After the catastrophic 2011 Tohoku earthquake and tsunami which struck cities and towns on the Japanese Pacific coast, Fukushima has been the focus of special and serious disaster relief procedures modification regarding nuclear power plant accidents. To date, the Japanese government has repeatedly issued evacuation orders to more than 100,000 residents. Huge numbers of refugees are still uncertain if they can return home and re-cultivate their farm land. Ambiguous public announcements concerning the radiation risks seem to have aggravated feelings of insecurity, fear and the desire to escape, both at home and abroad. This disaster has seriously undermined trust internationally and locally in Fukushima. Harmful rumors added further difficulties. In response to this disaster, local government, medical institutions, care facilities, police, emergency services and the self-defense forces continue to put their utmost effort into reconstruction. This seismic disaster has reminded us that supplies of water, electricity, gas, gasoline and telephone/communication facilities are essential prerequisites for reconstruction and daily life. Disaster and radiation medical association teams actively participated in the rescue efforts, and a number of organized medical teams cared for about 15,000 refugees in 100 shelters. We also visited home-bound patients, who were unable to evacuate from the 20-30 km inner evacuation area. In this relief role, we need to consider the following; (1) professionals, both healthcare and nuclear engineers, must always be prepared for unexpected circumstances, (2) the daily organic cooperation of individuals and units is closely linked to readiness against sudden risks, and (3) appropriate accountability is essential to assuage the fears of residents and refugees. A sincere learning process may benefit those innocent refugees who may be forced to abandon their homes permanently.
Aim: We investigated the characteristics of people who died in a special elderly nursing home and the current status of end-of-life decision-making. Methods: Subjects comprised 168 residents who were discharged from a special elderly nurshing home in Yokohama between April 1998 and June 2008. A total of 3 patients were excluded from this study due to insufficient inclusion criteria. We collected and retrospectively examined the basic descriptive information regarding the terminal phase of care from medical records, death certificates, and the notes of nurses, caregivers and counseling staff. Result: Of a total of 165 subjects comprising 38 men (23%) and 127 women (77%), 30 (18%) died in a nursing home facility (facility mortality group), 101 (61%) died in hospitals (hospital mortality group) and 34 (21%) were discharged from special elderly nursing homes for transfer to long-term hospitalization (hospitalization group). To clarify the factors which led to death within the facilities, we analyzed: 1) age at discharge, 2) sex, 3) residency period, 4) number of hospitalizations, 5) length of hospital stay, 6) number of children, 7) number of conferences regarding end-of-life care in 2 groups: the facility mortality group and all others as the second group, as explanatory variables on multiple discriminant analysis. This revealed a higher number of conferences, a higher age at discharge, and a smaller number of hospitalizations in the facility mortality group. Only 12 (7%) people were able to convey by themselves how they wanted to spend the remainder of their lives, and 61 (37%) people conveyed this information via family members. However, 100 (61%) people were unable to confirm it by either self-report or family members. Conclusion: The people who died in special elderly nursing homes had a higher age, fewer hospitalizations, and had been involved in more conferences regarding terminal care. However, it was very hard to confirm individual intentions regarding terminal care periods. Further studies will be necessary to determine what kind of terminal care is needed in special elderly nursing homes when it is difficult to confirm individual or family intention regarding the terminal period.
Aim: The purpose of this study was to cross-sectionally examine the relationships among leisure, household and occupational physical activity with the frequency of going out by various transportation modes, depression and social networks in older adults. Methods: We randomly selected a total of 2,100 community-dwelling adults aged 65 to 85 years of age from the Basic Resident Register. Of these, 340 people were the subjects of this study. The scales of measurement used were the Physical Activity Scale for the Elderly, the Lubben Social Network Scale (LSNS) and the Geriatric Depression Scale (GDS). Results: In a regression model, leisure-time physical activity significantly correlated with frequency of going out by bicycle (β=0.17) and LSNS score (β=0.17). Household physical activity and occupational physical activity were significantly correlated with LSNS score (β=0.21) and frequency of going out by motor vehicle (β=0.25), respectively. For total physical activity, in the 3 above-mentioned activities a significant correlation was observed among frequency of going out by bicycle (β=0.10), by motor vehicle (β=0.23), GDS score (β=-0.16) and LSNS score (β=0.23). Conclusion: These results indicate that the frequency of going out by bicycle and by motor vehicle were significant factors to predict leisure and occupational physical activity. Furthermore, social networks appear to be important determiners in leisure and household physical activity in community-dwelling older adults.
