The clinical background relating to edema in elderly inpatients was investigated, in terms of various items in elderly (aged≥65) cases with edema (n=96) and without edema (controls, n=95). Both groups were matched for sex, age, and underlying diseases. As compared with the control patients, the patients wth edema had longer hospital stays with more disabled status, and showed less activity of daily living (ADL). The rates of bed-restricted patients, dementic patients, and patients with decubitus, muscle atrophy, or incontinence were found to be significantly higher in the patients with edema. The measurement of biochemical parameters revealed that the patients with edema had significantly lower levels of serum albumin, Na, Cl, creatinine, and uric acid, in contrast to higher levels of C-reactive protein. According to the classification of the assumed causes of edema, we divided the patients with edema into five groups; group 1 (n=33): edema associated wth immobilization, group 2 (n=18): edema due to heart failure, group 3 (n=15): edema on paretic limbs, group 4 (n=6): edema due to hypoproteinemia, group 5 (n=5): edema associated with liver cirrhosis. Both group 1 and group 4 patients had lower levels of hemoglobin and albumin, whereas group 3 patients had higher scores of ADL, higher blood pressure, and higher levels of hemoglobin and albumin. These results suggest that immobilization and restriction in bed, as well as malnutrition, were important factors in causing edema in elderly inpatients.
Since decubitus, one of the common lesions, is not yet fully under medical control, it still offers serious problems. The incidence of this lesion once comprised about 12% of the patients hospitalized in a geriatric institution, and was responsible for the development of sepsis in about 20% of those cases. Although the incidence of this lesion has been declining, it still devilitates many geriatric patients, especially with neurological or malignant diseases. Care being necessary to disperse the pressure on the skin adjacent to the bone, many devices have been invented. The air-fluidized bed is especially effective in preventing and alleviating decubitus. However, a simple device utilizing polyvinyl sponge plates is worthy to try from the standpoint of cost-performance. Several surgical reparative manouvres as well as newly developed medicines, such as prostaglandin E1, etc. now promote favourable outcomes. However, the imortance of basic preventive care, such as postural change with massage, local hygiene, nutrition, etc. cannot be ignored.
Following the recent increase in the aged population, an increase in the number of cases of urinary incontinence among aged people can be anticipated. Considering the relative decrease of care-givers such as cohabitating family and increase of the cost of incontinence care, a social and national economic problem might be arise in near future. Therefore rapid steps to cope with this situation are necessary. Urinary incontinence of the aged has been mainly considered to be the problem for management and have been avoided by medical professionals until recently. Urinary incontinence is not only a problem of only aging, but generally is caused by some disease, therefor medical care might cure the incontinence or make the management of it easier. However, considering the increase in the number of elderly aged urnary incontinence patients, the number of incontinence-care professionals is very small. Help from the general practitioners is indispensable. Therefore this speach was drafted with the wish that the audiences, manly medical and geriatric doctors who usually are in contact with aged patients, may understand and become familiar with urinary incontinence of the elderly. This paper covered the physiology of urination especially in relation to the nervous system, abnormal bladder and urethral function found in urodynamic tests of elderly apparently normal persons, pathophysiological mechanism of urinary incontinence of aged people, urinary ncontinence evoked as a side effect of some drugs. In order to assess and manage elederly urinary incontinence better, we must be albe to recognize often there are two or more simultaneous basic underlying causes and how conbinations of these cause create multifactorial mixed types of urinary incontinence. It is therefore, often useful to assess and treat geriatric urinary incontinence by categorizing predisposing and precipitating factors in accordance with the method of Professor Brocklehurst. Before treating aged incontinent patients, the physician must decide beforehand not to dislike treating such patient. In treating incontinent patients, doctors had better differentiate the incontinence group from the transient group to established one following Professor Brockehurst's clinically useful classification. The former include acute urinary infections, acute confusional disorders, psychological diseases and retention with overflow due to faecal impaction and untoward effects of drugs (anticholinergic effect). The inocntinence of this group is curable by treating only underlying disease without professional knowledge of urinary incontinence. The latter includes several kinds of neurogenic bladders and prostatic diseases etc. And treatment must be done under professional knowledes and technics.
