Although the third generation regimens for the treatment of malignant lymphoma are used more predominantly than those of other generations in recent years, a number of elderly patients die due to the toxicity of those treatments. We treated elderly patients with non-Hodgkin's lymphoma (NHL) with COP-BLAM III, and compared its therapeutic and adverse effects on elderly NHL patients (more than 65 years of age) with those in non-elderly patients. Nine previously untreated elderly NHL patients (4 males and 5 females, with a median age of 71 years) and 13 previously untreated NHL non-elderly patients (6 males and 7 females, with a median age of 43 years) were treated with COP-BLAM III. According to the Ann Arbor staging rules for malignant lymphoma, 4 and 6 elderly patients were classified in stage III and IV, respectively, while 6 and 7 non-elderly patients were in stage III and IV, respectively. There were 5 elderly patients with diffuse large cell type lymphoma (D. large), 3 with diffuse mediumsized cell type (D. medium) and one with diffuse mixedcell type (D. mixed), while there were 6 non-elderly patients with D. large, 6 with D. medium and one with D. mixed. The COP-BLAM III regimen consisting of portion A with continuous infusion of the drugs and portion B with intravenous bolus administration of drugs was identical to that used by Boyd et al. Protion A and portion B were repeated every 3 weeks alternatingly. The administration of granulocyte-colony stimulating factor (G-CSF) was started, when the granulocyte count fell to below 1, 000/μl. Of the 9 elderly patients, 6 (66.7%) achieved complete remission (CR) and 2 had partial remission (PR), while 12 (92.3%) of 13 non-elderly patients achieved CR and the remainder had PR. According to the stage classification, 2 of 3 stage III and 4 of 6 stage IV elderly patients achieved CR, while 6 of 6 stage III and 6 stage IV non-elderly patients achieved CR. Granulocytopenia of less than 1, 000/μl occurred in 6 (66.7%) elderly patients and in 2 (15.4%) non-elderly patients. Three (33.3%) elderly patients and 2 (15.4%) non-elderly had thrombocytopenia of less than 5×104/μl. This means that elderly NHL patients showed more remarkable bone marrow suppression than non-elderly patients. Although none of the elderly patients died due to the chemotherapy toxicity, one elderly female patient died of pneumonia which had arisen as a complication of leukopenia. COP-BLAM III is considered to be a useful regimen for the treatment of elderly NHL. However, it is important in applying this intensified regimen to pay attention to the timing of G-CSF administration and to overcome severe infections.
Our geriatric health care facility was established 3 years ago. The real number of users since April 1989 to March 1991 amounts to 519, of which 62 have been admitted 3 times or more (defined as repeater here). At the same time, this facility has a day care activity 6 times a week. The utilization rate of day care activity was 14.8% for total users, while it was 59.7% for repeaters. These results indicate that repeaters actively utilize day care activity as well as geriatric health care facility. In other words, repeaters usually reside at home and their home cares are greatly supported by both repeated admissions to the facility and daily utilization of day care activity which are effective in improving ADL of the disabled elderly. It is concluded that geriatric health care facility plays an important part in supporting home care of the disabled elderly as well as trnasitional step from hospital to their own home.
With neuropathological diagnosis as the point of reference, the validity of clinical diagnosis was studied in 50 patients who had met DSM-III-R criteria for dementia. Clinical diagnosis of ATD (dementia of Alzheimer type) was made in 14 cases, of VD (vascular dementia) in 14 cases, of others in 5 cases and of undefined in 16 cases. At necropsy, 16 cases fulfilled the histological criteria for ATD, while 15 cases were VD, 3 cases were mixed dementia and 14 cases were other CNS disorders. In 2 other cases, the neuropathological picture was considered to be nondiagnostic. The accuracy of clinical diagnosis of VD was higher than that of ATD. Clinical diagnostic sensitivity was 81.8% for ATD and 91.7% for VD; corresponding specificity was 78.3% and 86.4%. With our clinical criteria, slowly evolving VD with no clinical evidence of stroke would not be identified as VD. On the other hand, AD patients who happened to have a stroke would be diagnosed as VD. These results suggest that further investigations as to VD (its clinical course, findings of computed tomographic scan and magnetic resonance imaging) are needed for more appropriate clinical criteria.
Nutritional assessment with respect to rapid turnover protein (RTP) in the elderly was performed in 22 outpatients (7 males and 15 females, mean age 77 years) who suffered from slight illnesses such as mild hypertension and osteoporosis. Their nutritional parameters were almost within the normal range, judging from body mass index (BMI) and their plasma levels of total protein, albumin, lipids and RTP (transferrin, prealbumin and retinol-binding protein). Statistically, BMI had a significantly positive correlation with subcutaneous fats and total protein and had a significantly negative correlation with HDL-cholesterol. Retionolbinding protein had a significantly positive correlation with prealbumin, ferritin and vitamin A. Conversely, in 12 bedridden patients the nutritional status was very poor, with their plasma levels of the above markers being significantly lower than those of the controls. We administered an enteral diet (EWH330) to 10 bedridden patients in an effort to restore their nutritional status. As a result, their nutritional parameters, especially RTP showed a significant increase after 4 and 8 weeks of the administration of EWH330. These results suggest that RTP is a very sensitive parameter of nutritional assessment in the elderly.
