Background: Senior citizens who have multiple diseases often receive multiple medications (polypharmacy). Because of the increased risk of adverse drug reactions with polypharmacy, trying to minimize the number of medications is important to medical care. Some rehabilitation physicians often treat multiple diseases alone, and hospitalization for rehabilitation provides a good opportunity to improve prescription practices. Our rehabilitation department has implemented a program to minimize the quantity of medications prescribed to hospitalized patients. Aim: To examine reductions in medication consumption through suitable prescribing patterns during rehabilitation. Methods: We investigated prescription practices and the reduction of medications from the clinical records of 203 patients who were admitted to our rehabilitation department from January to December, 2009. Results: Of the 203 patients, 131 (64.5%) were 75 years old or more, and 77 (37.9%) patients were less than 45 kg in weight. Patients took an average of 6.49 medications on admission and 6.02 on discharge. Ninety-two (45.3%) patients experienced a reduction in medication within one month. After a month, 77 (37.9%) patients experienced an increase in medication and only seven (3.4%) a decrease. No patient whose medications were reduced experienced adverse drug withdrawal reactions. The 14 patients whose antihypertensive medication was reduced experienced an excellent course. Similarly, those whose narcoleptic medications were reduced also did well. Conclusions: Medications should be optimized, and reduced if possible, in the early stages of hospitalization. In the absence of adverse events, it appears possible to decrease the quantity of analgesic and gastrointestinal drugs by one-third.
Aim: Hip fracture in elderly people is a major risk factor in the deterioration of activities of daily living (ADL). The aim of this study was to investigate the incidence of hip fractures and the neurological symptoms contributing to hip fracture in patients with subacute myelo-optic-neuropathy (SMON), a drug-induced neurological disease manifesting various symptoms. Methods: We investigated the incidence of hip fracture in 3,269 SMON patients with 24,187 medical check-ups from 1979 through 2007 by the SMON Research Committee in Japan. Neurological symptoms were evaluated in 80 patients who had undergone clinical examinations within 2 years before the fracture (hip-fracture group: age at examination = 75.7±8.8 years (mean±SD)), and the control group (160 SMON patients without a history of hip fracture; 76.5±10.4) were matched for age, gender, and duration of illness. Incidence of hip fracture in SMON as well as severity of visual acuity, motor and sensory symptoms, and ADL were investigated. Results: A total 230 hip fractures occurred in 208 patients (6.4%) with a men-to-women ratio of 21 : 187. In comparison with the Japanese general population, SMON patients showed a statistically high incidence of hip fracture in the 50s and 60s age groups in women (p < 0.002 in both), and in those under 40 (p < 0.02) and in their 50s (p < 0.002) in men. In those with neurological symptoms related to gait, the percentage of subjects who could walk with crutches was significantly higher in the hip-fracture group (43.8%) than in the control group (28.1%) (p < 0.05). Analysis of the vibratory sensation revealed that the hip-fracture group showed a significantly higher percentage of severe impairment (51.9%) than the control group (32.0%) (p < 0.025). There were no significant differences in variance between the two groups in other clinical symptoms or ADL. Conclusions: Impairment of vibration sense, a deep sensation, is more likely to be associated with falling and hip fracture than visual acuity or other neurological symptoms in SMON patients. Those persons with vibration sense disturbance, such as elderly or patients with neurological diseases, should be particularly cautious of falling.
Aim: The number of group homes for elderly people with dementia has been increasing since the introduction of public long-term care insurance in Japan. The aim of this report is to clarify the differences in the end-of-life policy and practices among group homes managed by medical corporations and those run by social welfare corporations. Methods: A questionnaire for end-of-life care policy and practices was mailed to 1,535 group homes managed by medical corporations and 2,022 group homes managed by social welfare corporations. The questions related to the general characteristics of group homes, availability of admission to hospital, whether a doctor visits regularly or not, involvement in end-of-life care, experiences of previous end-of-life care, and provisions for anticipated end-of life care. Results: The response rates were 55.2% for medical corporations and 59.6% for public welfare corporations. Most group homes have one care unit. More than 50% of medical corporation-managed and more than 30% of social welfare corporation-managed group homes were involved with end-of-life care. Previous experiences with end-of-life care experienced in both types of group homes were reported to be 38.0% and 30.1%, respectively. The results of end-of-life care were evaluated positively in both types of group home. Group homes managed by medical corporations which also managed hospitals and group homes managed by social welfare corporations with regular visits of doctors showed a high percentage of cooperation with and previous experience of end-of-life care. Conclusions: Cooperation between medical and care staffs in end-of-life care of the elderly with dementia in group homes is important. This report demonstrated that education about end-of-life care to the staffs of group home is necessary.
