In order to evaluate the prognostic importance of the conditions before abdominal surgery for patients over 60 years of age. Multivariate analyses of postoperative complications were performed in 634 patients (comprising 525 cases of elective abdominal surgery and 109 cases of emergency abdominal surgery). The Mortality rate was significantly higher (p<0.01) in the emergency group (11.9%) and relatively low among the elective abdominal surgery group (3.8%). In the emergency group, 13 patients died, and MOF (multiple organ failure) was found to be the direct cause of death in 11 (85%). Although, the majority (75%) of emergency operations were for benign disorders, the remainder (25%) had malignant tumors. It is noteworthy that among 25% of cases, obstructions and perforations due to large bowel cancers were found to be 59% and 19%, respectively. In the elective surgery group, postoperative pulmonary and cardiovascular complications were found in 11.6% and 9.6%, respectively. Death due to cardiovascular problems in rare (5%), however, postoperative pneumonia was the cause of death in 70% of all of postoperative death. Risk factors affecting postoperative pulmonary complications were malnutrition, advanced age, male sex, malignant disease, dementia, cerebrovascular disorders, impaired pulmonary function tests. Surprisingly, the risk factors were identical, except for impaired pulmonary function, for postoperative MRSA pneumonia. In our study, postoperative pulmonary death was not associated with impaired pulmonary function, and it appears to be rather affected by the presence of cerebrovascular disorders and malnutritional state. A poor nutritional states (<40 according to Onodera's nutritional index) was present in over 50% of patients with cerbrovascular disorders and low ADL. In agreement with other reports, MRSA infections were frequently found in compromised hosts, and especially in the aged, in malnutritoned cases of gastrointestinal cancer. In summary, a malnutritional state is frequently associated with cerebrovascular disorders and low ADL is one of the major risk factors among patients who developed peneumonia after surgery. Further analysis is required to evaluate the preventive roles of nutritional management.
It has been assumed that amyotrophic lateral sclerosis (ALS) involves precocious senility as one of its pathogenetic aspects. The authors studied 55 autopsied cases of ALS in relation to age at death, ranging from 42 to 86. The materials consisted of 8 cases in the fifth decade, 8 in the sixth, 20 in the seventh, 12 in the eighth, and 7 in the ninth. The total duration of illness ranged from 6 months to 14 years. The most distinct relationship was observed in the anterior horn lesion of the cervical enlargement which became less severe with advancing age, irrespective of the length of illness. Fifth decade cases showed marked atrophy with severe neuronal loss and fibrillary gliosis in the anterior horn, while those in the ninth decade showed slight changes which were similar to age-matched controls. On the other hand, pyramidal tract degeneration did not show any correlation to age at death or to length of illness. Pyramidal tract degeneration was found in all younger age group cases, being always severe. In the older age groups, however, the degeneration varied extremely in degree from case to case. Some cases showed severe degeneration comparable with that in the younger age groups, while the others had no findings suggesting degeneration. In addition, cases on artificial respirators had a longer duration of illness, and more marked degeneration in the anterior horn, irrespective of age. Our study did not reveal that senile changes including senile plaques and neurofibrillary tangles were more marked in ALS cases. No clinicopathological correlation with dementia was recognized. The findings suggest that the anterior horn change became less severe with age, and that normal aging in the anterior horn may play an important role in the development of disease.
