Aim: Most physical activity (PA) guidelines for health promotion recommend moderate to vigorous PA (MVPA) lasting at least 10 minutes (long-bout MVPA). However, recent studies have shown the beneficial effects of short-bout MVPA (intermittent and lasting <10 minutes). Therefore, we aimed to clarify the detailed patterns of MVPA of community-dwelling older adults using accelerometers.
Methods: This is a cross-sectional descriptive study. Community-dwelling older Japanese adults (total: 1,210; 70-80 years of age) randomly selected from residential registries of 3 municipalities (Bunkyo, Fuchu, and Oyama) were asked to wear an accelerometer (HJA-350 IT; Omron Healthcare, Japan). MVPA was classified by bout length (1-4, 5-9, 10-19, 20-29, and > 30 minutes). The mean frequency and duration of MVPA by each bout length and the proportion of long-bout MVPA were described.
Results: Valid data were obtained from 450 participants (men: 56.7%; mean age: 74 years). The mean±standard deviation of the frequency and duration of MVPA bouts were 21.8±14.6 times/day and 2.1±0.9 min, respectively. The total duration of MVPA was 46.5±33.0 min/day. Long-bout MVPA accounted for 26.9%±23.5% of daily MVPA, whereas MVPA of 1-4 minutes accounted for 43.4%.
Conclusions: Older adults performed about 45 minutes of MVPA a day, but most of this was short-bout MVPA, which is overlooked by current WHO PA guidelines. In particular, short-bout MVPA was frequent among older women and those living in rural areas.
Background and Aim: We examined oral dyskinesia (OD), wearing artificial tooth, food test findings and conducted a video - fluoroscopic swallowing study (VFSS) in bedridden elderly patients before they were received parenteral nutrition once daily. However, the validity and properties of these deglutition foods have not been evaluated. Therefore, in this study, we clarified four deglutition foods as four aspects.
Method: Forty-five patients (23 males, mean age: 82.5 years) receiving deglutition foods were evaluated. The OD and food tests were performed at the bedside. The VFSS (dynamics of swallowing, oropharyngeal transit time, distance of hyoid bone displacement and difference in the oropharyngeal transit time) was conducted via X-rayunder administration of contrast medium mixed with food. Additionally, the physical properties of the deglutition foods were evaluated in accordance with thestandard methods for patients with dysphagia by the Ministry of Health, and Labour, Welfare and Consumer Affairs Agency.
Results: The mean duration receiving deglutition foods was 8 months. Although OD and wearing artificial tooth were observed in 42% of the patients, the rate of OD was significantly higher in patients receiving thick than in patients receiving jelly. The deglutition foods were classified into four types based on their physical properties (thick 1, n=18; thick 2, n=10; jelly 1, n=10; and jelly 2, n=7). The food test scores markedly differ among the four types of deglutition food. The mean score for swallowing dynamics was significantly different among the four types. Although the oropharyngeal transit time was similar for each type, the thick 1 group was divided into fast and slow transitors. The distance of hyoid bone displacement was significantly different among the four types. The oropharyngeal transit time was significantly correlated with the number of teaspoons ingested at a time. In the physical properties test, all four deglutition foods showed appropriate results; thick 1 and 2 were within the standardII category, while jelly 1 and 2 were within the standardIII category.
Conclusion: The results of swallowing tests suggest that these four deglutition foods may be safe and reasonable for administration to bedridden elderly patients receiving parenteral nutrition.
Aim: This study aimed to investigate the effects of limited health literacy on arterial stiffness measured by the cardio-ankle vascular index (CAVI) in community-dwelling older adults.
Methods: A total of 288 older adults (mean age, 72.4 years, men, n = 99) participated. The degree of arterial stiffness was assessed based on the CAVI using the VS-1500 device (Fukuda Denshi Co., Ltd., Tokyo, Japan). Arterial stiffness was defined according to a cut-off point of ≥9.0. Comprehensive health literacy was assessed using the 47-item European Health Literacy Survey Questionnaire (HLS-EU-Q47). Other potential confounding factors, such as demographics, number of prescribed medications, mini-mental state examination results, grip strength, gait speed, current smoking, alcohol consumption, and physical inactivity, were also assessed. An analysis of variance for continuous variables or chi-square test for categorical variables was used for group comparisons. A logistic regression analysis was performed to examine the association between quartiles of HLS-EU-Q47 and arterial stiffness in crude and multivariate models adjusted for age, gender, and other confounding factors.
