Long term care insurance was changed in 2006. The main purpose of remodeling is to support preventive care and to develop community comprehensive care center and community based services. Community based services are composed by group homes, night care services, small multi-function complex care services, day care services for dementia, satellite nursing homes. Preventive care in long term care insurance is composed of muscle training, oral care and improvement of nutrition. Visiting nurse services can provide day care at nurse stations. These arrangements are strongly expected to support care workers and visiting nurses. An assessment for dementia, Center version was developed by the Tokyo Center for Dementia Care Training and Research. It is intended to lead to person-centered care for eldely people with dementia. An act to prevent abuse of the elderly has been started in 2005. This was established to protect the property of the elderly, even if they might have cognitive dysfunction. A support doctor system has been started to educate primary care doctors and to make early diagnosis for dementia. These changes are expected to provide better care for old people.
Management of dementia and cognitive decline is a major issue in geriatrics. Since the average age of society is advancing and patients of dementia are increasing, it is important to remove risk factors of dementia and cognitive decline in order to maintain quality of life in the elderly and to save cost of medicine and care. While hypertension has been known to be a risk factor of cerebrovascular events and vascular dementia, recent studies show that midlife hypertension is also a risk factor of cognitive decline and Alzheimer's disease in late life. Clinical trials and retrospective observation studies also show that treatment of hypertension decreases the risk of Alzheimer's disease. These issues are also related with the consideration of vascular factors in Alzheimer's disease. The white matter lesion as a consequence of hypertension and its meaning in Alzheimer's disease are also discussed.
Hypertension causes left ventricular hypertrophy and increases in large artery stiffness with ageing, both of which are cardiovascular risks. We studied cardiovascular remodeling in elderly hypertensive patients by measuring blood brain natriuretic peptide (BNP), left ventricular mass indices (LVMI), pulse wave velocities (PWV), and ambulatory blood pressures. We focused on ageing and sex-differences. Both LVMI and PWV correlated significantly with nocturnal blood pressures, which in turn correlated with BNP levels. Thus, BNP might be a candidate for a surrogate endpoint of target organ damage in elderly cases of hypertension. Left ventricular hypertrophy progressed with ageing more in women. Systolic blood pressures in women were shown to rise abruptly after menopause and to surpass those in men. However, more non-dippers were observed in men, suggesting that the absolute value of nocturnal blood pressure is a determinant of left ventricular hypertrophy. PWV accelerated with ageing, but it did not correlate with LVMI, suggesting that progression of cardiac remodeling with ageing was relatively independent of vascular remodeling. Finally, the greater mortality in elderly women might be associated with progressive left ventricular hypertrophy.
Angiotensin converting enzyme (ACE) inhibitor plays an important role not only as an antihypertensive drug but also for prevention of various complications related to geriatric syndrome. Pneumonia in the disabled elderly is mostly due to silent aspiration of oropharyngeal bacterial pathogens to the lower respiratory tract. Aspiration is related to the dysfunction of dopaminergic neurons by cebrovascular disease, resulting in impairments in both the swallowing and cough reflexes. ACE inhibitor can increase in the sensitivity of the cough reflex particularly in older post-menopausal women, and improvement of the swallowing reflex. In a 2-year follow-up study in stroke patients, patients who did not receive ACE inhibitors had a higher risk of mortality due to pneumonia than in stroke patients who were treated with ACE inhibitor. Moreover, the mortality of pneumonia was significantly lower in older hypertensive patients given ACE inhibitors than in those treated with other antihypertensive drugs. On the other hand, we found a new benefit of ACE inhibitor on the central nervous system. The mortality in Alzheimer's disease patients who received brain-penetrating ACE inhibitor was lower than in those who received other antihypertensive drugs. In a 1-year follow-up study, cognitive decline was lower in patients receiving brain-penetrating ACE inhibitors than in patients receiving a non-brain-penetrating ACE inhibitor or a calcium channel blocker. Brain-penetrating ACE inhibitors may slow cognitive decline in patients with mild to moderate Alzheimer's disease. ACE inhibitor might be effective for the disabled elderly, resulting in the prevention of aspiration pneumonia and Alzheimer's disease for the elderly.