The human oral mucosa atrophies with aging, and at the same time, loss of teeth occurs and the muscles involved in mastcation weaken, leading to masticatory hypofunction. The loss of teeth in animal is serious in that it leads to death. For humans, however, dental prosthesis may aim at functional recovery. From the viewpoint of oral functional recovery, it is important to have a firm grasp of the change in the oral environment with aging. Elderly patients who complain of dry mouth may often have glossodynia, stomatitis, dysgeusia, prosthetic disorder, etc. Although atrophy of the salivary gland is mainly responsible for these disturbances, influences of complications and/or medications cannot be ignored. Secretory immunoglobulin A (sIgA) secretion in the saliva of elderly cases showed a concentration comparable to that of young subjects in their twenties and was considered to be satisfactory from the viewpoint of oral infection control. On the other hand, plate prosthetic wearers may have high incidence of oral candidiasis, so that in case of loss of teeth, prostheses with so-called implant dentures using artificial dental implants are regarded as physiologically preferable to conventional plate denture.
We have studied 97 patients with dementia who have been discharged from our hospital and 106 inpatients with dementia who have been admitted during last two years in our hospital. The diagnosis of dementia was done according to the criteria of DSM-III. Based on their clinical course, neurological signs, Hachinski's ischemic score and neuroradiological findings, we divided patients into 4 groups, [senile dementia of the Alzheimer type (SDAT), vascular dementia (VD), unclassified dementia and other dementias which includes dementia with Parkinson's disease or motor neuron disease, etc)]. Concerning 70 demented patients who died during hospitalization, the average age of onset and the duration of illness of SDAT were 80.5 years old and 4.6 years respectively and those of VD were 77.6 years old and 2.7 years respectively. The common causes of death were pneumonia (50%) and cardiac failure (24%). Reccurrence of cerebral vascular accident (CVA) was also another frequent cause of death in VD. The most common behavioral problems causing admission in patients of SDAT were aimless wandering, nocturnal delirium, illusion and hallucination. In VD, nocturnal delirium, aimless wandering, violence and abnormal monologue were most common causes of admission. The important causes degrading ADL of inpatients were fracture, especially fracture of the hip joint, pneumonia, intestinal bleeding and CVA. Concerning the increase of the population of over 75 years old, it will be suggested that the care and treatment of demented patients in this age group will become a major social problem.
β blockers and Ca antagonists are popular therapeutic agents for hypertension and ischemic heart disease. Although these are reported to induce various bradycardiac arrhythmias, clincal studies remain insufficient. The author performed a clinical study of sinus node dysfunction caused by drugs for heart and circulatory diseases. Seventy-seven of the 1, 734 patients admitted to the CCU of our hospital during the past 11 years, were the subjects of this study. They showed sinus node dysfunction on electrocardiographs (ECG). Forty-two subjects had drug-induced sinus node dysfunction (DISD) and 35 had sick sinus syndrome (SSS). Rubenstein's classification based on 12-lead ECG was used to diagnose DISD and SSS. All patients underwent chest X-ray examination, ECG, echocardiogram and blood chemistry and were divided into DISD and SSS groups. The DISD group was subdivided into an older group (65 years or more), and a younger group. Ten patients in the DISD group were examined electrophysiologically. SSS II and III types appeared in 22 DISD patients (52.3%) and in 31 SSS patients (88.5%). Bradycardia in the DISD group was milder than in the SSS group, because the DISD group had a higher minimum heart-rate and a shorter maximum R-R interval. However, the DISD group showed significantly lower blood pressure and renal function and a higher grade on the New York Heart Association's (NYHA) classification. Echocardiographic findings following recovery were similar in the two groups. Electrophysiological examination revealed abnormal sinus node function in 3 of the 10 DISD patients (30.0%). In the DISD group, 27 were older patients (3.2%). This was significantly more than the 15 who were younger patients (1.6%). The SSS II and III types appeared in 18 older patients (66.6%) and 4 younger patients (26.6%). The two groups showed no difference in the minimum heart-rate or the maximum R-R interval, but the older group were more severely afflicted, judging from the NYHA classification, renal function and cardiothoracic ratio. The causative drugs were β blockers in 26 patients, Ca antagonists in 21, digitalis in 16 and IA antiarrhythmic drugs in 9. Diltiazem especially had been given to about half of the older patients. Whenever older patients are taking these drugs, we should follow their progress carefully.