Results: The first quartile with the lowest health literacy showed a significantly higher CAVI and prevalence of arterial stiffness than the fourth quartile with the highest health literacy (p<0.05). In logistic regression, the crude model showed that the third quartile (odds ratio [95% confidence interval] = 0.48 [0.24-0.93]) and fourth quartile (0.39 [0.19-0.77]) were significantly associated with arterial stiffness, while the multivariate model showed that to fourth quartile was significantly associated with arterial stiffness (0.44 [0.19-0.98]).
Conclusions: Older adults with limited health literacy might be at a higher risk of arterial stiffness after accounting for confounding factors.
Aim: To improve preventive strategies for readmission within 30 days after discharge among older patients receiving home medical care services, we examined the associations between readmission within 30 days and the medical institute factors among patients over 75 years of age.
Methods: All patients over 75 years of age receiving home medical care services and who had been admitted to hospital or clinic and discharged between September 2013 and July 2014 in Tokyo, Japan, were participants of this study (n=7,213). The primary outcome was readmission within 30 days after discharge. We performed generalized estimating equations (GEEs) using a model with logit link and binominal sampling distribution to examine the associations of sociodemographic variables, the prevalence of chronic diseases and medical institute factors with readmission within 30 days.
Results: Approximately 11.2% of the patients receiving home medical care services who had been discharged were readmitted within 30 days after discharge. Men, cancer patients, and emergency admission were positively associated with readmission within 30 days according to the GEEs. The rate of readmission within 30 days was lower in patients receiving home medical care services at home care support clinics/hospitals after discharge (adjusted odds ratio [aOR] = 0.205, p value < 0.001) and in patients discharged from hospitals with over 200 beds (aOR = 0.447, p value < 0.001, vs. clinics) than in others.
Conclusion: Home care support clinics/hospitals, which can provide home medical care services around the clock, may help reduce the rate of readmission within 30 days.
Aim: To clarify the minimum knee extension muscle strength needed to maintain walking speed and step length in older male inpatients.
Method: The participants were 786 male inpatients of ≥65 years of age without cerebrovascular disorder, orthopedic disease, malignancy, or dementia. We investigated the participants' isometric knee extension muscle force (kgf/kg), maximum walking speed (m/s) and step length, based on their medical records. The relationship of walking speed and step length to isometric knee extension muscle force was fitted to linear and nonlinear models, and the respective R2 values were compared. Next, the muscle force data were divided into two groups, and two linear functions were calculated. Then, the muscle force value that minimized the sum of the residual sum of squares of the two linear function expressions was obtained.
Results: The R2 values of each equation in the nonlinear model were higher than those in the linear model. Among all participants, the muscle force values that minimized the sum of the residual sum of squares for walking speed and step length were 0.33 kgf/kg and 0.43 kgf/kg, respectively. Among participants of ≤74 years of age, the muscle force value that minimized the sum of the residual sum of squares was 0.30 kgf/kg for both walking speed and step length, whereas the values were 0.32 kgf/kg and 0.43 kgf/kg, respectively, in participants of ≥75 years of age.
Conclusion: Walking speed and step length were significantly decreased in male inpatients of 65-74 years of age when the isometric knee extension force values for both were <0.30 kgf/kg. In contrast, among male inpatients of ≥75 years of age, these values were significantly decreased when the respective isometric knee extension muscle force values were <0.32 kgf/kg and <0.43 kgf/kg.
Aim: As the number of aged stroke patients increases in Japan, the proportion of older patients who receive recombinant tissue plasminogen activator (rt-PA, 0.6 mg/kg) is also rising. However, the Japanese stroke guideline indicates that rt-PA therapy must be administered very carefully in older patients (i.e. ≥81 years of age) because of serious complications after the therapy. We retrospectively assessed the clinical outcomes of rt-PA therapy in older patients.
