The 50th Annual Meeting of the Japan Geriatrics Society: Lecture for the 50th anniversary of the Japan Geriatrics Society: The history, the current status and the future of the Japan Geriatrics Society
Aim: To clarify the area in the brain related to responsible for vitality and volition. Methods: We studied 123 outpatients (39 men, 84 women, 77.7±6.7 years old) who visited the Center for comprehensive care on memory disorders in Kyorin University Hospital. No patients were prescribed with anti-depressants, anti-anxiety agents, psychomimetics, acetylcholinesterase inhibitors, Chinese herbal medicines or cerebrovascular circulation modifying drugs. Patients with frontotemporal dementia or depression were excluded. ADL-related vitality and volition was measured by a vitality index. Cerebral brain blood flow was measured by single photon emission computed tomography (99mTc-ECD SPECT). Relative blood flow changes were calculated by Statistical Parametric Mapping (SPM). Absolute blood flow changes were calculated by a three-dimensional stereotaxic ROI template on anatomically standardised 99mTc-ECD SPECT (3D SRT). Statistically significant correlations between semi-quantitatively measured scores of vitality index and blood flow changes in SPM and 3D-SRT were tested and displayed on a brain map. Results: Analysis of ralative and absolute blood flow showed that the common responsible area in the brain related to vitality was the frontal lobe, fronto-cingulate gyrus, temporal lobe, basal ganglia (caudate nucleus) and thalamus. Blood flow changes in the orbital gyrus were strongly correlated with vitality index specially in the frontal lobe. Conclusion: ADL-related vitality is affected mainly by the blood flow in the frontal-subcortical circuit. However, deep white matter was also important to determine vitality and volition.
Aim: The purpose of this study was to examine the relationship between preferred and actual place of death in community-dwelling disabled older people, based on a survey of visiting nurses. Methods: The present study was a two-year longitudinal study. At Time 1, 398 disabled older people were living together with their family caregivers. At Time 2 (two years later), the visiting nurses responded to a survey for these 398 disabled older people. The relationship between preferred and actual place of death of disabled older people was examined. Results: Of these disabled older people, 26.4% had died by Time 2. The preferences of the place of death of 60% of the disabled older people were not identified by the visiting nurses. Approximately 40% of the family caregivers' preferences concerning the place of death for their older adults were not identified by the visiting nurses. The disabled older adults tended to die at their preferred place of death if the visiting nurses had identified the preferences. Conclusion: In order to assist disabled older people to die at their preferred place of death, visiting nurses should identify the preferences of disabled older people or their family concerning the place of death of the disabled older people.
Aim: To clarify characteristics of static and dynamic postural control in elderly people, postural sway during static standing, during an activity, and static standing after the activity were compared between young and elderly subjects. In this study, the action of raising pants-type diapers was selected as the model activity for the measurement of dynamic postural control ability. Methods: To make differences in the ease of putting on the diapers, their contraction strength around the abdomen was adjusted at 5 levels from loose to tight. Postural sway was measured first during static standing with open and closed eyes and, then, during activity and static standing after activity. The subjects' perceived difficulty in putting on the diapers was also evaluated. Results: Postural sway tended to be larger in elderly than younger subjects during static standing, but the differences were not significant. Also, postural sway was markedly increased in elderly subjects during the raising of diapers requiring greater effort. In static standing after an action, postural sway also remained increased after putting on diapers requiring greater effort only in the elderly group. Conclusions: Postural sway increased, indicating a decline in the dynamic postural control ability, during an action in association with its level of difficulty even in elderly people showing no decline in static postural control ability. In addition, dynamic postural control responses appeared to affect subsequent static postural control responses, inducing a decline in ability.
Aim: Epidemiological studies on atrial fibrillation (AF) in Japanese is scarce. As aging is one of the contributing factors to AF, we investigated the prevalence of AF among aged members of a Japanese community. Methods: Samples were community residents who were aged 65 years or older from town I, which is located at the north end of Kyoto Prefecture, Japan, and 39.9% of the population is over age 65 years old. For a period of 22 months starting in March, 2006, three groups of residents were evaluated: out-patients of the community clinic (the patients group); those who participated in annual residents' check up including ECG (the check-up group) and residents who visited clinics for influenza vaccinations (the pulse-examination group). Results: This study screened 550 patients (81.2% of residents more than 65 years old) in the jurisdiction of the town clinic. A total of 44 residents were diagnosed as having AF, that is 8.0% of residents screened over 65 years old in town. This resulted in a prevalence of 6.5% among all residents over 65 years old. Patient's age ranged from 65 to 94 years old. The male to female ratio was 0.58: 1 and chronic AF was 52.3%. There were 42 subjects with AF out of 419 in the patients group, 2 subjects with AF out of 97 in the check-up group, and no subjects with AF in the pulse-examination group. Among the 42 subjects with AF in the patients group, 88.1% had non-valvular AF and 71.4% had hypertension. Eight patients (19%) suffered from brain infarction and transient ischemic attack, and ten had non-symptomatic AF (23.8%). Among this group, 37.8% had a CHADS2 score above 3. Twenty-three patients (54.8%) received anti-coagulation medication and 15 (35.7%) received anti-arrhythmic medication. Conclusion: The prevalence of atrial fibrillation among elderly patients in a community in Japan was 8.0%. This group has a high risk of brain infarction. As nearly 24% of patients had non-symptomatic AF, it is important to keep non-symptomatic AF in mind in the treatment of the elderly in order to improve their ADL and QOL.
