[in Japanese]

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[in Japanese]

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The role of certified specialists in geriatric medicine in Japanese University Hospitals is discussed in this section. First, they should act as geriatric general physicians to provide a comprehensive medical care for elderly patients against a background complicatedly divided medical departments in university hospitals. Second, they should create attractive undergraduate programs for geriatric education in medical schools and training programs in geriatric medicine for doctors to develop certified specialists in geriatric medicine in the future. Finally, they should perform clinical research to provide an evidence to construct better social policies to keep older people healthy.

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Rapid ageing of the society inevitably increases the demand for specialists in the healthcare of older people. Under these circumstances, how geriatricians work as specialists in the framework of healthcare services is becoming an urgent concern for those who are engaged in the healthcare for the elderly. Although some similarities can be identified in the development of geriatrics medicine across the countries, actual roles of geriatricians and the definitions of their specialties seem to vary depending on the healthcare systems of each country. Current issues related to the speciality of geriatric medicine are discussed.

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Geriatricians have a major roles to assess and head elderly patients using a team approach. In this paper, the first question is to ask what a geriatrician is, and the second question is to ask the role of a geriatrician. A geriatrician is a coordinator for elderly patients who have physical and mental disorders. We have to take care of not only diseases, but also the patients' lives after discharge from hospital. Geriatrician should coordinates a team approach and maintain contact with care managers. In general hospitals, discharge planning, which supports short and smooth discharge is an important role of geriatrician. We are frequently asked to see elderly patient by specialists because of difficult problems, such as delirium, cognitive dysfunction and communication disorder.

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Elevated plasma homocysteine levels are associated with an increased risk of developing atherosclerotic vascular disorders such as stroke, but have also been implicated for neurodegenerative diseases including Alzheimer's disease (AD). Other studies have reported that hyperhomocysteinemia is associated with developing silent brain infarctions and white matter lesions in community-dwelling elderly people. It is not uncommon for such ischemic cerebrovascular lesions to be found in otherwise typical AD patients on magnetic resonance imaging.
Such co-existing cerebrovascular diseases in AD must be important in developing aspiration pneumonia and falls. Previous studies demonstrated that basal ganglia infarcts, either silent or symptomatic, impaired swallowing function and these lesions were associated with an increased risk of developing aspiration pneumonia in AD patients, particularly in later stages. Further, periventricular white matter lesions are associated with an increased risk of falls irrespective of clinical stages of AD.

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Although alendronate treatment for the prevention of osteoporotic fracture has been considered to be first line treatment, there is little knowledge whether very old osteoporosis should be treated with alendronate or not. To elucidate this question, we investigated the effectiveness of osteoporotic drugs in terms of effects of treatment on bone mineral density (BMD), bone resorption markers and fracture prevention in osteoporosis aged over 75 years old or less. A total of 1, 041 postmenopausal osteoporosis cases were classified into 4 categories, Young controls (n=165) and Old controls (n=95) (Control group), Young (n=309) and Old osteoporosis (n=110) treated with alendronate (ALN group), and Young (n=238) and Old osteoporosis (n=124) treated with vitamins D3 or K2 (VDK group). We followed their lumbar BMD, urinary excretion of NTX and incident vertebral fracture rate for three years. The effects of the ALN treatment on lumbar BMD and on urinary NTX were not different between the two age-categorized osteoporosis groups, namely, the lumbar BMD increased by around 6-7% after ALN treatment in both Old and Young groups. The urinary excretion of NTX was decreased by 50% from baseline in both Old and Young ALN treated groups. Those effects of ALN were significantly superior to those in the controls and VDK-treated groups of both age categories.
Therefore, ALN biological effects on bone were not age-dependent and the effects of ALN were strongest than the other treatments. The effects on fracture prevention in the Old ALN-treated group showed a 66.7% risk reduction rate (RRR) (p<0.05) when the fracture incidence rate in the control group (50%) was taken as 100%, while it was 18.8% RRR (ns) in VDK-treated Old group. The Young group treated with ALN showed a 35.6% RRR from the Young control group (25% as 100%) (p<0.05). The VDK treated group did not show a significant RRR of incident fracture (24.4%). Thus, alendronate was the only effective modality to prevent fractures in both young and old osteoporosis. These results clearly indicated that very old osteoporotics should be treated with alendronate at this moment.

