Aim: The aim of this study was to develop a simple staging classification to measure leisure activity and social communication among the elderly at geriatric health care facilities. Methods: In order to construct a staging scale for measuring the participation of the elderly subjects, we developed a list of 28 items for three domains: leisure activities, social participation and communication. Data were obtained from users of institutional and day care services at geriatric health service facilities. The Rasch model was applied to test the degree of item fit and difficulty. Simple staging scales were constructed based on 12 leisure activity and nine social communication items. The validity and reliability were tested using these newly developed scales according to the Rasch model and assessments of the test-retest reliability. Results: The participants were 3,458 elderly persons, of whom 1,560 were currently using institutional services and 1,898 were using day care services. Among the 28 items, "traveling" was identified as the most difficult and "watching television" was identified as the easiest. Because items related to "social participation," such as volunteer activities, exhibited a low frequency, they were not used in the further analyses. Simple staging scales were constructed by analyzing the remaining items of leisure activities and social communication according to the Rasch model. The thresholds within the scales were determined in order of item difficulty. Cohen's kappa, as assessed by two different evaluators, was 0.75 for leisure activities and 0.77 for social communication. Conclusions: In this study, we developed staging scales for leisure activity and social communication. The construct validity and test-retest reliability were adequate for both scales. Service providers can improve service quality by using these scales for individual case management of elderly persons in conjunction with existing scales of activities of daily living.
Aim: This study aimed to identify factors associated with malnutrition in community-dwelling disabled elderly. Methods: A cross-sectional study of baseline data for 1,142 community-dwelling elderly (81.2±8.7 years) from of the KANAGAWA-AICHI Disabled Elderly Cohort (KAIDEC) study was conducted. The data included the participants' demographic characteristics, nutritional status (Mini Nutritional Assessment short-form: MNA-SF), dysphagia status (Dysphagia Severity scale: DSS), comorbidity, basic activities of daily living (bADL), hospitalization with in the past three months and care level according to the Long-Term Care Insurance program. The participants were considered to be in malnutrition or at risk of malnutrition if their MNA-SF score was 0-7 or 8-11, respectively. The chi square test, analysis of variance, jonckheere-terpstra trend test and logistic regression analysis were used for the statistical analysis. Results: A total of 16.7% of the participants were classified as having malnutrition. In addition, a higher prevalence of malnutrition was associated with a higher care level in the long-term care insurance program, and malnutrition was associated with a lower bADL score, the presence of dysphagia and dementia and hospitalization with in the past three months. Conclusions: The present study demonstrated that malnutrition in community-dwelling disabled elderly is associated with a lower bADL score, the presence of dysphagia and dementia and hospitalization with in the past three months.
Aim: Pseudogout is an important causative disease of febrile illness in elderly patients. We experienced cases of pseudogout during or after the progression of inflammatory disease. Methods: We investigated 14 patients with pseudogout admitted to the Department of Geriatric Medicine at Kyorin University Hospital. Seven patients who developed inflammatory disease prior to the onset of pseudogout are described in greater detail. Results: The affected joint was the knee joint in 12 of 14 cases. Other joints were affected in four cases, and four patients had more than two affected joints in this series. Clear joint cartilage calcification was noted on X-rays in nine of 14 cases, and CPPD crystals were detected in two patients treated with joint puncture. NSAIDs were administered in all cases for treatment. Seven patients had a preceding inflammatory disease, with infectious disease in all cases. Repeat elevation of temperature and inflammatory reactions were seen in seven cases, with progression to bimodal disease in two cases. The average duration of antimicrobial use was 11 days. In three cases, the average duration of antimicrobial use was 33 days, and two or more antimicrobials were used for long-term treatment. Conclusions: Pseudogout appears as delayed infective disease and fever of unknown origin in the elderly. This condition may easily be overlooked until joint symptoms become apparent. It is extremely important to keep pseudogout in mind as a differential diagnosis of thermogenesis in elderly patients.
A 94-year-old woman with Alzheimer's disease had been receiving nourishment via gastrostomy for three years and in a state in which communication was not possible. Upon the family's request for consultation and advice, and after a considerable discussion according to the guidelines, the decision was made to stop the gastrostomy feeding. The patient subsequently coincidentally contracted influenza one week later and died due to pneumonia. Based on our experience of making the decision to stop nutritional supplementation via gastrostomy according to the guidelines, there are various issues, such as the psychological distress of the family, which cannot be resolved based on the guidelines.
An asymptomatic 67-year-old woman was found to have renal tumors by chance on a screening abdominal ultrasound examination. Although surgical resection was planned for both a diagnostic purposes and treatment, she suddenly developed hemorrhage from the cerebral metastasis in the left thalamus, and the surgical procedure was postponed. Irradiation with a gamma knife was performed to treat the cerebral metastasis; however, the patient's general condition quickly worsened, and she died six months after diagnosis. An autopsy showed typical spindle cells in the primary lesion with multiple metastases. Renal spindle cell carcinoma is a relatively rare type of the renal carcinoma that is both very aggressive and exhibits a poor prognosis, with few established treatments. Hence, obtaining an early diagnosis on abdominal ultrasound is important in such cases.
