Evidence of old cerebral infarction on magnetic resonance imaging (MRI) is common in acute stroke patients without a prior history of stroke. This experience led us to investigate the incidence of silent cerebral infarction (SCI) in the patients with essential hypertension, a well-known major predisposing factor for stroke. The incidence, number, size and localization of SCI on MRI (MARK-J, 0.1T) and the prevalence of risk factors for stroke were investigated both in 66 hypertensive patients (WHO stage I or II; 63±9 (mean±S.D.) years old) and in 42 age-matched normotensive patients (61±9 years old). Risk factors selected were as follows: diabetes mellitus, hypercholesterolemia, daily alcohol intake, cigarette smoking, obesity, cardiac disease (arrhythmia and ischemic heart disease), hyperuricemia and high hematocrit. In hypertensive patients, the relationships between the incidence of SCI and hypertensive damages in major organs were also investigated. SCI was found in 45 out of the 108 subjects studied and a total of 216 SCI lesions were detected. All of the SCI lesions were localized in the subcortical white matter or in the basal ganglia. All SCI lesions were smaller than 3cm in diameter and 201 lesions (93%) were smaller than 1cm. The incidence of SCI tended to be higher in hypertensive patients (47%) than that in normotensives (33%) and increased significantly with advancing age in hypertensives from 26.9% in the 50s to 86.7% in the 70s, while no significant increase was noted in normotensives. In the hypertensives, significantly higher incidence of SCI was noted in patients with hypertensive changes in major target organs (72-73% in patients with organ involvement vs. 33-39% in those without). With respect to the characteristics of SCI lesions in the normo- and hypertensive patients with SCI, the average number of SCI lesions was significantly higher in the hypertensives than that in normotensives (6.0 vs. 2.1) and SCI lesions in the hypertensives were more frequently detected in the brain areas supplied by perforating arteries than in normotensives (47% vs. 24%). As for the incidence of stroke risk factors, patients with SCI showed a significantly higher incidence of cardiac disease than those without SCI (22% vs. 4%), while no significant differences were noted in the incidence of the remaining risk factors between patients with and without SCI. These results clearly demonstrated that SCI was frequently seen in older hypertensive patients free of stroke symptoms especially when moderate hypertensive changes were revealed in the target organs. Furthermore, the higher incidence of SCI of the hypertensives in the brain areas supplied by the perforating arteries strongly suggested that hypertensive arterial changes might play a crucial role for the occurence of SCI, because characteristic hypertensive angionecrotic and/or arteriosclerotic changes are known to be frequently observed in the perforating arteries of the brain.

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An assessment has been made regarding the changes of the particles of lipoprotein A-I without A-II (Lp A-I) and lipoprotein A-I with A-II (LpA-I/A-II) which correspond to HDL subfraction isolated by the use of anti-apo A-I and A-II antibody affinity columns in order to quantitatively and qualitatively investigate the change of HDL caused by administration of probucol and pravastatin which are therapeutic drugs for hypercholesterolemia. Probucol caused significant decreases of HDL- cholesterol, plasma apo A-I/apo A-II ratio and particles larger in diameter than 10.4nm. Comparing Lp A-I and A-I/A-II ratios with those in normolipidemic controls and the ratios before and after administration of probucol, the decrease of LpA-I ratio was found to be remarkable after prolonged administration of probucol, and it was presumed that the decrease of HDL cholesterol by prolonged administration reflects the decrease of LpA-I particles more than the decrease of LpA-I/A-II. On the other hand, no significant change was seen in HDL cholesterol, plasma apo A-I/apo A-II ratio or HDL particle size in the pravastatin group. It is considered essential to observe HDL from the aspect of apoprotein, which plays an important role in the metabolism of lipoprotein, in the assessment of the anti-atherogenic activity of HDL cholesterol in future. In other words, it is necessary to analyze the change of HDL from the aspect of Lp A-I and Lp A-I/AII and investigate their respective metabolisms and roles.