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To ensure a healthy elderly population, correction of life-style is one of the most important approaches. Smoking cessation, regulation of alcohol intake, prevention of obesity, improvement of nutrition, promotion of physical activity are key factors for prevention of bed-ridden and extension of healthy life span. Although corrections of life-style are essential in childhood, adolescence, and the middle-aged and elderly periods, the methods and purpose are different in each life stage. The risks of emaciation and malnutrition are more important rather than that of obesity in the elderly aged 75 years or over. As for the influence of smoking in cardiovascular and respiratory diseases, smoking can be a trigger for arrhythmia, peripheral vascular constriction, and irritation of the respiratory tract in the elderly. Smoking cessation is necessary even among elderly people. It is also necessary to decrease the amount of alcohol intake, because the ability of metabolize alcohol is limited in the elderly. Physical activity in the elderly people is fundamental not only to maintain the ability of daily living, but also to improve metabolic function and to prevent depression. Vigorous intervention to increase physical activity such as exercise class is recommended, especially in the elderly.

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[in Japanese]

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The Japanese long term care insurance has started since 2000. After 5 years' experience, it is scheduled to change in 2006, the most important point is preventive care which means to stop the deterioration of ADL or cognitive function. Prevention is thought to be best way to cut the cost of care services. The preventive care system will start in April, 2006, over 1 million people with supportive care needs will receive muscle training or oral care and nutritional support from care workers in the community.
New comprehensive community centers will open and these should which make assessments for preventive care, and provide consultations for care givers and families, and comprehensive care management in the community, and protect the dignity of the elderly will newly start.
To improve quality of care services is important, and each prefecture has to evaluate all services and to publish the data with internet, so that everybody can see it and select the most appropriate care or company. Also, the government will start a new system of community based services including group homes, small and multifunctional care services, and day care services for people with dementia. These services should have one room available for each individual.

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Although the prevention and reduction of requirements for long-term care is one of the main aims of the long-term care insurance system, most of care-recipients have deteriorated in their certified care levels since the implementation of the system in 2000. Demands for services at facilities rather than in-home services are increasing. Waiting lists for public nursing homes are becoming longer and longer. Residential care in for-profit private homes is growing rapidly. Homicides of disabled older persons by their exhausted caregivers are still prevalent. Concerning these serious situations, retaining the human dignity of care-recipients should be the most essential issue of the long-term care insurance system.

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Purpose: There are few longitudinal studies on the subjective quality of life for elderly persons living in their own homes. The purpose of this study was to clarify the validity and reliability of the Japanese version of the Dementia Quality of Life Scale (JDQoL) used in a follow-up survey as part of a longitudinal study in Japan.
Methods: A baseline study was conducted from November 2002 to January 2003, and a year later a follow-up study was conducted from October 2003 to January 2004. The subjects included 72 (19 men and 53 women) elderly persons with dementia living in their own homes. Sixty-six were diagnosed with vascular dementia (VD) and 6 had senile dementia of Alzheimer's type (SDAT). The follow-up study included 60 subjects (VD: 56 and SDAT: 4);_10 of the original subjects were hospitalized, one died, and one was unable to attend daycare because of deterioration. Evaluation was conducted using the JDQoL, Mini-Mental State Examination (MMSE), and Geriatric Depression Scale (GDS).
Results: For the MMSE, the average score of the subjects in the follow-up study was 20.87 (±4.80), which was significantly higher than the score of subjects that were excluded from the follow-up study(17.82±5.65). At baseline, reliability coefficient was demonstrated by Cronbach's α value of 0.744-0.886. One year later, Cronbach's α was 0.723-0.872. Among the subjects in the follow-up study, MMSE scores decreased significantly compared with the baseline study. In the subscales of the JDQoL, Negative Feelings (reversal item) significantly improved and Feeling of Belonging significantly decreased after one year (p<0.05). Each subscale of the JDQoL had significant correlation with the GDS at baseline and follow-up. Scores on the GDS at baseline had significant correlation with Self Esteem, Positive Feelings, Negative Feelings, and Feeling of Belonging of the JDQoL at follow-up (0.320 to 0.504; p<0.05).
Conclusion: We demonstrated that the reliability and validity of the JDQoL was comparable to the English version of DQoL. Subjective QOL did not decline for all sub-scales, Negative Feelings in the JDQoL significantly improved compared to baseline.