We examined the effect of rehabilitation on the prognosis of aged patients with a first episode of acute myocardial infarction. The mean age of patients was 77 years old. We divided them into two groups, one group consisted of 53 patients for whom a rehabilitation program was available, another group consisted of 84 patients for whom a rehabilitation program was not available. Of the patients with rehabilitation available, there were 20 who were unable to receive rehabilitation, 15 who were able to participate in only light rehabilitation, 27 who were able to walk and 22 who finished rehabilitation. During 3.5 years of follow-up after initial myocardial infarcton, the rates of cardiac death were 51% in the group without rehabilitation and 41% in the group with rehabilitation. For 26 patients who died of cardiac events and who had received rehabilitation, there was a positive correlation (r=0.53) between the level of rehabilitation reached and the survival in years. The incidence of angina pectoris after myocardial infarction was more frequent in the group with rehabilitation. However the exercise activity level was higher and the prognosis was better in the group with rehabilitation, although statistical significance was not found.
The relationship between coronary risk factors and the severity of coronary artery stenosis (coronary score: CS) was estimated in 225 male subjects (aged 29-82 years, median 60 years old) who had undergone coronary arteriography for suspected coronary heart disease. CS was positively related to age, and levels of fasting blood sugar, uric acid, total cholesterol, low density lipoprotein cholesterol, and apolipoprotein B. Alcohol consumption, apolipoprotein AI and AII levels were inversely correlated to CS. Although, the level of CS was significantly higher in diabetics and hypertensives than in non-diabetics and non-hypertensives, the difference of CS level between diabetics and non-diabetics was more remarkable than that between hypertensives and non-hypertensives. Furthermore the ratio of Apo-B/Apo-AI was the most sensitive index of coronary artery stenosis rather than conventional atherogenic indices such as (TC-HDL-C)/HDL-C. Correlation between CS and the ratio of Apo-B/Apo-AI was positively and closely associated with aging, and this positive relationship was observed even in non-drinkers, heavier drinkers, non-diabetics and non-hypertensives. The reweighted least squares based on the least median of squares regression analysis indicated that about 27% of the variation in CS could be accounted for by age, complication of diabetes mellitus, complication of hypertension and the ratio of Apo-B/Apo-AI. These results indicate that the ratio of Apo-B/Apo-AI is a more sensitive parameter of the severity of coronary artery stenosis than any other atherogenic index. Further, aging, complication of diabetes mellitus, complication of hypertension and an increased level of the ratio of Apo-B/Apo-AI were responsible factors for the severity of coronary arteriosclerosis in male subjects.
A 68 year old male, diagnosed as Alzheimer's disease clinically, pathologically showed both findings of Alzheimer's disease and Parkinson's disease. The brain weight was 940g. Macroscopically, severe cortical brain atrophy and depigmentation of the substantia nigra was noted. Microscopic examination showed marked appearance of senile plaque and a large number of neurofibrillary tangle with sever neuronal loss of the cerebral cortex. Additionally, the loss of neuron with many Lewy bodies was found in the substantia nigra. Lewy bodies were also found in the locus ceruleus and the dorsal vagal nucleus, but few in the cerebral cortical neurons. We compared this case neuropathologically with two autopsy cases of diffuse Lewy body disease (DLBD). There was no distinction concerning the lesions of the brain stem between this case and the cases of DLBD. In all three cases, the nucleus of basalis of Meynert showed marked neuronal loss. However, the brain was lighter than those of the cases of DLBD. Senile chages such as senile plaque and neurofibrillary tangles were more marked in this cases than in the cases of DLBD. Furthermore a large number of cortical Lewy bodies were found in the cases of DLBD, but few in this case. The distribution and number of Lewy bodies did not correspond with those of senile changes in the cases of DLBD. Also the cerebral cortical structure was better preserved in the cases of DLBD than in this case. In conclusion, from the clinicopathological findings, we considered that this case is Alzheimer's disease associated with Parkinson's disease. According to Kosaka's study, this case seemed to correspond with a transitional type of the Lewy body disease.