Aim: To explore attitudes towards advance care planning among the general public in Japan and to examine the association between the advance care planning and awareness about dementia. Methods: We conducted a postal self-administered questionnaire survey in a sample of the general population aged 40 and over and 86% (n=2,161) of the sample were eligible for analysis. The question items included sociodemographic characteristics, awareness about dementia (anxiety about dementia and knowledge about dementia), and advance care planning (decision making on own care preference if extra assistance were required and disclosure of their care preferences to family members). Results: More than a half of the participants had yet to consider what kind of care they preferred to receive if extra assistance were required, especially in men and younger people. Although some people had made a decision regarding care preferences, only 39% of those had disclosed their wishes for care to family members. People who had higher awareness (anxiety and knowledge) about dementia were more likely to consider or make a decision about care preferences, irrespective of age and gender. On the other hand, the disclosure of care preferences to family members was associated with the age groups but not with the extent of awareness about dementia. Conclusions: The general public in Japan are not used to determining and disclosing their own preferences on advance care planning. There is clearly a need for greater public awareness and further study about an effective method for enhancement of advance care planning.
Aim: The Trail Making Test (TMT) has been studied in western countries as an indicator of executive function, but there are few data on the TMT in Japan. This study was conducted to assess the characteristics of TMT and to explore the effect of TMT on physical function among community-dwelling elderly Japanese to promote health in the aged. Methods: Subjects were 175 individuals aged ≥65 years (57 men and 118 women). The TMT test which consists of two parts (part A and part B)was performed. 8 physical function items such as indicators of functional decline (usual walking speed, timed up-and-go (TUG), one-leg standing balance, and handgrip strength), and indicators of mobility (maximum walking speed, TUG with cup, stair-climbing, obstacle-negotiating gait) were measured. For this analysis, we used a difference score defined as TMT calculated as the difference between times (part B-part A = ⊿TMT). Data were analyzed by sex respectively. Results: The median ⊿TMT value was 58.61 seconds in men and 65.67 seconds in women. ⊿TMT value increased with age and there was no difference between men and women in absolute values. multinomial logistic regression analysis showed that poor ⊿TMT was related to low tertiles of TUG, handgrip strength, MWS, TUG with cup, stair-climbing and obstacle-negotiating gait, and to intermediate tertile of MWS with adjustment for age and sex. Conclusion: TMT was significantly associated with mobility-related functions, suggesting that TMT, as the indicator of executive function, should be considered to be included in the test batteries for evaluating older people.
Aim: To establish personalized treatment of osteoporosis. Methods: A T869→C polymorphism in exon 1 of the transforming growth factor-β1 gene, which results in a Leu→Pro substitution at amino acid 10, is reported to be associated with the rate of bone loss as well as the response to active vitamin D treatment. Therefore, we determined this single nucleotide polymorphism (SNP) to estimate the need of active vitamin D treatment. We also determined serum level of 25 hydroxy-vitamin D to evaluate a degree of vitamin D fulfillment. Based on these data, we categorized postmenopausal patients into four groups; C homozygote with vitamin D deficiency patients to whom 1 μg/day active vitamin D was administered, C homozygote without vitamin D deficiency patients or those who bore at least one T-allele with vitamin D deficiency to whom 0.5 μg/day active vitamin D was administered, and patients who bore at least one T-allele without vitamin D deficiency to whom no drug was given. The patients were checked up every 6 months with regard to changes in bone mineral density and occurrence of fresh fractures. Results: The SNP was associated with prevalent vertebral fractures; the frequency of the T allele was significantly greater in patients with vertebral fractures. Furthermore, the serum level of 25 hydroxy-vitamin D was significantly lower in patients with vertebral fractures, which were observed in 17 out of 34 patients who bore at least one T-allele as well as vitamin D deficiency, while only 2 of 15 homozygous C-allele carriers without vitamin D deficiency suffered from fractures. Conclusion: These findings suggest that the SNP in combination with the serum level of 25 hydroxy-vitamin D can predict fracture risk in postmenopausal osteoporosis.
A 76-year-old woman presented to a clinic with fever and loss of body weight. Abdominal echogram showed bilateral adrenal swelling (left adrenal 90×80 mm, right adrenal 50×20 mm) and she was admitted to the hospital for further examination. A tumor was also found inside nasal cavity by enhanced computed tomography (CT), and abnormal uptake in the nasal cavity and adrenal gland was shown in gallium scintigraphy. Laboratory tests revealed the elevation of lactate dehydrogenase (LDH) and sIL-2R. Biopsy of the nasal tumor revealed nasal natural killer or thymus-derived (NK/T) cell lymphoma. No Epstein-Barr virus (EBV) -encoded RNA was detected in tissue. After THP-COP chemotherapy regimen, both the nasal and adrenal tumors decreased in size. However, a CT scan taken on admission revealed a pulmonary embolism. After treatment with heparin and warfarin, emboli disappeared. Chemotherapy was continued, but perforation of the small intestine occurred. Since the prognosis was poor, no operation was performed. Her condition slowly, and she died 60 days after admission. Since she had a high level of plasma ACTH (158.0 pg/ml) and normal serum cortisol (14.6 μg/dl), partial adrenal insufficiency was suspected. In addition, since her cortisol circadian rhythm was lost and cortisol levels were not completely suppressed by the 1 mg and 8 mg dexamethasone test, she met the criteria of the diagnosis of preclinical Cushing syndrome. NK/T cell lymphoma with giant adrenal tumor is extremely rare, but should be considered as one of the differential diagnoses of bilateral adrenal tumor.