This study was done to clarify the relationship between asymptomatic brain infarcts and risk factors for atherogenis. A total of 312 patients (151 men and 161 women) who had no neurologic deficits were enrolled. Their ages ranged from 41 to 83 years (mean age 63 years). The patients were divided into two groups: 158 patients without asymptomatic brain infarct and 154 patients with at least one asymptomatic brain infarct of at least 5mm as diagnosed by magnetic resonance imaging. The patients with asymptomatic brain infarct were more likely than those without asymptomatic brain infarct to be 65 years old or older, and to have essential hypertension, diabetes mellitus, or atrial fibrillation. Among patients with hypertension the frequency of left ventricular hypertrophy or hypertensive ocular findings (Scheie's class H2) was significantly higher in those with asymptomatic brain infarct than in those without asymptomatic brain infarct. These results indicate that aging, essential hypertension (especially with left ventricular hypertrophy or hypertensive ocular findings), diabetes mellitus, and atrial fibrillation are associated with asymptomatic brain infarct.
Using a Minimum Data Set, we studied how the mental and physical status of elderly people with dementia was modified by institutionalization. We assessed patients with dementia at the time of their admission in Kyoto Higashiyama geriatric hospital, and again three months later. On admission, both mental and physical problems were noted with a Resident Assessment Protocols. The former included cognitive loss/dementia, delirium, behavioral progblem, activities, and mood state; the latter included visual function, activities of daily living (functional), urinary incontinence and indwelling catheter, nutritional status, dehydration/fluid maintenance, and dental care. Three months later, marked improvements were observed in 8 areas: delirium, psychological well-being, mood state, activities, urinary incontinence and indwelling catheter, nutritional status, dehydration/fluid maintenance and dental care. Cognitive loss/dementia and visual function were changed little. The unchanged areas were considered to be “core” manifestations of dementia, and those that changed were believed to reflect emotional problems and to be affected by the environment. Therefore, individualized care for elderly institutionalized patients with dementia should focus on these “peripheral” problems rather than on those that cannot be changed.
To evaluate the clinical significance of silent myocardial ischemia in elderly patients with coronary artery disease, 147 patients (aged 65 years and older) underwent coronary angiography and dipyridamole thallium scintigraphy. Seventy-four patients (44 men, 30 women) who showed reversible defects (RD) and ischemic ST depression during scintigraphy were divided into two groups: 13 with silent RD (18%, 12 men, 1 woman), and 61 with painful RD (82%, 32 men, 29 women). Most patients with silent RD were men. The prevalence of myocardial infarction was similar in patients with silent RD (62%) and in patients with painful RD (49%). The prevalence of multivessel disease was also similar in the two groups: 85% in patients with silent RD and 82% in patients with painful RD. Among 38 patients with infarction, 8 had silent RD and 30 had painful RD. The prevalence of RD in the area of infarction was greater in patients with silent RD (63%) than in patients with painful RD (47%), but the difference was not statistically significant. The prevalence of extensive infarction (fixed defects) was greater in patients with silent RD (75%) than in patients with painful RD (30%, p<0.05). Among 36 patients without infarction, there was no scintigraphic parameter which showed significant difference. Bypass grafting and angioplasty were initially performed in 23% of the patients with silent RD and in 36% of the patients with painful RD (ns). When the two groups were treated medically during the follow-up period of 29±22 months, the incidences of cardiac events were similar: 10% in patients with silent RD and 13% in patients with painful RD. The prevalence of silent RD is not high in elderly patients with significant coronary artery disease. Compared with the patients with painful RD, those with silent RD were more likely to have an old and extensive myocardial infarction, and they tended to have RD in the area of the infarct.