A recent dramatic increase in the number of elderly patients with hypertension has made the proper management of the disease in this population more important. Since quality of life (QOL) is greatly affected in elderly patients with hypertension, as a life-style disease, we reviewed QOL and related issues in the treatment of hypertension in the elderly. Assessment of QOL requires multi-dimensional evaluation from many aspects. Elderly individuals, especially those with hypertension, generally have impaired QOL. It has been shown that treatment of hypertension could affect QOL, and care in treatment is required because of possible effects on QOL. Given the major role of stroke in the deterioration of QOL among elderly people, treatment of hypertension may well be targeted at prevention of stroke. A recent meta-regression analysis demonstrated that calcium channel blockers are effective in reducing risk of stroke, as their effects are not limited to blood pressure reduction. Since overall benefit of hypertension treatment is determined by multiple factors, including safety, efficacy, compliance, as well as risk reduction, it is of particular importance to pay attention to QOL in the treatment of hypertension. Further clinical evidence is needed for the establishment of proper management of hypertension in the elderly, especially from the QOL point of view.
Aim: We examined the level of awareness of memory deficits in 63 patients with Alzheimer's disease (AD), 17 patients with dementia with Lewy bodies (DLB), 14 patients with vascular dementia (VaD), and 56 patients with amnestic mild cognitive impairment (MCI). Methods: The unawareness of memory impairment was evaluated with a standardized memory questionnaire system based on the Everyday Memory Checklist (EMC). The EMC scores for the patient's own rating, the caregivers' rating and the unawareness score, defined as the discrepancy between these (caregiver rating-patient rating), were analyzed. Results: Although the EMC self-rating scores were comparable among the four groups, the EMC scores in caregivers were significantly higher in the AD group than in the DLB, VaD, and MCI groups. Therefore, the unawareness scores were significantly higher in the AD groups than in other groups. When an unawareness score of 9 or more was defined as significant, impaired awareness was found in 41 (65%) patients with AD, 1 (6%) patient with DLB, 5 (36%) patients with VaD, and in 19 (34%) patients with MCI. Conclusion: We found that impaired awareness was found in two-thirds of patients with mild AD and even in one-third of patients with MCI. However, other dementias, in particular DLB, had less severe and less frequent unawareness of memory deficits than AD, suggesting the difference in the pathophysiology between them.
Aim: To demonstrate the characteristics of the Instrumental Activities of Daily Living (IADL), assessed by the Assessment of Motor and Process Skills (AMPS), and everyday memory functions (memory necessary function for daily life) assessed by the Rivermead Behavioral Memory Test (RBMT) in elderly people with dementia. To compare the ability and the function between them and community-dwelling normal subjects. Methods: We divided the RBMT result into three categories: prospective memory, retrospective memory, and prospective memory+retrospective memory. The study was performed in102 women (68-92 years old) with dementia who lived in a healthcare facility or three group homes (n=52) and cognitively normal subjects who lived in their own homes (n=50). Results: There were no associations between AMPS motor and prospective memory, retrospective memory, and prospective memory+retrospective memory in both groups. There were associations between the AMPS process and retrospective memory in both groups, but no associations between the AMPS process and prospective memory in either groups and a scatter chart revealed some subjects with a prospective memory deficit even though they had a normal IADL performance ability level. From those results, we found that IADL performance ability and everyday memory were not simultaneously damaged. Conclusion: When assessing elderly people, it is necessary to assess both IADL performance and everyday memory, including prospective memory. According to these methods, mild cognitive impairment may be screened more accurately.
