[in Japanese]

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[in Japanese]

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[in Japanese]

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Comprehensive geriatric assessment (CGA) is an important strategy to maintain activities of daily living and quality of life of elderly patients. It assesses physiological, psychosocial, and cognitive aspects of elderly. To carry it out effectively, not only is accurate the assessment but also to do appropriate recommendation and implementation are essential. In Japan, although the concept of CGA has been introduced and evaluated for elderly patients and also employed essentially in long-term care insurance, its application in the acute care setting of the elderly is still limited. This report, examines the present status and perspective of CGA application in Japan, through experiences in our university hospital and analysis of presentations from the Annual Meeting of the Japan Geriatric Society 2003.

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Insulin therapy is an effective measure of improving glucose control even in elderly patients with type 2 diabetes. However, it is controversial whether insulin therapy does disturb the quality of life (QOL) as well as cognitive function in the elderly. In our previous study of 455 diabetic patients, the well-being as assessed by the morale scale was similar in three treatment groups. In contrast, the symptom-burden, social burden, and worry about diabetes as assessed by the Elderly Diabetes Burden Scales was more increased in insulin-treated group as compared to the diet-treated group after adjustment for age, gender, HbA1c, frequency of hypoglycemia, microangiopathy, macroangiopathy, and social support. In another study of 213 patients, MMSE scores were similar among treatment groups, while attention and learning were most impaired in insulin-treated groups after adjustment for age, gender, HbA1c, and duration of diabetes. Although the mechanism for the association between insulin treatment and cognitive impairment is unknown, hyperglycemia, hypoglycemia, and cerebral complications in insulin-treated patients may be possible explanations. Whatever mechanism may be involved, hypoglycemia should be considered especially if unexpectedly low HbA1c (<6.5%) is observed or atypical neuropsychological symptoms appear.
It is unknown how insulin withdrawal is successful in elderly diabetic patients. Using rapid or ultrarapid insulin injections three times daily, good glucose control achieved the goal of plasma glucose level of <140mg/dl before meals and at bedtime. Then, insulin therapy was converted to oral treatment of glimepiride (2 to 6mg/day) and/or voglibose (0.6mg/day) in 30 patients with poorly controlled Type 2 diabetes. About 83% of the patients were successful in the insulin withdrawal according to the criteria of HbA1c levels after two months<8.0%. After removal of glucose toxicity, insulin withdrawal should be attempted to improve QOL in elderly patients with diabetes mellitus.

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The pathological hallmark of Alzheimer's disease (AD) is the deposition of senile plaques (SPs) and neurofibrillary tangles. The deposition of SPs, which initially occurs in the neocortex, is regarded as the critical event for the pathogenesis of AD. Previous pathological studies indicated that the earliest deposition of SPs is suspected to occur before any detectable cognitive decline. Therefore, noninvasive imaging of brain SPs is considered to be an ideal diagnostic method for presymptomatic detection of AD. For in vivo detection of SPs in the brain, a lipophilic probe that can selectively binds SPs is indispensable to the examination using positron emission tomography (PET) or single photon emission computed tomography (SPECT). For this purpose, many kinds of amyloid binding agents have been developed, such as FDDNP, BTA-1, IMPY. We have also developed a series of promising compounds for in vivo imaging of amyloid deposits. One of these compounds, compound-A, achieves high binding affinity for Aβ fibrils. This agent also showed abundant initial brain uptake and short brain clearance half-life in normal mice. Furthermore, to investigate the in vivo binding property of compound-A to amyloid plaques, compound-A was intravenously administered to APP transgenic mice. Brain slices at 120min post injection demonstrated specific binding of compound-A to amyloid plaques in the brain. These data emphasize the potential usefulness of compound-A as in vivo imaging probe for early diagnosis of AD.

