As society ages the number of dysphagia patients and elderly people who cannot independently manage oral care will also increase. Maintaining or improving proper swallowing and oral functions is an important issue from the perspective of retaining quality of life (QOL) and motivation in living. Dysphagia patients are susceptible to aspiration pneumonia, and are also more likely to be malnourished. Oral care for dysphagia patients does not involve simply cleaning the oral cavity, but also preventing aspiration pneumonia, which can be fatal. At the same time, it is related to improving eating and swallowing function and preventing dehydration and malnutrition. It is therefore very important from the perspective of improving QOL. Mechanical stimulation in oral care also plays a role as indirect training in eating and swallowing rehabilitation. The significance of oral care therefore lies in three points: (1) preventing aspiration pneumonia, (2) preventing malnutrition, and (3) indirect training in eating and swallowing rehabilitation. An oral care system of standardized oral care that can be completed in 5 minutes is promising as an effective means of oral rehabilitation.
Palliative care improves the quality of life of patients and their families facing problems associated with life-threatening illnesses by promoting the prevention and relief of suffering. Palliative care in Japan has been developed mainly for cancer patients. At the National Center for Geriatrics and Gerontology, an end-of-life care team (EOLCT) has been developed to promote palliative care for patients without cancer. In the first 6 months of its operation, 109 requests were received by the team, 40% of which were for patients without cancer or related disease, including dementia, frailty due to advanced age, chronic respiratory failure, chronic heart failure, and intractable neurologic diseases. The main purpose of the EOLCT is to alleviate suffering. The relevant activities of the team include the use of opioids, providing family care, and giving support in decision-making (advance care planning) regarding withholding; enforcement; and withdrawal of mechanical ventilators, gastric feeding tubes, and artificial alimentation. The EOLCT is also involved in ongoing discussions of ethical problems. The team is actively engaged in the activities of the Japanese Geriatric Society and contributes to the development of decision-making guidelines for end-of-life by the Ministry of Health, Labour and Welfare. The EOLCT can be helpful in promoting palliative care for patients with diseases other than cancer. The team offers support during times of difficulty and decision-making.
Aim: Cognitive impairment is the second leading cause of long-term care, and the number of cognitively impaired elderly individuals is increasing. Cognitive impairment has been reported to be associated with a low vitamin D level. However, many elderly individuals are deficient in vitamin D due to undernutrition and a house-bound status. It is unknown whether cognitive impairment is independently associated with the vitamin D level. The aim of this study was to examine the association between cognitive impairment and the levels of vitamin D among community-dwelling Japanese pre-frail elderly individuals. Methods: A cross-sectional survey was conducted in two towns (latitude: 36 degrees north) from June 2006 to January 2011. The subjects included 316 community-dwelling pre-frail elderly individuals 65 years of age or older (mean±SD: 77.0±5.7 yr) who attended a program for nursing care prevention. A questionnaire-based interview was conducted regarding activities of daily living. The serum levels of intact parathyroid hormone (iPTH), 25-hydroxyvitamin D (25(OH)D) and 1,25-dihydroxyvitamin D (1,25(OH)2D) were measured. Age and gender were recorded, as well as the presence of cognitive impairment determined according to the Mini Mental State Examination (MMSE). The factors associated with an MMSE score of ≤23 were examined using a multiple logistic regression analysis. Results: Of the subjects, 21.2% were men and 30.6% had an MMSE score of ≤23. The mean MMSE score was 25.3±3.7. The prevalence of severe deficiency of 25(OH)D was 1.7%, and only 14.0% of the participants had a sufficient vitamin D level. The multiple logistic regression analysis suggested that an MMSE score of less than 23 was significantly associated with the levels of iPTH and 25(OH)D among the pre-frail men, but not the women. Conclusions: Our data suggest that the vitamin D level is significantly associated with cognitive impairment in pre-frail elderly men.
