[in Japanese]

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[in Japanese]

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[in Japanese]

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To elucidate clinical features of infective endocarditis in the elderly, 20 elderly patients aged ≥60 years were compared in detail with 30 others aged <60 years retrospectively. Twelve of the 20 elderly patients had a calcific aortic valve or an artificial device as a predisposing heart disease, whereas 16 middle-aged patients had mitral valve prolapse or congenital heart disease (p=0.001). The prevalence of major extracardiac disorders such as neurological disease were higher in the elderly than in the middle (9/20 vs 3/30; p<0.01). The frequency of infected valve was similar; mitral in 8, aortic in 11 and other valves or congenital defect in 2 in the elderly versus 14, 11 and 6, respectively in the middle. Among 39 patients in whom causative microorganisms were identified, staphylococcus epidermidis was most frequently identified in the elderly (5/20), whereas streptococcus species was found in the middle (12/30). Time from the onset of symptoms to correct diagnosis was usually delayed in the entire group; the delay was longer particularly in the elderly than in the middle-aged patients (72±87 vs 36±32 days; p<0.1). Maximal body temperature was less in the elderly than in the middle-aged patients (38.5±0.7 vs 39.3±1.1°C; p<0.01), whereas peak level of C-reactive protein (10.4±6.1 vs 13.0±7.9mg/dL), the incidences of heart failure (9/20 vs 10/30), and embolic complications (7/20 vs 10/20) were similar in the 2 groups. Cardiac operation was performed less in the elderly than in the middle-aged patients (9/20 vs 21/30; p<0.08). Five elderly patients had disease-related mortality, whereas only one middle-aged patient died (p=0.02). These results suggest that although predisposing heart disease and causative microorganism in infective endocarditis are different between the elderly and middle-aged patients, the incidence of major complications are similar. However, due to the delay of correct diagnosis in the elderly who usually have major extracardiac disorders, the prognosis of infective endocarditis in the elderly is poor.

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[in Japanese]

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[in Japanese]

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We treated 510 elderly case (over 65 years old) among 1, 017 patients with community-acquired pneumonia and 60 similar cases among 112 patients with pulmonary tuberculosis in Kawasaki Medical School Kawasaki Hospital during approximately the past 15 years. These were compared with non-elderly caser (below 65 years old). In the elderly cases with community-acquired pneumonia, atypical clinical symptoms or physical signs were frequent and the mortality rate was high because of severe underlying diseases, and poor general and nutritional conditions. Regarding a prospective study of 84 elderly cases with community-acquired pneumonia during the past two years, S. pneumoniae, Respiratory virus, Gram-negative bacilli, H. influenzae, M. Tuberculosis were frequently isolated. In addition, mixed viral and bacterial infections, which were frequently noted during the winter, were significantly related to the increased frequency of community-acquired pneumonia. In treating elderly cases with community-acquired pneumonia, immunization therapy (e.g., influenza vaccine), second cephalosporin and/or macrolide antimicrobial agents for outpatients with mild pneumonia, and carbapenem and/or macrolide antimicrobial agents for hospitalized patients with moderate or severe pneumonia were most effective.
The number of elderly cases with pulmonary tuberculosis has recently increased and the recognition of 10 cases was delayed because of a low percentage of positive smears, but no resistance to antituberculosis drugs have been observed. Regarding the treatment of pulmonary tuberculosis, fluoroquinolone and rifamycin derivative antibiotics have been developed as antituberculosis drugs with strong antituberculous activity. However, due to the high percentage of adverse effects in elderly patients, careful treatment with desensitization therapy for antituberculosis drugs is considered important.

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[in Japanese]

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[in Japanese]

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[in Japanese]

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People with severe disabilities use many assistive devices, such as computers and robots, to improve their quality of life. However, the elderly use only limited assistive devices, such as canes, wheelchairs, walkers, or handrails. This state is caused by two characteristics of the elderly: first, the elderly generally have difficulties in learning the operation of new equipment, especially equipment with digital interfaces. Secondly, the elderly have limited desire to improve their lives if it takes considerable effort. To solve these problems, speech recognition, gesture recognition and power assist technology have been proposed for various useful devices. Virtual reality technology and pet robots may encourage the elderly to use assistive devices to improve the quality of their lives.

