Aim: To clarify the opinions of members of the Japan Geriatric Society regarding the revised version of their Position Statement on terminal medicine and care in elderly patients. Methods: A self-report questionnaire was sent to special honorary members, emeritus academic staff, and officers and delegates of the Japan Geriatrics Society (789 people). The questions were: 1) Do you agree with the Position Statement as revised by the Ethics Committee of the Japan Geriatric Society or not? 2) Do you have any ideas about any specific item and its' content or necessary revisions and if so, what are they? 3) Are there any headings or items that should be added to the Q&A section and if so, what are they? Results: The response rate was 28.5% (225/789). Of these, 91.6% agreed with the revised version of the Position Statement. More than 80% of respondents had no suggested revisions. Suggested items that should be added to the Q&A were: advanced directives or advanced care plans, legal interpretation on the withholding of life-support treatments including hemodialysis, the establishment of a guardian system, and legal interpretation of the decisions made by the Ethics Committee. Conclusion: Although most respondents agreed with the revised version of the Position Statement, some issues remain to be discussed, including the relationship of patient autonomy with the optimal benefits for those in terminal-stage disease, the decision-making systems regarding the introduction and withholding of life-support treatments such as artificial nutrition, artificial ventilation, and hemodialysis.
Aim: To identify predictors for the onset of frailty in Japanese older adults using the Frailty Index for Japanese elderly people, we focused on subjects who participated in a routine health check. Methods: Of 357 older people (age, ≥70 years) who participated in a routine health check-up in Kusatsu, Japan in 2005, 334 individuals were identified as non-frail and were followed up 2 years later. A logistic regression model using the stepwise method was used to identify predictors for the onset of frailty, after controlling for age and gender. Results: A total of 45 subjects (13.5%) had developed symptoms of frailty at follow-up. Even after multiple adjustment for controlling factors, a history of hypertension, hand grip strength, and albumin were significantly associated with frailty 2 years later (odds ratio [OR], 2.55; 95% confidence interval [CI], 1.24-5.25; OR per 1 kg decrease, 1.08; 95% CI, 1.00-1.16; OR per 0.1 g/dl decrease, 1.22; 95% CI, 1.03-1.46, respectively). Conclusion: These results supported a definition of frailty which includes geriatric symptoms such as vascular disease and sarcopenia in Japanese older adults. Undernutrition was strongly associated with the onset of frailty and is an important target for prevention.
Aim: We hypothesized that during walking, mediolateral instability with gait disorders could be reflected in the characteristics of lateral trunk control while sitting. We investigated the association between lateral trunk control while sitting, mobility and Instrumental Activities of Daily Living (IADL) among community-dwelling elderly people. Methods: A cross-sectional analysis was carried out of the data of 33 men and 102 women in a community-dwelling elderly population (average age, 73.2±6.0 years). A Seated Side-Tapping test was developed to assess lateral trunk control while sitting. We used the Lawton IADL scale, the 5-m normal walking test and the Timed "Up & Go" test (TUG) to measure mobility. Results: The mean duration of the Seated Side-Tapping test was 5.0±0.9 seconds, ranging from 3.1 to 8.2 seconds. The test was normally distributed (p=0.200). The Seated Side-Tapping test was significantly associated with TUG, after controlling for age (r=0.46). The group with disability in at least 1 IADL item was significantly slower in the Seated Side-Tapping test, especially in men (5.7 sec for men, 5.5 sec for women vs. the independent group, 4.8 sec for both). Only the Seated Side-Tapping test remained significantly associated with IADL disability after logistic regression analysis. Conclusions: These results indicate that lateral trunk control in sitting is associated with mobility and disability in at least 1 item of the IADL. These results support the potential use of the Seated Side-Tapping test to safely carry out risk assessments for frail elderly patients.