Aim: We compared gender differences in the sociodemographic characteristics of community-dwelling dependent elderly who use various community-based services under long-term care insurance programs, as well as in mortality, hospitalization, and institutionalization during a 3-year follow-up period. Methods: We conducted a cross-sectional study using the baseline data of 1,875 care recipients from the Nagoya Longitudinal Study for Frail Elderly (NLS-FE), and a prospective study using their 3-year follow-up data. The data, which were collected at the patients' homes or from care-managing center records, included the clients' and caregivers' demographic characteristics, living arrangements, community-based services used, depression as assessed by the Geriatric Depression Scale (GDS-15), a rating for basic activities of daily living (ADL), and comorbidities. The data included, at 3-year follow-up, all-cause mortality, hospitalization, and institutionalization. Results: Among 1,875 care recipients 66.3% were women. They had a higher rate of living alone (26.2% vs 14.6% in men), and a lower rate of receiving care by a spouse (22.1% vs. 73.6% of men). Although there were no differences in ADL levels or GDS-15 scores between genders, a higher Charlson comorbidity index, higher prevalence of cerebrovascular disease, chronic obstructive pulmonary disease (COPD), and cancer were observed in the male care recipients. Kaplan-Meier analysis demonstrated that during the 3-year follow-up, higher mortality, hospitalization, and lower institutionalization rates were observed in men. Conclusion: We observed that two thirds of care recipients were women. Compared with male recipients, female recipients were more likely to live alone, and to be cared for by non-spouse caregivers. Lower mortality and hospitalization, but higher institutionalization, were observed in female recipients.
The case was a female in her early 80's. Due to abdominal bloating and lower limb edema, she visited a nearby doctor, was diagnosed to have nephrotic syndrome, and then was referred to our department. Upon initial consultation, TP of 4.1 g/dl, Alb of 1.7 g/dl, UN of 73 mg/dl, and Cr of 1.43 mg/dl, along with pleural effusion were observed by chest X-ray. A renal biopsy was not performed because permission could not be obtained. Despite the fact that management of the edema was performed using diuretic agents and albumin preparations, a reduced renal function and deterioration of the fluid retention were gradually observed. She originally displayed lower back pain and digestive symptoms and, therefore, cyclosporine monotherapy was initiated in order to address concerns of side effects such as osteoporosis and peptic ulcer due to adrenocortical steroid drugs (hereinafter abbreviated as steroid). Subsequently, hemodialysis was temporarily required but reduced urine protein and an improved renal function were gradually observed and she eventually achieved a complete remission. The possibility of a spontaneous remission of membranous nephropathy, etc. was considered, but a relapse occurred when the amount of cyclosporine was reduced. Thereafter, a complete remission was obtained with an increased dosage. As a result, the effectiveness of cyclosporine was thus confirmed. In treating nephrotic syndrome, steroid therapy is commonly performed and it is common for cyclosporine to be limited to steroid-resistant cases and/or steroid-dependent cases. However, it is believed that monotherapy could also be an option in cases in which the use of steroids is difficult, such as in cases of elderly patients.
We report a case of a patient with dementia for whom a psychoeducational intervention based on a cognitive functional assessment by multiple cognitive functional tests was useful. She was an 82-year-old woman with hypertension and hyperlipidemia. She often asked about the date, scorched pans several times, and bought large amounts of the same items over 2 years. Her family worried that she might have dementia and hospitalized her. Mixed type dementia was diagnosed from the results of a cognitive functional assessment and magnetic resonance imaging findings. A psychoeducational program was conducted based on the findings of retained and impaired cognitive abilities derived from the above assessment. Her daily life disturbances were modified by an external compensation method. For example, her son told her repeatedly when it was not necessary to make supper, and made use of a block calendar. To consider how to cope appropriately with daily life disturbances derived from the symptoms of dementia, it is important to understand retained and impaired cognitive abilities, by comparing multiple cognitive functional assessments with the type of disturbances, and to deepen understanding of patients' psychological profiles, from the viewpoint of psychoeducation for the patient and family.