Fifty patients, aged 60 years or more, who had been admitted to a hematology ward for more than 1 month, were studied in regard to their understanding of informed consent. The doctors informed 74% of their patients about the disease for which they were being treated. The rate of informing patients remained low in those with advanced age or with malignant tumors. However, only 42% of the patients realized that they had been informed of their diagnosis and clinical condition. The comprehension rate remained low at 43.2% even in patients who were informed by their doctors. While 60% of patients declared that they understood what the doctors described, only 36% could write something about the name or the state of their disease. Even among the patients who could understand the doctor's explanation, the comprehension rate was 43.3%. Sixty-six percent of patients demonstrated their wish to have a correct explanation of their diagnosis, 36% of patients wanted to be treated according to their own wishes, and 48% of patients left the decisions regarding their treatment to the doctors.
The aim of this study was to assess the effect of menopause on circadian profile of blood pressure (BP) and heart rate (HR) in the normotensive pre- and postmenopausal women. Systolic BP (SBP), diastoic BP (DBP) and HR were monitored every 30min for 48hrs using noninvasive ambulatory BP monitoring in 24 premenopausal and 40 postmenopausal women. Mean 48-hours, daytime (awake), and nighttime (sleeping) SBP, DBP and HR values were analyzed by reviewing the patients' diaries, and the nocturnal reduction rate (NRR) of SBP, DBP and HR were calculated according to the following formula. NRR (%9=[(daytime mean-nighttime mean)/daytime mean]×100. The study subjects were then divided into two groups according to the presence (dipper) or absence (nondipper) of a significant reduction in nocturnal BP (>10%). Mean SBP, DBP and HR measured over 48 hours were similar between the premenopausal and the postmenopausal group. The NRR of DBP and HR in the postmenopausal group were significantly smaller than those in the premenopausal group (17.1±6.0% vs. 13.5±7.0%, 241.1±6.0% vs. 19.8±9.0%: p<0.05). There tended to be higher prevalence of nondipper in the postmenopausal (37%) than in the premenopausal group (29%).
Physical activity is known to increase glucose tolerance and insulin seisitivity. To examine the influence of physical inactivity on insulin sensitivity in aged people, insulin sensitivity and secretion was measured by using a two-step euglycemic glucose clamp, a glucagon tolerance test (GTT), an oral glucose tolerance test (OGGT) and urinary CPR excretion in 11 aged patients immobilized in bed for more than 12 weeks. The results were compared with those of nine healthy mobile aged controls. The muscle volume of the immobilized patients decreased by 20-25% compared with that of the controls, and insulin sensitivity decreased 50% in each step. These results mean that the immobilized patients had decreased insulin sensitivity and responsiveness, even when there was muscle atrophy. The glucose and insulin responses in both the GTT and OGTT showed that there was a slight decrease in the initial response of insulin in the immobilized patients and was in the controls compared with adolescent controls. There was no difference in the initial response of insulin between the immobilized patients and the aged controls. The ratio of impaired glucose tolerance in the OGTT was 4/11 of the immobilized patients and 3/9 of the controls. Total insulin secretion was increased and insulin sensitivity and responsivenes was decreased in the immobilized patients. This suggests that the decreased insulin sensitivity was compensated for increased by insulin secretion in the immobilized patients.
The pulmonary function test and arterial blood gas analysis were performed before and after a 2-month rehabilitation program in a pool filled with 38°C hot-spring water in 15 elderly patients (75.7±3.7 years of age; 12 males and 3 females; 6 cases of pulmonary emphysema and 9 cases of bronchial asthma) and 10 young patients (56.4±14.2 years of age, 7 males and 3 females; 4 cases of pulmonary emphysema and 6 cases of bronchial asthma) with stable chronic obstructive pulmonary disease treated at Gunma University Hospital between 1995 and 1996. After the exercise program, the ratio of forced expired volume in one second to forced vital capacity (FEV1.0%) was significantly increased (p<0.05), while the ratio of forced vital capacity to predicted normal value (%VC) did not change in either group. Furthermore, a tendency toward an increase in peak flow (PF) and maximal expiratory flow at 25 and 50 percent (V25 and V50) was observed in both groups. An increase in PaO2 was observed in both groups, while an decrease in PaCO2 was observed in the young group (p<0.05). These effects were observed more clearly in patients with asthma than in those with emphysema. The changes in pulmonary function and arterial blood gas were considered to be resulted from respiratory muscle training and expiration into water in addition to an increase in cardiac output by hydraulic pressure. Therefore, physical therapy in a pool filled with hot-spring water may be useful in treating chronic obstructive pulmonary disease in elderly as well as in young patients.