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Parkinson's disease (PD) is often associated with dementia in elderly patients, and sometimes PD coexists with senile dementia of the Alzheimer type (SDAT) or cerebrovascular disease (CVD) in the elderly. However, since there are few previous clinical studies on the coincidence of, or relationship between PD and CVD, the authors evaluated these aspects in 34 elderly patients with PD using MRI and SPECT. All the patients were over 70 years old. The diagnosis of PD was based on the presence of three symptons (resting tremor, cogwheel rigidity and bradikinesia) which are characteristic of PD, and the effectiveness of L-DOPA therapy. We therefore believe that patients with vascular Parkinsonism were excluded from our study. In 34 cases, 24 (71%) had MRI evidence of CVD (mainly the lacunar state). In the 10 cases who had no CVD, 2 (20%) had severe dementia and the decrease of regional cerebral blood flow (rCBF) in the temporal and parietal lobes bilaterally correlated with the SPECT findings commonly found in SDAT. A comparison of the rCBF and the results of Hasegawa's dementia score (HDS) (verbal intelligence score) was made between the patients with PD associated with CVD and the patients with PD who had no CVD and no SPECT findings which correlated with SDAT. The rCBF in the frontal lobes and the results of the HDS of the former group were significantly lower than those of the latter. As mentioned above, elderly patients with PD often had CVD, leading to dementia. We also pointed out the difficulty in making a differential diagnosis between PD with CVD and vascular Parkinsonism, and the necessity of whether or not the concept of “mixed type Parkinsonism” should be considered.

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A total of 32 patients with hypertensive putaminal hemorrhage, who had been admitted within 24 hours of onset, were reviewed. Patients were divided into three groups on the basis of their outcome at hospital discharge, as follows: Group A, 11 patients who were able to walk independently with good or full recovery from hemiparesis; Group B, 9 patients who were able to walk with a cane and 2 patients in wheel chairs; and Group C, 6 patients who required evacuation of hematoma and 4 who had died. We investigated factors affecting outcome by comparing the clinical features during the acute stage and degrees of hypertensive damage to the retina, heart, and kidney of the above three groups. Furthermore, we examined interrelationships among the volume of the hematoma (as calculated from CT scan), systemic blood pressure, and urinary catecholamine excretion in 10 of these patients. The mean age in groups A, B and C was 61.4±8.1, 58.0±11.3, and 52.4±6.8, respectively. The mean volume of hematoma on admission (Day 1) in Group C (50.2±28.2ml) was significantly larger than in the other two groups (p<0.01, vs Group A: 19.5±8.8ml; p<0.05, vs Group B: 25.1±12.6ml). In Group C, the mean hematoma volume on Day 2 (98.4±39.5ml) was significantly larger than the volume on Day 1 (p<0.01). Among the three groups, the level of systemic blood pressure in Group C was the highest on Day 1 and the mean systolic blood pressure on Day 2 in Group C was significantly higher than that on Day 2 in Group A (p<0.05) and in Group B (p<0.01). There were no significant differences among the three groups in blood chemistry, blood coagulation data, or severity of hypertensive changes. Systemic blood pressure and urinary excretion of catecholamine had no correlation with the volume of hematoma. However, urinary excretion of norepinephrine showed a good correlation with mean systolic blood pressure (r=0.735, p<0.05). From the results of the present study, it is suggested that the risk of the growth of hematoma increases if the hematoma volume is more than 50ml and/or systemic blood pressure is high during the early stage of cerebral hemorrhage. Moreover, these patients appeared to be in a state of elevated sympathetic nervous function. Furthermore, our data indicate that there is no correlation between severity of hypertensive changes and development of hematoma.

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The present study was conducted in order to examine epidemiologic factors related to physical locomotion ability among the aged in an area with long life expectancy, a village in Okinawa Prefecture. Medical examinations and interviews were performed for 756 inhabitants aged 65 years and older, who were classified into 2groups of physical locomotion ability, a high group and a low group. According to the results after multiple logistic regression analysis, the following factors showed positive relation to physical locomotion ability: age, working status, food intake frequencies (fish, eggs and green vegetables), skinfold thickness, grip strength and serum albumin. However, no statistical associations were observed between physical locomotion ability and other factors such as sex, smoking status, alcohol intake, hypertension, Quetelet's index, serum total cholesterol or and hemoglobin.

