level increased with age. Furthermore smoking was associated with increasing PWV level and this effect was also related to age. We concluded that the PWV was valuable as an index of arteriosclerosis, and instead of the classical least squares method, LMS regression was very useful for analysis of medical data.
To get normal reference ranges for blood chemistry in elderly subjects, laboratory data on serum chemical analytes obtained from 1822 male and 1870 female outpatients were statistically analyzed with a non-parametric method with iterative truncation. Regarding the difference in the test data between male and female, the values for most analyses except for inorganic phosphorus and total protein were significantly higher in male than in female when an adult group including subjects of age ranging from 21 to 50 years was compared. The values for lactic dehydrogenase, albumin, sodium and calcium were higher in female of over 50 years of age than in their counterpart. When male and female were combined, the normal reference ranges for lactic dehydrogenase, alkaline phosphatase, uric acid, blood urea nitrogen, creatinine and potassium tended to be elevated while those for total protein, albumin and calcium to be declined with ageing. The values for total cholesterol and triglyceride reached a peak at a certain age. Total and direct bilirubin, sodium and chloride values were constant throughout whole age categories.
The relationship between the age and the clinical efficacy of a new long acting calcium entry blocker, nisoldipine, was investigated in essential hypertension using two double blind group studies, in which nifedipine or atenolol was used as a control drug. Following 4 weeks of the observation period, nisoldipine was administered 2.5mg once a day and an increase in dose was available up to 5 to 10mg per day for 12 weeks of the treatment period. One hundred fourty nine cases who received nisoldipine were divided into the following two groups; 97 cases of the middle aged patients under 59 years old (mean age of 49.5 years) and 62 cases of the elderly patients more than 60 years old (mean age of 64.8 years). Average dose of nisoldipine at 12 weeks of treatment period was 4.8mg in middle age and 5.8mg in elderly group. The positive antihypertensive effect was observed in 82.2% in the middle aged patients and in 83.6% in the elderly patients; there was no significant difference between the two groups. In each group, significant fall in blood pressure was observed after the treatment, although no significant difference in the fall of systolic and diastolic blood pressure in the treatment period was observed between the two age groups. The side effect was observed in 16 cases (16.5%) of the middle aged patients and in 7 cases (11.3%) of the elderly patients, but no significant difference in the incidence was observed. The significant deterioration of the clinical laboratory findings was not observed in both groups. The rate of usefulness (useful or above) was 74.7% in the middle aged patients and 81.5% in the elderly patients, and there was no significant difference between the two groups. These results indicate that a new long acting calcium entry blocker, nisoldipine, is effective and safe antihypertensive drug for the elderly as well as for the middle aged patients.
Survival data analysis was carried out in a community to aim at linking the home visit survey of the 106 chronically bed-restricted elderly aged 60 and older to whom care was given exclusively by their coresidents, to deaths certified within 40 months of the baseline interviews. The questionnaire in the baseline survey included items concerning demographic attributes, functional status, activity of daily living, mental status and family contact. During the 40-month observation interval 59 deaths were registered in this population. The association of 16 independent variables with fatal outcome derived from the above survey was evaluated using two kinds of life-table analyses. First, a non-parametric technique was applied to estimate the survival distribution and computing rank tests for association. Subsequent multivariate analysis made with the step-wise method revealed the significant importance of being stimulated everyday by TV or radio and that of the relationship of caregivers to the elderly as well as good physical function and mental well-being for longevity of chronically bed-bound elderly.
To test the diagnostic accuracy and safety of dipyridamole-loading myocardial imaging with thallium-201 (Tl) in the elderly, we performed myocardial tomography in 42 patients with coronary artery disease (CAD). While monitoring of ECG and blood pressure, dipyridamole was infused at a rate of 0.57mg/kg body weight over 4 minutes, and 4 minutes later Tl (3mCi) was injected. Five minutes later (initial) and 3 hours after Tl injection (redistribution) myocardial image swere obtained from 32 projections by a rotating gamma camera. After low-pass filtering, images were reconstructed into short-axis, horizontal long-axis and vertical long-axis tomograms. Myocardial Tl distribution both on initial and redistribution images and myocardial Tl washout rate's (WOR) of the entire left ventricle were expressed into two-dimensional polar maps by using short-axis cuts (bull's-eye maps). In addition to visual interpretation, abnormal WOR (<18%) was used as a criteria of dipyridamole induced myocardial ischemia. Patients were divided into 2 groups. Group I consisted of 24 patients more than 70 years of age and Group II consisted of 18 patients less than 65 years of age. The clinical and coronary angiographic characteristics of the two groups did not differ. The sensitivity of this method for the detection of CAD was identical (83%) between the 2 groups, and the detection of coronary artery stenosis was 73% in Group I and 74% in Group II (NS). Decrease in blood pressure and increase in heart rate due to dipyridamole infusion did not differ between the 2 groups and abnormal blood pressure response was not observed (maximal decrease in blood pressure was 30mmHg and 10mmHg, systolic and diastolic respectively). The most common cardiac side effects were ischemic ST depression in ECG and chest pain. ST depression appeared in 29% of Group I and 33% of Group II (NS). Chest pain developed in 21% of Group I and 22% of Group II (NS). Intravenous aminophylline was required to reverse cardiac side effects in one patient of each group, after which cardiac side effects disappeared rapidly. Dipyridamole induced arrhythmia was subtle and did not require any treatment. No major side effect was not observed after dipyridamole injection. It was concluded that dipyridamole-loading myocardial tomography with Tl is a safe and useful method for the detection and evaluation of CAD, even in the elderly.