[in Japanese]

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[in Japanese]

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[in Japanese]

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There is little consideration about the elderly factor in JRS and other countries' guidelines for management of community-acquired pneumonia (CAP) in adults. However, there seem to be several important differences in clinical manifestation, managing methods and outcome of pneumonia between young and elderly persons. I hope that the detection, management, and strategies to protect against pneumonia in the elderly will be included in the next guidelines.

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To analyze the reason why home care service which community pharmacists provide has not been effectively utilized, a questionnaire on home care services was submitted to 472 home care service users, 215 general practitioners, 10 visiting nurses and 153 home-helpers, and 75 community pharmacists. We were interested in whether or not gaps existed between users' needs, practitioners' demands, and pharmacists' awareness of professional responsibility to pharmacy services. Also, we were interested in whether or not gaps existed in awareness of the importance of cooperation with community pharmacists and influencing factors between practitioners and home-helpers and visiting nurses.
The main results were as follows: users and practitioners considered that counseling about home care and welfare services by community pharmacists was important and home visiting was not so important. However, pharmacists considered that home visiting was important and counseling about home care and welfare services was not so important. Therefore, gaps existed between users' needs, practitioners' demands, and pharmacists' awareness of professional responsibility to pharmacy services. Practitioners' awareness of the importance of cooperation with community pharmacists in comparison to that of other professionals was low as well as that of home-helpers, and visiting nurses. However, over 70% of them recognized the necessity of home visiting services by pharmacists. As far as factors influencing the awareness of the importance of cooperation with community pharmacists, practitioners' recognition to home visiting by pharmacists was higher than that of home-helpers and visiting nurses. However, expectations regarding community pharmacists' participation in home care services was higher than that of practitioners.

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We studied the therapeutic effectiveness of chemotherapy by ranimustine (MCNU) for essential thrombocythemia (ET) in 14 ET patients over 60 years of age. The median age was 73 years (range: 61-88 years), and the male/female ratio was 6:8. The mean platelet counts before chemotherapy was 1, 157±28.4×10³/μl. Five of them had been referred becuase of thrombotic episodes before admission to our hospital, while one was referred because of nasal bleeding. The platelet counts were maintained at a level below 500×10³/μl by intravenous administration of MCNU in 12 patients and below 700×10³/μl in two patients. One of the patients suffered cerebral infarction during MCNU thrapy. No other patient suffered thrombotic episodes during MCNU therapy. The patient who was referred because of nasal bleeding had no hemorrhagic eposode during control of platelet counts by chemotherapy. MCNU chemotherapy appears effective for the prevention of thrombosis and bleeding in ET.

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We investigated the incidence of bone lesions in elderly cases of multiple myeloma (MM) and the course of those lesions, and also evaluated the relationships of skeletal symptoms with prognostic factors, and prognosis. The subjects were 146 patients, aged 65 years or more (median age 74, range 65-97 year), who were admitted to 11 institutions between January, 1988 and December, 1997. They consisted of 64 men and 82 women. The disease type was IgG type in 88 patients, IgA type in 37 patients, Bence-Jones (BJ) type in 17 patients, IgD type in three patients, and non-secretory type in one patient. Bone lesions in elderly MM patients were compared with those in 65 non-elderly MM patients. Skeletal symptoms were noted in 104 patients, and bone pain in 75 patients at the time of diagnosis. The bone lesions were evaluated as only osteolytic lesions in 26 patients, osteolytic lesions+osteoporosis in 23 patients, only osteoporosis in 2 patients and pathologic bone fractures in 53 patients. The occurrence rate of osteoporosis plus osteolytic lesion was higher in elderly patients (63.5%) than that in non-elderly patients (NE-MM group) (28.3%) (p<0.0001). The bone lesions were most often observed in lumbar vertebrae (58.7%), cranial bone (56.7%), thoracic vertebrae (40.4%) and ribs (27.9%). The occurrence rate of bone lesion in lumbar vertebrae was higher in elderly patients (58.7%) than that in non-elderly patients (22.6%) (p<0.0001). The life activities were limited in 71 patients because of the bone lesions. The relationship between the prognostic factors of MM and bone lesions was evaluated. There was a significant difference in the serum Ca level between patients with and without bone pain (P<0.0001) and between those with and without pathologic bone fracture (P<0.01). There was a significant difference in the appearance rate of plasma cells in the bone marrow between the patients with and without bone lesions (P<0.05), between those with and without bone pain (P<0.01), and between those with and without pathologic fracture (P<0.05). There was a significant difference in the serum β₂-microglobulin level between the patients with and without bone pain, and between those with and without pathologic fracture. There were no significant differences in survival times between elderly MM patients with and without bone lesions, bone pain and pathological bone fractures, while signifcant differences of survival times were found between non-elderly MM patients with and without bone lesions, bone pain and pathological bone fractures (P<0.05, each). These data suggest that there are some differences in bone lesions between elderly and non-elderly MM patients.