Aim: In Japan, it is rare for patients to confirm their intentions regarding terminal care treatment in hospital by signature. To maintain respect for the autonomy of elderly patients, we encouraged confirmation by signature regarding terminal care treatment in elderly patients, after repeated discussions. The purpose of this study was to clarify the status of confirmation of intention by signature. Method: The subjects were 98 patients who signed documents signaling their intention regarding terminal care (signature group), and 165 patients who did not sign such documents (non-signature group), all of whom died in our hospital between April 2009 and March 2010. We surveyed and examined their backgrounds and treatment experiences based on the clinical records. Furthermore, we gave a questionnaire survey to these patients. A total of 31 (35.2%) patients from the signature group and 58 (35.2%) patients from the non-signature group responded. Results: In the signature group 32 (32.7%) patients judged to be in a terminal state were discharged alive. Those in the signature group had a significantly higher age, higher ratio of dementia, lower activity level in their daily life and were hospitalized with respiratory illnesses. In addition, the frequency of the informed consent discussions was greater than that of the non-signature group. A total of 90% of the signature group was able to accept the confirmation of their intention regarding terminal care by signature. In both groups, the doctors' explanations were understood, and the patients' wishes were successfully conveyed. Conclusion: In Japan, confirmation of intention regarding terminal care by signature can be effective and useful as one of the methods to determine intention regarding terminal care treatment in elderly patients.
Aim: To assess the prevalence of the fecal carriage of extended-spectrum β-lactamase (ESBL)-producing Escherichia coli among nursing home residents and to demonstrate the relationship between fecal carriage and urinary tract infections (UTIs) in elderly patients. Methods: Data were collected for 12 months on aerobic bacteria obtained from the urine of elderly patients with UTI. Feces were analyzed for the blaCTX-M gene at the Department of Bioinformatics, Osaka University Graduate School of Medicine. Results: Among 56 strains of aerobic bacteria obtained from 40 patients with UTIs, there were 24 strains of Escherichia coli, 14 (58.3%) of which were ESBL-producing. All of these ESBL strains were also resistant to levofloxacin (LVFX). Fecal ESBL-carriage was detected in 21.5% of the residents, with similar ratios in men and women. Statistical analysis of the backgrounds of residents showed that the carriage rate was markedly high in those elderly patients who came from hospitals after the treatment of infectious/purulent diseases. Among the 145 residents, whose feces were analyzed for ESBL, UTIs developed in 10 patients, only 1 of whom was a man; urinary examination did not detect ESBL-producing Escherichia coli as a pathogen in this patient. In 9 female patients, ESBL-producing Escherichia coli was isolated from the urine of 8 women. While the combination of fosfomycin and minomycin was useful in the treatment of the UTIs in these cases, it did not completely remove the ESBL-producing bacteria from feces. Conclusions: Fecal carriage of ESBL-producing Escherichia coli is prevalent in our facilities and is related to a high incidence of UTIs in elderly women, presenting treatment challenges.
Purpose: The purpose of this study was to develop a decision-making process to assess the conditions for predicting gait independence in patients with femoral neck fracture. Methods: A total of 108 patients were divided into 2 groups on the basis of their walking abilities at discharge for an unrelated illness; an independent (n=55) and dependent group (n=53). Details regarding age, sex, length of hospital therapy, operative procedures, classification of fracture, past history of stroke and fracture were collected from medical records. Body mass index (BMI), knee extension power, maximum walking speed, functional reach test (FRT) and the mini-mental state examination (MMSE) were measured to evaluate motor ability and cognitive status at discharge. Student's t-test and the chi-squared test were used to test for statistical differences between the 2 groups. On multivariate analysis, classification and regression trees (CART) was used to determine the predictive value of those measures that differed significantly between the 2 groups. Results: On bivariable analysis, significant differences were found in nearly all variables, except for BMI and length of hospital therapy. As a result of this analysis, the decision tree, which consists of knee extension power, FRT, MMSE and a past history of stroke, was created. CART analyses showed that when knee extension power was >0.34 kgf/kg, the MMSE score was >13.5; with no past history of stroke, the rate of independent walking at discharge was 93.8%. In contrast, when knee extension power was ≤0.33 kgf/kg, FRT was ≤25.5 cm, the MMSE score was ≤13.5, and the rate of dependent walking at discharge was 100%. Conclusions: Our findings indicate that the decision tree can be helpful in predicting gait independence in patients with femoral neck fracture.
