Depression screening was conducted to determine the health status of community-dwelling elderly individuals, and the concept of advance care planning was introduced. While depression screening among the elderly often uses the Geriatric Depression Scale, a single question regarding depressive mood also provides a valid measure of depression in elderly persons. Depression is associated with lower activities of daily living, competence, and subjective quality of life among the elderly living in Vietnam and Indonesia, as well as in Japan. Advance care planning is a process of discussion between individuals and their care providers to make decisions about future care preferences and priorities, while they are still capable. If they wish, they may prepare an advance directive to inform others about their decisions and best interests, such as a written advance decision to refuse treatment and/or appointment of a person with lasting powers of attorney. The purpose of advance care planning is to enable elderly persons to receive better end-of-life care. To promote introduction of advance care planning in Japan, voluntary discussion among family members should be encouraged.
The health status of high-altitude population in Qinghai (China), Ladakh (India), and Arunachal (India) was investigated using comprehensive geriatric functional assessment in relation to their recent lifestyle change with the socio-economic globalization. People in urban areas had a higher prevalence of lifestyle-related diseases and poorer geriatric functions, and a lower subjective quality of life (QOL) than people in rural areas. The optimal prevention of lifestyle-related diseases and preservation of a high QOL are important for the people living in each of the above-mentioned areas with a high altitude.
Aim: Suicide rates in the United States are higher in higher altitude areas, and hypoxia has been cited as a factor in these higher rates. There may be a significant correlation between rates of depression and altitude, but little data exist outside the United States. The purpose of the present study is to conduct a survey of depression among the elderly residing in the Himalayas and the Andes. Method: We visited Ladakh (altitude 3,800-4,800 m) in India, Qinghai (3,700 m) in China and Puyca (3,600 m) in Peru between July 2009 and July 2011. We recruited 114 farmers from Domkhar in Ladakh (mean age, 69.2 years; female-male ratio, 58.8%), 206 nomads from Changthang in Ladakh (55.1 years; 43.7%), 173 Tibetan subjects from Qinghai (66.5 years; 61.3%) and 103 indigenous Andean subjects from Puyca (69.0 years; 68.0%). The two-item Patient Health Questionnaire (PHQ-2) was administered to the subjects. A psychiatrist interviewed the residents with single or double positive scores on the PHQ-2. Result: The ratio of subjects with one or more positive score in PHQ-2 was significantly higher in Qinghai than in other regions. (Domkhar vs. Changthang vs. Qinghai vs. Puyca = 7.0% vs. 5.3% vs. 36.9% vs. 15.5%, P<0.001). However, prevalence of depression by interview did not change in these regions. (1.8% vs. 1.9% vs. 2.3% vs. 2.9%). Conclusion: Despite the high altitude, the prevalence of depression was low in elderly highlanders in the Himalayas and the Andes. These results may relate to being presumed to related to a deep devotion to a religion and tight interpersonal networks.
Background and aim: Cerebral infarction causes permanent neurological damage. Recently, the intravenous administration of bone marrow-derived mononuclear cells has been shown to improve functional recovery through enhanced angiogenesis in an experimental stroke model. Based on these observations, we have started a phase 1/2a clinical trial of cell-based therapy for patients with cardiogenic cerebral embolism. Methods: The major inclusion criterion was patients in whom severe cerebral embolism was diagnosed (more than 9 in the NIHSS score on day 7 after the onset of stroke) at age 75 or younger. The patients received 25 ml (low-dose group, n=6) or 50 ml (high-dose group, n=6) of bone marrow aspirate on days 7-10 after the onset of stroke. Autologous bone marrow-derived mononuclear cells were purified by the density gradient method and administered intravenously on the day of cell aspiration. The primary endpoint was safety and improvement of the NIHSS score compared with our historical control. Results: We treated 6 patients in the low-dose group and 4 patients in the high-dose group. No adverse effects were observed and most of the patients showed a significant improvement in neurological function at 6 months after cell transplantation. No enrolled patients showed worsening of the NIHSS score at 30 days after the treatment compared with the NIHSS score before the treatment. Conclusion: Autologous bone marrow mononuclear cell transplantation is apparently safe and feasible, and it improves functional recovery.