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In 1999, 8 elderly people aged over 70 stayed for 5 days in Mizusawa Welfare Techno-house and their health conditions and activities of daily life were monitored using 16 sensors attached around the house.
To determine a few feasible, practical sensors and optimal sensor positions, acumulated data was analyzed. Because of bud get conditions only two sensors (infrared sensor and life line monitor sensor) were placed in one voluntary house and the data were transferred from the voluntary house to the techno-house through the ISDN and CATV lines. The data were analyzed every days. Only 2 sensors to detect were placed and attached this year, however one more sensor to detect phisical conditions such as ECG records during sleeping time, will be used next year. On the other hand, an integrate system that can analyze many data transferred from various sensors simulta neously was developed. To intrroduce this system into privatehouse, many problems such as privacy protection, security, etc must be solved.

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[in Japanese]

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Active life expectancy (ALE) is defined as an expected duration to be spent with a certain level of physical/mental function. The objectives of this article are to indicate ALE values based on our prospective observation, and to discuss factors influencing regional and gender differences in ALE values.
We estimated ALE without disability in basic activities of daily living (ADL) on a 5% random sample (n=3, 459) of the residents aged 65 years and over in Sendai City between 1988 and 1991. At the age 65, ALE was 14.7 years for men and 17.7 years for women. ALE occupied 91% of the total life expectancy for men and 87% for women. As compared with the reports for the American elderly, ALE was longer in Sendai than in the United States. The duration to be spent with disability was shorter among the subjects in Sendai.
We estimated ALEs in three functional areas: basic ADL, instrumental ADL, and mobility, on all the residents aged 65 years and over (n=3, 590) at Wakuya Town between 1994 and 1996. For both sexes, ALE in IADL was shorter than those in basic ADL and mobility. The development and progression of disability were different between sexes: men experienced disability at a younger age and progressed at a faster rate than women.

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Diagnoses and symptoms are recorded by physicans in the chapter E of the Minimum Data Set (MDS), if they are relevant to disabilities of activities of daily living, cognition, behavior, medical treatments or risk of death. We improved the chapter so that it is suited to disease patterns in Japan in a format useful not only for nursing and ADL care but for medical treatment in our practice.
In E1, diseases directly underlying the current disability states were recorded in the international classification of Disease, 9^th Revision (ICD9). In 24, 670, 195, and 45 patients respectively, there were 0, 1, 2, and 3 separate recorded diseases. A Total of 63 ICD9 codes were observed, but only four codes; 290, 332, 431, and 434, were underlying diseases for 3% or more patients. These codes included mostly ischemic and degenerative diseases of the brain.