In the elderly, cerebrovascular diseases (CVD) are often complicated by severe infections such as pneumonia. This study aimed to examine the possible relationship at various timepoints of observation between immunological functions and the clinical course and to correlate the changes of immunological functions with CVD lesion side. The study was based on 25 right-handed patients (14 male and 11 female, mean age; male 69.0 years and female 74.9 years) with acute, focal neurological deficits of CVD (5 cerebral bleeding, 20 cerebral infarction; 11 right cerebral lesioned subjects, 14 left cerebral lesioned subjects). All patients were evaluated in terms of lymphocyte counts, T, B cell counts, T cell subsets, lymphocyte transformation and natural killer activity in peripheral blood as indices of immunological functions at various timepoints during the clinical course. Some of these immunological functions decreased within two months (acute stage) after onset of CVD, and some cases with decreased immunological functions developed complications of severe infection such as pneumonia. Patients who had both decreased immunological function and severe infection were 1 out of cases with 7 right cerebral lesions and 6 out of with 9 left cerebral lesions. This study suggests that the decreased immunological function in CVD subjects may be correlated with the site of the CVD lesion. In all left cerebral lesioned subjects, a reduction of immunological functions and a susceptibility to severe infection were not observed in the acute stage of CVD, however, some left cerebral lesion cases may be more closely related than in right cerebral lesion cases. The mechanism remains to be clarified. We hope that it will be possible to estimate prognoses of patients with CVD based on the above-mentioned immunological functions and act to prevent severe complications, especially infections, at the acute stage of CVD.
To clarify the mechanism of postprandial hypotension in the elderly, blood pressure and humoral factors were measured before and after meal, water, and glucose ingestion in 20 healthy elderly. The elderly patients were divided into 10 normotensive and 10 hypertensive cases. A reduction in systolic BP after meals in the hypertensive group was significantly larger than that in the normotensive group (-12.0±4.1 vs. 4.0±3.2mmHg, p<0.05). Systolic BP in hypertensive group significantly decreased at 30, 45 and 60 minutes after meals compared to the value before meals. However, no significant reduction in systolic BP was observed in the normotensive group. A change in systolic BP after meal significantly correlated with that after glucose, but not with that after water ingestion, suggesting that glucose intake mainly contributes to the postprandial hypotension in the elderly. An increase in plasma renin activity and plasma catecholamine were observed after meals in the normotensive group, but not in the hypertensive group. An increase in systolic BP significantly correlated with an increase in PRA. It was suggested that an impairment of the sympathetic nervous system in the elderly with hypertension was involved in the mechanism of postprandial hypotension.
Some elderly patients with chronic illness such as stroke, or Parkinsonism cannot take food orally because of dysphagia. In such cases, tube feeding can be used as a supplement to oral intake when malnutrition is present. This route allows for easier nursing care and decreases the frequency of aspiration pneumonia. Complications of tube feeding include nutrient deficiency states, pulmonary aspiration, gastrointestinal and metabolic disorders. We report two cases with complications of acute gastric ulcer which was thought to be induced with long-term tube feeding. Case 1 was a 61-year-old male patient with Parkinson's disease for ten years. L-DOPA had been administered with good control of his condition. However, his ability to swallow has deteriorated gradually. As he often suffered from aspiration pneumonia, nasogastric tube feeding was performed. After three years of tube feeding, he suddenly vomited much bloody material. He died from massive bleeding with acute gastric dilatation. Autopsy showed giant acute gastric ulcer covered with coagulated blood. UL3, 50mm in maximum diameter, was observed in the middle portion of the greater curvature, where the top of tube probably came in contact with the gastric wall. Case 2 was an 83-year-old female patient with stroke and chronic heart failure. She had been hospitalized for about one year because of the intermittent deterioration of her cardiac condition. Furthermore, her inability to swallow increased during her hospitalization. She also suffered from aspiration pneumonia. Nasogastric tube feeding was performed to prevent aspiration pneumonia and malnutrition. She died of acute heart failure after twelve months. Autopsy revealed heart dilatation, old myocardial infarction and stroke. In addition, two acute gastric ulcers (UL3, 10 and 30mm in diameter) were recognized; one was in the upper portion of the greater curvature, the other in the lower portion of the greater curvature. The location of these gastric ulcers was unusual. Moreover, they concided with location of top of the nasogastric tube. From these two cases, we conclude that in long-term tube feeding the tip of the tube often comes in contact with the gastric wall, and gastric ulcer could be produced by repeated mechanical stimulus of the wall. Reports of acute gastric ulcer induced by tube feeding have not been published previously. Therefore, we should pay much attention to this complication in the care of the elderly people with long-term tube feeding.