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Long-term care insurance (LCI) started from April 2000 in Japan. LCI now occupies a central position in the health care of the aged. We reviewed all original papers and reports on LCI published in 1996-2002. At the end of 2002, we searched for papers on LCI in a computer database using the keyword of LCI, and found 3, 606 papers. Authors and contents of each paper were categorized using 54 kinds of keywords. Frequent authors were government agencies, care managers, physical therapists, and physicians. When we analyzed these papers according to the places where LCI was used, more than 50% of reports concerned LCI at home. Most frequent keywords were Government/LCI system, Regional health, Physician' assessment and grades for care, Care management, Care manager, and Rehabilitation. Care manager was less observed after the start of LCI. In contrast, the use of keywords including Care service, Dementia, Geriatric syndrome, Nurse, Institutional medicine, Hospital care, Medicine for the aged, Terminal care, Dialysis therapy, Abuse of the aged, and Caregiver burden were increased after LCI. At the beginning of LCI, main concerns are on the new LCI system. However, more individual issues in the care of the aged are now discussed. New issues such as Abuse of the aged and Caregiver burden have been recently raised. From these observations, the role of geriatric medicine seems also to be changing after the induction of LCI. We would now contribute actively to crucial aspects of LCI, such as comprehensive assessment of the aged, functional medical network with care staffs, and new therapeutic approaches to each geriatric syndrome.

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This study was aimed at confirming the cross-validity and construct validity of the short version of the Japanese version of the Zarit Caregiver Burden Interview (J-ZBI_8) developed by Arai and colleagues. A total of 169 family members caring for disabled elderly were assessed by a self-administered questionnaire which included the Japanese version of the Zarit Caregiver Burden Interview (J-ZBI).
Cronbach's alpha of the J-ZBI_8 was 0.88, indicating a high reliability of this instrument. A confirmatory factor analysis revealed that the two factor model of J-ZBI_8 fitted the data. Pearson's correlation coefficient between J-ZBI_8 and J-ZBI was 0.92; and the correlation coefficient between J-ZBI_8 and item 22 (a single global burden) was 0.66. These data indicated that J-ZBI_8 had a high concurrent validity.
The J-ZBI_8 was found to be significantly correlated with Barthel Index, duration of caring, hours of caregiving/day, physical fatigue and mental fatigue among caregivers, but not with the duration of caring (months). Caregivers of disabled elderly who did not have any behavioral disturbances had a significantly lower J-ZBI_8 score than those who were caring for elderly with such behaviors. Also, caregivers who declared that they did not abuse disabled elderly had a significantly lower J-ZBI_8 score than those who replied they abused them, when compared by t-test. These results indicated that J-ZBI_8 had a high construct validity.
It is concluded that the J-ZBI_8 had a high cross-validity and construct validity. This instrument can thus facilitate the assessment of family caregiver burden in clinical settings.

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We examined the effects of γ-aminobutyric acid-rich germinated brown rice (germinated brown rice) on principal indexes of life-style related diseases in 67 volunteers aged 71±8. They were divided into two groups; germinated brown rice group, which had an equal amount of the germinated brown rice to polished rice for 11 to 13 months, and control group, which had polished rice alone for the same period. Differences of indexes before and after the examination between the two groups were compared. Significant increases in body fat ratio, hemoglobin A_1c and mean red cell volume and a significant decrease in mean red cell hemoglobin concentration were observed in the germinated brown rice group. However, there was no difference of changes in body mass index, blood pressure, serum lipid, hepatic and renal functions, bone metabolic markers, bone density, depression score, red blood cell counts, hemoglobin, hematocrit, and homeostasis model assessment of insulin resistance between the two groups. These findings suggested that germinated brown rice might not improve glucose metabolism.

