[in Japanese]

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Disability and the resulting lowered quality of life are serious issues accompanying increased longevity. Active life expectancy #(8) can be to used to distinguish the number of years without disability from the number with disability; increases were found in both in longevity #(9, 19). With the same rate of age-related new disability in the cohorts between 1970 and 1990, the total disability increased three fold #(11). In elderly patients I showed that 1) the duration of disability of those at a specific age at death (predeath) #(1) increased with age, and it decreased in those who remained without disability, 2) the cumulative number of days of disability for patients who died at a specific age (a convolution function of predeath and mortality) #(2), approached a normal distribution, which is consistent with the central limit theorem, 3) competing risk with chronic disease in a patient greatly affects the incidence and duration of disability, 4) using the central limit theorem we can predict that preventing dementia will retard premature rectangularization of the disability-free survival curve, and will thus reduce the total disability, 5) disability is an example of how variation and selection of chronic diseases (disease Darwinism) can alter population structure. Insights into the evolution of senescence # (14-21), pleiotropy, and slower rates of molecular evolution in the core than at the border #(26, 27), reveal that the central nervous system is relatively robust and conservative for pleiotropy and may senesce relatively slowly, which support a new way of thinking #(3, 4) about old age. To minimize disability, public knowledge and education about an ideal lifestyle and the evolution of senescence is essential.

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Atherosclerotic plaque with central depression (depressed lesion) may indicate regression of atherosclerosis in the aorta. Aortic depressed lesions have a solitary elevated area of plaque with a sharply-bordered roung depression in its center and no area ulceration. This may be interpretable as a sign of regression of atherosclerosis. To clarify the pathogenesis of depressed lesiosn, we studied clinical risk factors such as hypercholesterolemia in patients with depressed lesions that were confirmed at autopsy. The patients were divided into 3 groups according to their total cholesterol level at autopsy: a high-risk group (≥220mg/dl), a moderate-risk group (180-220mg/dl), and a low-risk group (≤180mg/dl). Depressed lesions were found in 16.4% of those in the high-risk group, in 14.6% of those in the moderate-risk group and in 69.0% of those in the low-risk group. Severe aortic atherosclerosis was found in 69.8% of the patients; 50.9% of those with severe disease were in the-low risk group. Depressed lesions were also found in those with low levels of low-density lipoprotein cholesterol (≤140mg/dl), 58.8% of whom were found to have severe atherosclerosis. There was no relationship between total cholesterol level and the presence of depressed lesions. However, a clinical prevention trial may result in sufficient control of ahterosclerosis among those in the high-risk group and may also lead to regression of aortic lesions.

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Social activities such as visiting friends or participating in community groups have been shown to correlate positively with active health promotion, more frequent physical exercise, and maintenance of activities of daily living in older people. Social inactivity may result from personal factors such as physical condition and from environmental factors such as limited means of transportation. To study the latter factors, we focused on perceived transportation difficulties and on the influence of those perceptions on the daily activities of elderly people. We sought to test the hypothesis that perceived transportation problems restrict health promotion or social activities and accelerate the decline in activities of daily living, and also to determine how transportation can be improved. A questionnaire was sent to 238 people (a fifth of the population) aged 60 years or older who were living in a small town in Kanagawa prefecture. Buses are the principal mode of public transportation from their residences to the nearest train station and the trip takes about 50 minutes. Responses were received from 190 persons (83.3%, excluding those who had died, moved, or were in the hospital). Of the respondents, 166 (74 men and 92 women) went out by themselves and their responses were subjected to logistic regression analysis. The results revealed the following points. (1) For both men and women, riding buses to the hospital was associated with a greater perception of problems with respect to convenience, physical exertion, or anxiety when crossing the road. (2) Among women, greater perceived inconvenience of transportation correlated with a lower frequency of going out for daily shopping; a higher frequency of visiting friends correlated with greater perception of physical exertion. (3) Among women, the main desire was to visit friends. Men indicated that they wanted to be more active in hobbies. The women indicated that the main reason they do not fulfill their desires was that transportation is inconvenient. These findings indicate that perceived transportation problems can prevent elderly people, especially women, from going out for health promotion and social activities. This indicates that to support social activities of elderly people, the means of transportation should be made more convenient and more physically accessible, and local circumstances should be taken into consideration.

