Since behavioral disturbance among patients with dementia is a great burden for their caregivers, quantification of behavioral disturbance is essential in determining disease severity and assessing the impact of the disease on caregivers. However, the method of its quantification for objective assessment is not established yet. We studied the reliability and validity of a Japanese version of the Dementia Behavior Disturbance Scale (DBD Scale) which was originally developed by Baumgarten et al. We also studied the relationship between DBD scores and the degree of burden felt by caregivers. Our subjects consisted of 27 cases with dementia (mean age 77.7 years), and 17 cases of patients with neurological disorders without dementia (76.8 years), and 10 institutionalized patients with dementia (82.3 years). The test-retest reliability, internal consistency, and inter-rater reliability were very good; the coefficient of correlation between DBD scores at the two interviews was 0.96, the coefficient of internal consistency was 0.95, and the intraclass correlation coefficient was 0.71±0.10. DBD scores correlated significantly with SPMSQ errors and caregivers' burden; r=0.54 and 0.53, respectively. Our results indicate that the DBD Scale is highly reliable, and may be useful for objective assessment of behavioral disturbance and caregivers' burden.
Morning rise in blood pressure (morning surge; MS) has been shown to be associated with the occurrence of myocardial ischemic events and stroke. This study aimed to elucidate the incidence and the mechanism of MS in hypertensive patients (HT). We monitored ambulatory blood pressure (BP) and physical activity in 68 untreated HTs using TM2421 (A & D Co. Ltd.) and ACTIVETRACER (GMS Ltd.) for detection of MS. MS was defined as a rise in BP>50mmHg (90% tile of 35 normotensives) during early morning (4:00 to 9:00 A.M.) compared with the lowest basal BP at night. MS was seen in 41 patients (52.6%) and was classified into two groups; MS1: BP rose steeply after waking up (27 patients) and MS2: BP started to rise gradually during sleep (14 patients). The mean age of MS1 was significantly higher than that of MS2 (72 vs. 62 years, p<0.01). BP reached its basal value earlier in MS2 than in MS1 at night though the basal BP values were comparable between the two groups. Mean 24-hour BP and physical activity were similar between the two groups, though significantly higher incidence of cases with a correlation between SBP and activity was seen in MS1. In conclusion, there are two types of MS, the mechanisms of which may differ. MS occurring immediately after waking up was more common in older HTs, and possibly was related to augmented arousal response in BP, while MS beginning gradually during sleep was more common in younger HTs and was characterized by reaching basal BP earlier at night.
To determine how to treat silent gallstones in the elderly, 1771 autopsied cases 65 years of age or older were studied retrospectively, and 121 cases with asymptomatic gallbladder stones were followed for over 3 years. Of these, 47 cases treated with urosodeoxycholic acid (UDC) for over 3 years were investigated to determine the efficacy of UDC therapy. In the autopsied cases, the incidence of gallbladder stones was 16%, and increased with age. The ratio of males to females was 1:1.2. Only 3.2% of people with silent gallstones developed symptoms. Autopsy studies showed that the majority of people with gallstones died of unrelated causes such as benign respiratory and circulatory diseases. Only 1.8% of patients with gallstones died of acute cholecystitis or gallbladder cartinoma. UDC treatment was effective in 55.9% of patients with radiolucent stones. The percentage of patients requiring surgery due to becoming symptomatic was much lower (6.4%) in UDC-treated patients. The visualization of the gallbladder on cholecystogram improved in cases treated with UDC. These results indicate that elderly patients with silent gallstones generally develop neither symptoms nor carcinoma. Therefore, follow-up management by ultrasonography and cholecystography can be allowed. We also emphasized that a satisfactory response was obtained with long term UDC therapy.