Objective: The objective of this study was to investigate the difference of physical ability depending on the presence or absence of confidence in motor function (CIMF) and fear of falling (FOF) in independently living community-dwelling older adults. Methods: Participants in this study were 368 community-dwelling older adults (mean age±SD, 72.2±5.7 years) without instrumental activity of daily living (IADL) problems who participated in a comprehensive health check-up. CIMF (existence or non-existence), FOF (existence or non-existence), past medical history, history of a fall within the past year, and self-rated health were assessed by interview. Physical ability [grip strength, one-leg standing (OLS), maximum walking speed (MWS), and timed up & go test (TUG)] was also measured. Results: Our results revealed significantly more older adults with FOF and without CIMF than expected, indicating that CIMF might be a component factor in FOF. Two-way ANOVA adjusted for sex and age showed main effects of the CIMF factor on grip strength, OLS, and TUG, indicating that these physical abilities are reduced in participants without CIMF, regardless of FOF. On the other hand, we found a main effect of the FOF factor on MWS. Logistic regression analysis showed that frequency of going outdoors, self-rated health, arthropathy, and OLS were factors associated with CIMF. Conclusions: Our results suggest that CIMF is a useful screening tool for older adults with potential problems and evaluation of intervention for health promotion in community-dwelling older adults without IADL problems.
The objective of this multicenter open-label randomized study was for evaluating nutrition intervention on pressure ulcer healing. Tube-fed patients with Stages III to IV pressure ulcers were enrolled. Target energy levels to be given were the same value as at the time of enrollment or BEE×1.1 (activity factor)×1.1-1.3 (stress factor) in the control group, and BEE×1.1×1.3-1.5 in the intervention group. Both groups received the feeding formula Racol® for 12 weeks, and were prescribed to have pressure relief mattresses, and to unify the repositioning method, treatment drugs, and wound dressing materials. Ulcer sizes (length×width), nutritional state, and adverse events were evaluated. Results of the study: Energy levels administered to the control (n=29) and intervention (n=21) groups were 29.1±4.9 (mean±SD) and 37.9±6.5 kcal/kg/day, respectively. Regarding pressure ulcer size, the interaction between the nutrition intervention and the courses during observational weeks was significant (P<0.001). Similarly, significant differences were observed with weight, waist circumference, Cu (P<0.001), suprailiac skinfold thickness (P<0.01), thigh circumference, and prealbumin (P<0.05), but not with the incidence of adverse events (P=0.360). Principal component analysis indicated remarkable decreases in ulcer size and improvement rates of waist circumference and suprailiac skinfold thickness in the intervention group. Covariance structure analysis showed that nutrition intervention has a direct effect on reduction in ulcer size. The results suggested that aggressive nutrient intervention accelerated the pressure ulcer of wound healing process and had a direct effect on reduction in ulcer size.
Aim: Leg edema, observed on comprehensive geriatric assessment (CGA) of 142 elderly outpatients with a variety of chronic diseases, was studied clinically to clarify its incidence and its associated risk factors. Methods: The severity of pitting edema was assessed at 3 points, namely, the pretibial edge, medial malleolus, and the dorsum of the foot. On palpation, edema was graded as 0 to 3 for each point on one leg, the sum of which was used as the edema score. According to the edema score, subjects were divided into 3 groups; the moderate to severe (MS) group, the slight to mild (SM) group, and the group without pitting edema. The MS group was defined as having an edema score of 4 or more or edema of grade 2 or more, while the SM group was defined as having an edema score of 2 to 3 points without edema of grade 2 or more. The status of underlying disease, vascular risks, varicose veins, medications, daily activity, nutrition, total protein (TP), albumin, brain natriuretic peptide (BNP), and the estimated glomerular filtration rate (eGFR) were compared among the 3 groups. Results: There were 36 subjects in the MS group and 19 subjects in the SM group. Diabetes, atrial fibrillation, varicose veins, and polypharmacy were more frequent in the MS group than in the control group. Sedentary life style, house-bound, and gait trouble were significantly more frequent in the MS and SM groups. There were no significant differences in the scores of the Mini-Nutritional Assessment Short Form among the groups, although both the body weight and calf circumference in the MS group were significantly greater than those in the group without pitting edema. Low serum TP, albumin and eGFR were seen in the MS group as well as high BNP levels. Multiple regression analysis revealed diabetes, varicose veins, sedentarism, and hypoalbuminemia as risk factors associated with leg edema (R2=0.365, p<0.0001). Conclusion: Leg edema was frequent in the elderly outpatients and was associated strongly with diabetes, varicose veins, sedentarism, and hypoalbuminemia. These findings suggest that advising against a sedentary life style could help the resolution of edema, and also indicates the clinical usefulness of CGA. Furthermore, leg edema should be seriously considered along with nutritional assessment because edema could influence various anthropometric parameters.