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The purpose of the present study was to investigate some symptoms related to dysphagia, comprehensive health status, and oral care in the frail elderly. The subjects were 92 elderly individuals (30 men, 62 women) above 65 years in a nursing home. The risk factors of dysphagia were evaluated by 15 items of self-assessment and 18 items of assessment by their caregivers. Both assessments contained 12 identical items. Basic ADL, cognitive status, and QOL were evaluated by the Barthel index, HDS-R, and PGC morale scale respectively. The status of oral care was evaluated by the frequency of tooth cleaning a day and the number of total anaerobic bacteria or streptococci in the dental plaque. “Chewing difficulty with hard food” was frequently found (21.74%) in the self-assessment, while “fever” was frequently found in the caregiver's assessment (20.65%). Also, in the duplicate items in both assessments, “anamnesis of pneumonia” showed a high agreement (k=0.85), while “decline of appetite” had a low agreement (k=0.27). These results suggest that dual assessment is effective to detect dysphagia. We also investigated the relationship among dysphagia, comprehensive health status, and oral hygiene. The status of dysphagia was related only to the Barthel index (p<0.01). These results suggest that subjects with decreased basic ADL tend to have some risk factors related to dysphagia, and that subjects with dysphagia risk factors need to improve oral care to prevent aspiration pneumonia.

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The relationship between obesity and incidence of stroke and ischemic heart disease is known to be weaker in elderly people compared with younger people. The relationships between obesity and atherosclerotic risk factors have been reported to decrease with age in healthy subjects. In order to clarify whether obesity influences atherosclerotic risk factors in elderly diabetic patients, we investigated the relationship between body mass index (BMI) and atherosclerotic risk factors in elderly (65 years or more) patients (61 men and 65 women) with type 2 diabetes mellitus. BMI significantly correlated with blood pressure, serum triglyceride, uric acid and sialic acid concentrations and negatively with duration of diabetes and serum HDL cholesterol concentration. These relationships, except that with serum uric acid concentration, were still significant after adjustment for sex and age. Diabetic subjects with a BMI of 25 or over showed significantly higher arterial pressure and serum triglyceride and sialic acid levels and lower serum HDL cholesterol level compared with diabetic subjects with a BMI of below 22. These results suggest that obesity increases the atherosclerotic risk even at higher ages in diabetic patients and that correction of obesity helps prevention of atherosclerosis in elderly diabetic patients.

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A 70-year-old woman was admitted to our hospital for treatment of abdominal tumor. She had complained of left abdominal pain, body weight loss and slight fever. Upper gastrointestinal endoscopy revealed on profunding ulcerous and upheaval lesion from the upper part of gastric body to the antrum. The pathological diagnosis of the biopsy specimens was T-cell lymphoma and proviral DNA (GAG) of HTLV-I was demonstrated in the biopsy specimens. Although the patient was serologically positive for anti-human T-lymphotrophic virus type I (HTLV-I) antibody, there were no leukemia/lymphoma cells in the peripheral blood or systemic lymphadenopathy. Primary gastric Adult T-cell leukemia/lymphoma (ATLL) was diagnosed. Although she received chemotherapy, the response was poor. The prognosis of lymphoma-type ATL is known to be extremely poor. This disease is frequent in aged people. Although gastrointestinal involvement is frequent in ATLL, primary gastric ATLL is rare. We report this rare case with primary gastric ATLL and reviewing 13 cases previously reported.

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A 72-year-old man was admitted to our hospital due to dysuria and frequent syncope. The patient had been well until the age of 70 years, when he began with these symptoms and neurogenic bladder was diagnosed in the other hospital. On admission, neurological examinations revealed no abnormal findings except blepharoptosis, anisocoria and orthostatic hypotension. Frequent apnea was evident during sleep. Autonomic function tests showed mainly sympathetic postganglionic dysfunction. Brain magnetic resonance imaging showed lacunar infarctions without cerebello-pontine atrophy or abnormal signals of the basal ganglia. We diagnosed pure autonomic failure (PAF) with sleep apnea syndrome (SAS). After starting nasal continuous positive airway pressure (CPAP) for SAS, his sneezing and sleep apnea drastically improved. Interestingly, CPAP also decreased the severity of orthostatic hypotension and syncope. Ambulatory blood pressure monitoring (ABPM) showed remarkable improvement in diurnal fluctuation of blood pressure after CPAP therapy. Although SAS is frequently associated with Shy-Drager syndrome but not with PAF, patients with PAF had been reported to have degenerative changes in the central nervous system overlapping with Shy-Drager syndrome or Lewy body disease. This case raised the possibility that nasal CPAP may be useful for orthostatic hypotension as well as SAS in neurodegenerative diseases.

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