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To examine satisfaction with medical care in hospital for elderly people, a questionnaire was sent to 900 patients who discharged two geriatric hospitals recently. 598 answers were obtained (66%) and analyzed in relation to activity of daily living (ADL) and types of disorder. Although patients who were not satisfied with medical care were only 7 cases (1.2%), patients with lowered ADL and with cerebrovascular disease or bone/joint disease showed significantly negative response. These patients admitted immediately and stayed longer periods than other patients, but they wanted to stay more days in hospital. In addition, these patients judged attitude of medical staffs negatively in comparison with other ADL groups and other disorders. On the contrary, total dependency in daily living did not relate to dissatisfaction with medical care and attitude of medical staffs. Withholding of judgement was characteristic answer in this group. Satisfaction with keeping privacy in hospital decreased in parallel to decrease of ADL. These results suggest that dissatisfaction with medical care is centered on patients with compromised independence. This must be considered when improving quality of life in elderly people.

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Systolic anterior motion of the anterior mitral leaflet and asymmetric septal hypertrophy (ASH) are characteristic features of hypertrophic obstructive cardiomyopathy (HOCM) on an echocardiogram. Among 9, 670 patients over 60 years old examined by echocardiography from January, 1984 to October, 1990, 55 patients showed systolic anterior motion of the anterior mitral leaflet and/or the chordae tendinae (SAM). We investigated clinical features and morphological features of the left ventricle on an echocardiogram in the 55 patients with SAM. They were classified into three groups according to the degree of SAM. Thirty eight cases (group I) had no mitral and/or chordal-septal contact, 10 (group II) had brief contact (<30% on the echocardiographic systole) and 7 (group III) had prolonged contact (≥30%). Ages ranged from 60 to 99 with a mean age of 78.2 years. There were 19 males and 36 females and there was a predominance of females in each group. Thirty five cases had hypertension and 34 left ventricular hypertrophy on electrocardiograms. One case of group I, 3 of group II and 7 of group III had a clinical diagnosis of HOCM. In comparison with each group, the incidence of LVH (SV1+RV5≥35mm) was 52% in group I, 90% in group II and 83% in group III and that of LVH (SV1+RV5≥70mm) was 29%, 20% and 67%, respectively. On echocardiographic examination, the diastolic descent rate of the anterior mitral leaflet in the 3 groups was 36.1±13.1mm/sec, 19.4±13.1mm/sec and 10.7±11.8mm/sec (p<0.01). The septal thickness was 14.4±4.3mm, 13.9±3.3mm and 18.2±4.1mm and the posterior wall thickness was 11.6±2.2mm, 12.2 ±3.6mm and 13.6±4.8mm. In particular, septal hypertropy led to ASH in group III. The left ventricular end-diastolic dimension was 42.7±8.5mm, 36.6±2.9mm and 38.9±5.6mm in each group. The IVS-AML distance at the onset of systole was 16.7±4.5mm, 13.4 ±3.2mm and 12.4±3.9mm, respectively (p<0.05). The incidence of proximal septal bulge was 32%, 70% and 86% (p<0.01). Out of 9 autopsied cases (6 in group I, 1 in group II2 in group III), 3 of group II and III demonstrated the septal band characteristic of HOCM in the elderly. The characteristic features of 55 aged patients with SAM were as follows; 1) small left ventricular cavity on the low side of the normal range, 2) slackened chordae due to the small left ventricular cavity, 3) narrowing of the left ventricular outflow tract due to the narrow aortoseptal angle and the proximal septal bulge, 4) anterior displacement of the mitral valve due to the mitral ring calcification, 5) good contraction of the left ventricle. This study showed that some of the abovementioned factors, in combinaiton, might cause SAM and the progression of SAM was associated with increased narrowing of the left ventricular outflow tract and the progressive hypertrophy of the septum. The septal band was observed in cases of Group II and III, which had mitral and chordal-septal contact on systole.