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To study vascular lesions of the spinal cord in the elderly, a pathological study of atheromatous emboli in the spinal cord was done. Among 604 patients examined at autopsy, atheromatous emboli of the spinal cord were found in 7 (1.2%). The average age of these patients was 76 years. The most common underlying disorders in these patients were hypertension, severe aortic atherosclerosis, and diabetes mellitus. Atheromatous emboli were also often found in the arteries of the kidneys, spleen, pancreas, and colon. The small arteries of the spinal arachnoid at the lumbosacral level were most frequently affected by the atheromatous emboli. Two patients had spinal-cord infarctions associated with atheromatous emboli: one had a cystic infarction of the lateral column at the T9 segment, and the other had cystic infarctions of the lateral column at the C7 and T3 segments. The low incidence of spinal cord infarction was attributed to good collateral circulation in the spinal cord. Atheromatous embolism should be considered as a possible cause of vascular lesions of the spinal cord in elderly persons with aortic atherosclerosis.

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Among 1470 patients over 65-year-old who were treated for various diseases, 50 had gastric ulcer and 10 had duodenal ulcer. About half the gastric ulcers were located in the body and fundus (n=24, 48.0%). One third of the patients with gastric or duodenal ulcers had as their chief complaints hematemesis and hematochezia (n=20, 33.3%), and a greater number had atypical gastrointestinal complaints (general malaise, fever etc, n=25, 41.7%). In 10 patients (16.7%) the ulcers were due to nonsteroidal anti-inflammatory drugs, in 5 (8.3%) they were due to steroid hormones, both of which had been given to treat other conditions; in 45 (75.0%) the origin of the ulcers was unknown. Complications of gastric and duodenal ulcers were hematemesis and hematochezia (n=20, 33.3%), and perforation (n=2, 3.3%). Duodenal ulcers tended to be severe, and were associated with death due to bleeding and peritonitis.

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We propose the following guidelines for treatment of hypertension in the elderly.
1. Indications for Treatment. 1) Age: Lifestyle modification is recommended for patients aged 85 years and older. Antihypertensive therapy should be limited to patients in whom the merit of the treatment is obvious. 2) Blood pressure: Systolic BP>160mmHg, diastolic BP>90-100mmHg. Systolic BP<age+100mmHg for those aged 70 years and older. Patients with mild hypertension (140-160/90-95mmHg) associated with cardiovascular disease should be considered for antihypertensive drug therapy.
2. Goal of Therapy for BP: The goal BP in elderly patients is higher than that in younger patients (BP reduction of 10-20mmHg for systolic BP and 5-10mmHg for diastolic BP). In general, 140-160/<90mmHg is recommended as the goal. However, lowering the BP below 150/85 should be done with caution.
3. Rate of Lowering BP: Start with half the usual dose, observe at the same dose for at least four weeks, and reach the target BP over two months. Increasing the dose of antihypertensive drugs should be done very slowly.
4. Lifestyle Modification: 1) Dietary modification: (1) Reduction of sodium intake is highly effective in elderly patients due to their high salt-sensitivity. NaCl intake of less than 10g/day is recommended. Serum Na⁺ should be occasionally measured. (2) Potassium supplementation is recommended, but with caution in patients with renal insufficiency. (3) Sufficient intake of calcium and magnesium is recommended. (4) Reduce saturated fatty acids. Intake of fish is recommended. (2) Regular physical activity: Recommended exercise for patients aged 60 years and older: peak heart rate 110/minute, for 30-40 minutes a day, 3-5 days a week. (3) Weight reduction. (4) Moderation of alcohol intake, smoking cessation.
5. Pharmacologic Treatment: 1) Initial drug therapy. First choice: Long-acting (once or twice a day) Ca antagonists or ACE inhibitors. Second choice: Thiazide diuretics (combined with potassium-sparing diuretic). 2) Combination therapy. (1) For patients without complications, either of the following is recommended. i) Ca antagonist+ACE inhibitor, ii) ACE inhibitor+Ca antagonist (or low-dose diuretics), iii) diuretic+Ca antagonist (or ACE inhibitor), iv) β-blockers, α₁-blockers, α+β blockers can be used according to the pathophysiological state of the patient. (2) For patients with complications. Drug(s) should be selected according to each complication. 3) Relatively contraindicated drugs. β-Blockers and α₁-blockers are relatively contraindicated in elderly patients with hypertension in Japan. Centrally acting agents such as reserpine, methyldopa and clonidine are also relatively contraindicated. β-Blockers are contraindicated in patients with congestive heart failure, arteriosclerosis obliterans, chronic obstructive pulmonary disease, diabetes mellitus (or glucose intolerance), or bradycardia. These conditions are often present in elderly subjects. Elderly subjects are susceptible to α₁-blocker-induced orthostatic hypotension, since their baroreceptor reflex is diminished. Orthostatic hypotension may cause falls and bone fractures in the elderly.

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