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Recently, much attention has been paid to small sized low density lipoprotein (LDL) as a risk factor for ischemic heart disease. We investigated the effect of celiprolol hydrochloride (CH), which is a β1 selective β-blocker with high intrinsic sympathomimetic activity (ISA), on the LDL particle size. We treated 41 hypertensive patients with CH and studied the change in LDL particle size according to the score of fast β lipoprotein and LDL relative mobility value (LDL-Rm) measured by lipoprotein polyacrylamide gel disc electrophoresis (PAGE). We also studied changes in blood pressure, total cholesterol (TC), trygiyceride (TG), high density lipoprotein cholesterol (HDL-C), low density lipoprotein cholesterol (LDL-C) and midband on PAGE. Systolic and dyastolic blood pressure and pulse significantly decreased during treatment. TC levels were significantly decreased at 8 weeks in all subjects and at 4, 8 and 12 weeks in patients with a TC value of over 220mg/dl.
TG levels were significantly decreased at 4 and 8 weeks in patients with initial levels of over 150mg/dl, and significantly increased at 4 and 8 weeks in those with initial levels of under 150mg/dl of TG. HDL-C levels did not significantly change during treatment.
LDL-C levels were significantly decreased at 4, 8 and 12 weeks in patients with initial levels of over 150mg/dl. Apo AI, AII, B, CII, CIII and E levels did not significantly change during treatment. Fast β lipoprotein scores did not significantly change overall during treatment, but were significantly decreased at 4 and 8 weeks in patients initial TG levels of over 150mg/dl and at 4 and 12 weeks in those with initial levels of over 220mg/dl of TC. LDL-Rm scores did not significantly change during treatment.
Midband scores were significantly reduced overall at 8 weeks, and after 4 and 8 weeks in patients with initial TG levels of over 150m/dl and at 4, 8 and 12 weeks in those with initial TC levels of over 220mg/dl. These results indicated that CH did not change LDL particle size. It was suggested that CH might be a beneficial β-blocker from the standpoint of prevention for atherosclerosis.

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A cross sectional survey was performed to quantify factors that exhaust caregivers. We report that the degree of difficulty for caregivers correlated well with the burnout score (r=-0.517; p<0.001), but the correlation between caregivers' burnout score and the level of their patient's basic ADL was lower (r=-0.317; p=0.014). In this paper, we investigated other factors related to exhaustion. Caregivers' burnout score correlated with their age. The level of disease that caregivers complained increased burnout score. The need for nocturnal care and continuous observation, as well as rejection of aid burned out caregivers.
Multiple regression analysis clarified that significant independent contributing factors for burnout score were help with toilet use, nocturnal aid and diseases suffered by caregivers.

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Purpose-related activates are often lost in severe dementia, including oral hygiene habits such as brushing teeth.
The aim of this study is to investigate whether patients with severe dementia can be induced to develop an oral hygiene routine through an occupational therapy approach and whether routine training in oral hygiene habits can reduce dental or denture plaque.
Six female inpatients in the same room, who had been given diagnosis of multiple carebral infarction and dementia.
The project design included 4 periods a, b1, b2, and c. a and c were observation periods, while b1 and b2 were general approach periods. In the approach periods we held meetings, and made the program for oral hygiene, planning and problem-solving.
In the b2 period both direct intervention by the dentists, dental hygienists and occupational therapists reinforced the habit of brushing teeth in subjects and educated care approach guidance.
No patient completely resumed routine habit of brushing teeth, but an improvement in brushings was found in four subjects, one case had no change, and in one case brushing deteriorated.
The state of oral hygiene showed improvement in periods b1 and b2. Although the adherence of dental plaque decreased in period b2, it increased in period c.
Despite the improvement in performance, sufficient improvement in oral disease prophylaxis was not recognized, suggesting the necessity of professional oral health care by dental staff, and of a disciplinary team approach.

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Oxidised LDL is taken up by macrophages via scavenger receptors, leading to foam cell formation and is thus considered to contribute to atherogenesis. Aging results in the increase of lipids and the decrease of antioxidant enzyme activity in serum. In this study, we investigated the effects of aging on LDL oxidisability. We measured LDL oxidation lag time, plasma lipids, albumin and uric acid were examined in 306 Japanese (169 men, 137 women). The mean±SE of LDL oxidation-lag time in subjects was 58.9±1.0min. The lag time (80.3±4.8min) was longest in subjects in their 20s and shortest in those in their 40s (58.9±1.0min). The longest lag time was in second-decade men (88.9±6.2min) and shortest in fourth-decade women (50.7±2.2min), and these results were similar even excluding subjects with abnormal biochemical data (total cholesterol, triglyceride, GOT, GPT, γGTP, creatinine and glucose). We analyzed the effects of various factors on lag time using multiple linear regression. Aging, uric acid and LDL-cholesterol significantly influenced lag time.
Our results suggest that LDL oxidisability might been regulated by aging, changes in LDL-cholesterol with aging and variations in physical antioxidant function.