Aim: The present study was designed to assess the validity of the "Kihon ("basic") Check-list (KCL)" as a frailty index, and to investigate its biomarkers in an elderly population. Methods: We enrolled 420 elderly persons aged 65 years and over in comprehensive geriatric assessments in 2007 and 2008. We examined the temporal relationship between the Fried frailty criteria (external criteria) and KCL items 1-20 to evaluate concurrent validity. In 2008, 665 elderly people aged 65 years and over who participated in the comprehensive geriatric assessment in 2008 were assessed based on their frailty and non-frailty using the KCL. We compared biomarkers, including TNF-α, IL-6, CRP and β2-microglobulin (β2-MG) between frail and non-frail groups. Results: The KCL items 1-20 showed good concurrent validity against the Fried criteria in terms of frailty. When using a cut-off point of 5/6, the KCL items 1-20 showed a sensitivity of 60.0% and a specificity of 86.4% for the Fried frailty criteria. Overall, 34 males (12.3%) and 74 females (19.0%) were defined as frail. Among varying biomarkers, IL-6 (odds ratio [OR] of highest tertile vs. lowest tertile, 2.05; 95% confidence interval [CI]: 1.15-3.64), grip strength (OR: 0.19; 95% CI: 0.07-0.46) and walking speed (OR: 0.23; 95% CI: 0.12-0.45) were significantly associated with risks of frailty. The highest tertile of IL-6 and β2-MG combined highly increased the risk of frailty (OR: 5.61; 95% CI: 2.34-13.11) compared with those in the lowest tertile of the 2 markers combined. Conclusions: The KCL items 1-20 can be used as a frailty index for Japanese elderly population. IL-6 and β2-MG are potential candidates for biomarkers of frailty.
An 81-year-old woman had been visiting 2 hospitals for hypertension and dementia, prior to admission to our emergency room for nausea, hypertension, severe hypokalemia (K 1.29 mEq/l) and abnormal electrocardiography findings. She had been taking a Chinese herbal remedy (Yokukansan, 7.5 g/day) for the behavioral and psychological symptoms of dementia (BPSD) for 6 months before admission. On admission, she presented with metabolic alkalosis with hypokalemia, a high urinary excretion of potassium, low plasma rennin activity and hypoaldosteronism. We diagnosed pseudoaldosteronism caused by the Chinese herbal remedy Yokukansan (which includes licorice). Discontinuation of Yokukansan and the administration of potassium supplements normalized her serum potassium level within 2 weeks. However, we could not successfully control her BPSD by drugs such as tiapride hydrochloride or risperidone. BPSD is a serious problem in an aging society, with the ever-increasing incidence of dementia. The use of Yokukansan has recently been receiving attention as a new treatment modality for BPSD. Because this agent has relatively few adverse effects compared with typical antipsychotic agents, the use of Yokukansan is continuing to increase sharply. Pseudoaldosteronism, if caused by Yokukansan, may cause death by severe hypokalemia, but the early identification of hypokalemia is sometimes difficult because drug-induced hypokalemia is not dose-dependent. We think it is important to create awareness of the possible adverse effects of Yokukansan, such as hypertension and electrolyte abnormalities to make the most of this commonly used drug for the treatment of BPSD among dementia patients.
We report the case of a 72-year-old man who had been given a diagnosis of semantic dementia (SD) at 64 years of age, and who began to use honorifics in all situations during the later clinical course. His initial clinical features were problems in word comprehension and naming, and some behavioural changes, including clockwatching and aberrant eating behaviours. The most prominent feature in this case was the use of honorifics in all situations, while other aspects of his language ability deteriorated. He even used honorifics with members of his family, including young grandchildren. Although it is difficult to explain the reason why the patient used honorifics in all situations, we considered 2 possibilities. The first is that although he remains able to use honorifics, he is unable to distinguish when the use of honorifics is not required. The second is that a change in emotional state, such as the "taming effect" or "placidity" that has been suggested to accompany frontotemporal lobar degeneration, might have affected his use of honorifics. The regular schedule of daycare services provides him with emotional stability because he does not have to constantly be aware of the time. Since no standard treatment has been established for SD, our experience with this case might be beneficial in caring for patients with SD.
We report 2 elderly patients with fulminant type 1 diabetes mellitus. Case 1: A 61-year-old-man was admitted because of hyperglycemia (blood glucose level, 1,071 mg/dl) and metabolic acidosis. His hemoglobin A1c level was almost normal (5.8%), glutamic acid decarboxylase (GAD) antibody was not detected, and a low level of C-peptide (CPR) was excreted in his urine. We diagnosed his condition as diabetic ketoacidosis, and administered intensive insulin therapy. Case 2: A 77-year-old-man was admitted because of hyperglycemia (blood glucose level, 925 mg/dl). His hemoglobin A1c level was slightly high (5.9%), GAD antibody was not detected, and low levels of CPR were excreted in his urine. He showed no signs of metabolic acidosis, but showed metabolic ketosis. The findings of these cases were consistent with those of fulminant type 1 diabetes mellitus. Thus, it is necessary to consider the possibility of this disease in elderly people.