Prior to recent revisions, civil law had established a system of interdict and quasi-incompetency. This system was begun in 1898 and, up until the revisions of April 2000, it had spanned more than one hundred years without undergoing any major changes. Statistically, there was a steady increase in the number of pronouncements and retractions of incompetency in recent years. A 1980 survey showed that people in their 40s were the most common, and that the proportions of psychiatric disorder, mental retardation, and dementia were of nearly the same level. A 1996 survey, in contrast, showed a greater proportion of elderly, with about half of cases being dementia or a vegetative state. The new adult guardianship system currently in place, as well as a voluntary guardianship system (enduring power of attorney), was established together with the change from the interdict/quasi-incompetency system to a system of assistance, curatorship, and guardianship. The care insurance system that was put in effect at the same time shifted from an enforcement system to a contract system, so the judgment ability of the person at the time of the decision to enter the contract has become an issue. Finally, in dealing with people with dementia, especially mild dementia, problems arise as to the best method of informed consent, including notifying people of their specific disease, and who should decide the treatment for incompetent people with dementia.

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[in Japanese]

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[in Japanese]

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[in Japanese]

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After long-term care insurance commenced in April 2000, various types of in-home care began, including delivery of prescriptions medicines to the elderly. However, the effects of in-home care workers on patient drug compliance are unclear as yet.
In this study, we examined the characteristics of the care workers who delivered prescription medicines to the elderly, and analyzed the effects on patient drug compliance and knowledge about medication. The subjects included 163 homecare recipients aged 60 and older, who were taking more than one prescribed drug, who ranked worse than J-2 who were physically disabled, and cognitively normal.
The rate of good compliance was 71.1% when pharmacists provided the prescribed drugs and counseled the patients at home, which rate was significantly higher than that of self supply by the patient (35.0%), caregiver supply (44.7%), and home-helper supply (0.0%). The difference in compliance may be explained by the possibility that when caregivers and home-helpers provided prescribed medications, thorough and accurate information about the drugs were not clearly imparted to the elderly, whereas when pharmacists provided prescribed medications, a pharmacological examination was performed and thorough and accurate information was communicated to the elderly. In the group counseled by pharmacists, knowledge about the effects and purpose of medication positively correlated with drug compliance. However, in the group provided drugs by caregivers, knowledge about the effects and purpose of medication inversely correlated with drug compliance. These findings suggested that the elderly in the latter group chose, to some degree, not to comply.
Many elderly people had difficulty getting to hospital, and 23.1% of the patients in this study had not consulted the doctor for more than 2 months.
Our data suggest that drugs provided by pharmacists and the availability of pharmacist counseling play an important role in preventing drug noncompliance and in making home care more effective, and also suggest that it is important for pharmacists to cooperate with other care workers, including a care-manager, and to provide written information on prescription medicine to caregivers and home-helpers as well as to elderly patients.

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To estimate the usefulness of the bedside swallowing assessment proposed by Smithard et al and neuroimaging findings characteristic for dysphagia, we studied the outcome of 102 patients with chronic cerebral infarction after assessment of swallowing by this test with brain computerized tomography (CT). All patients had a variety of motor disturbance and were admitted on a long-term medicare basis. They were divided into two groups according to the findings: the positive group (n=33), who showed any of the listed types of difficulty in swallowing water, and the negative group (n=69). Followed up to 2.2 years, their outcomes were studied. CT findings were studied on type of infarction, number and laterality of infarction, grade of periventricular lucency (PVL), presence of ventricular dilatation (VD), and severity of cortical atrophy (CA). The mean age was 76.4 years at registration and 61 were men. The frequency of severe dementia and disturbed ADL were significantly higher in the positive group. Eighteen patients died during the observation period and 15 of those were in the positive group, indicating higher annual death rate (29.9% vs 2.2% in the negative group). All of the 15 patients in the positive group died of pneumonia. CT findings showed high incidence of multiple infarction, bilateral hemispheric lesion, severe PVL, VD, and severe CA in the positive group. These findings indicated that this evaluation method was useful in screening swallow function for patients with cerebral infarction in the chronic phase. Furthermore, CT findings suggested that severe white matter lesion, VD, and severe CA as well as multiple infarction seen in bilateral hemisphere was related to dysphagia, probably due to multiple factors involving pyramidal- and extrapyramidal-tracts with higher brain function.