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To study the level of interest and knowledge about care and terminal care for the elderly of medical students in Nagoya University, we made a questionnaire for first-year medical students (about 90 students per year) each April from 1998 to 2000. To assess the differences, we also gave the same questionnaire to 75 first-year non-medical students in 1999. Only about 10% of students had experienced providing care for member(s) of their family, but about one third stated that other family member(s) such as their mother, cared for older family member(s). The introduction of long-term care insurance was known by 22%, 43.5% and 96.6% of medical students in 1998, 1999 and 2000, respectively. Moreover, 19.8%, 13.0% and 52.3% of medical students knew about the care managers, respectively. About 80% of students hoped to be informed about their disease if they had terminal-stage cancer. However, about half of students could not decide whether to tell a family member who had terminal-stage cancer. Medical students had significantly more interest in the care system (68.5% in 1999) and terminal care (72.8% in 1999) for the elderly than non-medical students (41.3% and 40.0% in 1999, respectively). There were no significant differences between medical and non-medical students with regard to experiences of care, knowledge of long-term care insurance system and the attitudes to informing about terminal-stage cancer. However, more medical students had an interest in the elderly care system and terminal care than non-medical students.

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We quantitatively measured the physical and psychological burden of caregivers of 25 patients with senile dementia of Alzheimer type (SDAT). The Barthel Index (BADL, full score: 20 points) and the caregiver burden in terms of physical symptoms correlated well (r=-0.964, p<0.001), as did the degree of abnormal behavior and caregiver burden in terms of psychological symptoms (r=0.946, p<0.001). The correlation with the burnout scale (BOS) of Pines was best when both factors of psychological and physical symptoms were included. The correlation between BOS and the caregiver burden in terms of both physical and psychological symptoms was r=0.874, p<0.001, and the correlation between BOS and “the degree of abnormal behavior”+(20-“BADL”) was r=0.853, p<0.001.
The burden in terms of physical symptoms increased as the BADL score decreased, but the burden in terms of psychological symptoms increased initially and decreased in the last phase of the disease.
We conclude that the BOS score of SDAT caregivers was stable in the initial phase, then increased rapidly, thereafter preserved high, and dropped rapidly as the BADL score decreased.

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Previous studies have suggested that type 2 diabetic mellitus could lead to learning and memory deficits. We studied cognitive function tests and brain computed tomography (CT) findings in elderly subjects with drug-treated type2 diabetic patients (n=9), diet-treated type 2 diabetic patients (n=8) and nondiabetic subjects (CR, n=21). A battery of cognitive function tests (Cog-T; WAIS-R's digit span test and symbol test, Stroop Test, ADAS's verbal memory test, and MMSE) was carried out on two occasions, separated by at least 6 months. Brain CT was analyzed by the following 5 variables; 1) Evan's Ratio, 2) Inverse Cella Media Index, 3) maximum width of the third ventricle, 4) maximum width of temporal horn tips on both sides and 5) maximum width of the Sylvian fissure at the insula, bilaterally.
The scores of Cog-T did not differ significantly between the groups. On brain CT measurements, maximum width of the temporal horn tips on right side were significantly different in the three groups (ANOVA, P=0.035). The drug-treated diabetics subjects had wider temporal horn tips on the right side than did the diet treated diabetics and nondiabetic subjects (Fisher's post hoc test, P=0.030, P=0.016).

