[in Japanese]

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Aim: We aimed to examine the effectiveness of information provided by a physician to patients and their family in a geriatric rehabilitation unit for facilitating terminal care decision-making process.
Method: The subjects were 338 patients who entered our rehabilitation unit between July 2005 and June 2007. Of the 338 patients, we provided terminal care consultation for 224 upon admission. We surveyed the 224 patients who received consultation as well as the 114 patients who did not, and examined the effect of the consultations on decision-making regarding terminal care.
Results: In both the intervention and non-intervention groups, approximately half of the patients' families had an opportunity to discuss terminal care prior to entering the hospital. The intervention group, however, had a significantly higher ratio (42.0%) of having the opportunity to discuss terminal care among their family members after leaving the hospital. In the non-intervention group, 31.4% had the knowledge of an artificial respirator and 37.1% tube feeding. This was low compared to the intervention group, among 60% understood both. Among the intervention group, there were many who desired these consultations to be provided far in advance of the critical stage of disease to allow more time to make end-of-life decisions. Furthermore, 60% of the intervention group indicated that the terminal care consultations were effective and useful.
Conclusion: In light of these results, physicians should provide terminal care consultations before death is imminent. Since this will encourage self decision-making and help clarify the family's intentions, these kinds of consultations should be more actively implemented.

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Aim: Clinical and pathologic features in Alzheimer's disease (AD) patients differ depending on the age of onset. The aim of our study was to compare the regional cerebral blood flow (rCBF) patterns of younger, elderly, and extremely elderly patients with AD with that of controls to characterize the rCBF patterns in extremely elderly patients with AD.
Methods: Single photon emission CT (SPECT) was performed in 113 patients with probable AD, including 34 younger (<70 years), 41 elderly (70-84 years), and 38 extremely elderly (≥85 years) patients divided according to age at examination. The SPECT data were analyzed using three-dimensional stereotactic surface projection (3D-SSP).
Results: No significant differences regarding gender, duration of disease, education, and Mini-Mental State Examination score were found among the groups. As compared with controls, younger and elderly AD demonstrated significant reduction of rCBF in the temporo-parietal areas, posterior cingulate cortices and precunei, which is considered to be a characteristic rCBF pattern in AD. On the other hand, the extremely elderly AD group demonstrated significant reduction of rCBF in the frontal and medial temporal areas, in addition to the temporo-parietal areas, posterior cingulate cortices and precunei, but the reductions were milder than in those in younger and elderly AD groups.
Conclusion: The extremely elderly patients with AD showed atypical rCBF patterns in AD compared to younger and elderly patients with AD. Our data suggest that pathological features in extremely elderly AD may be different from those in younger and elderly AD and that diseases different from AD, such as senile dementia of the neurofibrillary tangle type may be clinically diagnosed as extremely elderly AD.

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Aim: To evaluate the prevalence of geriatric syndrome and risk factors associated with obesity in community-dwelling elderly women.
Methods: The baseline survey was conducted in November 2006. Subjects were 925 women aged 70 years and older who participated in a comprehensive health examination which included a face-to-face interview, body composition, and physical fitness tests. The participants were classified, the based on percentage of body fat, as normal (<30.0), mild obesity (30.0 to 34.9), and obesity (≥35.0) groups. To evaluate the differences among the groups with regard to the physical fitness and the interview data, one-way analysis of variance performed for continuous variables and the chi-square test for categorical variables. Multivariate logistic regression models were used to assess the factors associated with obesity in elderly women.
Results: Although obese women had a higher prevalence of urinary incontinence than the normal and mild obese women, there were no significant differences in history of falls during the last year, or fear of falling. A high percentage of body fat was significantly associated with a higher level of instrumental activities of daily living (IADL) and intellectual activity disability, use of 3 or more medications, pain, and circumference (abdominal, hip, calf), and was associated with a lower level of balance and walking ability. According to the logistic model, history of hypertension (odds ratio (OR)=1.70, 95%confidence intervals (CI)=1.25-2.32), pain (OR=1.46, 95%CI=1.07-2.01), urinary incontinence (OR=1.44, 95%CI=1.08-1.92), SBP (OR=1.02, 95%CI=1.01-1.03), and usual walking speed (OR=0.43, 95%CI=0.24-0.75) were independent variables significantly associated with obesity.
Conclusions: These cross-sectional data show that a higher percentage of body fat is associated with high prevalence of urinary incontinence, IADL and intellectual activity disability, and is related to lower level of walking ability and balance. The present study suggests that regular physical activity and weight control may contribute to the prevention of IADL disability and improvement of physical fitness in obese elderly women.