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The purpose of this study was to develop a behavior rating scale to measure adaptation of the elderly using care staff as evaluators and to examine the reliability and validity of the scale. The behavior rating scale consists of 51 items and 5 subscales to measure areas of ADL, activity, interpersonal relationships, dementia syndromes, and socially irritating behavior. The scale was administered to 280 elderly residing in 4 nursing homes. Each reliability index, including internal consistency, test-retest, and inter-rater agreement was satisfactory. Validity was examined by relating total score or each subscale score to 19 external variables including physical condition, state of daily living, cognitive ability and personality. The correlations between external variables and the scale scores indicated that the behavior rating scale was valid.

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Event-related potentials (ERPs) occurring in response to attended and unattended stimuli were studied in 31 patients with Parkinson's disease (mean age: 66.9 years), 9 patients with Alzheimer's disease (mean age: 73.6 years) and 37 normal subjects (mean age: 47.5 years). Of the 31 patients with Parkinson's disease, 6 met the criteria for dementia in DSM-III-R. ERPs were recorded during the performance of visual discrimination tasks using three kinds of stimuli: frequent non-target (62%), infrequent non-target (19%) and infrequent target (19%) stimuli. The P3a and P3b were identified as the components of the P3 (P300) responses to infrequent nontarget stimuli and infrequent target stimuli. Both the P3a and P3b latencies were significantly prolonged with normal aging. Nine of the Parkinson's disease patients showed a P3b latency above the 95% confidence limit of the age estimated regression line, while only one patient showed a prolonged P3a latency. There was no significant correlation between the P3a and P3b latencies in the patients with Parkinson's disease, although a significant correlation was found in the normal subjects. There was a significant correlation between the P3b latency and Hasegawa's dementia scale (HDS) score although the P3a latency showed no correlation with HDS score. These results indicate that the P3a and P3b components have some differences. In demented patients with Parkinson's disease, the P3b latency was significantly longer than that in 15 age-matched normal subjects, although no significant difference was found in the P3a latency. On the other hand, patients with Alzheimer's disease showed a significant prolongation of both P3a and P3b latencies compared to the age-matched normal subjects. Furthermore, there was a significant difference in P3a latency between demented patients with Parkinson's disease and those with Alzheimer's disease. There were no significant differences in any of the amplitudes among these three groups. These results suggest that the automatic processing stage, as reflected by P3a, may be less impaired than attentional controlled processing reflected by P3b in patients with Parkinson's disease, and further indicate that there may be some differences in the changes of the cognitive process between patients with Parkinson's disease and those with Alzheimer's disease.

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An elderly case of idiopathic retroperitoneal fibrosis (IRPF) with bilateral ureteral obstruction was reported. A 74-year-old man was admitted with complaints of general fatigue and loss of appetite. An elastic hard mass with a smooth surface was palpated in the left upper quadrant of the abdomen. Abnormal ESR and CRP were noticed. Abdominal ultrasonography showed both a homoechoic mass which surrounded the aorta in the retroperitoneal space and bilateral hydronephrosis. Computed tomography revealed a retroperitoneal mass involving bilateral ureters. Magnetic resonance imaging demonstrated a mass with a sharp image and signal intensity. Furthermore the morphological relationship between the mass and the ureters and major vessels clearly indicated the characteristics of benign retroperitoneal fibrosis. Based upon the above findings, a diagnosis of IRPF was made. After confirming the histological diagnosis by biopsy, treatment consisting of bilateral ureterolysis, intra-abdominal transposition of ureters and oral administration of prednisolone was performed, resulting in a normalization of laboratory findings. Analysis of 86 previously cases of IRPF reported up to 1990 in Japan, revealed the peak age to be in the 7th decade with predominace in males (males: females=57:29).