Aim: The purpose of this study was to examine factors related to fear of falling (FOF) in elderly adults who showed no reduced performance regarding independent instrumental activities of daily living (IADL). Methods: A total of 119 elderly adults participated in the study (mean age, 75.7±7.2 years, women, n=60). We investigated the prevalence of FOF, anamnesis, medications, body pain, and history of falls, the Geriatric Depression Scale, International Physical Activity Questionnaire, Life-Space Assessment (LSA). The Timed Up and Go test (TUG) and one-legged standing time were measured to evaluate physical performance. Participants were divided into elderly adults with FOF (FOF group) and those without FOF (non-FOF group). The unpaired t-test or chi-square test was used for group comparisons. Multiple logistic regression analysis was then performed to examine the factors associated with FOF. Results: The prevalence of FOF was 51.3% overall. The FOF group had a higher prevalence of anamnesis, body pain, and history of falls than the non-FOF group. The FOF group had lower LSA scores, longer durations on the TUG, and shorter durations on the one-legged standing test than the non-FOF group. On multiple logistic regression analysis, LSA (total score, 120 points) was significantly associated with FOF (odds ratio: 0.96, 95% confidence interval=0.93-0.99). Conclusion: Fear of falling was significantly associated with life space in community-dwelling elderly adults who showed no reduced performance regarding IADL. In future, it will be necessary to clarify any possible causal relationship by longitudinal investigations.
Aim: The aim of this study was to make a short version of the 28-item Dementia Behavior Disturbance (DBD) scale. Methods: The 28-item DBD was evaluated twice, with a mean interval of 1 year in 221 outpatients with dementia attending our institution (mean age, 78.3 years). First, 6 items which did not show substantial changes were excluded. Next, 4 items that were less frequent were excluded. After factor analysis, a new, 13-item short version of the DBD scale (DBD13) was developed. Results: The DBD13 showed high internal consistency (Cronbach's alpha=0.96). A high correlation was observed between the scores of the DBD13 and those of the Mini-Mental State Examination (r=-0.27, p<0.0001), Assessment of Daily Living (r=-0.307, p<0.0001), Instrumental Activities of Daily Living (r=-0.375, p<0.0001) and Zarit Burden Interview (r=-0.68, p<0.0001). Conclusions: The DBD13 may be a useful and valid measure of the behavioral and psychological symptoms of dementia to evaluate response to care for patients with dementia.
Aim: To investigate the manner in which community-dwelling older adults' foot problems affect their history of falls. Methods: This study included 112 community-dwelling older adults. Foot problems (e.g., inflammation, ingrown nails, and pain while walking), self-rated physical ability (e.g., gait, tripping over, and balance), history of falls within a year, and physical ability (e.g., walking speed, Timed Up & Go test, and one leg balance test) were measured during a routine health checkup. Of these, five subjects were excluded due to incomplete all the measurement. Thus, the subjects eligible for analysis were 107 older adults (mean age±standard deviation=73.0±5.5 years). Covariance structure analysis was used to identify the inter-relationships among all measurements. Results: The covariance structure analysis showed that foot problems negatively influenced participants' self-rated physical ability, and this relationship was also linked to history of falls. The overall fit of this model was judged to be statistically satisfactory (GFI=0.959, AGFI=0.912, CFI=0.981, RMSEA=0.043). Conclusions: Our model indicated that the association between foot problems and history of falls was affected by self-rated physical ability. Furthermore, in order to prevent falls, the current results suggest that foot care could be an important intervention in older adults to prevent decline in their overall physical ability.
Aim: To evaluate the feasibility of locomotion training (single-leg standing and squats) in a home-visit preventive care program for the elderly. Methods: We invited 246 people who were not attending any preventive care programs within the long-term care insurance system. Among these, 60 participated in the current program. We administered a hearing survey, measured the single-leg stance time with eyes open, and subjects underwent locomotion training. Each participant was asked to repeat 1 set of training exercises 3 times per day at home. One set consists of standing on each leg for 1 minute and squatting 5 to 6 times. We telephoned the participants regularly during the 3 month program (locomo call). At the end of the program, we visited the participants and measured the single-leg stance time with eyes open. Results: A total of 60 elderly adults participated in the program (15 men, 45 women). Among subjects secondary prevention of musculoskeletal (n=313), 67 were participating in site-visit preventive care programs conducted by the local authorities (21.4%). Among these 313, 127 were participating in site-visit preventive care programs or locomotion training (40.6%). It shows the increasing of the participation rate 21.4% to 40.6%. The continuance rate was 91.7%. The single-leg stance time improved for both men (16.2±17.7 sec, p<0.05) and women (57.2±79.7 sec, p<0.01) compared to the baseline. Similarly, improvement was observed in the single-leg stance time for both the young-old (62.2±67.9 sec, p<0.01) and the old-old (39.2±73.8 sec, p<0.01). Conclusions: We consider that the locomotion training program which we introduced in the current home-visit preventive care program was effective and highly feasible for the elderly who have not previously responded conventional site-visit preventive care programs.