In order to evaluate the effect of gender and aging on the diurnal rhythm of blood pressure (BP), we performed ambulatory BP monitoring in 267 normotensive volunteers (mean age±SD 52.1±24.6 years, range 16-93 years, 114 men, 153 women). Ambulatory 24-hour BP was recorded every 30 minutes with an oscillometric method by ABPM630 (Nippon-Kolin, Japan). Circadian rhythm was determined by fitting the 24-hour cosine function curve. Subjects were divided into three age groups, consisting of the Y group (age<30), M group (age≥30 but<60), and E group (age≥60). Highest normal values of the 24-hour mean BP (90 percentile of the values) were 126/75mmHg in the Y group, 126/76mmHg in the M group, and 154/85mmHg in the E group in men. They were 117/67mmHg, 125/77mmHg 151/79mmHg respectively in women. The MESOR of SBP increased with age in women, though it was significantly higher only in the E group among men. The amplitude of SBP decreased with age significantly only in men. The acrophase of SBP shifted to an earlier time of day with aging in both men and women. The trends in the circadian rhythm of DBP with age were similar to those of SBP. In conclusion, the circadian rhythm of blood pressure varies with gender and aging. The 24-hour blood pressure values should be considered with evaluating sex-age matched reference values.
Cognitive potential using two-tone auditory discrimination task has been widely used as a standard and useful test to quantify the severity of cognitive dysfunction. According to our experience, however, this method (the T method), sometimes cannot be performed even in normal elderly subjects because of difficult discrimination between these two different tone bursts. In order to overcome this disadvantage, we developed two other methods which had easier discrimination tasks: one using a tone burst and click sound (the C method), and the other using red and green color (the V method). We adopted these three methods to 64 normal adults and aged subjects whose age ranged from 20 to 88 years old. As a result, most of the P3 latency and amplitude in all subjects tested correlated significantly among these three methods. Any peak latency of P3 correlated significantly (p<0.05) and positively with age, but the rate of increment of latency per year differed. For example, the value recorded from the Cz scalp site was 0.77ms/year in the T method, 1.05ms/year in the C method, and 1.67ms/year in the V method, respectively. The rate of undetected P3 potential in aged subjects more than 60 years old was higher in the T method (3/18 subjects=17%) than by both the C and V methods (1/19 subjects=5%). In conclusion, the effect of age on P3 latency varied according to method and our new technique was sufficiently applicable to elderly subjects.
Methicillin-resistant Staphylococcus aureus (MRSA) is frequently isolated from skin lesions, such as in the decubitus region. There is a possibility that MRSA through these lesions can spread widely in a hospital. However, local treatment with most antibiotics and antiseptics (povidone-iodine) is not effective to eradicate MRSA from the infected decubitus. We have recently demonstrated that gentian violet (Gv) possessed a bactericidal effect against MRSA isolated from clinical specimens in vitro. This examination evaluated whether or not a topical ointment containing 0.1% Gv is effective to eradicate MRSA which existed in decubitus regions. Decubitus (14 clinical cases, ages 59-87 years) infected with MRSA were treated with 0.1% Gv-ointment once or twice daily after bathing in 0.1% Gv aqueous solution. Although all patients were treated with povidone-iodine and 9 out of 14 patients were given either local or systemic administration of antibiotics, those treatments were not effective to eradicate MRSA from decubituses. However, MRSA was not detectable in all cases within 34 days (average: 10.8 days±2.7) after treatment with 0.1% Gv-ointment. The eradication of MRSA from decubitus areas tended to be delayed, depending upon the size and depth of decubituses (Grade III and IV) and complications such as diabetus millitus. Skin irritability was not observed in any patients. These results suggest that 0.1% Gv-ointment is a useful material for the treatment of the MRSA-local wound infection. Treatment with Gv-ointment to MRSA-infected decubitus may exhibit a protective effect with regard to infection with MRSA in hospital
Recently an increase of the elderly patients with hematological malignancies has been pointed out. We analyzed second malignancies in elderly patients with hematological malignancies (95 aged 65 or more), and made a comparative study with non-elderly case for the past 5 years. Second malignancies were observed in 26 cases out of the total of 282 hematological malignancies (9.2%). The percentage of patients with second malignancies in the elderly group (19/95; 20%) was significantly higher than that of the non-elderly group (7/187; 3.7%). Among the all kinds of hematological malignancies, the second malignancies were mainly observed in cases with myelodysplastic syndrome and chronic myelo-proliferative disorder. Colon carcinoma, gastric carcinoma and lung carcinoma accounted for nearly half of all the second malignancies. On 11 of the 26 cases with second malignaieies, the first malignancies had been treated with some anti-cancer drug such as alkylating agents. Development of a second cancer was greated in cases in which the first hematological malignancy was treated with alkylating agents more than in cases in which the first carcinoma was not treated with alkylating agents.
