Healthy elderly people are mildly anemic peripheral blood data on 3, 583 healthy elderly people (1, 590 men and 1, 993 women aged 65 years or older) from among those undergoing medical examinations at our hospital in the 8 years from 1988 to 1995 were compiled into 5-year age groups. For both men and women the mean values of red blood cell count, hemoglobin, and hematocrit were slightly lower among older subjects. The main causes of this apparent reduction may be a decrease in the number of hematopoietic stem cells and regression of the hematopoietic microenvironment. Observation of arteries in specimens of hematopoietic bone marrow obtained from the spines of elderly people showed arteriosclerotic changes such as greater hypertrophy of the media than of the intima, and adventitial fibrous hypertrophy. The number of venous sinuses was low and the amount of adipose tissue was high compared to the bone marrow of younger people. The cell density and the ratio of hematopoietic tissue to fat tended to be lower in older subjects. The number of erythroid burst-forming units formed after 14 days in culture medium containing erythropoietin was 28±19 in 32 healthy elderly people, which was significantly lower than the number in 30 young people 54±30, (p<0.005). The value for erythroid colony-forming units was 170±67 in eight healthy people, which was much lower than in young people, 276±54. In the elderly subjects, the plasma iron disappearance time (PIDT/2) was 60-80min (mean: 71.9min), which was similar to that in the young, but the percent red cell iron utilization was 67.6%-84.9% (mean: 79.7%), which was slightly lower than in younger people. When the diagnostic criterion for anemia in the elderly was set at a hemoglobin value of 11.0g/dl, about 13% of outpatients who came to our Geriatrics department were found to have anemia, and in most of them the anemia had resulted from another disease. In conclusion, anemia in the elderly is likely to be affected by reduction in the function of various organs and by the decreased reserves associated with aging. The causes of anemia are complex and diagnosis is often difficult. The present article gives a general outline of the diagnosis and treatment of common types of primary and secondary anemia in the elderly.
Lipoprotein (a) (Lp (a)) is an independent risk factor for cardiovascular diseases in non-diabetic people, but few studies have been done in diabetic patients. To investigate whether Lp (a) is a risk factor for cardiovascular disease in elderly people with diabetes, we examined the association of Lp (a) and serum lipid levels (total cholesterol: TC; triglycerides: TG; and high-density lipoprotein cholesterol: HDL-c) with the incidence of coronary artery disease and cerebrovascular disease. We studied 354 outpatients(131 men and 223 women, 60-97 years of age) with non-insulin-dependent diabetes mellitus. The mean concentration of Lp (a) was 21.1±19.6mg/dl and the median was 14.0mg/dl. The Lp (a) concentration did not correlate significantly with age or with sex, but it did correlate significantly with TC (r=0.152, p<0.05) and with the level of apoprotein B (r=0.168, p<0.05). The incidence of cerebrovascular disease was significantly higher in patients with high concentrations of Lp (a) (≥30mg/dl) than in those with low concentrations (<30mg/dl). Multivariate logistic regression analysis revealed that male sex, hypertension, a high level of HbA1c, a low level of HDL, and a high level of Lp (a) were independent risk factors for cerebrovascular disease. The incidence of coronary artery disease tended to the higher in those with high concentrations of Lp (a) (≥30mg/dl). However, multivariate logistic regression analysis revealed no significant correlation between Lp (a) concentration and the incidence of coronary artery disease. We conclude that a high concentration of Lp (a) is an independent risk factor for cerebrovascular disease in elderly patients with diabetes.
