Aim and methods: We distributed 282 questionnaires to doctors to ascertain their opinions on obtaining the advance directives regarding the end-of-life treatment of patients at the terminal stage. We received 136 (48%) responses. Results: A total of 62% of the respondents stated a desire for patients to indicate their advance directives "if at all possible". Only 36% stated that the need for advance directives "depended on the circumstances". A total of 80% of doctors aged under 40 wished patients to provide advanced directives "if at all possible", while 59% of doctors over 61 wanted advanced directives "depending on the circumstances" (p=0.008). A large number of doctors stated a desire for patients to indicate their preference in writing, particularly directives regarding the "use of a ventilator to prolong life" (76%) or the "use of artificial nourishment through a gastric fistula etc. as part of a proactive approach to sustaining life" (67%). Regarding the optimal timing of this declaration, 59% chose "at the first diagnosis of a terminal illness", and 47% chose "at the diagnosis of a chronic illness", regardless of whether it could become terminal. Of those respondents under 40, 32% believed that doctors should strictly follow the patients' advance directives, while only 11% of doctors over 61 years old believed the same. There was a statistically significant relationship between aging and dealing with advance directives of patients in the terminal stages of illness (p=0.002). Conclusion: These results suggest that doctors under 40 years of age should focus on how to correctly interpret the wishes of the patients expressed in the directives, while doctors over 61 should concentrate on the importance of the clinical application of advance directives, and how to balance the need to make qualified medical decisions on treatment in compliance with the wishes of end-stage terminal patients.
Aim: In this study we aimed to evaluate the frequency of cerumen impaction in Japanese elderly and clarify the associations between cerumen, cognitive function, and hearing impairment. Methods: The subjects enrolleded in this study were participants in the National Institute for Longevity Sciences, Longitudinal Study of Aging (NILS-LSA). The data of 792 community-dwelling participants aged 60 to 88 years old were collected. All had taken the Mini-Mental State Examination (MMSE) and had undergone pure tone audiometry (PTA) assessment and video recording of an otoscopic examination. We then analyzed associations between the incidence of the cerumen impaction of better-hearing ear, hearing level and MMSE scores using a general linear model. Results: Cerumen impaction of the better-hearing ear was observed in 10.7% of all participants. In participants with an MMSE score of less than 24, the frequency of cerumen impaction was 23.3%. Cerumen was significant associated with poorer hearing after adjustment for sex and age (p=0.0001). Cerumen impaction also showed a significant association with a low MMSE score after adjustment for sex, age, hearing level and education (p=0.02). Conclusions: The frequency of cerumen impaction in Japanese elderly was estimated to be approximately 10%. The existence of cerumen impaction was associated with poorer hearing level and lower MMSE score.
Aim: We studied the association between the activities of daily living (ADL) and oral diadochokinesis (OD) among 84 Japanese elderly individuals residing in a nursing home. Methods: We assessed OD in terms of speech and articulation. Each subject repetitively produced the syllables /pa/, /ta/, /ka/ and the sequence /pataka/. We also evaluated comprehensive ADL (basic, BADL; instrumental, IADL; and communicative, CADL) based on the criteria of the ADL-20 and intellectual ability using the revised Hasegawa Dementia Scale (HDS-R). We classified types of OD into a hypokinesia group (less than 3 times per second for OD /pa//ta//ka/ or less than once per second for OD /pataka/) and a repetition exercise maintenance group (more than 3 times per second for OD /pa//ta/ /ka/ or more than once per second for OD /pataka/). Results: After adjusting for age, sex, and HDS-R score, the ADL-20 total score of the hypokinesia group was significantly lower than that of the maintenance group for OD (/pa/ and /pataka/) (p<0.01). The BADL for mobility (BADLm) score in the hypokinesia group for all OD sections was significantly lower than that in the maintenance group (p<0.05). The BADL for self-care score (BADLs) in the hypokinesia group for OD (/pataka/) was lower than that in the maintenance group (p<0.01). The CADL score in the hypokinesia group for OD (/pa/) was lower than that in the maintenance group (p<0.05). Conclusion: A decline in OD may have been associated with a decline in ADL in our subjects, suggesting that the rate of decline in OD may affect overall ADL in elderly individuals.