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Maintaining to good glycemic control is necessary to treat diabetes effectively and it is also necessary to understand the mental characteristics of elderly patients with diabetes. We investigated evaluation of the mental state, using self-depressive scale (SDS) and the Tokyo university egogram form (TEG), of 356 asymptomatic diabetic patients (254 non-elderly, 102 elderly) admitted for educational about diabetes. On TEG, we studied evalution of five ego states for the following showing: critical parent (CP), nurturing parent (NP), adult (A), free child (FC) and adapted child (AC).
First of all, we studied evaluation of mental characteristics of the elderly, NP and A of TEG were higher in the elderly than in the non-elderly (p<0.01). Furthermore, the SDS was lower on discharge than on admission in both groups (p<0.01).
The group showing improvement had a significantly higher SDS score on admission than the group showing aggravation (p<0.01). We classified the group with an SDS score 50 or more SDS as the depressed group; those with a 40 to 49 score as the slight distress group; and a score of 39 or less score was considered normal. The depressed group had significantly lower A and FC, and a higher AC on TEG, than other groups (p<0.01).
Therefore, elderly diabetic patients seem to be rational and obliging. This study revealed the mental effects of diabetic education to be similar in elderly and non-elderly diabetic patients.

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This study examined whether around-the-clock medical support is a contributing factor to dying at home, and also tried to identify other such factors. Visiting nursing records of 81 elderly patients who died at home or in hospital after receiving home care at two facilities, one with and one without 24-hour medical support respectively were examined retrospectively. The subjects were divided into two groups: those who died at home and those who died in a hospital or nursing home. The two groups were compared in terms of clinical and sociodemographic characteristics and preferences for dying at home, expressed by patients, families and medical staff.
Those who died at home showed a significantly higher rate of total dependence (84.6% vs. 48.1%) at month before death. Dying at home was significantly more preferred by all patients, families and medical staff. The major reason for hospitalization was rapid deterioration of the patients' condition.
The facility with around-the-clock medical service had a higher rate of dying at home (42% vs. 27%, p=0.18). Also, patients, families, and medical staff associated with their facility showed a higher preference for dying at home. We concluded from the above that the contributing factors for dying at home are: 1) total dependence level of ADL at one month before the death, and 2) preference for dying at home expressed by the patient, family and medical staff. This study suggests 24-hour medical support should be a requirement for in-home terminal care. Supporting advice from the staff to the family seems to be another contributing factor.

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An 80-year-old man with MDS-refractory anemia (RA) suffered transformation to a leukemic state after 18 months. The karyotype of the bone marrow cells was 47, XY, +8 in 8 cells among 20 dividing cells analyzed. Combination therapy of 150μg of granulocyte colony-stimulating factor (G-CSF) and 250mg of cytarabine ocfosfate (SPAC) for 3 weeks had no beneficial effect. Then, the patient was subjected to low-dose (2mg daily) melphalan therapy. Gradual and concurrent improvement in anemia, thrombocytopenia, and neutropenia occurred, and the patient became free of transfusions at 2 weeks after the treatment began. Since then, his performance status has improved from grade 4 on his diagnosis of AML to grade 2. Cytogenetic analysis was normal in all 20 dividing cells in the bone marrow examination and melphalan had no adverse effect.
Recently, several reports of low dose chemotherapy for elderly patients or high risk leukemia have been described, and have sustained for the QOL therapy. In the present case, low-dose melphalan therapy was effective and, moreover the abnormal karyotype of trisomy eight had disappeared.

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A 79-year-old woman was admitted on January 18, 2000, with a lumbar compression fracture. Two days after admission, a chest X-ray film showed reticular infiltrates in the right lung field. She was diagnosed as having pneumonia and was treated with antibiotics. Despite this therapy, her symptoms did not improve and the infiltrates diffusely extended to involve both lungs on chest X-ray films. She was placed on noninvasive positive pressure ventilation (NIPPV) for progressive respiratory failure at 5 days after admission in order to avoid endotracheal intubation. Her hypoxemia was immediately improved by oronasal bilevel positive airway pressure ventilation (BiPAP) and chest X-ray films revealed improvement of the reticular infiltrates. Measurement of viral antibody titers showed that the cause of acute respiratory failure was influenza A virus pneumonia. In conclusion, NIPPV may reduce the need for intubation of elderly patients with acute respiratory failure, as well as chronic obstructive pulmonary disease (COPD) patients.

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