Aim: To analyze the present status of patients in a rehabilitation unit at a geriatric hospital. Methods: Subjects were 232 patients (74 male and 158 female; mean age, 78.6±12.9 years) and they were divided into two groups (group A had 83 with cerebrovascular disease; group B had 149 with disuse syndrome). In these groups, we retrospectively examined such items as; age, ADL, length of stay, underlying disease and complications, and outcome. Results: Mean ages of groups A and B were 75.9±14.0, 80.0±12.0, respectively (p<0.05; group A vs. B). Mean value of length of stay was 140.9±9.4 in group A and 107.3±11.3 in group B (p<0.05). Cerebral infarction and pneumonia were the most frequently seen as the underlying diseases in group A (55 cases) and B (33 cases), respectively. During the hospital rehabilitation period, cases requiring medical care occurred in 30.1% of group A and in 26.8% of group B. The total number of patients who returned home or moved to facilities for the aged were 53 in group A and 109 in group B. In almost all of the cases who returned home, they were able to walk upon discharge. Conclusion: It was suggested that comprehensive geriatric medical care is necessary for the elderly during the rehabilitation period. The improvement of physical function up to the level of ambulation seems required for discharge.
Aim: Community-acquired pneumonia (CAP) remains a common and serious illness. CAP can be a major cause of morbidity and mortality in elderly patients. This study aims to investigate the precision of disease severity staging scales such as Pneumonia Outcomes Research Team (PORT) Severity Index (PSI) and A-DROP (Age, Dehydration, Respiratory failure, Orientation disturbance, shock blood Pressure) in elderly patients with CAP. For this study, 111 elderly CAP patients admitted to our hospital during a two-year period were recruited and stratified using these scales. Methods: We reviewed the precision of the above-mentioned scales in the 111 patients aged 65 years or above, and investigated the disease severity classifications, initial treatment, and clinical course of these patients. Results: The mean age of the patients was 82 (±7.6) years. Among these patients, 15% were aged between 65 and 75 years, 50% were older with their ages ranging from 75 to 84 years, and 35% were extremely old with their ages over 85 years. The mortality rates for the patients with the A-DROP score of 0, 1, 2, 3, 4, and 5 were 0%, 0%, 2.2%, 17.2%, 20.0%, and 40.0%, respectively, and those for the patients with PSI class I, II, III, IV, and V were 0%, 0%, 0%, 0%, and 36.0%, respectively. Conclusions: PSI is a useful method for estimating the prognosis in elderly CAP patients. On the other hand, the A-DROP score may be inadequate in terms of judging the disease severity in these patients. With regard to the severity of pneumonia in elderly patients, we should consider not only the A-DROP score but also the underlying diseases such as malignancy, cardiac failure, cerebrovascular disease, liver disease, or renal disease.
Aim: A new screening test for detecting mild cognitive impairment (MCI) with higher sensitivity that can easily be administered at the bedside is necessary. In this study, we proposed the delayed recall task using the word booklet of Alzheimer's Disease Assessment Scale-cognitive component-Japanese version (ADAS-Jcog) and compared the score of the task in patients with MCI with that of cognitive normal elderly (NE) and patients with AD. Methods: Thirty six patients with MCI, 13 very mild AD, 104 mild AD, 13 moderate AD, and age- and education-matched 19 NE, recruited from the memory clinic of Nagoya University Hospital, were evaluated by the ADAS-Jcog word recall task which consisted of immediate recall (IR), a classical method on ADAS-Jcog, and delayed recall (DR) that has been newly introduced. Results: Compared with controls, patients with MCI were significantly impaired on both IR and DR. On the other hand, DR is more sensitive than IR for distinguishing MCI from NE. The highest sensitivity (94.4%) and specificity (68.4%) were achieved when the results of IR were combined with those of DR. Conclusion: The result suggests that the delayed word recall task using the word booklet of ADAS-Jcog may be a useful tool as a screening method for the detection of MCI.
Background: Because long-term care facilities are being asked to care for more and more residents who are dying, the facilities require that new residents and families make decisions regarding their end-of-life care at the time of the admission process. An advance directive including "do-not resuscitate directives (DNR)" or "do-not-hospitalize directives (DNH)" is a written document that afford individuals the opportunity to determine the type and extent of end-of-life care when they are incapable of participation in medical decision making. It is expected that Japanese elderly and families make individual decisions regarding end-of-life care by a Japanese-style decision-making model including advance directives. The purpose of this study was to explore families' decision-making factors regarding cardiopulmonary resuscitate (CPR) and hospitalize orders in a long-term care hospital. Method: We assessed 70 admissions in a long-term care hospital in Aichi prefecture from April 2005 to September 2006. All residents were divided into two groups according to their CPR or hospitalize order. Data on the admission characteristics of the residents were collected from medical charts. Results: The prevalence of older age, functional dependence, and illness did not vary significantly with CPR or hospitalize order recorded by families, however, significant variation among physicians existed in the CPR and hospitalize orders. Conclusion: Wide variation in the likelihood of having CPR and hospitalize orders among physicians who explain an advance directive suggests a need for standardized methods for eliciting the end-of-life preferences of residents and families on admission to long-term care hospitals.