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Although percutaneous endoscopic gastrotomy (PEG) has been widely acknowledged as a safer method for enteral feeding, its long-term impact on prognosis and quality of life (QOL) in elderly patients is not sufficiently understood. Regarding the indications of PEG, there still exist issues to be studied due to lack of convincing evidence for reduction of expected complications such as aspiration pneumonia or for improvement of prognosis in patients with severe dementia. In this study we investigated the survival rate after PEG placement and family satisfaction retrospectively in 78 elderly inpatients who underwent PEG, by sending questionnaires to the patients or their caregivers. The results of 68 cases (88%) recovered showed that the 1-year survival rate was 64.0%, and the 2-year survival rate was 55.5%. Fifty-three percent of families of patients showed overall satisfaction regarding the induction of PEG. The survival rate was relatively higher than that from previously reported studies. The differences we observed may be attributed to variations in patients' backgrounds (clinical, socio-economic, cultural) in therapeutic interventions. We recognized the importance of clarifying factors which would affect the prognosis and QOL in elderly patients who undergo PEG. The indication for PEG can be made based on comprehensive assessment of the relevant factors in individual cases, taking patient's or caregiver's wishes into consideration.

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Among the elderly patients with seronegative polyarthritis, McCarty et al. (1985) proposed a disease entity of “remitting seronegative symmetrical svnovitis with pitting edema (RS₃PE) syndrome”, but only a few cases have been reported in Japan. Here we report 7 cases suspicious of RS₃PE syndrome, 2 men and 5 women with an average age of 75.9 years, ranging from 67-82 years. Their common findings were (1) relatively acute onset, (2) polyarthritis, (3) pitting edema of the dorsum of both hands and both feet, and (4) negative rheumatoid factor and antinuclear antibody. McCarty et al. found that RS₃PE syndrome was more prevalent in men; however, in our experience, the opposite was observed. The clinical courses of all patients were good, and they were effectively treated either by small dosages of oral prednisolone, nonsteroidal anti-inflammatory drugs, or Chinese herbal (Kampo) medicines. Since this syndrome might not be rare in Japan, it seems necessary to evaluate elderly patients with seronegative polyarthritis with pitting edema as RS₃PE syndrome in their routine medical examinations.

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We report a case of a 74-year-old woman whose symptoms of dementia may have been caused by sarcoidosis and in whom steroid treatment was effective. The patient, who had receved treatment for hypertension, started to exhibit symptoms of dementia one year previously and progressively deteriorated during the month before she was admitted. Brain computed tomography showed multiple lacunae infarctions. Chest X-ray showed mild swelling of bilateral lymph nodes in the mediastinum. The patient was referred to an ophthalmologist because of complaints of disturbed visual field, and bilateral uveitis was diagnosed. Negative tuberculin, high serum ACE value and high absorbance in the lung hila on Ga scintigram were recognized. Lymph node biopsy revealed typical granuloma compatible with sarcoidosis. Cerebrospinal fluid (CSF) showed elevated protein concentration without an increased cell count. EEG showed a diffuse slow wave pattern.
We observed the progression of dementia shown by declining scores of Mini-Mental State Examination (MMSE) from 17/30 on admission to 7/30 on day 30 after admission. Although enhanced MRI of the brain showed no typical findings of sarcoidosis, we started treatment with prednisolone (50mg/day) based on the suspicion that the progression of dementia was caused by sarcoidosis. One month after the start of steroid treatment, we observed gradual improvement of symptoms. The MMSE score increased to 20/30.
According to previous reports, elderly sarcoidosis patients relatively rare by show dementia, but sarcoidosis should be considered in the differential diagnosis because steroid treatment can be effective.

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Familial hypocalciuric hypercalcemia (FHH) is a relatively rare disease showing autosomal dominant heredity. Despite hypercalcemia, it shows a low urinary calcium excretion rate, and calcium clearance-creatinine clearance ratio. Since the serum calcium level does not increase to more than 12mg/dl, this disease is basically asymptomatic and is incidentally found on medical examinations in many cases. However, it sometimes presents dangerous hypercalcemia and requires treatment. In this disease, parathyroidectomy is not sufficiently effective to cure hypercalcemia. We encountered a female patient with advanced age who presented marked hypercalcemia. Several examinations suggested FHH. While we had difficulty in controlling the serum calcium level, periodic administration of alendronate sodium hydrate, a bone resorption inhibitor, was effective. In this patient, the serum calcium level was normal on the examination about a year and a half before the appearance of symptoms, and hypercalcemia manifested itself in her advanced age, which is different from the usual course of FHH. This case presumably suggests that the pathophysiology of FHH is varied.

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