The prevalence of dementia in the elderly (65 years old and over) was estimated at 6.3% (men 5.8%, women 6.7%) in Japan in 1985. Epidemiological studies done in several prefectures in 1989 and later showed a tendency for patients with Alzheimer's disease (AD) to outnumber those with vascular dementia (VD); the VD/AD ratio was less than 1.0 in over half of the surveys. A pathologic study (Kosaka 1996) of 79 patients with dementia revealed that AD was more common than VD, although clinical diagnoses were the reverse, which indicated that VD is still overdiagnosed in Japan. Diffuse Lewy body disease was observed in 15% of those patients without correct clinical diagnosis. Many biological markers for AD have been reported. We used 1H-magnetic resonance spectroscopy of the brain and found that the ratio of N-acetyl aspartate to creatine in AD patients was significantly smaller than that in age-matched controls without dementia. Based on genetic studies, AD is classified into five types. These are related to chromosomes 14 (presenilin-1), 21 (βAPP gene), 1 (presenilin-2), 19 (ε4 alleles), and other. The causes of most sporadic cases remain unclear. Tacrine is the only drug authorized in the U.S.A. for treatment of AD, but it is not used in Japan because of its side effects. Many other drugs to treat dementia are now in nationwide clinical trials although only four are in phase III. Therefore, rehabilitation therapy is mandatory and details of that therapy should be individualized. A new system of public insurance for nursing care may be implemented by the government.
A generation ago, geriatric depression was regarded either as a natural reaction to the privations and multiple losses that accompany old age, or as an irreversible consequence of cerebral degeneration heralding dementia. Even if physicians overcame their expectation of the inevitablity of depression in old age, an unhealthy nihilism concerning the effects of antidepressant treatment in this group held sway. Elderly depressed patients, probably more than any other group, have been helped by the remarkable advances in biological treatments for depression. Those of us too young to remember the advent of electroconvulsive therapy in the 1930s and the introduction of the tricyclics and monoamine oxidase inhibitors in the 1960s can only dimly imagine the extraordinary impact that such advances must have had on psychiatric practice. In the hands of experienced clinicians, these treatments offered safe and efficacious relief of depression. Introduction of the selective serotonin reuptake inhibitors in the 1980s was particularly welcome to geriatric psychiatrists. Although those drugs are probably no more effctive than the tricyclics, they are significantly more benign with regard to side effects and to the consequences of overdose. This is an obviously important point in the treatment of elderly patients, who are so often exquisitely sensitive to the hypotensive, cardiotoxic, and central and peripheral anticholinergic effects of the tricyclics.
We evaluated the clinical characteristics of 297 consecutive patients who underwent permanent pacemaker implantation. Their mean age was 67±13 years; those at least 75 years old accounted for 30.9%. The underlying diseases were sick sinus syndrome in 36.7%, atrioventricular block in 58.9%, and atrial fibrillation with bradycardia in 4.4%. There was no association between age and either the voltage threshold or the R wave amplitude at the time of implantation. When pacemakers were exchanged, only patients aged 75 years or less had voltage thresholds that were higher and lead resistances that were lower than those measured at the time of initial implantation. No clear differences were observed in the R wave amplitude, regardless of age. With careful long-term management, permanent pacemaker implantation and follow-up clinical care can be safe, even in aged patients.
Results of pathological studies of surgical specimens have led to widespread acceptance of the belief that with aging the gastric mucosa gradually becomes atrophic and the incidence of intestinal metaplasia increases. To distinguish natural age-related changes in the incidence of fundic gland atrophy and intestinal metaplasia from changes related to disease, we studied stomachs removed at autopsy from 187 people who had had no gastric diseases and were over 60 years old at the time of death (27 were over 100 years old). The autopsies were performed at Tokyo metropolitan geriatric hospital. None of the stomachs had circumscribed gastric lesions, and those found to have cancer or ulcer were excluded. Age at the time of death was not associated with the incidence of fundic gland atrophy or of intestinal metaplasia. Thus, the incidences of fundic gland atrophy and of intestinal metaplasia in elderly people were much lower than those found in studies of surgical specimens. In addition, the incidences of fundic gland atrophy and of intestinal metaplasia did not differ significantly between the sexes, regardless of age.
For 3 months, 4 patients in a nursing home for the elderly received supervised professional oral care in conjunction with oral hygiene instruction. Within the first month after the start of this program, plaque was reduced to 1/3 and gingivitis was reduced to 1/9 of their respective initial levels. In 5 patients who did not receive either oral hygiene instruction or professional oral care, plaque retention and gingivitis were unchanged. We conclude that professional oral care combined with oral hygiene instruction supervised by dental professionals can help to control gingivitis in the elderly.