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We conducted animal-assisted therapy (AAT) for the elderly with senile dementia in a day care center. AAT was performed between July 27 and October 12, 1999 for a total of six biweekly sessions. The AAT group consisted of 7 subjects; 5 with senile dementia of Alzheimer's type (SDAT) and 2 with vascular dementia (VD). The control group was 20 elderly subjects (7 SDAT, 13 VD).
The results were as follows:
Comparing between MMS scores at the baseline and those three months later, the average score on MMS before AAT (baseline) was 11.43 (±9.00), and that three months later was 12.29 (±9.69). In the AAT group, the average baseline NADL score was 28.43 (±14.00) and that after ATT was 29.57 (±14.47). In the AAT group, the average baseline score on Behave-AD was 11.14 (±4.85), and that three months after AAT was 7.29 (±7.11) (p<0.05). In the control group, the average baseline score was 5.45 (±3.27) and that three month later was 5.63 (±3.59). However, the results of eight subscales of communication behavior three months later were significantly low comparing to those at the baseline in the control group. The evaluation of CgA, which was a mental stress index, showed a decreasing tendency in the AAT group.
Our findings suggested we should use several evaluation methods for evaluation of the changes of patients receiving AAT.

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The purpose of this study was to examine the usefulness of information about outcome in evaluation of the quality of special nursing homes. Two special nursing homes A and B were selected. These two facilities were the same in their service capacity and are also owned as well as managed by the same organization. There were no differences in the structural elements between the two facilities. The hospitalization and mortality rate of the two facilities were compared.
There were no significant differences in terms of the distribution of the characteristics of the residents between facility A and B at the time of their admission. However, the average survival time of the persons who died was significantly shorter in facility B than that in facility A. (A facility=1, 165 days, B facility=831 days; p<0.05). There were significant differences in cumulative survival and non-hospitalization rate of residents in the two facilities (p<0.05). The differences were seen even after controlling for the prognostic factors by Cox's proportional hazard model (hazard rate: mortality=1.562, hospitalization=2.526, p<0.01). Furthermore, the proportion of residents hospitalized right after their first visit to the hospital was significantly higher in facility B than that in facility A (A=9.6%, B=19.3%; p<0.05). Also, the mortality risk of hospitalized persons was significantly higher than non-hospitalized persons in facility B (p<0.05), although there was no significant difference in terms of the mortality risk between the two groups in facility A.
Because the differences in the cumulative survival and non-hospitalization rate could occur in the facilities that are similar in institutional structures, it suggests that these outcomes are indicators of the quality of special nursing homes. It would be, therefore, important to collect the information about outcome including cumulative survival and non-hospitalization rate of the residents in order to evaluate the quality of special nursing homes.

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Bone mineral density (BMD) and bone structure are very important indices for prevention of fracture. However, it is very difficult to quantify bone structure, and only a few indices for structural quantification of bone have been reported. The purpose of this research was to investigate a new index for bone structure.
The subjects were 52 women aged from 20 to 85 years. Directivity index (DI) is a new index of bone structure calculated by directivity of power spectrum from radiographs of metacarpal bone using fast Fourier transform (FFT). DI was obtained by subtracting the integral power value at 0 and 90 degree directions on the x-y plane of the two-dimensional power spectrum of bone from the integral power value at a direction of 45 degrees.
A significant relationship between BMD and DI was indicated by correlation coefficient. However, no significant relationship between BMD and the first moment of the Fourier power spectrum or the fractal dimension was found.
There is a possibility that DI estimates a slight deformation of bone structure. In the future, we will apply DI to the prevention of fractures and osteoarthritis.

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A 75-year-old woman was referred to us because of cough, high fever and skin erythema in April 1999. Malignant lymphoma (diffuse mixed cell type) was previously diagnosed in 1990 and she achieved complete remission after treatment with a series of CHOP regimen treatments. In 1998, multiple myeloma (IgG λ type) was diagnosed and she was treated with a combination of melphalan and prednisolone. On physical examination, superficial lymphadenopathy and skin erythema were noted. Biclonal gammopathy (IgG κ/λ) was shown in serum, and Bence Jones protein in urine. Computed tomography showed pleural effusion and swelling of paraaortic lymph nodes. The bone marrow examination showed an increased number of abnormal plasma cells (19.2%) and no evidence of lymphoma. Left axillary lymph node biopsy revealed that she had non-Hodgkin's lymphoma (immunoblastic lymphadenopathy-like T cell lymphoma). She was treated with the CHOP regimen at reduced doses for both diseases. The lymphoadenopathy reduced after 6 courses of CHOP and 4 courses of CHOPE (CHOP+VP16), however, she had bone pain on November 1999 and received treatment with MCNU-VMP (MCNU+VDS+L-PAM+PSL). Her rib pain improved, but she died of systemic infection of herpes zoster virus. We report here a rare case of malignant lymphoma concomitant with multiple myeloma.

