Aim: The purpose of this study was to measure the caregiver burden caused by behavioral and psychological symptoms of dementia (CBBD) using an originally developed scale and to estimate the CBBD scores in a large sample of family caregivers of elderly people. Methods: The subjects were 1,818 users of the public Long-term Care Insurance, randomly stratified and sampled in Higashi-osaka city, Osaka prefecture. Data were collected through mailed, anonymous self-report questionnaires. The survey was conducted in October 2003. We created a 10-item CBBD scale based on previous studies on caregivers of dementia. The CBBD scale was applied to all caregivers regardless of dementia symptoms, and we also collected the following information: demographic data of the care-recipients and caregivers, the level of cognitive disorders of the care-recipient and the overall subjective caregiver burden. Results: All items of the CBBD scale were selected at higher percentages by caregivers of care-recipients with cognitive disorders than caregivers of care-recipients without cognitive disorders. In particular, the relative risk and odds ratio of caregivers of care-recipients with cognitive disorder was higher in items such as 'the caregiver feels fear and anxiety about the care-recipient's unpredictable behavior', 'the care-recipient doesn't understand what the caregiver says', 'the caregiver feels irritated with incomprehensible care-recipient's behavior' which pose psychological stress or pressure on caregivers. On the other hand, the relative risk and odds ratio of the overall subjective caregiver burden was lower than that of any item of the CBBD scale. Furthermore, all CBBD items were related to symptoms of dementia (aroused/paranoid behavior, memory disorder, cognitive dysfunction, pica behavior). Conclusion: The CBBD scale had sensitivity for the care-recipient's cognitive disorder. In addition, it can detect more precisely the caregiver burden such as psychological stress or pressure due to the care-recipient's cognitive disorders, and it is also useful to assess the needs of caregivers who care for elderly family members with dementia.
Aim: To clarify the usefulness of the number of steps walked daily as a health promotion parameter in the elderly. Methods: The study was performed at five welfare centers for the elderly in the suburban area of Takatsuki-city, Japan. Subjects comprised 339 community-dwelling persons (96 men and 243 women) aged 60-89 years. The number of steps walked daily, usual walking speed, "timed up and go" (TUG) time, handgrip strength, body muscle mass and bone density were measured. Psychological and physical status and lifestyle factors were determined vie questionnaire. Subjects were classified into one of two groups, a low- or high-level walking group, according to the Healthy Japan 21 criteria. Differences between the two groups were analyzed. Results: Men walked 8,075 steps (mean number) daily, and women walked 7,902 steps daily. The number decreased with age in both men and women and correlated with usual walking speed and TUG time. Low-level walking was found in 41.7% of men and 28.8% of women. Intermittent claudication and fear of falling were the main contributors to low-level walking, whereas walking almost daily and engaging in physical activity with a view toward health promotion were the main contributors to high-level walking. Conclusion: For the elderly population, the number of steps walked daily was related to their walking ability, such as walking speed and walking balance, and could be considered as a useful health promotion parameter. Taking a walk daily could be the main approach to increase the number of steps walked daily in the elderly.
Aim: Unitil now, most terminal cancer patients have received end-of-life care service in a hospital. How, recently, home health care services have received much attention instead of the hospital care. In this study, we investigated important factors affecting smooth transition to home health care from hospital care. Methods: We examined the records of 66 deceased subjects with terminal cancers who received medical care by staff of home heath care agency "Yunomori Tnapopo clininc" were included in this study. Methods: The categories evaluated were: 1) general condition, 2) breakdown of family caregivers, 3) rate of application for care insurance, 4) the percentage of cases with a discharge planning conference, 5) the time of death and, 6) frequency of visiting care in the first 1 week and the last 1 week. Results: The 66 subjects consisted of 38 men (58%) and the average age of the group was 71.1 2.0. 1) Dementia was indicated in 20 (30%) patients and 23% of the patients were reliant on intravenous nutrition. Oxygen treatment was required for 45% of the patients. Some help for excretion was required by 70% of the patients. 2) 70% of a main care giver were woman and the average number of persons per household was 2.0. 3) 50% of the patients did not apply for care insurance. 4) Discharge planning conferences between the hospital and the clininc were held in only 21% of the case. 5) over 70% of the patients died outside duty hours (between 8AM and 6PM). 6) Although the average duration of stay at home was 62.5 days, 10% of the cases died or had to leave their home due to worsening condition during the first 2 weeks. Vsits by medical doctor in the last 1 week significantly increased in frequency compared to that in the last 1 week. (5.0 0.2 vs. 3.9 0.2, p<0.01). In addition, frequency of care visits by nurses increased significantly as well (3.2 0.2 vs. 2.4 0.2, p<0.01). Overall the number of care visits in the last 1 week was more than once a day. Conclusion: 1. A home-health care clinic which gives 24-hour care is necessary so that the patients receive end-of-life care as well as hospital care. 2. Earliest possible transfer to the home health care setting is needed so trhat the patients could have enough time to live in their hom with their family. On this account, it is most important to convene a conference co-organaized by the home health care adjusytment. In addition, the patients or their family need to apply to the munided office for care insurance. Medical staff should provide information and help them.