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An elderly case of systemic lupus erytematosus (SLE) with suspected hemolytic anemia was experienced. A 70 year-old female was admitted to our hospital on December 31 with complaints of herpetic eruption. She complained of arthralgia since 3 month prior to her admission. The positive findings on examination were skin eruption in the left chest, a systolic heart murmur and a palpable elastic hard liver. Laboratory data showed raised erythrocyte sedimentation rate of 149mm per hour, decreased Hb (10.1g/dl), decreased hematocrit (30.0%), increased reticulocytes (33‰), decreased thrombocytes (73, 000/mm³), increased γ-globulin (33%) and positive rheumatoid factor. During admission, she developed anemia. A stool test for occult blood was negative. The haptoglobin was 38.8mg/dl and bone marrow aspiration showed increased erythropoesis, suggesting features of immune hemolytic anemia, except she was negative on Coomb' test. Eye fundi were similar to case of typical bleeding observed in SLE. Concerning immunoglogical findings, the antinuclear factor was ×1280 and the anti-dsDNA antibody was ×80, on which a diagnosis of SLE was based. She experienced numbness of the left arm and developed left hemiparesis 2 days later. Therapy with 15mg/day prednisone obtained a good response and anemia, abnormal immunological findings and hemiparesis disappeared.

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A case of symptomatic hypobetalipoproteinemia (hypo-βLP) with unusual distribution of apolipoprotein E (apo E) in a 68-year-old male patient with chronic heart failure and liver cirrhosis associated with low triiodothyronine (T₃) syndrome is reported. There was nothing in the family history to suggest familial hypo-β LP. In this case, levels of apo B and low-density lipoprotein were very low, and the fraction of β lipoprotein on polyacrylamide-gel disc electrophoresis (PAGE) was only 7%. However, the triglyceride level was normal due to the presence of chylomicron, in spite of hypocholesterolemia and hypophospholipidemia. The mid-band lipoprotein on PAGE showed that Lp (a) lipoprotein concentration was normal (18.3mg/dl). The activities of lecithin cholesterol acyltransferase, hepatic triglyceride lipase and lipoprotein lipase (LPL) were low. The concentrations of apo C-II, apo C-III and apo E were low, while those of apo A-I and apo A-II were normal. The author recently reported that the apo C of high-density lipoprotein (HDL-apo C) was detected in α lipoprotein, but that HDL-apo E was detected in the near α₂-globulin region behind α lipoprotein on agarose-gel immunofixation electrophoresis. The author therefore named it α₂- apo E, and later found that the fraction percentage of α₂-apo E depends on lipolysis and is inversely correlated to the concentration of apo B. It was confirmed that apo C-III and apo E in 22 patients with symptomatic hypo-β LP were distributed for the most part in the HDL and near the α₂-globulin regions respectively, and that the percentage of α₂-apo E in 10 patients with low T₃ syndrome was higher than that in 20 healthy controls. However, in the present case α₂-apo E was absent, so that apo E was distributed only in chylomicron and pre-β lipoprotein, while apo C-III was distributed mostly in HDL and, to a lesser extent, in the apo B-containing lipoproteins. It is suspected that the unusual distribution of apo E in this case is due to the decrease of LPL activity.

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A 76-year-old man was referred to our hospital with complaints of productive cough, dyspnea and peripheral cyanosis. The chest X-ray film indicated the pulmonary emphysema and acute bronchitis, but no abnormal intracardiac calcification. The electrocardiogram revealed a peaked P-wave, complete left bundle branch block, and ventricular premature contraction. Chest tomography demonstrated abnormal intracardiac calcium deposition in the right heart region. Two-dimensional echocardiography revealed the tricuspid annular calcification in the postero-lateral portion, showing a synchronous movement with tricuspid annular motion throughout the cardiac cycle. The size of calcification was 10×14mm. The tricuspid valve showed no significant regurgitation. Left ventricular dilatation, associated with mild mitral regurgitation and impairment of systolic function (EF=49%) was revealed by echocardiography. Serum examination revealed positive in Wassermann reaction. This case of tricuspid annular calcification might be caused by atherosclerotic degenerative change related to the aging process, or by an unknown mechanism related to pulmonary emphysema.

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