In order to clarify the relationship between dementia and osteoporosis, bone mineral metabolsim was studied in elderly female patients with dementia. We measured bone mineral densities of the vertebral body and the femoral neck using DEXA, and evaluated Ca-related factors in 22 patients with dementia of the Alzheimer type (DAT), 23 patients with vascular dementia (VD), and 22 age-matched controls (C). Activity of daily living was significantly poorer in VD patients than controls, but no difference was shown between DAT and C groups. Bone mineral density values of the vertebral body and the femoral neck were significantly decreased in both DAT and VD groups when compared to C group. DAT patients showed significant decreases in serum Ca and Ca2+ ion, increase in serum parathyroid hormone, and decrease in serum 1, 25-dihydroxyvitamin D, a tendency towards decrease in serum calcitonin, and a tendency towards increase in urinary Ca. However, VD patients showed only significant increase in urinary Ca and a tendency towards decrease in serum 1, 2-dihydroxyvitamin D, without showing other changes of Caregulating hormones. These results suggest that patients with dementia are more often associated with osteoporosis, and that in DAT several abnormalities of Ca-regulating factors play an important role in the development of osteoporosis, while in VD limited physical activities contribute to bone mineral loss.
The remedial effect in elderly patients with malignant lymphoma in two groups treated with combination chemotherapy, one including doxorubicin (ADM) (A group) and the other excluding ADM (V group) were compared. Forty patients aged 65 years or more with malignant lymphoma were entered from January 1982 to December 1991. The A group was made up of 10 patients and the V group of 18 patients. As to pathological classification, two of the A group had low grade malignancy lymphoma, four had intermediate grade and three had high grade. Four of the V group had low grade, eight had intermediate grade and five had high grade. In terms of clinical stage, three of the A group were in stage II, 3 in stage III and 4 in stage IV. Two of the V group were in stage II, 7 in stage III and 9 in stage IV. The effective rate for the A group was 90% and the V group was 61%. The survival rate over five years in the A group was 37.5% and 21.8% in the V group. There were no adverse effects on the cardiovascular system in the A group. No significant differences of effects were shown in this study, however, the A group showed a higher tendency in terms of the CR rate and the survival rate. Cases of early death during chemotherapy were few and the quality of life of the patients was raised by discharge in the A group. Combination chemotherapy including ADM appears to be satisfactory in aged patients with malignant lymphoma.
Ninety-five patients aged 60 years or over with a permanent pacemaker implanted for sick sinus syndrome were divided into two groups: 32 patients with physiological pacing (group P) and 63 patients with ventricular pacing (group V). The mean follow-up period was 45.0±36.6 months in group P and 50.3±37.8 months in group V. Paroxysmal atrial fibrillation (Af) occurred in 28% of group P and 71% of group V (p<0.05). The incidence of stable Af was also lower in group P than in group V (9% vs. 30%, p<0.05). None of group P with only bradyarrhythmia had stable Af. However, 6 of 21 patients (29%) in group V with bradyarrhythmia showed stable Af. There was no significant difference in stable Af between group P with bradycardia-tachycardia syndrome (BTS) and group V with BTS (19% vs. 31%). A lower incidence of embolic events was also observed in group P (3% vs. 25%, p<0.05). Nine of 16 patients with embolic events in group V died of complications following embolism (8 patients; cerebral embolism, one patients: renal and superior mesenteric arterial embolism). The survival rates at 5 and 10 years were 80% and 69%, respectively, for group P and 56% and 33% for group V (p<0.01). Thus, with regard to permanent pacing for patients with sick sinus syndrome, physiological pacing should be selected for control of morbidity and total mortality.
Gastric ulcer was studied with regard to the relationship with patterns of distribution of intestinal metaplasia (IM). 882 stomachs of elderly patients, obtained from autopsies from 1987 to 1991 were examined histopathologically. There were 74 open gastric ulcers and 88 ulcer scars. Distribution of IM was classified into 7 types. Open ulcers and scars were found more often in type O (IM found in the entire lesser curvature which is the most common type in the elderly) than in other types. Open ulcers in type O were mostly shallow and located in the IM area. Many open ulcers in type A (IM involving the antrum) and type B (IM involving both the antrum and cardia) were deep and on the boundary zone between the IM area and the proper gastric mucosa area. Most of the deep scars that did occur in type O were in the IM area but in types B and A most of them were located on the boundary zone. Scars in type O probably developed on the boundary zone when they were open ulcers and removed in the IM area because of progression of the IM area. In some cases ulcers were at the boundary zone of IM involving the cardia and this finding was characteristic of elderly cases.