In 15 elderly residents of an old-age home, we measured the total number of bacteria and the numbers of streptococci and staphylococci in the pharynx over 5 months. Seven residents received professional oral health care from dentists and dental hygienists and eight practiced oral care by themseleves or together with a helper. During the 5 months, the total number of bacteria and the numbers of streptococci and staphylococci decreased (p<0.01) in those who received professional care. In contrast, the total number of bacteria and the numbers of streptococci and staphylococci neither did not change or increased in those who did not receive professional care. These findings show that professional oral health care by dentists and dental hygienists can decrease the total number of bacteria and the numbers of streptococci and staphylococci in the pharynx of elderly people, which might prevent aspiration pneumonia.
We studied the cases of 909 patients with malignant tumors (497 men and 412 women) who were admitted to Tokyo Metropolitan Geriatric Hospital from April 1994 to July 1995. The mean age was 78.6 years (range: 60 to 103 years). The most common tumors were gastric cancer, colo-rectal cancer, and lung cancer. However, the most common tumors in those who died (n=263) were gastric cancer, lung cancer, and liver cancer. In 425, abnormalities were found during routine health checks or incidental laboratory examinations, while the patients were asymptomatic. On the first admission, 23.4% were found distant metastases. The rate of complications with other diseases was 82.3%. About one third (31.2%) were informed of their situation, and 18.5% had not recieved any treatment for their malignancies. In 63%, performance status at the time of discharge was the same as that measured on admission or better.
We describe 308 patients hospitalized for rehabilitation incorporating balneotherapy in our hospital between 1986 and 1996, with respect to age, place of residence, disease, duration of impairment, duration of hospitalization, reason for hospitalization, person taking care of the patient, and family size. Patients in eighth decade of life were the most common and 41% of the patients were residents of Kusatsu. Cerebral diseases were the most common (36%). The average length of hospitalization was 72 days. The reason for hospitalization, person taking care of patient and family size were compared between patients 60 to 79 years old and patients 80 years old or older. Many patients came from afar to our hospital with expectation of rehabilitation using balneotherapy. More than half of the patients 80 years old or older were admitted at their own request without a doctor's letter of introduction. The person who most often took care of a patient 80 years old or older was the patient's daughter in law. The average length of hospitalization of patients who were taken care of by their wife, husband, daughter, son, daughter in law, and nobody were 58, 71, 75, 114, 86, and 124 days, respectively. Many patients 60 to 79 years old lived alone or with another family member, but most of those 80 years old or older lived with at least 2 other family members. The lack of a definite goal for rehabilitation might have prolonged these patients' hospital stays. Balneotherapy might have given them an incentive to continue their rehabilitation and made their quality of life better.
We studied carotid intima-media thickness at non-plaque sites and the occurrence of plaque in 25 centenarians (8 men and 17 women) living in Tokyo. The studies were done by B-mode ultrasonography and the results were compared with those found in 126 healthy subjects (83 men and 43 women) aged 28 to 82 years. The intima-media complexes were diffusely thickened in the centenarians; average thickness at bifurcations and at three sites in each common carotid artery ranged from 0.91 to 1.12mm. The thickness was not associated with blood pressure or with serum lipid concentration. The thickness in the control group correlated with age, and that relationship fit a second degeee equation. The expected values of mean intima-media thickness of the common carotid arteries at age 100 were computed with these equations; the predicted values ranged from 0.92 to 0.98mm, which are close to the mean values measured in the centenarians (0.95 to 1.05mm). However, the variations in intima-media thickness were greater in the centenarians. The prevalence of plaque in the centenarians was 40% for the right carotid artery and 36% for the left, but the prevalence among those in the eighth decade of life was 9.5% for both sides; plaque was not found among subjects in the sixth decade of life or younger. These data suggest that the degree of carotid arteriosclerosis is one factor that limits human longevity.
We studied the rate of isolation of methicillin-resistant Staphylococcus aureus (MRSA) from throat cultures obtained from elderly patients. The subjects were 151 consecutive patients admitted to Kitakyusyu Tsuyazaki Hospital from December 1994 to November 1995. MRSA was found more frequently in samples obtained from patients tranferred from other hospitals or from nursing homes than in samples from those admitted from their own homes. Patients transferred from other hospitals or from nursing homes had lower levels of serum total protein, albumin, and hemoglobin, and also lower scores for activities of daily living than did those admitted from their own homes. Status prior to admission, nutrition, and the scores for activities of daily living may explain the differences in the rate of isolation of methicillin-resistant Staphylococcus aureus among patients admitted to geriatric hospitals.