In order to examine the current status of antihypertensive drug therapy for elderly hypertensive patients, and the effect of clinical characteristics and drugs on their prognosis, 1669 hypertensive patients in the Chugoku and Shikoku districts, aged between 65 and 84 years, were enrolled and followed for 3 years. Of the 1669 patients enrolled, 1459 were selected for evaluation and 1127 patients were followed. Group A comprised 955 patients who had not suffered from any accident, group B comprised 139 patients who had suffered from a cerebral, cardiac, renal or other non-fatal accident, and group C comprised 33 patients who died. The mortality rate was 10.7/1000 patient·years and the morbidity rate was 55.6/1000 patient·years. The number of patients who received monotherapy was 736 (calcium channel blockers: #436, beta blockers: #100, angiotensin converting enzyme inhibitors: #80, diuretics: #64, α blockers: #16; others: #13). In group C, there were more male, and the patients were older and showed a higher level of serum cretinine concentration at enrollment compared with other groups. The use of diuretics and beta blockers tended to be low in this group. Among the three groups, however, there was no difference in blood pressure, heart rate or the use of each drug at enrollment. In summary, it is suggested that the different antihypertensive drug therapies die not influence the prognosis of elderly hypertensive patients.
A 62-year-old woman developed headache, vomiting and fever. On admission to hospital, she showed an imparied level of consciousness, diplopia on left lateral gaze, bilateral hearing loss and left hemiparesis. Cranial contrast computed tomography (CT) revealed basal meningeal enhancement. Lumbar cerebrospinal fluid (CSF) showed an increase in cell count (80/mm3) and total protein (3000mg/dl), and a decrease in glucose (65mg/dl) in comparison with blood sugar (173mg/dl). Polymerase chain reaction was positive for Mycobacterium tuberculosis in the CSF. She was diagnosed as having tuberculous menigitis and was treated with anti-tuberculous chemotherapy. Her level of consciousness recovered and other clinical signs improved gradually the first month after admission. However, in spite of the combination of anti-tuberculous chemotherapy and steroid therapy, her combination of anti-tuberculous chemotherapy and steroid therapy, her consciousnes level worsened again in association with paraplegia at the sixth week after admission and magnetic resonance imaging (MRI) revealed multiple tuberculomas, spinal arachnoiditis and spinal cord infarction. On T2-weighted imaging some of the tuberculomas showed a central hyperintense area (a central bright core) with an isointense periphery, which was surrounded by a hyperintense area. The lesion appeared hyporntense with an isointense rim on T1-weighted imaging, showing a ring enhancement on post-contrast T1W imaging. The spinal cord infarction was situated at the third thoracic cord, which corresponded to the borderline of spinal artery perfusion. This is a rare case of progression of spinal arachnoiditis and spinal cord infarction during anti-tuberculous chemotherapy, and who had tuberculoma with a central bright core on MRI.
A 91-year-old male patient was admitted to hospital with acute myocardial infarction complicating cardiogenic shock. An emergency coronary arteriogram showed 99% stenosis at the mid-section of the right coronary artery, and in order to achieve an early recovery direct percutaneous transluminal angioplasty (PTCA) was performed through the brachial artery using a 6 french catheter. The lesion was successfully dilated up to 25% residual stenosis. Hypotention had been sustained during the admission; however, it gradually improved and he was discharged on the 31st hospital day. He has been followed up for 6 months after discharge at the out-patient clinic and has not recurrent ischemic episodes. According to other reports on the use of direct PTCA in the elderly, the postdischarge mortality rate is lower than that with medical therapy or thrombolysis. When cardiogenic shock occurs even in the eldely, direct PTCA should be selected as the first choice of treatment.