Aim: This study was done to clarify the characteristics of elderly patients with nontuberculous mycobacteriosis. Methods: We investigated the clinical features of 10 patients at an advanced age who had been given diagnosis of nontuberculous mycobacteriosis. Results: Mycobacterium avium intracellulare complex (MAC) were detected in all cases. The age of the patients ranged from 65 to 92. Four cases had underlying respiratory diseases (old pulmonary tuberculosis in 3 cases, pulmonary emphysema in 1 case, bronchiectasia in 1 case). Six cases suffered from dementia. The symptoms were relatively nonspecific, such as low grade fever, fatigue, appetite loss in almost all cases in this study. On computed tomography (CT) scans of the chest, mainly small nodular infiltrates were seen. MAC was detected in clinical samples such as sputum, gastric juice and bronchial lavage. The examination of gastric juice was performed in 6 out of the 10 cases. Gastric juice samples were smear-positive for acid-fast bacilli in 5 of 6, and culture-positive for MAC in 5 of 6. The detection of MAC in gastric juice samples was higher than that in sputum samples on admission. Conclusion: Gastric juice might be useful to differentiate infection from casual isolation of MAC in elderly patients.
A 78-year-old man was referred to his local hospital at the beginning of July 2006 with low grade fever and cough, and was admitted on August 22 with pneumonia. Hematology tests on admission revealed leukocytosis, anemia, and thrombocytopenia, so he was subsequently transferred to our hospital on August 24. A diagnosis of chronic myelomonocytic leukemia (CMML) was made from the hematological findings and he was given hydroxycarbamide from September 7. Seventeen days later, abdominal CT revealed hemorrhage into a giant liver cyst, as well as both intraabdominal and intrathoracic hemorrhage. He died of hemorrhagic shock on September 25. Autopsy showed extensive infiltration of myelomonocytic leukemic cells into the walls of the liver cyst, as well as the pleura and multiple other organs. In summary, we report an elderly autopsy case of CMML with infiltration of a giant liver cyst and multiple organs.
A 87-year-old woman presented with hypretension and motor disturbance in upper and lower extremities due to severe muscle weakness. As she had a history of licorice administration, laboratory data was obtained approximately 3 months after the drug cessation. She showed hypokalemia (2.7mEq/l), metabolic alkalosis and reduced plasma renin activity (PRA). Despite the mineralocorticoid excess, plasma aldosterone concentration (PAC) and 24-hour urine aldosterone were markedly diminished (32pg/ml and 1.1μg/day, respectively). Thyroid function was normal, and plasma ACTH and serum cortisol levels were within normal limits. Serum potassium levels was elevated (3.9mEq/l) and blood pressure returned to normal by cortisol suppression with dexamethasone, 1.5mg per day. Moreover, administration of spironolactone, 50-75mg per day, caused additional elevation of serum potassium level (4.7mEq/l) with clinical improvement. These results revealed that the mineralocorticoid excess, found in the present patient, was responsible to dexamesathone and spironolactone, suggesting 11β-HSD2 deficiency. Serum cortisol/cortisone ratio (0.95) was also elevated, as compared with age-matched female control (0.28-0.72). The active component of licorice, glycyrrhetinic acid, has a mineralocorticoid-like side effect. However, in the present patient, diminution in serum potassium level and PAC were still found approximately 1 year after stopping licorice. Recently, elderly patients with 11β-HSD2 deficiency are often reported, therefore further investigations in relation to the changes caused by aging are needed to elucidate this abnormality.