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We encountered 4 patients aged over 80 with acute coronary syndrome involving the left main coronary trunk (LMT) who obtained a successful outcome by non-surgical management.
CASE 1: An 80-year-old women suffered acute myocardial infarction. A coronary stent was placed at the orifice of the LMT for dilatation of severe 90% stenosis. Cardiac function was markedly improved after treatment during the chronic period.
CASE 2: An 81-year-old man who developed non-sustained ventricular tachycardia. Coronary angiography demonstrated severe stenosis with haziness of the LMT. Intra-aortic balloon pumping was performed for one whole day after the attack and the follow-up study performed one month later revealed that the stenosis was markedly diminished to an insignificant grade without residual ischemia.
CASE 3: An 81-year-old man developed acute inferior wall infarction with a background of severe triple vessel disease accompanied by an LMT lesion. Coronary stents were placed at three sites, i. e, the right coronary, LMT, and left anterior descending branch. Though initial treatment was successful, this patient died due to severe arrhythmia.
Patients in who CABG is strongly indicated due to LMT lesion complicated with multiple organ disorders will increase as the population of the aged continues to increase in Japan. We obtained satisfactory results by intensive intense non-surgical management including PTCA. From our experience, adequate selection of therapeutic regimens for individual patients is important to improve the long-term prognosis as well as the immediate outcome in the acute stage.

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A 65-year-old man with sarcoidosis, accompanied by muscle nodules, noticed a painless and enlarged nodule in his forearm. MRI of the nodule showed that a star-shaped area of lower signal intensity was surrounded by an area of higher signal intensity. Histological examination showed granulomas composed of multinuclear giant cells and epithelioid cells. Sarcoidosis was diagnosed. Eight months later, he was admitted to our hospital because of enlargement of the nodular region with pain and stiffness. Marked uptake of ⁶⁷Ga was observed in the right arm and leg. MRI revealed sarcoid nodules in these regions. An enlargement of the higher signal intensity area was observed in the right forearm nodule. We started administration of prednisolone. Forty days later, his symptoms had disappered and the size of higher signal intensity area of the nodule had reduced dramatically. ⁶⁷Ga scintigram and MRI were useful for diagnosis and monitoring during therapy in this patient.

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An 86-year old man presented with a 7-year history of gait disturbace. He was admitted to our hospital on April 2000 because he was experiencing difficulty eating due to progression of dropped head syndrome. Upon standing and sitting, remarkable dropped head and kyphosis were observed. When lying, the patient was able to strech his neck, and he could stand and walk with the aid of a walker. Rigidity and resting tremor were present predominantly in the lower limbs. Parkinson, s disease was diagnosed therefore L-dopa and Cabergoline were administered. Parkinsonism and dropped head syndrome improved in response to treatment. Cases involving dropped head syndrome due to Parkinson, s disease are reportedly improved by L-dopa, but exasperated by dopamine agonists. The mechanism of dropped head is thought to be an imbalance in the tonus of the anterior and posterior neck muscles. Dropped head in the present case may have been a complication of Parkinson's disease since it improved in response to L-dopa.

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A 71-year-old woman receiving both angiotensin II receptor antagonist and calcium antagonist suffered severe systemic edema. She had been treated for essential hypertension with amlodipine for 2 years and candesartan for 3 months, and systemic lupus erythematodes (SLE) with steroids. During treatment, severe systemic edema appeared, mainly on her face, arms, and legs. At first, we suspected drug-induced edema by candesartan, so it was halted, but the edema still continued. We then considered amlodipine to be the culprit, and finally, the severe systemic edema disappeared after cessation of amlodipine. To control her blood pressure, we recommended candesartan, but 3 months later she suffered severe systemic edema again, thus the causative we drugs of her edema were thought to be both amlodipine and candesartan. Edema is a common symptom in elderly patients and we frequently observe drug-induced edema. In this case, there was underlying acceleration of blood vessel permeability induced by SLE and steroids and moreover, vasodilatation by candesartan and/or amlodipine further accelerated blood vessel permeability, and thus might have caused severe edema. It is very difficult to determine the cause of edema, especially in elderly patients, but we should consider not only one but also two or more drugs as being involved in drug-induced edema.

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A 75-year-old man was admitted to our hospital with disorientation and progression of speech disturbance and gait disturbance. He had been given a diagnosis of cervical spondylosis about four years previously, and gait disturbance and numbness in his extremities have been gradually increasing. Hyperchloremia and a careful history taking, which led to the discovery of habitual use of an analgesic containing bromvalerylurea, suggested bromism. A high level of bromide in serum yielded a diagnosis of bromism. Disorientation and speech disturbance were treated and improved by infusion diuresis. Gait disturbance only partly improved. There is a possibility that not only cervical spondylosis, but also chronic bromvalerylurea intoxication, may have contributed to the neurological disturbance resulting in gait disturbance and numbness. Bromvalerylurea, which is contained in many commercially available analgesics, should be noted as a possible cause of neurological disturbance.

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