A normal value is a laboratory parameter to discriminate between "normal" and "abnormal" in clinical decision-making. Because individual differences in the elderly are large, it can be difficult to determine a normal value as a group, thus reference values are basically used to assess laboratory parameters. However, the reference value only shows the range of average values in the healthy population, and does not determine or predict present and future health status. In geriatric practice, reference values of laboratory parameters in life-style related disease to predict independent life is indispensable. Although there are many risk factors of cognitive impairment related to independent life, the contribution rate of each factor is small and it is often difficult to determine a cut-off point by conventional methods. A new methodology is required to determine the optimal range of clinical parameter of life-style-related disease using longitudinal data.
After reviewing the direction of the national dementia strategy from the perspective of the establishment of a community-based integrated care system, we present our recent work on strengthening medical services and promoting the early detection and intervention, and the integration of services for elderly patients with dementia. We developed a self-rating scale for assessing the capacity of medical facilities to provide services needed for dementia in terms of 7 latent factors. This scale is expected to be useful for assessing the effectiveness of programs aimed at strengthening medical resources, such as training programs for primary care physicians to increase their capacity to provide general medical services for patients with dementia or public programs for the establishment of a Medical Center for Dementia in each medical service area. We also developed an informant-rating scale for assessing change in behaviors affected by impairment of cognitive function and activities of daily living in patients with dementia, which had adequate reliability and validity as a screening tool for detecting mild dementia. The use of this scale should promote early detection, comprehensive geriatric assessment, access to diagnosis, care planning, and the integration of services for patients with dementia.
Aim: It is important to establish treatment goals and optimal anti-diabetic therapy for diabetic patients with dementia. However, there are currently no established treatment guidelines. Recently, the West Tokyo Diabetes Association has established the Diabetes and Dementia Study Group to investigate the status of anti-diabetic therapy for diabetic patients with dementia. Here, we assessed the current status of such patients by a questionnaire survey. Methods: In November 2011, we conducted a mailed survey to the clinics and hospitals affiliated with Kita-Tama, Hachioji and Tachikawa Medical Associations in Tokyo, Japan. The survey evaluated the most suitable anti-diabetic therapy for elderly diabetic patients or diabetic patients with dementia, combined anti-diabetic therapy, insulin therapy for elderly diabetic patients and diabetic patients with dementia, combination therapy of insulin and oral anti-diabetic agents for diabetic patients with dementia, factors that make it difficult for diabetic patients with dementia to continue insulin therapy, and selection of treatment or care for diabetic patients with dementia. Results: The responses indicated that the anti-diabetic agents appropriate for diabetic patients with dementia are dipeptidyl peptidase-4 inhibitors. Those inappropriate for the same patients are metformin and insulin. Family support was a major factor for insulin therapy continuation for diabetic patients with dementia. Moreover, anti-diabetic agents for these patients are selected according to their ease of use and compatibility with available familial and social resources. Conclusion: Our survey results can be utilized for the creation of new guidelines and educational resources for the anti-diabetic therapy of diabetic patients with dementia.
Background: Aging is an established risk factor for contrast-induced nephropathy (CIN). However, little information is available on the incidence and clinical outcome of CIN for the elderly patients in Japan. Objectives: We determined the incidence and clinical outcome of CIN in the Japanese elderly patient. Methods: We studied 292 patients who had mild renal dysfunction (estimated glomerular filtration rate (eGFR) <60 ml/min/1.73 m2) at baseline and underwent coronary angiography. Patients were divided into two groups base on their age: the elderly group (age≥75, n=108) and the control group (age<75, n=184). CIN was defined as a 25% increase in serum creatinine or an increase in serum creatinine by>0.5 mg/dl above the baseline value at or within 2 days post procedure. Results: Patients in the elderly group had a higher incidence of CIN (14%) than those in the control group (9%). In patients who developed CIN, there was no significant difference between the two groups in baseline GFR and GFR on days 1, 2, 7 and 30 after the procedure. However, the relative increase in GFR above baseline on day 7 (-4.0±6.1 vs -8.3±8.0 ml/min P=0.096) and day 30 (1.5±9.4 vs -10.1±9.6 ml/min P=0.0017) in the elderly group was higher than that in the control group. Furthermore, death occurred in 3 patients in the elderly group (20%) whereas no patient died in the control group (P=0.092). Conclusion: Aging (age≥75) is a risk factor for CIN in Japanese. CIN in the elderly patients may be associated with prolonged renal dysfunction and poor prognosis.