Aim: The purpose of this study was to investigate the effects of comprehensive intervention on the development of exercise habits and self-perceived health among community-dwelling elderly individuals. Methods: A total of 44 elderly individuals (mean age: 71.1±5.0SD) who had provided consent to participate in the study were randomly allocated to either an intervention (n=23) or control group (n=21). The intervention group participated in a comprehensive intervention program (including nutrition classes, group exercise and enjoying meals with other community members). The following factors were measured: age, the frequency of going out, a history of falls, the frequency of exercise, the duration of exercise, self-efficacy for exercise, the stage model of change, self-perceived health before, immediately after and one month after the intervention. Results: The attendance rate in the intervention group was over 90%. The intervention group exhibited significant improvements in the frequency of exercise (p=0.001), duration of exercise (p=0.02) and self-efficacy for exercise (p=0.012) compared with the control group following the intervention program. On follow-up, the intervention group demonstrated significant improvements in the frequency of exercise (p=0.027) and self-efficacy for exercise (p=0.043) compared with the control group. Conclusions: These findings suggested that a comprehensive intervention program composed of nutrition and exercise can improve the developing exercise habits and self-perceived health. Self-perceived health was improved by several factors, which appeears to have contributed to the results. These factors include sharing and exchanging ideas and having the opportunity to enjoy meals with other community members. Further activities promoting such interactions and exercise habits are therefore necessary.
Aim: To examine the association between gait parameters and knee pain, urinary incontinence, and a history of falls. Methods: Comprehensive health examinations were conducted in 2009 among 971 elderly women over 70 years of age, in which the questionnaire and gait parameter results of 870 participants were analyzed. Knee pain, urinary incontinence and a history of falls were assessed through face-to-face interview surveys. Gait parameters were measured using a walk-way to assess walking speed, cadence, stride, stride length, step width, walking angle, toe angle and the differences in each parameter between the right and left foot. Multiple logistic regression analyses were performed to examine the associations between the gait parameters and knee pain, urinary incontinence and a history of falls. Results: The elderly women with knee pain, urinary incontinence and a history of falls had slower walking speeds, smaller strides and strides length, and wider step width and walking angles. The multiple logistic regression analysis showed the walking speed to be significantly associated with mild knee pain and urinary incontinence and single a history of fall; moderate/severe knee pain was significantly associated with step width (OR=0.58, 95%CI=0.40-0.84) and walking angle (OR=1.62, 95%CI=1.30-2.01); moderate/severe urinary incontinence was significantly associated with walking speed (OR=0.97, 95%CI=0.96-0.99), walking angle (OR=1.14, 95%CI=1.02-1.26), and difference in walking angle between the right and left foot (OR=1.43, 95%CI=1.09-1.86); multiple a history of falls was significantly associated with stride length (OR=0.85, 95%CI=0.79-0.93) and the difference in walking angle between the right and left foot (OR=1.36, 95%CI=1.01-1.85). Conclusions: The data suggest that combining assessments of walking speed and other gait parameters may be an effective screening method for the early detection of geriatric syndromes.
Objective: To evaluate the influence of age at the time of gastrostomy placement as a prognostic factor and examine the survival rate in long-term hospitalized patients with gastrostomy. Methods: The subjects were 408 inpatients with gastrostomy admitted to our hospital between December 2005 and March 2012. All inpatients, including the present subjects, received oral care in the form of attendant care by nurses or caregivers. First, the subjects were divided into two groups according to sex. Second, the subjects were divided into four groups according to the age at the time of gastrostomy placement: the sixties group (60-69 years), seventies group (70-79 years), eighties group (80-89 years), and nineties group (90-99 years). Each survival curve was drawn using the Kaplan-Meier method, and the log-rank tests were used for statistical analysis. The Cox proportional hazard models were used to calculate hazard ratios. Results: The overall survival rates at one year and five years after gastrostomy placement were 75.4% and 23.2%, respectively. The median survival period was 32.2 months. A significantly better prognosis was observed in women than in men; the age-adjusted hazard ratio was 1.748 (95% CI, 1.364-2.242) for men. The eighties and nineties groups exhibited significantly poorer prognoses than that of the sixties group (p<0.008); the sex-adjusted hazard ratios were 2.173 (95% CI, 1.341-3.521) and 3.071 (95% CI, 1.627-5.797), respectively. Conclusions: These results suggest that oral care, even after gastrostomy placement, can improve the prognosis in patients with gastrostomy. Physicians should therefore be cautious when recommending gastrostomy placement for patients aged>80 years.