The risk factors for postoperative morbidity and mortality in elderly patients with Parkinsonism after gastroinetestinal surgery were evaluated by univariate and multivariate analyses in comparison to those of patients with cerebrovascular disease and to those of patients with no comorbid condtion. Data were obtained on 36 patients with Parkinsonism (PK), 77 with cerebrovascular disease (CVD) and 120 with no comorbid condition (ND). All data were adjusted for age, sex and operative procedure. The postoperative morbidity rate was highest in the PK group (77.8%), followed by the CVD group (70.1%), and both differed significantly from the rate of the ND group (32.5%). Gastrointestinal and pulmonary complications and delirium were the major postoperative complications, and were significantly more common in the PK group than in the ND group. Patients in the PK group had the longest postoperative hospital stay, followed by those in the CVD and ND groups; the differences were significant between the PK and ND groups and between CVD and ND groups. The PK group had the highest operative and hospital mortality rates, and they differed significantly from the ND group. Hayashi' s second method of quantification was used to assess the risk factors for postoperative death. The highest partial correlation coefficient was that found for postoperative pulmonary complication. We conclude that we should pay close attention to postoperative respiratory management, particularly in elderly patients with Parkinsonism, to prevent pulmonary complications and reduce postoperative mortality.
The apolipoprotein E4 (apoE4) ε4 allele is a major riks factor for Alzheimer's disease. However, ε4 is neither a neccessary nor a sufficinet condition for the development of this disease, and many cognitively healthy elderly people carry the ε4 allele. To look for age-dependent changes in ε4 allele frequencies in the general population, we measured the frequencies in 141 normal healthy residents of a mountainous rural area in north-west Gunma prefecture. Levels of cholesterols in plasma were measured and their relation to apoE genotypes was studied. We also measured the levels of α2-macroglobulin (α2M) and plasminogen activator inhibitor 1 (PAI-1) in blood, and studied their relation to apoE genotypes. Because low-density lipoprotein receptor-related protein (LRP) binds apoE, α2M, and PAI-1, it is of interest to see whether the α2M and PAI-1 concentrations in blood differ between ε4 carriers and non-carriers. ApoE allele frequencies were 0.05, 0.84, and 0.11 for ε2, ε3, and ε4, respectively. In both men and women, the frequency of ε4 was lowest among those in the seventh decade of life. The frequency of ε4 among octagenarians was high (0.17). Serum levels of total cholesterol and low-density lipoprotein cholesterol did not differ significantly between ε4 carriers and non-carriers. The α2M level in serum was higher in women than in men and was higher in older subjects than in younger subjects. Plasma PAI-1 levels were significantly higher in men than in women (Student' s t-test; p=0.0197). Neither α2M levels nor PAI-1 levels differed between ε4 carriers and non-carriers, which suggests that the levels of these two proteins in blood do not reflect the status of LRP in individuals with various apoE genotypes. Studies that include data on life style and diet are necessary before we can conclude that rural life contributes to longevity in ε4 carriers.
To study the relationship between lipids and longevity, we examined the level of serum lipids and apolipoproteins, and the susceptibility of low-density lipoprotein (LDL) to oxidation of 45 centenarians (15 men, 30 women, mean age 101.1±1.4) living in the Tokyo metropolitan area. The average levels of total cholesterol (TC), of LDL-C of high-density lipoprotein cholesterol (HDL-C), and of apolipoproteins A1 and B were significantly lower in centenarians than in healthy middle-aged controls. The frequency of hypobeta-lipoproteinemia (apoB<60mg/dl) in centenarians was almost ten times as high as in controls. The time course of copper-mediated LDL oxidation (assessed by monitoring 234nm diene absorption (lag time)) did not significantly differe between the two groups. Analysis of LDL subfractions by non-denaturated gradient-gel electrophoresis showed a predominance of large, buoyant LDL particles (pattern A) in 75%, and a predominance of small dense LDL particles (pattern B) in 25% of centenarians. We also assessed activities of daily living (ADL) and cognitive function in the centenarians. Centenarians were divided into two groups according to the median ADL score, and were classified into five groups with a scale clinical dementia. In subjects with good ADL scores, the mean concentration of HDL3-C was significantly higher than in those with poor ADL scores. Average levels of HDL-C were also significantly lower in subjects with moderate or severe dementia than in those with normal cognitive function. These findings suggest that centenarians have protective phenotypes of lipids and lipoproteins that protect them from ahteroscierosis.