Aim: As 2 years have passed since its implementation, and we have received several comments regarding our original article, we report the recent developments of end-of-life (EOL) care in a special elderly (SE) nursing home and describe the role of doctors. Participants: A total of 7 female EOL care patients (age, 101.5±4 years) in a special elderly home and 130 patients (98 years, 42 men, 88 women; age, 87±6.5 years) receiving palliative therapy in a hospital. Results: Four of the 7 EOL care patients died after an average of 480±297 days within our EOL care system, while 3 patients spent an average of 805±662 days in our SE home. Among the hospitalized patients, 93 (71.5%; 27 men and 66 women; age, 86.7±10 years) were able to be discharged to our facility, whereas 37 (28.5%; 15 men, 22 women; age, 86.4±11 years) died during hospital care. A number of patients who could discharge had a greater incidence of gastrointestinal disorders than congestive heart failure (p<0.05). Among 15 patients (≥98 years) who could not enter EOL care because of family problems, 12 were hospitalized and 9 died before discharge. This number was significantly greater than the number who died before discharge and who were <98 years (p<0.05). One patient (aged 103 years) who had a solid breast tumor successfully underwent surgery and was discharged after 3 days of admission, but she died within 90 days of EOL. The death rates in our nursing home were significantly lower than the average death rate in other facilities (15.3% vs. 37.2%, p<0.01). Conclusion: Patients of over 98 years old did not live longer, despite hospitalized care; however, the number of patients (28%) who were less than 98 years could be discharged and were alive was significantly less than centenarians (p<0.05). Doctors in nursing homes should provide communication support for nursing homes and hospitals after providing medical education for care workers.
Objective: To examine the prevalence and characteristics of frailty in community-dwelling people over 70 years of age. Methods: Data collected from in-home interviews conducted in 2001 were used to determine the prevalence of frailty. A total of 916 out of 1,039 older adults responded, and the data of 914 were eligible. Secondly, data collected from a comprehensive health examination undertaken in two areas in 2005 were used to identify the characteristics of frailty. 1,005 older adults participated and the data of 974 were eligible. We used a frailty index (Kaigo-Yobo Checklist) developed by Shinkai et al. (2010) to divide data into Frail and Non-frail groups. Results: The prevalence of frailty was 24.3% for men and 32.4% for women. The prevalence showed a tendency to rapidly increase after age 80 in men and 75 in women. Even after controlling for age, study area, ADL disability and comorbidity, a number of variables showed significant associations with frailty. The results showed poor functional status in physical, mental and social areas in the Frail group. The Frail group was more likely to have comorbid geriatric syndromes than the Non-frail group, such as lower MMSE scores, higher prevalence of depression, higher prevalence of hearing impairment in men, and urinary incontinence and walking impairment in women. In contrast, almost no associations with frailty were detected on routine clinical tests such as blood pressure or blood examination. Conclusions: Overall, frailty was identified as a multifactorial syndrome which was strongly related to other geriatric syndromes. The symptoms of frailty manifested as poor functioning in multiple areas. Routine clinical tests may not be useful for detecting frailty.
Purpose: Dementia Care Mapping (DCM) is an observation and evaluation technique intended to improve the quality of care for elderly people with dementia, based on aims of person-centered care. The purpose of this study was to clarify that well-being and ill-being (WIB) levels affects the behavior category code (BCC) in long-term care insurance facilities. Methods: In this study, we evaluated people with dementia who used care facilities between April 2005 and July 2007. The evaluation indices used were the 6-hour DCM, the Mini-Mental State Examination (MMSE), and the Gottfries-Brane-Steen Scale (GBS). Results: The total number of subjects whose families submitted written informed consent to participate was 256 (50 men and 206 women). The mean MMSE score of the total subjects was 10.83 (±8.58), and that of individuals receiving home care was the highest 17.14 (±6.38). The next highest mean MMSE score was that of the group home residents: 16.56 (±6.83). The lowest mean MMSE score was of individuals in health services facilities for the elderly (serious dementia ward), at 2.16 (±3.88). Multiple regression analysis was performed after controlling for age, sex, type of dementia and GBS, and we used the WIB value as dependent variables. The BCC variables of L (Labor) in group homes, and E (Expression) and H (handicrafts) variables in welfare institutions and long-term care facilities for the elderly significantly promoted WIB value. Conclusions: Among BCC indices such as L in group homes, and E and H in welfare institutions and long-term care facilities for the elderly, which reflect WIB values (and therefore, quality of life), it was found that those activities associated with work reflected quality of care. However, the BCC indices of B (Borderline) C (Cool), and U (Unresponsiveness) significantly inhibited WIB level; these behaviors are categorized as passive behaviors in the DCM. It is probable that these behaviors in elderly people with dementia reflect problems in long-term care insurance facilities. It is necessary to further examine these passive behaviors, because they can accurately reflect the quality of care for elderly people with dementia.
A 69-year-old woman was admitted because of unconsciousness and multiple cranial neuropathy. She had suffered diarrhea 2 weeks previously. On examination, she was noted to have total external and internal ophthalmoplegia, bilateral facial palsy, dysphagia, dysarthria, neck weakness, distal motor weakness of all limbs, and ataxia. She had also presented with hyporeflexia and hypoesthesia, but with a bilateral pyramidal tract sign. A study of her cerebrospinal fluid revealed albuminocytologic dissociation, and nerve conduction study revealed demyelination of her peripheral nerves. Moreover, electroencephalography findings were abnormal and anti-GQ1b antibody was positive. We diagnosed Fisher syndrome with Guillain-Barré syndrome and Bickerstaff brainstem encephalitis. We administered intravenous immunoglobulin treatment for 5 days and her symptoms gradually improved. However, her external ophthalmoplegia continued for several months.