The usefulness of the urinary calcium/creatinine (Ca/Cr) ratio, the oldest marker of bone resorption, is limited because of the influence of sodium intake and urine volume. The urinary Ca/Cr ratio was therefore compared with urinary calcium corrected for the urine osmotic pressure (Ca/OSM). Significant correlations are found between the Ca/Cr ratio and both creatinine (r=-0.386) and osmotic pressure (r=-0.473) in random urine samples from normal subjects, but similar correlations were not found for urine Ca/OSM. No significant correlation was found between Ca/OSM and Na/OSM, but the correlation coefficient between Ca/Cr ratio and Na/Cr ratio was 0.399. Thus, the Ca/Cr ratio is affected by urinary volume and sodium concentration, but the Ca/OSM ratio is not. The Ca/OSM ratio may therefore be a more accurate marker of bone resorption, because one of the main components of urinary osmotic pressure is sodium that inhibits tubular calcium reabsorption. The Ca/OSM ratios measured from 24-hour urine samples were found to be strongly correlated with the values measured from samples obtained during sleep (sleep urine, 0.823) and were slightly less strongly correlated with the values measured from second morning samples (0.641). Because bone resorption is especially active at night, the Ca/OSM ratio in sleep urine may be the most sensitive maker of bone resorption. The Ca/OSM ratio in sleep urine samples increased with age in normal women.
A 76-year-old woman was found to have acute aseptic meningoencephalitis with meningial irritation, disturbance of consciousness, elevation of cell counts in cerebrospinal fluid, and swelling of a right temporal-lobe lesion on a CT scan of the head. Muscle weakness in the lower extremities and urinary dysfunction developed and progressed gradually. The protein content of cerebrospinal fluid was high, and the distal latencies of F waves were prolonged, which suggested that the inflammation extended to the nerve roots. Sjögren's syndrome was diagnosed on the basis of atrophy of the labial salivary glands; invasions of lymphocytes and plasma cells to the intercellular space; and elevation of the titers of serum antinuclear antibody, anti-SS-A antibody, and anti-SS-B antibody. The patient had no xerosis. Aseptic meningoencephalitis was the first manifestation of Sjögren's syndrome. In recent years, several cases in which Sjögren's syndrome was associated with aseptic meningitis have been reported. However, we know of no previous report of such a case in a patient of this age. Aseptic meningoencephalitis can be the first manifestation of Sjögren's syndrome.
Case 1. An 85-year-old woman had a papillary adenocarcinoma of the thyroid gland and a pleural effusion. The pleural effusion appeared to be a chylous exudate and it did not re-accumulate after thoracenthesis. Thoracic imaging indicated that the chylothorax was caused by direct invasion of the thoracic duct by the thyroid carcinoma. Case 2. A 53-year-old woman had a 20-year history of recurrent chylothorax. She died due to sepsis one year after the third admission for dyspnea and chylothorax. The autopsy findings included papillary adenocarcinoma of the thyroid gland with metastasis to the left supraclavicular lymph nodes. The thoracic duct was inflamed, fibrotic, and completely obstructed. Invasion by the carcinoma may have compressed and destroyed the thoracic duct, and caused chylothorax. Recurrent inflammatory granulation caused total obstruction of the thoracic duct. Reports of chylothorax associated with carcinoma of the thyroid gland are rare.
An 82-year-old man was admitted to the hospital in the summer of 1995 due to dyspnea, peripheral edema, and a tingling sensation and muscle weakness in all extremities. Physical examination showed heart failure and polyneuropathy. Laboratory data showed a low concentration of vitamin B1 (10ng/ml normal 23.8-45.9ng/ml) and a low level of erythrocyte transketolase activity (0.58IU/gHb normal 0.75-1.30IU/gHb). A chest X-ray film revealed cardiomegaly (cardiothoracic ratio 57.1%) and ultrasonic cardiography revealed increased motion of the left ventricle. A diagnosis of beriberi was made. The disease in this case may have been caused by hard work in the summer heat. The patient was treated with thiamine and his symptoms and signs resolved within a few weeks. A search of the literature revealed no previous report of beriberi in a patient of this age, but reports of beriberi in older patients in Japan are more common now than in previous years. Beriberi should be included in the differential diagnosis of polyneuropathy in elderly patients.