An 88-year-old female was admitted to our hospital for examination of hyperalphalipoproteinemia. The high level of her serum high-density lipoprotein cholesterol (HDL-C, 148mg/dl) was due to cholesterol amount of HDL2-C but not HDL3-C, and serum cholesteryl ester transfer activity (CETA) was at a non-detectable level. Despite her age, apparent atherosclerotic changes were not observed. She may be the oldest case of hyperalphalipoproteinemia, possibly due to deficiency of serum CETA.
A 78-year-old woman was admitted to our hospital because of acute onset amnesia in March 1991. Neurological examination revealed right homonymous hemianopsia and clumsiness of the right hand. Magnetic resonance imaging (MRI) demonstrated abnormal intensity areas in the left hippocampus, parahippocampal gyrus, fimbria of the hippocampus and the occipital lobe. Immediate memory and long-term memory were relatively well-preserved, but short-term memory was severely disturbed. Her memory disturbance persisted for more than 9 months and she eventually developed an “amnesic stroke”. According to the MRI findings, the “amnesic stroke” was produced by infarction of the left hippocampus, parahippocampal gyrus and fimbria of the hippocampus. We emphasized that in this case an “amnesic stroke” was caused by infarction of the left hippocampal lesions.
A 77-year-old male presented at our Department of Urology in August 1990 with a gradually enlarging swelling in the right scrotum. On August 21, right high orchiectomy was performed. This was diagnosed histologically as non-Hodgkin's lymphoma (diffuse large cell type), and the patient was transferred to our department on September 11 for further examination and treatment. As enlargement of the lymph nodes around the abdominal aorta was evident, it was diagnosed as stage IIA according to the Ann Arbor Classification. Beginning on September 21, three courses of COP-BLAM therapy (CPM, VCR, PDN, BLM, ADR, PCZ) were administered (the third course started on November 8) to achieve complete remission. Hepatic dysfunction appeared, however, from November 16, and by November 19, GOT and GPT increased to 6700 and 2120, respectively, with aggravation of jaundice. PDN therapy was instituted, and GOT and GPT improved gradually, but jaundice did not improve. On December 22, laparoscopy was performed, and liver biopsy produced histologic findings of drug-induced hepatitis. Further, lymphoblastic response was positive for CPM. Hepatic failure occurred on December 29, and plasma exchange was performed, but it failed to improve the condition, and the patient died on January 15. We described a case of non-Hodgkin's lymphoma complicated by hepatic dysfunction, probably induced by CPM, in an elderly patient who died to hepatic failure.
We report a 72-year-old woman who showed marked orolingual dyskinesia and choreoathetoid movements of the neck, with rolling and nodding of the head. She had been treated for postural tremor and other complaints with multiple drugs, including trihexyphenidyl HCl (THP) 6mg/day for about two years. Moreover, two months before admission to our hospital, a doctor added tricyclic antidepressant, dosulepin HCl (DL) because of her state of anxiety. Two weeks following DL administration, the persistant dyskinesia described above appeared. Suspecting the dyskinesia to be induced by anticholinergics, we withdrew THP, which decreased the intensity of the dyskinesia. Then, when DL was ceased the dyskinesia almost completely disappeared, slightly recurring only during calculating, when excited or writing. In order to confirm that anticholinergics were the cause of the dyskinesia, we administered THP 6mg/day again. In a few days the same dyskinesia reappeared, disappearing following THP withdrawal. In this case the overlap of anticholinergics might have resulted in the dyskinesia, because both THP and DL have anticholinergic effects. It should be stressed that inappropriate administration of anticholinergics could cause severe dyskinesia in the elderly.