Aim: The purpose of this study was to evaluate whether the clock drawing test (CDT) is useful to assess the cognitive function of community-dwelling elderly people. We evaluated the CDT as a tool to measure cognitive function by qualitative and quantitative analyses. Methods: A total of 14,949 community-dwelling elderly were invited by mail to undergo cognitive screening by CDT. Of these, 8,815 responded, of which 8,684 were eligible for enrollment. We were also able to determine the educational background of 7,404 of these. There were 3,525 men (age: 73.05±6.20 [mean±standard deviation] years old, duration of education: 11.40±2.81 years) and 3,879 women (73.67±6.66, 10.34±2.19) . The drawn clocks were evaluated using the Freedman method, and those clocks drawn with obvious errors such as no circle, numbers, or hands were recorded and analyzed. In addition, any vertical deviation from the center points was also evaluated. Results: The recorded percentages of the subjects who correctly completed the individual clock drawing test components varied. The mean total scores were 14.16±1.67 in men and 14.40±1.36 in women. The percentages of subjects with total scores of less than 13 were 16.09% in men and 11.7% in women. The percentage of subjects who made obvious errors was 3.24%, whose total points were significantly lower than those of the subjects who did not. Approximately half of all subjects showed vertical deviation from the center of the clock, and the percentage of upper deviation was greater than that of lower deviation. Conclusion: CDT is useful to assess the cognitive function of community-dwelling elderly people, and it is also helpful to determine subjects with a potential risk of cognitive impairments.
We report a patient with optic neuropathy and longitudinally extensive myelitis associated with anti-aquaporin 4 (AQP4) antibody and other autoantibodies. An 89-year-old woman presented with progressive numbness and weakness of the extremities which had acutely developed. She also complained of neck pain and gait disturbance. The results of a general physical examination were unremarkable. Neurologic examination disclosed right optic atrophy, an absence of touch sensation, pain, and muscular weakness in all her extremities. Her deep tendon reflexes were decreased, and the Babinski sign was bilaterally positive. Immunoserologic study yielded positive titers for anti-nuclear antibody (ANA), anti-double-stranded DNA, anti-Sjögren syndrome (SS)-A, anti-SS-B, and anti-ribonucleoprotein (RNP) antibodies. A lumbar cerebrospinal fluid examination showed a protein concentration of 54 mg/dL, a glucose concentration of 50 mg/dL (simultaneous blood concentration, 140 mg/dL), and a cell count of 2/mm3. Chest radiography revealed interstitial pneumonia. Magnetic resonance imaging (MRI) of the cervical spine showed spondylotic cervical canal stenosis with cord impingement. T2-weighted MR images demonstrated increased signal intensity extending from C2 to C6, while contrast enhancement was noted in T1-weighted MR images upon gadolinium-DTPA administration. We suspected longitudinally extensive myelitis associated with the autoimmune disorders systemic lupus erythematosus and Sjögren syndrome. After intravenous methylprednisolone administration, her neurologic abnormalities gradually decreased, while MRI no longer showed increased signal or contrast enhancement. Anti-AQP4 antibody titers were positive. We consider that this patient had a neuromyelitis optica (NMO) spectrum disorder which was associated with systemic autoimmune disease. The possibility of NMO should be considered in similar patients with autoimmune disease, and anti-AQP4 antibody should be assessed.