Ageing axonal dystrophy was studied electron microscopically in the gracile nucleus of a very old Japanese monkey (28 years of age) from the standpoint of comparative neuropathology. It was revealed that the Japanese monkey has characteristics different from albino rats concerning the ultrastructure of the dystrophic axonal spheroids. Spheroids in the former animal contained no traces of so-called layered loops of membrane nor coiled tubular rings etc. which have been interpreted in cases of albino rats and other animal species as morphological expression of secondary metamorphosis of primarily accumulated normal axoplasmic organelles at the presynaptic boutons. Instead, spheroids in the Japanese monkey contained dense homogeneous osmiophilic granules and screwnail-like filament crystalloids, which have not been found in other animal species including albino rats. These abnormal substructures were already present in the early stage of axonal dystrophy and tended to occupy a large volumetric proportion of gigantic spheroids. It was concluded that these substructures constitute essential components of formed spheroids in combination with smooth axoplasmic reticulum, and that they represent primary products of axonal dystrophy and not the secondary products of metamorphosis like coiled tubular rings or layered loops of membran described above. The enormous accumulation of smooth axoplasmic reticulum in other animal species including albino rats is characterized by the formation of a dense tridimensional reticular network. In the Japanese monkey, this process is characterized by massive dense parallel aggregation of straightened tubules of apparently smooth axoplasmic reticular origin rather than by formation of tridimensional network. The significance and implication of this species difference of spheroid ultrastructures was discussed in relation to the pathomorphogenesis and pathobiology of axonal dystrophy in general and specifically in humans.
In order to characterize age-related and choronological changes of the brain, longitudinal studies of aged volunteers were conducted using computed tomography since 1982. The present paper discusses correlations between brain function and findings of MR images which were obtained a using 1.5T superconductive MR instrument since 1989. A total of 118 volunteers aged 60 to 88 years old with a mean age of 75.0±6.7 participated in the study, which consisted of MRI, EEG recording, the Benton Visual Retention Test and a medical interview. Subjects with a past history or clinical evidence of CVD, head trauma or dementia were excluded from the study. Incidence of T2 high signal intensity lesions increased with age. Some showing T1 low signal intensity in the same lesion were considered to be lacunar infarction, over all incidence of which was 24.6%. Numbers of correct responses on the BVRT showed a negative correlation with numbers of T2 high signal intensity lesions. Although the aged volunteers in the present study could achieve all activity of daily living without any trouble, high cortical function evaluated by visuoperceptual performance of BVRT was somewhat disturbed in participants with multiple T2 high signal intensity lesions. Brain atrophy seems to be more advanced in groups with T2 hyper intensity lesions than in the group without them. These findings may support the notion that T2 high signal intensity lesions are not merely an index of ageing but pathologic lesions accompanied with senescence, although further studies including clinico-pathological correlation are necessary to establish this concept.
A 91-year-old patient with essential thrombocytemia presented with marked bone marrow suppression induced by long-term administration of busulfan. Her pancytopenia extended for over two months even after the cessation of busulfan, suggesting that she had devleoped a severe decrease in hemotopoietic reserve. We administered G-CSF and M-CSF to accelerate recovery from marrow failure and to evaluate the recovery of hematopoiesis. The standard doses of G-CSF and M-CSF increased her neutrophil and platelet counts sufficiently but only transiently. Transient eosinophilia was also noted after cessation of M-CSF. The possibility that the expansion of abnormal clone(s) induced the transient increase in platelet and eosinophil counts could not be completely excluded. We suggest that the administration of hematopoietic growth factors should be limited to patients, irrespective of age, who present marked clinical symptoms attributable to marrow failure when the patient has a chronic myeloproliferative disorder.