Aim: "Saving appearances behavior", pretending to know the correct answer, or a reply of deceptive replies, are often found in the reply of patients with dementia. We have already found that we can classify the answers to "what is the latest news on TV or newspapers?" into 4 types, including saving appearances answer. The purpose of the present study is to develop a simple clinical diagnostic method based on the answers to "what is the latest news on TV or newspapers?" for differentiating patients with Alzheimer's disease (AD) from those with mild cognitive impairment (MCI), and to test the validity, sensitivity and specificity of the method. Methods: We recruited 133 consecutive outpatients with AD, 116 with MCI, and 54 normal cognitive aging controls (NC). Mini-Mental State Examination (MMSE) was performed for all of the subjects. Severity of memory disturbance was rated 0 (none) to 3 (severe) according to the results of the 3-object recall portion of the MMSE questionnaire. Results: Only 20% of AD and 32% of MCI responded correctly about the recent news while 96% of NC responded correctly. Among patients with AD and MCI, one third of them showed "saving appearance behavior". Taking the result of the memory disturbance according to the MMSE in consideration, the present study indicates that the AD patients can be distinguished from MCI and NC with high sensitivity (98%) and high specificity (94%) using this simple, one-phrase question. Conclusions: "What is the latest news on TV or papers?" was highly effective in identifying AD and MCI. The present study suggests that the "saving appearances answer" is associated with the onset or awareness of memory impairment, the maintenance of the frontal lobe function and other characteristics of the patient.
We report an 84-year-old woman with left lower limb muscle weakness and numbness who also had weakness in her right lower limb, which showed spontaneous partial improvement. Neurological examination revealed lower extremity weakness and sensory disturbance in all modalities, predominantly distally on the left side. Laboratory studies yielded normal results, except for a slightly high erythrocyte sedimentation rate. Nerve conduction studies showed axonal neuropathy in the right tibial nerve, and loss of action potentials in other lower limb nerves. Histological study of the left sural nerve revealed mainly loss of axons and differences in the density of fascicules in the axons. In addition, inflammatory cells infiltrated around small blood vessels. Therefore, we diagnosed nonsystemic vasculitic neuropathy. Magnetic resonance imaging revealed that she also had spondylosis deformans and radiculopathy, which was more difficult to differentiate. Neural biopsy was important for diagnosis.
An 83-year-old Japanese woman given a diagnosis of type 2 diabetes mellitus 3 years previously was hospitalized for markedly elevated plasma glucose (386 mg/dl) and glycated hemoglobin (9.3%) levels. Laboratory study results showed urinary connecting peptide immunoreactivity (CPR) concentrations of 8.9 μg/day and serum CPR levels <0.2 ng/ml before and 0.3 ng/ml 6 min after glucagon administration, indicating decreased insulin secretion. Although antiglutamic acid dehydrogenase (GAD) antibody levels were negative, insulinoma-associated tryrosine phosphatase-like protein-2 (IA-2) antibody levels were positive (50 U/ml), leading to a diagnosis of type 1 diabetes mellitus. Furthermore, human leukocyte antigen (HLA) typing revealed DRB1*0901, a diabetes-susceptibility gene. Intensive insulin therapy was initiated. This was a rare case of elderly-onset type 1 diabetes.
Although macrocytic anemia can develop in patients with acute blood loss, such anemia in very old patients is uncommon. In this report, we describe the course of an 89-year-old woman who had a rapid recovery from macrocytic anemia by medication only after acute blood loss due to a gastric ulcer. She had been treated with antihypertensive drugs for the previous 28 years at our outpatient clinic, and was admitted because of acute anemia 6 days after she had experienced tarry stool. Her hemoglobin (Hb) count and mean corpuscular volume (MCV) were 8.4 g/dl, and 103 fl, respectively. A gastroscopic examination indicated that the tarry stool originated from a fresh gastric ulcer. She was treated with an iron preparation, a diuretic and a proton pump inhibitor. The anemia was rapidly improved to Hb 10.5 g/dl and MCV 106 fl in one week, and to Hb 14.5 g/dl and MCV 99 fl in 4 weeks. At admission, she had slight pleural effusion and slight edema associated with an increase in her plasma brain natriuretic peptide (BNP) level (323 pg/ml), and her left ventricular ejection fraction was 76% based on the echocardiography findings, which are signs of the high-output heart failure without remarkable left ventricular diastolic dysfunction (E/e': 11.2). However, these signs improved rapidly, and her BNP level thereafter decreased to 114 pg/ml within four weeks.