Aim: To identify elderly patients who are at high risk for falls, we used the timed up-and-go test (TUG) as an assessment tool for gait and balance function in a comprehensive geriatric assessment (CGA) initiative named 'Dr. SUPERMAN'. However, this test is difficult to perform in a small area because it requires at least 3 meters of movement space. Therefore, we investigated whether another, newly-developed test, based on the Berg balance test, could be an alternative to the TUG test. Methods: We enrolled a total of 99 eligible subjects out of 105 elderly patients with disorders such as Alzheimer disease, Parkinson disease, cerebral infarction, osteoporosis and vascular risk factors, and administered the TUG test and the newly -developed standing and balance test (SBT). Of these 99, 6 patients could not stand independently. While the time to accomplish TUG was determined, any unsteadiness during TUG was also recorded. The SBT consists of 3 components: standing up independently, standing on a narrow base for 15 seconds without any swaying of the trunk, and a timed one-leg standing test (TOLS) for 15 seconds on both sides. Taking more than 14 seconds to accomplish the TUG or abnormal unsteadiness during the test was defined as positive, and each cut-off point was measured on the TOLS, with or without swaying of the trunk. Results: The time to accomplish TUG significantly increased with age, and positive TUG findings were observed in 43 subjects. The mean TOLS time significantly and suddenly worsened at over 75 years of age, including among those subjects who showed swaying of the trunk and who could only perform the TOLS for less than 1 second. The receiver operating curve indicated that a TOLS cut-off point of less than 3 seconds, together with standing with help or swaying of the trunk during the SBT, most efficiently determined a positive TUG score, with high sensitivity (86%), high specificity (87.5%), and a high positive predictive value (84.1%). Conclusion: In a narrow space, the SBT can adequately determine gait and balance abnormalities among elderly patients, indicating it to be an alternative to the TUG test. Subjects who could stand dependently, who showed swaying of the trunk in SBT, or who had a TOLS cut-off point of less than 3 seconds, were at high risk for falls. Further assessment of similar patients is necessary.
Aim: We examined the risk of the diabetic complications among older elderly diabetic patients. Methods: We compared the HbA1c levels of 117 type 2 diabetic patients ≥ 75 years old over a 5-year period, before patients received a diagnosis of diabetic complications, with those of diabetic patients without diabetic complications. Results: The HbA1c levels of diabetic retinopathy patients were significantly higher than those of patients without diabetic retinopathy (7.9% vs. 6.8%, p<0.01). Similarly, the HbA1c levels of patients with diabetic nephropathy were significantly higher than those of patients without diabetic nephropathy (7.3% vs. 6.7%, p<0.01). The HbA1c levels of diabetic patients with cerebral infarction or ischemic heart disease were also higher than those in diabetic patients without these vascular complications (7.7% vs. 7.0%, p<0.05). Conclusion: The current findings emphasize the importance of careful glycemic control for the prevention of diabetic complications in older elderly patients.
Aim: To investigate the outcome of percutaneous endoscopic gastrostomy (PEG) in elderly patients with swallowing difficulties who required high-level nursing care. Methods: We extracted the data of 57 patients (24 men and 33 women) who were admitted to our hospital with a diagnosis of pneumonia over a 5-year study period between January 2006 and December 2010. Evaluation included activities of daily living (ADL), nursing care level (NCL) based on assessment of care requirement, pre-existing disease, blood test data, swallowing function before PEG, and outcome. Results: The mean age of the patients was 84.7±8.3 years old. The mean total functional independence measure (FIM) score was 29.7±16.2 and the median NCL value was 4. The most frequently observed pre-existing diseases were degenerative central nervous system disorders including Alzheimer's disease and cerebrovascular disease, which occurred in approximately 80% of participants. A low serum albumin value and high c-reactive protein (CRP) level were also often observed, suggesting chronic inflammatory conditions. For swallowing function, the median value according to the Fujishima swallowing grading system was 5, and aspiration and pharyngeal residues were observed on videofluoroscopic examination of swallowing (VF) (82.5% and 100% of all cases, respectively). The median survival time after PEG was 451.0±79.7 days, with a one-year survival rate of approximately 56%. A total of 51 patients (89.5%) died after PEG and the mean duration from the PEG to death was 518.5±471.7 days. Of these 51, 45 (88.2%) died of pneumonia. Conclusions: In patients with advanced cognitive impairment and severely reduced ADL, there appears to be little benefit on ADL and the prevention of pneumonia by PEG, and most outcomes following PEG were not favorable in the current results.