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Aim: Enteral feeding of patients who are unable to eat or drink because of neurological disorders finally undergo percutaneous endoscopic gastrostomy (PEG) or nasogastric tube feeding. Their most common serious complication is aspiration pneumonia. Our objectives were to evaluate the effect of sarpogrelate (a 5-HT2A receptor blocker) on gastroesophageal reflux (GER) in these patients.
Methods: This study was performed in 5 elderly patients, aged 70-87 years with neurological disorders (stroke 4, post herpes encephalitis 1), on PEG or nasogastric feeding for 5 weeks-1 year. A 48-hour esophageal pH study was performed using the Degitrapper pH400 (Medtronic Co.). The pH monitor catheter was passed into the esophagus transnasally and positioned with the pH electrode 5cm above the lower esophageal sphincter. During the first 24 hours drug no drug was given, and during the next 24 hours we gave 100mg sarpogrelate 3 times. We analyzed the frequency of acid reflux (when the pH in the esophagus become less than 4.0 for more than 5 seconds, we defined this is 1 episode of acid reflux), frequency of acid reflux and mean pH values between drug-on and drug-off periods. An upright position was maintained for two hours after each meal.
Results: When the results of pH monitoring during two half days (from 7pm to 7am: 12 hours) was compared between drug-on term and drug-off term, mean pH value was statistically elevated from 6.0±0.2 (drug-off) to 6.5±0.4 (drug-on) (mean±SD, p<0.05). Frequency and the total time of acid reflex showed no difference between the two periods.
Conclusion: Treatment with sarpogrelate might be effective in patients with GER by blocking activated serotonin receptor in the gastrointestinal system.

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Objectives: We investigated the incidence of lower urinary tract symptoms (LUTS) in people consulting a general practice (GP) clinics.
Materials and Methods: The questionnaire included 7 questions regarding LUTS and 1 question regarding QOL (QOL index) based on the International Prostate Symptom Score (I-PSS), 3 questions on the Overactive Bladder Symptom Score (OABSS) and 4 questions on the International Conference of Incontinence Questionnaire Short-form (ICIQ-SF) and the survey was conducted among 1, 120 people aged 50 or older who consulted a GP clinic.
Results: Questionnaires were collected from 958 persons (86%) and the data from 822 (73%) who completed all the above questions were analyzed. There were 364 men (mean age: 67 year-old) and 458 women (68 year-old). Moderate or severe grades on I-PSS and OABSS were indicated in 99 (27%) and 43 (12%), respectively, for men, and 55 (12%) and 40 (9%) for women. Moderately or severely impaired QOL was indicated in 206 (57%) men and 193 (42%) women. Fifty-five (15%) men and 185 (40%) women indicated that they had some type of urinary incontinence. There were 138 (38%) men and 165 (36%) women showing both moderate or severe I-PSS and moderate or severe impairment of QOL, and/or with an ICIQ-SF score greater than 1.
Conclusion: When I-PSS and QOL score were used for LUTS screening, 38% of men and 36% of women aged over 50, consulting a GP clinic, had some LUTS which should be assessed to determine whether they need treatment.

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Aim: In order to suppress increases in medical costs in Japan, with regard to rehabilitation, it is extremely important to shorten the length of stay at rehabilitation units. Thus, factors related to the length of stay were analyzed in the study.
Methods: The subjects of the study were patients who stayed and left the rehabilitation unit at H hospital in Fukuoka, Japan during the period of May 1, 2003 and December 31, 2004. Of the 236 patients, 167 patients had no missing values with respect to 15 study variables. Thus, these 167 patients were used for analyses. In order to isolate factors related to the length of unit stay, a multiple regression analysis was performed with the length of stay as a dependent variable and other factors as independent variables.
Results: Of the 3 types of rehabilitation interventions (i.e., physical, occupational and speech therapies), the quantity of physical therapy was a significant predictor (p<0.05).
Conclusion: The findings imply the following. (1) The level of physical activity, which is a target of physical therapy, is used as a criterion for leaving the unit. (2) The three types of rehabilitation interventions highly correlated with one another, and the quantity of physical therapy is greatest. Thus, it is possible that only physical therapy could be isolated as a significant predictor. Since the present finding is based upon patients in a single rehabilitation unit, further studies using patients from multiple facilities is necessary.

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Aim: We examined the prevalence of depression and identified the factors associated with depression among community-dwelling Japanese frail elderly eligible for long-term care insurance.
Methods: A cross-sectional study of the baseline data of 1, 409 elderly from the Nagoya Longitudinal Study for Frail Elderly was conducted. The data, which were collected at the patients' homes or from care-managing center records, included the clients' demographic characteristics, care levels, depression as assessed by the short version of the Geriatric Depression Scale (GDS-15), a rating for basic activities of daily living (ADL), prescribing medications, and physician-diagnosed chronic diseases. The participants were considered to be in depression or severe depression if their GDS-15 score was 6≤ or 10≤, respectively.
Results: Although 57.2% or 23.1% of the participants had a GDS-15 score of 6 or higher, or 10 or higher, only 4.2% of sever depressive participants were taking an antidepressant. The higher prevalence of depression was associated with a higher care level in the long-term care insurance program. The depression was associated with 3 or more eligible care level, poor nutritional status, 3 or more prescribed medications, and nonuse of day-care/service.
Conclusion: We observed a high prevalence of depression among community-dwelling Japanese frail elderly eligible for long-term care insurance. However, very few depressed elderly were taking an antidepressant.

