Aim: Clinicians need an objective scale to measure apathy in patients with dementia. However, different cutoff scores for the Apathy Evaluation Scale Informant version (AES-I), an international apathy scale, have been used in previous studies. The purpose of this study was to investigate the cutoff score, reliability and validity of the Japanese version of the AES-I (AES-I-J). Methods: We acquired the author's permission to translate the AES from English to Japanese. The subjects of this study included 50 patients with dementia living in institutions or the community. The mean (standard deviation; SD) age of the subjects was 82.7 (5.7) years, the mean (SD) educational level was 8.9 (2.7) years and the mean (SD) Mini-Mental State Examination score was 14.8 (8.1). We provided the caregivers with two apathy scales to assess each patient: the AES-I-J (re-test: four weeks later) and the Neuropsychiatric Inventory in Nursing Home version apathy score. Results: The mean (SD) score for the AES-I-J was 45.8 (16.2). For this test, Cronbach's α was 0.97, and the intraclass correlation coefficient of test-retest was 0.88 (95%CI: 0.72-0.95) (p<0.0001). In addition, the area under the receiver operating characteristic curve was 0.90 (95%CI: 0.78-1.00) (p<0.0001) and the cut-off score was 45/46, with a sensitivity of 89.5% and specificity of 81.0%. Conclusions: Our findings suggest that the cutoff score for the AES-I-J is higher than that used in previous reports.
A 78-year-old woman was admitted to our hospital with lumbago. Her activities of daily living had previously been completely independent. However, she developed temporary chills in January 2009, that improved without treatment, but recurred on February 7, 2009 in association with left lumbago and loss of appetite. She was then referred to our hospital with a disturbance of consciousness and high fever on February 14. A blood test performed on admission revealed an elevated inflammatory response, coagulation disorder and low platelet count, and abdominal computed tomography demonstrated findings suggestive of pyogenic spondylitis. The patient was therefore admitted and treated with antibiotic therapy; however, she died on day 8 due to complications of disseminated intravascular coagulation. An autopsy showed isolated pulmonary valve endocarditis. The patient's history was later found to include regular dental treatment, and the same Streptococcus group G was detected in cultures of the sputum, blood and vegetation. It is important to interview patients regarding their history of dental treatment, particularly elderly individuals with fever of unknown origin.
A 90-year-old man with a previous history of brain infarction and diabetes mellitus presented with a gait disturbance. Although brain computed tomography (CT) showed no abnormalities, except for the old infarction, the patient experienced recurrent epileptic seizures. He was therefore admitted to our hospital for a further examination of the seizures. However, upon admission, he also presented with a fever and elevated C-reactive protein levels, indicating systemic inflammation. Based on the presence of bilateral infiltration visible on a chest X-radiograph, the patient was diagnosed with aspiration pneumonia. The administration of 4.5 g of sulbactam and ampicillin did not reduce the inflammation or resolve the abnormal lung findings. Therefore, he was intubated and placed on a ventilator. With the patient under ventilator management, we subsequently performed bronchoscopic alveolar lavage. Elevated neutrophil and lymphocyte counts were noted in the alveolar lavage fluid; therefore, we administered pulse steroid therapy with 500 mg of methylprednisolone. The sputum and alveolar lavage fluid samples collected 13 and 14 days, respectively, after admission were negative for Mycobacterium according to a smear test. In contrast, the cultured sputum samples collected on day 13 were positive for Mycobacterium tuberculosis; polymerase chain reaction testing confirmed the sputum culture results. A postmortem pathological examination of the lungs revealed neutrophilic exudative pneumonia as well as acute fibrinous and organizing pneumonia. Although Ziehl-Neelsen staining demonstrated a large number of positive bacteria, no epithelioid-cell granulomas were observed. M. tuberculosis lesions were also found in the liver, spleen, bones, and adrenal glands, suggesting hematogenous dissemination. Aspiration pneumonia is very common in elderly patients with a history of stroke, and these patients are also at risk of other pulmonary disorders and infections including M. tuberculosis. Prior to administering treatment for aspiration pneumonia, clinicians should consider the potential for other pulmonary infiltration disorders in the differential diagnosis, particularly in elderly post-stroke patients.