A 73-year-old Japanese man with Hashimoto's disease and diabetes mellitus received regular medical checkups for type 2 diabetes care. Blood tests indicated macrocytic anemia (red blood cell count, 279×104 /μL; hemoglobin, 12.2 g/dL; hematocrit, 34.0%; mean corpuscular volume, 121.9 fL). The laboratory data demonstrated a normal folic acid level with a low vitamin B12 level. An endoscopic examination indicated no signs of gastric or intestinal bleeding. Positive results for anti-intrinsic factor antibodies were strongly suggestive of pernicious anemia. The patient refused cobalamin injections to treat the anemia. However, the oral administration of mecobalamin for the treatment of diabetic neuropathy was simultaneously initiated. Subsequently, the anemia gradually improved. Oral mecobalamin was presumably effective for pernicious anemia management. Anemia is frequently observed in elderly patients, and the incidence of pernicious anemia increases with age. Anemia is conventionally treated with cobalamin injections. Currently, the oral administration of mecobalamin is not the typical treatment for anemia. However, as in our case, a few reports have documented positive results following oral mecobalamin treatment. Moreover, oral mecobalamin is a fairly recent, novel, noninvasive mode of treatment, making it ideal for elderly patients, who are generally frail. This case suggests the efficacy of mecobalamin for the treatment of pernicious anemia.
A 68-year-old woman presented with a sudden severe headache, vomiting, and disturbed consciousness. She was admitted to the emergency room. Computed tomography (CT) revealed a hemorrhage in the right temporal lobe. Angiography demonstrated a ruptured aneurysm in the right middle cerebral artery (MCA) and an unruptured aneurysm in the left MCA. The subarachnoid hemorrhage was grade 3 (Hunt and Kosnik classification). Emergency craniotomy, clipping of the ruptured aneurysm and removal of the hematoma were performed. The left hemiparesis improved, and the patient was able to walk. We prescribed triazolam (0.25 mg/day) to treat the patient's insomnia. The unruptured aneurysm was additionally clipped on the 15th hospital day. After the second operation, the patient complained of delirium with restlessness, excitement, disorganized behavior, and sleep disturbance. Treatment with thiapride (150 mg/day) did not improve the delirium. We additionally administered Yi-gan san (7.5 g/day) and switched the triazolam to ramelteon (8 mg/day). The Memorial Delirium Assessment Scale score improved dramatically (from 16 at onset to 5 on day 7 and 1 at two months). Yi-gan san is reported to be effective for the treatment of behavioral and psychological symptoms of dementia. Ramelteon, a melatonin receptor agonist, is implicated in the regulation of the sleep-wake cycle. Ramelteon, unlike other hypnotic drugs, does not cause oversedation, rebound insomnia, withdrawal symptoms or dependence. In addition, we have noted no adverse effects, including oversedation or clinically significant changes in laboratory data, during combination therapy. A combination of ramelteon and Yi-gan san may therefore be beneficial in elderly patients with delirium, especially when there is a risk of oversedation.
A 77-year-old man being treated for Alzheimer-type dementia and an old cerebral infarction was admitted to our hospital due to disturbance of consciousness. The patient's Mini-mental State Examination and Hasegawa Dementia Scale scores were 23 and 17 points, respectively. His blood glucose level was low (18 mg/dl), with a relatively high insulin level (15.2 μU/ml). Computed tomography and an 18-hour fasting test showed no signs of insulinoma. Since his wife had been taking medications for dementia and diabetes, including Glimepiride, we considered the possibility that he may have taken glimepiride by mistake. Five months later, he was admitted again due to severe hypoglycemia with a relatively high insulin level (23.4 μU/ml). More than 660 g of glucose and 100 mg of hydrocortisone were administered, and the hypoglycemia resolved approximately 24 hours after admission. Again, there were no signs of insulinoma. We asked Sanofi-Aventis to measure the level of glimepiride in a blood sample obtained six hours after admission. Glimepiride was detected at a concentration of 24.48 ng/ml, which roughly corresponded to the accidental ingestion of 6 mg of the drug. We were later informed by the patient's home doctor that he had visited the emergency department of another prefecture hospital with the same symptoms. Thereafter, the couple received counseling by their home doctor, and the hypoglycemia has not recurred since. Given the increase in the number of elderly households, an increase in the number of episodes of accidental ingestion of medicine is expected. Clinicians should be aware of the potential for accidental exposure to drugs prescribed to other family members especially, in elderly patients.