An 81-year-old man was admitted to our hospital due to dyspnea in July 2008. A physical examination revealed marked splenomegaly, and the results of laboratory tests were as follows: hemoglobin (Hb)=7.0 g/dL, Ret=6.4%, WBC=24,100/μL (Ly: 20,003/μL), indirect bilirubin=3.6 mg/dL, LDH=232 IU/L. The cold agglutinin titer was 1 : 8,192, and a direct antiglobulin test was positive. A PET scan showed abnormal accumulation in the spleen and bone marrow. A bone marrow aspirate examination and biopsy demonstrated diffuse involvement of abnormal lymphocytes that were found to be positive for CD20 and negative for CD5, CD10, and cyclin D1. The immunoglobulin genes were clonally rearranged. Based on these findings, splenic marginal zone B-cell lymphoma (SMZL) associated with cold agglutinin disease (CAD) was diagnosed. Because the patient refused splenectomy, he was treated with four cycles of rituximab therapy (375 mg/kg, once a week). The Hb level and lymphocyte count subsequently normalized and the splenomegaly resolved. One year later, he relapsed and was again treated with rituximab therapy with complete remission. CAD accompanied by SMZL is very rare. Rituximab may be chosen as an alternative and effective therapeutic option in patients with SMZL-particularly those with autoimmune hemolytic anemia.
We herein describe a case of HIV-associated nephropathy (HIVAN) in a 64-year-old HIV antibody-positive man presenting with proteinuria. Laboratory examinations showed positive proteinuria, a high β2-microglobulin level and decreased creatinine clearance. He underwent a percutaneous renal biopsy, and a pathologic evaluation revealed a collapsing form of focal sclerosing glomerulosclerosis. Histologically, HIVAN is a collapsing form of focal sclerosing glomerulosclerosis (FSGS), which can be distinguished from idiopathic FSGS by the presence of microcystic tubular dilatation and interstitial inflammation. The patient was diagnosed with HIV-associated nephropathy and was started on ART. The HIV-associated nephropathy did not progress to acute renal failure, and long-term survival has been observed for over 12 years.
An 83-year-old Japanese man had a 29-year history of well-controlled diabetes mellitus. His HbA1c level was approximately 6.0%, with no microalbuminuria and a serum creatinine level seven days before admission of 0.8 mg/dl (eGFR: 69.67 ml/min/1.73 m2). Five days before admission, he visited an ophthalmologist with inflammation of the right palpebra and conjunctiva and began taking valacyclovir at a dose of 3,000 mg for the treatment of herpes zoster. Two days before admission, he was prescribed loxoprofen at a dose of 180 mg for a headache. One day prior to admission, he developed dysarthria, wandering and loss of appetite. He was subsequently admitted to our hospital with progressive deterioration of consciousness (Japan Coma Scale: II-20). On admission, he exhibited renal dysfunction, with a serum creatinine level of 5.11 mg/dl (eGFR: 9.16 ml/min/1.73 m2). Based on his diverse symptoms and current treatment with valacyclovir, the patient was diagnosed with acyclovir-induced neurotoxicity and his symptoms rapidly improved after hemodialysis. The serum acyclovir level on admission was found to be 9.25 μg/ml. Although acyclovir-induced neurotoxicity is commonly seen in elderly patients with renal dysfunction, there are also reports of this condition in patients with a normal renal function. Valacyclovir is frequently prescribed to the elderly to treat diseases such as herpes zoster. As valacyclovir induces renal dysfunction, which raises the serum acyclovir level to the toxic range, special attention must be paid when administering this drug in elderly subjects.
A 76-year-old woman with a 10-year history of chronic glomerulonephritis was treated at a clinic after presenting with a gradual worsening of the renal function. The patient had no history of tuberculosis. She was subsequently hospitalized for uremic symptoms and treated with internal shunt insertion and dialysis. Thyroid ultrasonography was performed to screen for secondary hyperparathyroidism, which revealed a calcified thyroid mass and cervical lymph node swelling. Fine-needle aspiration biopsy was thus conducted to assess suspected thyroid cancer. The cytological findings showed few follicular epithelial cells, without any signs of malignancy. However, a diagnosis of thyroid cancer continued to be strongly suspected based on the imaging features. Total thyroidectomy and bilateral cervical regional lymph node dissection were therefore performed, and the pathological examination of the thyroidectomy specimen disclosed scattered epithelioid granulomas with caseous necrosis in the entire right lobe as well as the cervical lymph nodes. Based on these findings, the patient was diagnosed with thyroid tuberculosis. As the symptoms and imaging findings of tuberculosis are nonspecific in elderly patients, it is necessary to consider this disease in this population. We therefore propose the inclusion of thyroid tuberculosis in the differential diagnosis of elderly patients who present with malignant thyroid tumors on aspiration biopsy cytology, regardless of whether or not they have a previous history of tuberculosis.