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Aim: To study the epidemics of the hemophilus influenzae (HI) infection in the summer, 2005 among 46 residents in the second floor of our insurance care facility, Mam Cuore.
Methods: The spreading pattern of HI infection, antibiotic susceptibility and serological identification of HI isolated from sputum culture were investigated, and underlying diseases, functional disorders, body weight, age, sex, ADL- and dementia-scores were compared among patients with the non-symptomatic group, HI infection and severe HI pneumonia groups.
Results: Lower ADL and body weight were noted to suffer significantly more HI infection and severe pneumonia. Furthermore, stroke patients tended to suffer more HI infection. Dementia patients suffered significantly more severe pneumonia. Residents of rooms close to the room of original patient showed symptoms earlier than patients in more distant rooms. While the numbers of patients with HI infection were 15 (60%) and 10 (40%) before and after the first isolation of HI, 5 out of 15 patients (33%) and one out of 10 patients (10%) progressed to severe pneumonia, respectively. Although these results did not have statistical significance, they suggests that rapid assessment and therapy of HI infection tended to prevent aggravation. Non-typeable strains were detected and were all β-lactamase nonproducing ampicillin resistant (BLNAR) without susceptibilities to cefaclor (CCL) and cefdinir (CFDN). Preceding the epidemic, an outbreak of the common cold syndrome was recognized.
Conclusion: Assessing elderly patients suspected of the HI infection, and organized management for treatment are essential to improving outcome.

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A 76-year-old man was referred to our hospital because of memory impairment. He was diagnosed as having early Alzheimer's disease, in addition to hypertension and type II diabetes mellitus. Nilvadipine (a Ca-channel blocker), telmisartan (an angiotension II receptor blocker), and pioglitazone (an insulin sensitizer) were administered for the control of the hypertension and diabetes. After 6 months of treatment, the scores on verbal fluency (animals and vegetables/60 seconds) and frontal assessment battery of the patient improved despite no significant changes on the Mini-Mental State Examination and Alzheimer's Disease Assessment Scale. Moreover, follow-up examination of SPECT demonstrated an improvement of cerebral perfusion in the frontal and temporoparietal regions. In addition to nilvadipine, a highly lipophilic Ca channel antagonist agent that easily penetrates the central nervous system, PPARγ agonists, such as pioglitazone and termisartan, may have had favourable effects on cognitive function and cerebral perfusion in this patient.

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We reported an 83-year-old woman, who suffered from bacterial meningitis and subsequent vasculitis. She experienced episodes of loss of consciousness several times in July, 2006. She also had recurrent fever and was admitted to a local hospital. Routine examinations, including brain MRI and electroencephalogram, were negative and urinary tract infection was diagnosed. After successful antibiotic therapy, she was transferred to a rehabilitation hospital. After transfer, she had no headache, but presented fever again, and a reduced level of consciousness. Cerebrospinal fluid test showed that cell counts were high with a predominance of neutrophils, and her glucose level was low. She received antibiotic therapy on her suspicion of bacterial meningitis. Bacterial cultures of CSF and blood were negative, probably due to the previous antibiotic therapy. Repeated CSF analysis showed a decrease in cell counts, but her lower consciousness did not improve. Moreover, neurological symptoms such as left pyramidal tract sign appeared. She was transferred to our hospital on the suspicion of vasculitis. Diffusion MRI showed high intensity in the right middle cerebral artery (MCA) area and CT angiography showed the stenosis of the right MCA at the M3 portion. Two courses of steroid pulse therapy were performed. Her consciousness gradually improved and eventually could talk although cognitive decline remained as a residual deficit. Our patient failed to be diagnosed early because of atypical symptoms of meningitis. Caution seems necessary for elderly cases presenting with atypical initial symptoms of meningitis. Steroid pulse therapy was effective for the subsequent vasculitis, as reported previously.

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