Aim: To determine factors influencing on the death of the elderly at home in an institution specializing in-home medical care (home death rate: about 80%). Methods: This study was an anonymous mailed survey of bereaved families of patients (the caregivers) who died using the home medical care setting provided by an institution specializing in home medical care in Japan. We analyzed the relationship of demographics of the patients and the caregivers with such factors as the anxiety of the caregiver and eventual death at home, and that of such factors as perceived quality of home medical care by the caregiver, and satisfaction with home medical care, satisfaction with death bed nursing, regret for death bed nursing. Results: The most significant determinant factor associated with home death was that both patients and caregivers preferred death at home (OR=19.42). Determination coefficients (R2) in the multiple linear regression analysis of caregiver's satisfaction with home medical care, satisfaction with death bed nursing and regret for death bed nursing were as high as 0.68, 0.55 and 0.62, respectively. Significant influential factors were: peaceful death, psychological consistency of the caregiver, a good relationship with one's physician and fulfillment of the care service system. Conclusions: Important components of home medical care and death bed nursing for the realization of death of the elderly at home are 1) peaceful death, 2) psychological consistency of caregivers, 3) a good relationship with one's physician, 4) fulfillment of the care service system.
A 72-year-old man was admitted to our hospital complaining of an axillary mass. He underwent left total nephrectomy for renal cell carcinoma (RCC) 15 years previously (in 1990). Since further evaluation yielded no evidence of extra renal metastases, he was followed up in the outpatient clinic. On admission, there was a hard tumor in the right axilla. Ultrasonography demonstrated a vascular tumor with a smooth surface, 26 by 24mm. Laboratory findings were generally close to normal, including tumor markers. Chest contrast-enhanced dynamic CT showed that the tumor was enhanced. Furthermore, abdominal contrast-enhanced dynamic CT revealed some enhancing lesions within the right side of the rectus muscle of abdomen and pancreas head as well. Open simple axillary mass biopsy was performed on August 2 and the tumor was histologically confirmed as a metastasis of the RCC to the axillary. His overall status was normal, and he underwent an operation for the pancreas tumor and the tumor in the rectus muscle of the abdomen. On histological examination, both excised specimens were found to be metastases of RCC. During 2 years follow-up period in the outpatient clinic, additional metastasis has not been observed in any organ. Since this case confirms the potential of RCC for late and multiple distant metastases, careful long-term follow-up after radical nephrectomy is needed.
An 86-year-old woman was referred with acute epigastric pain. She had tenderness, but no muscular guarding of the epigastric lesion. Abdominal ultrasound showed a gallstone with a normal gallbladder wall and no ascites. The white blood cell count was 11,600/mm3, but she was negative for C-reactive protein (CRP). An upper gastrointestinal tract endoscopic examination revealed only edema of the duodenal mucosa. Although H2-receptor antagonists were given, she had to be admitted due to chills and high fever. While the abdominal symptoms did not change, the CRP concentration became 14.79mg/dl. While plain abdominal X-ray did not show an abnormal gas pattern, subsequent abdominal CT examination showed air and fluid collection around the second portion of the duodenum. We diagnosed duodenal perforation and prepared for emergency operation. However, her general condition had markedly deteriorated during the hours. Laparotomy revealed a free purulent fluid around second portion of the duodenum caused by perforation of a duodenal diverticulum. The patient gradually recovered and was discharged after 58 days. Since a duodenal perforation in an elderly patient is difficult to diagnose early in spite of serious illness, abdominal CT should be encouraged.
A 79-year old woman was admitted with disturbed consciousness (JCS II-30). She had been given a diagnosis of type 2 diabetes 7 years previously, and was being treated with oral hypoglycemic agents. She also suffered Alzheimer's disease and Parkinson's disease. Plasma glucose and HbA1c upon admission was 676mg/dl and 9.7%, respectively. Serum Na was 153mEq/l. Urine ketone body test was negative and metabolic acidosis was not observed. Hyperglycemic hyperosmolar non-ketotic coma (HHNC) was diagnosed, and treatment was started immediately with normal saline infusion. Continuous infusion of regular insulin was needed to lower blood glucose. Disturbed consciousness and dehydration improved by the third hospital day. However, she became bedridden afterwards and received tube feeding. Up to 46 units of insulin was needed daily to control blood glucose. Urine C-peptide secretion was very low (10μg/day), suggesting that insulin therapy was essential for glycemic control long before admission. It is thought that a number of elderly diabetic patients who need insulin therapy do not receive or continue it for various reasons. Discussion is necessary to grasp the actual situation and defensive actions that can be taken.
We report a 77-year-old woman with Group B streptococcal bacteremia, subcutaneous abscess and reactive polyarthritis. Two years previously she suffered from atrial fibrillation and osteoarthritis of the knee. After she was admitted for treatment of the knee joint with hyaluronate sodium, she complained of pain in the left shoulder and both knees. Pyogenic arthritis was suspected and administration of cefazolin was started immediately after blood culture. One set of blood cultures showed Group B streptococcus. Therefore the antibiotic was changed to ampicillin. To investigate the cause of polyarthritis, enhanced CT of the left shoulder and both knees was performed and demonstrated fluid collection with marginal enhancement, suggesting a bacterial abscess. However, findings of arthrocentesis and synovial fluid culture were incompatible with bacterial arthritis. A subcutaneous abscess, which appeared at 5 days after admission to the hospital, was not connected to the synovial fluid, suggesting reactive arthritis was the main cause of her polyarthritis. We performed drainage surgery and one week later, the clinical symptoms and inflammatory findings mostly disappeared. Several microbes are able to cause reactive arthritis, however, cases with Group B streptococcus are very rare. Group B streptococcus infection should be taken into consideration not only in patients with diabetes and cerebrovascular disease but also in elderly patients.