The 51st Annual Meeting of the Japan Geriatrics Society: A chairperson's special program: Develoment of geriatric medicine and care for the society; A historical role of the Department of Geriatric Medicine of Kochi Medical School
Aim: The goal of this study was to quantify the extent of possible day-to-day differences in 24-hour ambulatory blood pressure (ABP) monitoring results especially in association with age. Method: A total of 514 community-dwelling subjects were initially recruited to participate in this study, and 450 subjects (average 58.8 years, 186 men and 264 women) had ABP monitoring for at least 6 days using an oscillometric monitor (TM-2430). We calculated the mean ABP and blood pressure (BP) dipping ratio for each day. Subjects were devided into 3 groups, 91 subjects aged from 40 to 49 years (average 41.8 years, younger group), 192 subjects from 50 to 64 years (average 57.5 years, middle-aged group), and 167 subjects over 65 years of age (average 69.5 years, elderly group). A mean ABP of >130/80 mm Hg was a criteria for hypertension (HT), and a decrease of less than 10% in BP during the night was defined as non-dipper. From the view point of day-to-day difference of ABP, 450 subjects were classified into (1) persistent normotension, masked ABP HT, intermittent ABP HT and persistent HT, and (2) persistent dipper, masked non-dipper, intermittent non-dipper and persistent non-dipper. Results: Frequency of masked and intermittent ABP HT was higher in the elderly group than the younger or middle-aged groups (47.3% vs. 27.5% or 39.6%), and the frequency of masked and intermittent non-dippers was also higher in association with age (55.0%, 59.5%, 69.7%, p<0.01). Conclusion: Aging can affect ABP variability. ABP monitoring should be used more precisely for the better diagnosis and treatment of HT in the elderly.
Background: In 2002-2003, the practice of doctors lending their names to appear as "staff" of hospitals became known. Problems regarding funds from public hospitals were also revealed. Tohoku University asked regional societies how to improve the medical situation, and redefined its responsibilities. The Educational Development Center for Local Medicine and Department of Local Medical Service System were set up (2005-2008). Investigation and research: A severe shortage of medical doctors prevails in Japan: the number of doctors per population is at the 4th lowest among OECD countries, and the number per hospital bed is the lowest. We have no nursing homes whose beds are not counted as hospital beds. The number of faculty staff in Japanese medical schools is 1/3 to those of Western countries. The reported number of doctors working in hospitals and offices surpasses that by census for medical doctors by >40,000. Japanese doctors work for >60 hours per week. Results and conclusions: I propose essential plans to improve Japanese situation for medical service: 1. Immediately increase the number of doctors by at least 50%. Based on our calculation, we need 450,000 doctors. 2. When the shortage of doctors is severe, establish a magnet hospital with c.a. 500 beds for every 200,000 population, capable of treating highly emergency patients and attracting doctors who need medical training. Hospitals should not belong to each city or town. 3. Establish a comprehensive organization to nurture doctors on a long-term basis. It should consist of a medical school, hospitals, and the prefectural government. It should help doctors to move between hospitals, and be responsible both for designing doctors' career paths and for allocating them appropriately.
Aim: Diabetes mellitus (DM) outpatients were followed for 30 years or more. The impact of age and variability of fasting plasma glucose (FPG) and HbA1C on the onset of simple diabetic retinopathy (SDR) was analyzed. Methods: The analysis included 84 DM patients who were free of retinopathy on their first visit between 1969 and 1977, then followed at the outpatients clinic through 2006. The plasma glucose and HbA1C were measured on every visit. The indices of variability were expressed as standard deviation (SD), coefficient of variance (CV) and range. Results: The SDR incidence was significantly higher in the group of FPG SD ≥37 mg/dl (n=21) than in that of <37 mg/dl (n=63). The hazard ratio, adjusted for the mean FPG, presence of hypoglycemia, age, duration of diabetes, hypertension and treatment of diabetes was 2.64 (95% CI: 1.26-5.50). The mean HbA1C, HbA1C SD, mean FPG and FPG SD were significant risk factors for onset of SDR. Multivariate analysis identified the mean HbA1C and FPG SD as significant independent factors of increase in the risk of SDR onset. The SDR incidence was significantly lower in those aged 42 y or more (n=45) than in those under 42 y (n=39). The hazard ratio, adjusted for the mean FPG, gender, duration of diabetes, hypertension, and treatment of diabetes was 0.53 (95% CI: 0.30-0.95). All values for mean, SD and CV of FPG were significantly lower in the age group of ≥42 y. Conclusions: The risk of SDR onset in DM patients increased with the mean values of HbA1C and/or FPG and also with the variability of these parameters. The risk decreased in the group above age 42, which was speculated to be due to the smaller variability in FPG and also due to the fact that subjects included in the group started SDR at the age exceeded the age of predilection for SDR onset.