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Aim: To confirm the convergent validity of the Home Care Quality Assessment Index (HCQAI), developed by Dr. Arai et al., which is used for overall assessment of home care in three areas: 1) conditions of the disabled elderly (outcome); 2) caregiver and caregiving situation (process); and 3) the home care environment (input), based on professional staff observation.
Methods: We surveyed 102 pairs of disabled elderly and their family caregivers who used the visiting nurse station of the Okazaki Medical Association were surveyed. The validity of HCQAI was investigated by computing the Spearman rank correlation coefficient between the subscales of the HCQAI and the variables measuring “outcome”, “process” and “input”, respectively.
“Yokaigodo” (Government-Certified Disability Index), the Activities of Daily Living (ADL) of the disabled elderly, severity of dementia, the Short-Memory Questionnaire (SMQ) and Troublesome Behavior Scale (TBS) were used for the “outcome” variables. “The impression of home care”, a new scale developed for this study, was used as a variable to evaluate “process and input”.
Results: The HCQAI subscales for “outcome” indicators were significantly correlated with the other above-described variables measuring “outcome”, but not with “the impression of home care”, the variable evaluating “process and input”. All 5 HCQAI subscales for “process” and “input” were significantly correlated with “the impression of home care”, but 4 out of 5 HCQAI subscales were not significantly correlated with the variables measuring “outcome”.
Conclusion: These findings indicate that each subscale of the HCQAI has the expected properties. Therefore, the convergent validity of the HCQAI is confirmed.

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Aim: To determine whether age influences the relationships of drinking alcohol with blood pressure and lipids in women.
Methods: The subjects were 53, 911 female Japanese workers (20-69 years old) receiving annual health checkups at each workplace. The subjects were divided into three groups by daily average amount of ethanol consumed (non-drinkers; light drinkers, less than 30g ethanol day; heavy drinkers, 30g ethanol/day or more). Blood pressure, body mass index (BMI) and total and HDL cholesterol were measured.
Results: In the age groups from twenties to fifties, BMI was significantly lower in light drinkers than in non-drinkers. In the forties and fifties age groups, systolic blood pressure in heavy drinkers was higher than that in non-drinkers, while no significant difference was found between non- and heavy drinkers in the twenties and thirties age groups. Diastolic blood pressure was higher in heavy drinkers than in non-drinkers in all age groups. Blood total cholesterol tended to be lower in drinkers than in non-drinkers at ages less than 60 years, while this relation was not observed in the sixties age group. Blood HDL cholesterol and atherogenic index tended to become higher and lower, respectively, with an increase in the amount of alcohol drinking in all age groups.
Conclusion: In elderly women, the elevating effect of drinking on systolic blood pressure is increased and the lowering effects on BMI and blood total cholesterol are decreased. These results imply that drinking alcohol has less beneficial and more harmful effects on atherosclerotic risk in elderly women.

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A 75-year-old woman was given a diagnosis of malignant lymphoma (non-Hodgkin, diffuse large B cell type, stage IIA) at our hospital on August 2003. She received six courses of rituximab-based chemotherapy (R-CHOP regimen) and then she achieved complete remission. On August 16, 2004, she was readmitted in our hospital for difficulty in swallowing. Upper gastrointestinal endoscopy reveled esophageal stricture and an ulcerative lesion on the esophageal mucosa. The X-ray examination of the upper gastrointestinal tract reveled a severe esophageal stricture with niches and hiatus hernia. No malignancy was seen on CT scanning, gallium radioisotope scanning and histological examination of biopsy specimens with the upper gastrointestinal endoscopy. The physical examination showed gibbosity, and MR imaging showed multiple compression spined fractures. Finally, we diagnosed benign esophageal stricture with reflux esophagitis. She underwent laparoscopic partial esophagectomy in September 21, 2004, and the postoperative course was satisfactory. The pathological findings showed benign esophageal stricture caused by esophagitis. We report here a case of esophageal stricture following complete remission after chemotherapy for malignant lymphoma in an elderly patient.

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