Whether elderly patients can take prescription drugs as directed by a physician is often unclear. So elderly patients could receive adequate instruction regarding their medications, we developed a regimen comprehension scale (RCS) with simple questions regarding information on dosage and administration. This information was written on the outside of the paper bags in which the medications are usually dispensed. The subjects were 21 healthy volunteers (11 men and 10 women, averaged age 38.3±11.2 years) and 17 inpatients (9 men and 8 women, averaged age 73.1±6.8 years). Five kinds of drugs, which differed with respect to dosage and administration were used. The subjects were questioned in an interview about taking the five drugs and their regimen comprehension was assessed with the RCS (maximum score: 10 points, lowest score: -10 points). Then regimen comprehension was classified into 4 grades: normal (10), caution needed (9 or 8), training needed (7 or 6), and assistance needed (5 or less). In addition, intelligence was tested with the revised version of Hasegawa's dementia scale (HDS-R). Eight of the 21 healthy volunteers (38%) and 13 of the 17 elderly patients (76%) misunderstood some aspects of the regimens written on the paper bags. The regimen comprehension was classified as “normal”, “caution needed”, and “training needed” in 13, 7, and 1 of the healthy volunteers, respectively, it was classified as “normal”, “caution needed”, “training needed”, and “assistance needed” in 4, 4, 4, and 5 elderly patients, respectively. The five elderly patients classified as “assistance needed” were suspected to have dementia because they had scores on the HDS-R of 21 or less. A significant positive correlation (r=0.797) was noted between scores on the HDS-R and on the RCS. When treating elderly patients with chronic disease (for example, hypertension) it is important to evaluate their regimen comprehension with an index such as the RCS to determine the need for medication counseling before the start of a medication regimen.
A 72-year-old man was admitted to our hospital because of a tumor-like shadow on a chest X-ray film. At the initial examination, he had clinical signs of Cushing's syndrome: moon face, central obesity, and hypertension. A computed tomographic scan of chest showed an abnormal shadow in the lung (5×6cm) with involvement of the right paratracheal and anterior tracheal lymph nodes, and a right-sided pleural effusion. Small cell lung cancer (extended disease; T2N2M1; stage IV) was diagnosed after a transbronchial biopsy. The concentrations of adrenocorticotropic hormone, cortisol, and parathyroid hormone in plasma were markedly elevated, and there was no circadian rhythm (336pg/ml, more than 60.1μg/ml, and 805pg/ml, respectively). Fluid obtained by thoracentasis had malignant cells, and the levels of adrenocorticotropic hormone and parathyroid hormone in the effusion (1120pg/ml and 1810pg/ml, respectively) were higher than those in serum, which indicates that these hormones were produced by the tumor cells. The patient received chemotherapy and responded well, but he died of respiratory failure 26 months later. The response rate to chemotherapy in elderly patients with lung cancer is said to be comparable to that in younger patients, but treatment may be difficult because of poor performance status and diminished physical capacity. Although patients with lung cancer complicated by Cushing's syndrome have a poor prognosis, this patient survived for more than 2 years after the disease was diagnosed.
A 79-year-old man with marked hepatosplenomegaly and lymphadenopathy was admitted to the hospital. Analysis of serum protein resulted in the diagnosis of γ-chain disease (total protein 6.2g/dl, M-protein positive, IgG 4150mg/dl, IgG-Fc fragment positive). Specimens obtained by lymph node biopsies showed infiltration of plasmacytoid cells, which were stained with anti-IgG but not with anti-κ or anti-λ antibodies. The patient was given combination chemotherapy, but without effect. Then a regimen of long-term administration of low-dose etoposide was begun, and resulted in remission of the lymphadenopathy, hepatosplenomegaly, and abnormal IgG.
A 92-year-old woman was admitted to our hospital due to hypertension, nausea, pain in the anterior part of the chest, epigastralgia, and tachypnea. During the initial examination of the patient in the emergency ward, she was very excited, howled, and both her hands were numb. Arterial blood gas analysis revealed a marked alkalemia (pH greater than 7.55) and hypocapnia (PCO2 24.1mmHg). After paper bag re-breathing, the pH and PCO2 were within normal limits. Because there was no lesion in the lungs or the brain that would account for hyperventilation and convulsions, the attack was considered to be a manifestation of hyperventilation syndrome. This case suggests that hyperventilation syndrome should be carefully considered in the differential diagnosis of disturbance of consciousness even in elderly patients.