Aim and Method: To elucidate the problems of insulin self-injection in elderly, we evaluated the procedure in 194 outpatients, using a checklist. Result: Errors in insulin self-injection were found in about two-thirds of patients. There is no difference in error frequency among any age group. Also, there was no error difference between the elderly group (people aged 65 or over) and the adult group (under 65). However, there were more errors in the elderly group than in the adult group on rechecking after guidance. Conclusion: It is necessary to perform periodical confirmation of insulin self-injection at all ages. In particular, early re-inspection should be done in the elderly patients.
An 80-year old woman presented with macroscopic hematuria on June 4th, 2008. She had been suffering from general malaise and appetite loss since about 10 days previously. She had received anticoagulant therapy with warfarin due to chronic atrial fibrillation and PT-INR was well controlled between 1.6-2.2. When she presented, PT-INR was 12.88, and urinary tract infection (UTI) and hypoalbuminemia (2.2 g/dl) were observed. Therefore, warfarin therapy was discontinued, and antibiotics and vitamin K were administered. Normalization of PT-INR resulted in the disappearance of hematuria and UTI improved as a result of antibiotics administration. As the appetite loss improved, for serum albumin level increased. The previous dose of warfarin achieved PT-INR around 1.8. Her drug compliance had been good, and she took no drug nor food which could interact with warfarin. We also found no liver dysfunction, acute renal failure, malignancy, nor hyper- or hypo-thyroidism. Hypoalbuminemia caused by appetite loss due to UTI seems very likely to increase concentration of circulating free warfarin resulting in extreme prolongation of PT-INR. Our findings in the present case may suggest that we should pay more attention on changes of drug pharmacokinetics in elderly patients because of their poor adaptation to their circumstances such as infection or dehydration.
A 65-year-old woman had been treated for type 2 diabetes mellitus, familial hypercholesterolemia and old myocardial infarction. Combination therapy of atorvastatin (40 mg/day), ethyl icosapentate (1,200 mg/day), probucol (500 mg/day) and colestimide (1 g/day) had never reached an ideal low-density lipoprotein cholesterol (LDL-C) level. However the conversion to high dose of colestimide (4 g/day) with the same dose of atorvastatin, ethyl icosapentate, and probucol obviously decreased her LDL-C level from 181.2 mg/dl to 148 mg/dl. Reduction of LDL-C level was also associated with the lowering of glycohemoglobin A1c from 10.7% to 8.7% simultaneously. Challenge tests by the cessation and resumption of only colestimide treatment clearly indicated that colestimide has both cholesterol and blood glucose lowering effect. Her body weight and appetite did not change by colestimide treatment. We think that colestimide therapy might provide a beneficial effect on atherosclerotic disease in diabetes mellitus with dyslipidemia through reduction of cholesterol and blood glucose.
We report a 90-year-old man who was given a diagnosis of pleural effusion lymphoma (PEL) based on the detailed immunochemical and DNA analyses of the pleural effusion. He was bed-ridden and on enteral nutrition due to severe Alzheimer's disease, and also had diabetes mellitus. He was transferred to our hospital with fever and massive pleural effusion. A cytological examination of the pleural effusion revealed class 5 atypical lymphocytes with a high nucleus/cytoplasm ratio. The origin of the atypical cells could not be determined by flow cytometry of the pleural effusion, which only suggested the existence of inflammatory changes. Considering his general physical status, further investigations were not performed. The respiratory failure progressed, and he died on the 45th hospital day. At autopsy, no atypical cells were identified in his organs other than in the right thoracic space. We conducted immunochemical staining after making a cell block from the effusion sample. Most of the atypical cells were CD30 positive, with human herpes virus-8 (HHV-8)-associated protein. A PCR analysis of the immunoglobulin heavy chain gene detected monoclonal rearrangement, thus indicating the atypical cells to be involved in the B-cell lineage. These findings led to a final diagnosis of PEL. PEL is a rare type of lymphoma confined to the body cavities without any prominent tumor mass, and its pathogenesis is related to HHV-8 infection. PEL develops mostly in immunocompromised patients, such as those with AIDS. However, it may also occur in elderly patients as well. We should therefore also consider the possibility of PEL in elderly patients presenting with pleural effusion of unknown origin.
A 79-year-old woman attended the Center for Comprehensive Care of Memory Disorders at the Kyorin University Hospital in 2006 due to forgetfulness. Her initial diagnosis was vascular dementia. In 2007, her cognition declined gradually. Then, impaired verbal fluency and stuttering, the symptoms of non-fluent aphasia, were presented. Thereafter, 5 mg/day donepezil hydrochloride was prescribed. She later suffered type II respiratory failure. Needle electromyography revealed denervation of lower motor neurons. This led to the diagnosis of frontotemporal dementia with motor neuron disease. Interestingly, before developing type II respiratory failure, cognitive decline and non-fluent aphasia occurred in this case.