Aim: Assessment of the nutritional state is important in comprehensive geriatric assessment (CGA). Several standardized screening tests for malnutrition are available such as the Mini-Nutritional Assessment (MNA) and MNA-Short Form (MNA-SF). However, it takes more than 10 minutes to perform the MNA-SF alone. We have developed a CGA initiative named 'Dr. SUPERMAN', which is designed to accomplish CGA within 10 minutes. In this study, we evaluated a short-form screening test for malnutrition preceding the MNA. Methods: The MNA-SF, which consists of 6 items (A-F), was administered to 163 elderly outpatients (mean age: 83.4 years, 80 men) with various diseases. Using the results of the MNA-SF score (normal ≥12 and abnormal ≤11) as a gold standard, the sensitivity, specificity, and positive predictive values (PPVs) of each item were calculated and the best combination of 2 items for identifying malnutrition among the elderly outpatients was selected. According to the combination of 2 items (item B: weight loss during the last 3 months; item F: body mass index (BMI)/calf circumference (CC) in cm), they were divided into 2 groups: the normal control (NC) group (neither items B nor F) and the malnutrition/at risk (MN) group (either items B or D, or both). Findings of the clinical feature, anthropometric measurement, and nutritional biomarker between the 2 groups were examined to clarify the characteristics of each. Results: The MNA-SF score was distributed as follows: 3-7 in 12 cases, 8-11 in 68 cases, and 12-14 in 83 cases. Based on the MNA-SF score, the combination of items B and F revealed the highest sensitivity (91.3%), specificity (63.9%), and PPV (70.9%), resulting in 103 cases in the MN group and 60 cases in the NC group. A high frequency of anorexia, living alone, hypoprealbuminemia, lymphocytopenia, and dehydration was observed in the MN group, whereas a high frequency of leg edema was observed in the NC group. Cases showing a positive wall-occiput test, which compelled the alternation of CC with BMI, accounted for 24% of all cases. Conclusions: The combination of 'weight loss during the last 3 months' and initial BMI ≥23/CC <31 cm along with a positive wall-occiput test was a useful and valuable SF screening test for malnutrition in elderly outpatients.
Aim: It is well known that patients with Parkinson's disease (PD) prominently experience difficulty in smelling, a nonmotor symptom, without any signs or symptoms from an early stage. However, no study on the classification of the reduced sense of smell has been performed. We compared the classification of reduced sense of smell (bromine) between PD patients and healthy subjects to clarify the disorder profile. Methods: The subjects were 14 female neurology outpatients clinically diagnosed with PD (mean age: 71.6±6.1 years) and 11 female elderly healthy subjects without any psychiatric or neurological disorders (mean age: 68.9±6.9 years). In this study, the Japanese odor stick identification test was used. Results: Both the PD patients and the healthy subjects showed a reduced sense of smell for the bromine of lumber, orange, and domestic gas. The PD patients preserved a sense of smell for perfume, but they showed a significantly lower sense of smell than the healthy subjects for the bromine of China ink, menthol, curry, rose, cypress, sweaty socks, and condensed milk; this indicates that bromine can be a supportive diagnostic index for PD. Conclusion: It was considered important to evaluate the reduced sense of smell in PD patients to avoid hazards in their daily lives and to conduct an effective rehabilitation program.
Purpose: Lower urinary tract symptoms, particularly in overactive bladder (OAB), are frequently observed among elderly patients. The impact of OAB on their quality of life is so strong that the assessment of OAB is necessary in comprehensive geriatric assessment (CGA). As CGA takes time to complete, we established a convenient instrument consisting of 2 questions on OAB and assessed its utility. Method: We recruited 123 elderly patients with various diseases (mean age: 83.2 years, 63 men), in whom 2 questions on nocturia (Q1) and urinary incontinence at night (Q2) were asked. Thereafter, overactive bladder symptom scores (OABSS) were obtained to diagnose OAB based on the OAB criteria. Statistical analyses for Q1 and Q2 were performed using the OABSS criterion as a gold standard. To elucidate the clinical characteristics of the elderly patients, they were divided into 2 groups on the basis of the presence or absence of nocturia: nocturia (+) and nocturia (-) groups. The nocturia (+) group was subdivided into 2 subgroups: with or without incontinence. Results: Nocturia (Q1) was observed in 82 elderly patients and urinary incontinence (Q2) in 23, whereas OAB was diagnosed in 22. The sensitivity, specificity, and positive predictive value (PPV) of Q1 (Q1+Q2) were 100% (68.2%), 40.6% (92.1%), and 26.8% (65.2%), respectively. The nocturia (+) group patients were characterized as predominantly composed of men with cerebrovascular disease, disturbed activities of daily living, interrupted sleep, delayed wake-up time, and treatment with diuretics. Furthermore, Parkinson disease, depressive state, sedentary life style, and treatment without diuretics were frequently observed in patients in the incontinence (+) subgroup. Conclusion: A low PPV with a high sensitivity of Q1 was improved by using Q1+Q2, where both Q1 and Q2 enable better assessment of OAB resulting in being a useful screening test for OAB.
Aim: We investigated oral diadochokinesis (OD) among 212 Japanese aged over 55 years to assess the standard values of articulation ability. Methods: Each subject repeatedly produced the OD syllables /pa/, /ta/, and /ka/. Subjects were divided into three age-groups (55-64 years, 65-74 years, and over 75 years) and by gender to compare the number of OD syllables per second. We also calculated the lower limit of values that determined the standard range for OD syllables. Results: The number of all OD syllables in the over-75 age-group was significantly lower than in the 55-64 group. The number of OD /pa/ syllables in the over-75 group was significantly lower than in the 65-74 group. The number of OD /ta/ syllables in the 65-74 group was significantly lower than in the 55-64 group. The lower limit of the standard values for OD /pa/, /ta/, and /ka/ was, respectively, as follows: 4.9, 4.7, and 4.5 times in the 55-64 group; 3.8, 4.1, and 3.7 times in the 65-74 group; and 3.8, 3.3, and 2.6 times in the over-75 group. Among women, the number of OD /pa /, /ta/, and /ka/ syllables was significantly lower in the over-75 group than in other age-groups. Conclusions: We demonstrated that the lower limit of standard OD values is a means of assessing articulation in elderly subjects. We found that OD /ta/ tends to decrease from age 65 years. The decline in articulation ability clearly begins earlier in women than in men.