Aim: To characterize the impact of respiratory syncytial virus (RSV) infection on respiratory illness in a geriatric health service facility. Method: All facility residents were observed for respiratory symptoms from January 2010 to March 2012. The presence of an RSV antigen was examined in selected patients using rapid antigen test. Results: I observed one outbreak of RSV and four outbreaks of respiratory infection without RSV. I also observed two cases of sporadic RSV infection, one of which had pneumonia. An RSV outbreak in the facility was observed only when RSV cases from pediatricians were four times more frequently reported than the usual seasonal average. More patients with severe respiratory illness were observed during an RSV outbreak than during other outbreaks. Conclusion: RSV can cause severe respiratory illness in elderly patients. Repeated invasion from surrounding infectious environments may be essential for an RSV outbreak to occur. Moreover, although the sensitivity of rapid RSV antigen tests may have influenced the results of the current study, such sensitivity in elderly patients is reportedly diverse in the literature, and the reasons for such variation have not yet been elucidated. We postulate that a reason for such variation is a viral co-infection, in particular of the bocavirus, which has a reported high incidence of co-infection and which affects viral shedding. Furthermore, human metapneumovirus has been reported to influence the severity of RSV infection. Most of these knowledges concerning the influence of co-infection were obtained from pediatric studies, therefore we need further investigations targetting elderly patients.
A 69-year-old woman had received oral treatment of propylthiouracil (PTU) under a diagnosis of hyperthyroidism for 35 years. In the first 10 days of January 2009, she noticed the development of a cough. In February of the same year, she consulted a clinic with bloody sputum. Chest X-ray films revealed diffuse infiltration in both lungs, and she came to our hospital for further examination. An alveolar hemorrhage was identified by bronchial alveolar lavage testing. Because the cough was relieved by stopping PTU administration and there has been no relapse during 2-year follow-up, this case was diagnosed as PTU-induced diffuse alveolar hemorrhage. Her myeloperoxidase (MPO) -anti-neutrophil cytoplasmic antibody (ANCA) level was 55 EU, suggesting ANCA-associated angitis. However, as a drug lymphocyte stimulation test to PTU was also positive and her MPO-ANCA level was not elevated, the onset mechanism of this case was unclear.
Case: We report a 67-year-old man in whom pseudoaldosteronism developed following consumption of the health food Shin-Gojoshin. The patient began consuming Shin-Gojoshin in February 2007. His serum potassium level, which was within the normal range until he began consumption, gradually decreased to 3.0 mEq/L. The administration of potassium supplements and spironolactone was initiated. However, his hypokalemia persisted, and in December 2009, he was referred to our hospital for further examination. Laboratory data revealed hypokalemia, metabolic alkalosis, urinary potassium wasting, low plasma renin activity, and a low plasma aldosterone concentration. Pseudoaldosteronism was suspected and he was admitted. Although he reported no history of consumption of other traditional herbal medicines at the initial medical outpatient examination, he reported the consumption of Shin-Gojoshin in a medical interview taken on admission. Discontinuation of Shin-Gojoshin and potassium supplementation on admission successfully normalized his electrolyte imbalance. Conclusion: The present case describes the occurrence of pseudoaldosteronism induced by consumption of Shin-Gojoshin. A history of consumption of traditional herbal medicines and other health foods should be obtained, particularly in elderly individuals presenting with symptoms of pseudoaldosteronism.
Herein, I report the improvement of visual hallucinations (VHs) in 2 patients with a clinical diagnosis of probable dementia with Lewy bodies (DLB) through the use of ramelteon, a selective MT1/MT2 melatonin receptor agonist. When first seen with complaints of VHs and insomnia in our memory clinic, their scores on the Mini-Mental State Examination were 25 and 20. One patient developed VHs at the age of 72 and could describe them in detail (e.g., a large crowd attending a midnight party). The other patient had dreamed of his deceased wife since the age of 78. He developed VHs at the age of 81 and could describe them in detail: his deceased wife was present and he tried to talk to her, but she did not respond. Both patients lived alone and telephoned their family with complaints of VHs in the middle of night, resulting in an increase in the burdens of care. Because cholinesterase inhibitors had been prescribed for both patients, further pharmacotherapeutic interventions targeted their insomnia rather than their VHs to avoid neuroleptic drug sensitivity, a recommendation of the DLB guidelines. Furthermore, ramelteon has few adverse effects. Results: Within 8 weeks of initiating ramelteon, the VHs had disappeared and the insomnia had improved in both patients. Melatonin is recommended for the treatment of REM sleep behavior disorder (RBD), which is a frequent feature of DLB. The efficacy of ramelteon for VHs suggests a possible association of RBD with psychiatric symptoms in patients with DLB.
We report a case of a 75-year-old woman with urgent watery diarrhea, occurring 5 to 8 times per day, which began after starting lansoprazole (30 mg/day) for erosive gastritis. Her chronic watery diarrhea persisted for over 2 years with mild weight loss. Colonoscopy was performed and biopsies showed collagenous colitis in her transverse colon. We therefore replaced lansoprazole with famotidine (20 mg/day). Within 3 days after the discontinuation of lansoprazole, her watery diarrhea resolved and she recovered, and reported normal feces. Increasing age and female gender are major risk factors for collagenous colitis. The differential diagnosis of collagenous colitis should include: 1) an appropriate clinical history, excluding other etiologies, 2) normal or near-normal endoscopic and/or radiographic findings, and 3) colonoscopic biopsy histopathologic findings consistent with collagenous colitis. The histopathologic findings of colonoscopic biopsy are important for diagnosis. However, because of the colonoscopic burden in elderly patients, we first recommend the discontinuation of medications suspected to cause collagenous colitis.