In order to study the relative assessment of atherosclerosis among arteries of various organ (coronary, aortic, peripheral and cerebral artery), 94 patients aged 43-69 underwent examination by coronary angiography (CAG), pulse wave velocity (PWV), ankle pressure index (API) and funduscopy simultaneously. The severity of coronary sclerosis was determined by the coronary atherosclerotic index (CAI) which was based on the size and number of stenotic lesions, which that of funduscopic findings was evaluated using Scheies' score (S+H). The relationship between risk factors of atherosclerosis and each value for the examinations (CAI, PWV, API, S+H) were studied. Furthermore, subjects were divided into two groups of normal or early change groups and a progressive group based on the degree of atherosclerosis. Then, the difference of atherosclerosis in each vessel of major organs was compared. A positive correlation between PWV and age, and a negative correlation between API and age were noted (p<0.01, p<0.05). A higher prevalence of hypertension in groups of progressive PWV or API were observed (p<0.05). Total cholesterol in the CAI progressive group was significantly higher than in the normal group (p<0.005), and it became higher in relation to the progression of PWV or API (p<0.001). HDL-C in the progressive groups of CAI, PWV API and S+H were significantly lower (p<0.05, p<0.05, p<0.02, p<0.01). On the other hand, glucose intolerance influenced the progression of CAI, PWV, API and S+H, statistically. In subjects whose age was limited to between 55-64, statistically significant correlations were noted between any pair of examinations among CAI, PWV, API and S+ H. The percentage of API and S+H progressive groups were lower in CAI normal or PWV early change groups, suggesting earlier sclerotic change of the coronary artery or aorta than that of peripheral or cerebral artery. These results demonstrate that the atherosclerosis in major vessels could be assessed relatively using a non pathological process, which supports the usefulness of these examinations in clinical practice.
The effects of high-purity IPA-E administration on changes in serum lipids and factors that may affect those changes were investigated in 55 patients with arteriosclerotic disease (34 males and 21 females, aged 43-85) under a regular daily diet. Daily administration of 1800mg or 900mg IPA-E resulted in a significant decrease or tendency to decrease in serum TG, TC and LDL-C 4 weeks after the initial administration, which continued throughout the administration period. Apoprotein analysis revealed a significant increase in A-I and a significant decrease in B and E after the administration of IPA-E. Lipoprotein analysis disclosed decreasing tendency of VLDL, IDL, LDL and TG, where the changes in VLDL-C, VLDL-TG and TG were significant. The amount and rate of change in TG, TC and LDL-C after IPA-E administration had a significant negative correlation with their respective pre-administration values. The decrease from pre-administration values was significant for patients with abnormal values in both dosage groups. The average rate of decrease in TC and LDL-C were greater in the group receiving administration of 1800mg/day than that receiving 900mg/day, but the difference in the change was not significant between the 2 groups. Correlations between the amount or rate of decrease in TC or LDL-C and the baseline value, achieved value, or amount or rate of increase in plasma IPA concentration and IPA/AA ratio were not significant. However, the negative correlation between the rate of change in TG and achieved IPA concentration was significant. Factors such as age, gender, presence of diabetes mellitus, or calcium antagonist or diuretic administration did not significantly affect the changes in serum lipids resulting from administration of IPA-E. According to phenotype, the decrease in TG and the increase in LDL-C after IPA-E administration were great and HDL-C increased slightly in type IV hyperlipidemia group. By contrast, LDL-C and HDL-C decreased slightly in type IIa hyperlipidemia group. The changes in type IIb hyperlipidemia group were an intermediate type between the type IV and type IIa hyperlipidemia groups. The changes in serum lipids were minimal in the normolipidemia group.
This study compared the “Clock-Drawing Task” to the Mini-Mental State Test (MMST) in 834 elderly persons. A cut-off score of 20 or less on the MMST was used to determine cognitive impairment. The “Clock drawing Task” was score of 20 or less on the MMST was used to determine cognitive impairment. The “Clock drawing Task” was scored by three components; frame, numbers, and two hands. Using a criterion of completion on two or more of the three components, the sensitivity, specificity, and correct identification of the diagnosis of cognitive impairment of “Clock Drawing Task” were 89%, 65% and 83% respectively. “Clock Drawing” appears to be a practical test which can be useful for clinicians as a screening for cognitive impairment in old age.
An elderly patient with acute-type ITP is reported. An 89-year-old man was admitted to the Department of Physiatrics, Ureshino-Onsen Hospital on July 19, 1991 and commenced rehabilitation treatment. Laboratory data on January 28, 1992 showed decreased platelets (2.8×104/mm3). According to this data, the patient was transferred to the Department of Internal Medicine, where laboratory data showed positive occult blood in urine and stool, prolonged bleeding time (over 10min.) and positive PAIgG (630ng/107 cells). Bone marrow showed an ITP pattern (megakaryocytes 55/mm3). The patient received steroidal pulse therapy (methylprednisolone 1, 500mg/day for 3 days). Subsequently, serum platelet count increased gradually and reached 10×105/mm3 in May 1992. We reviewed the case reports of ITP published in Japanese, and conclude that this case was the oldest reported patient with acute-type ITP in Japan.