Methods: This study included 321 patients who received rt-PA therapy for acute cerebral infarction at our hospital between April 2007 and April 2017. The outcomes (modified Rankin Scale [mRS] score at 3 months after treatment) and symptomatic intracerebral hemorrhaging (sICH) were compared and analyzed between patients ≥81 years of age (group A) and those <81 years of age (group B). In addition, propensity score matching was performed for the factors shown to have significant differences by a univariate analysis in order to adjust for confounding factors, and the outcomes were compared.
Results: There were 58 patients in group A (18.1%) and 263 patients in group B (81.9%). The rate of favorable outcomes (mRS 0-1) was lower in group A (12.1%) than in group B (44.1%) (P<0.01). The mortality rate was higher in group A (17.2%) than in group B (4.6%) (P=0.002). No marked differences were observed between the 2 groups regarding the rate of sICH (group A, 3.4%; group B, 3.0%; P=1.00). After propensity score matching, the proportion of patients with favorable outcomes was significantly lower in group A (13.2%) than in group B (36.8%) (P=0.032). There were no marked differences in the mortality rates between the groups (group A, 17.2%; group B, 4.6%) (P=0.200), and no patients in either group had sICH.
Conclusion: No marked differences in the incidence of ICH were observed between the older and younger groups receiving intravenous rt-PA therapy. However, in terms of efficacy, the proportion of patients with favorable outcomes was significantly lower in the older group than in the younger group.
Aim: In Geriatrics Gerontology International we previously reported the efficacy of reducing diuretics to prevent falls and fractures in older adults. We have since noticed another important problem, regarding the diuretic therapy for older adults with decreased muscle and water volumes. We performed a study on renal insufficiency and diuretic therapy in an attempt to confirm the need for case control study between standard diuretic therapy administered, according to guidelines and "NY-mode" diuretic therapy, which involves the administration of the mineral-corticoid receptor inhibitor spironolactone at 12.5 mg orally every other day.
Methods: We reviewed the causes of death among 1,855 residents living at 2 atomic bomb survivors nursing homes, with a focus on the death certification and diuretic therapy status of 48 older adults who died due to renal insufficiency. We also evaluated the relationship between the estimated glomerular filtration rate of 407 residents using serum creatinine data and the level of independence in daily life of disabled older adults.
Results: We found that deaths due to chronic renal insufficiency were concentrated within certain period in two nursing homes examined and in patients receiving standard diuretic therapy (continuous daily loop diuretics or combination of loop diuretics with mineral-corticoid receptor inhibitor). Older adults with a relatively low level of independence in daily life showed a relatively higher estimated glomerular filtration rate, depending on their muscle volume.
Conclusion: These results suggest the need for a case control study of standard diuretic therapy and "NY-mode" therapy among older adults with decreased muscle and water volumes to not only prevent falls and fall-related fractures but also protect the kidney from damage.
Aim: To examine the association between health literacy (HL) and life space in community-dwelling older adults.
Methods: In this cross-sectional study, we analyzed 210 community-dwelling older adults (mean age: 74.6 years, women: 63.8%). Health literacy was measured using the 14-item Health Literacy Scale (HLS-14). The 14 items consist of 5 items for functional HL (FHL), 5 items for interactive HL (CHL), and 4 items for critical HL (IHL). We calculated the total score, FHL score, CHL score, and IHL score. Life space was measured using the life-space assessment (LSA). A linear regression model was used to analyze the association between the HLS-14 score and LSA score. We adjusted for variables associated with the LSA score.
Results: The FHL score was significantly associated with the LSA score (crude model: β = 1.40, p < 0.01, adjusted model: β = 1.11, p = 0.01). However, the total score, IHL, and CHL were not significantly associated with the LSA score.
Conclusions: A higher FHL is significantly associated with a greater larger life space in community-dwelling older adults. This finding may help elderly people maintain a greater life space which will help them to improve their HL while also making it possible for them to obtain easy-to-understand information.
Providing defecation care can be challenging because bowel movements cannot be directly observed in home-care settings, and the objective evaluation of constipation symptoms is difficult, particularly for elderly patients with cognitive impairment. We evaluated the use of rectal ultrasonography (US) to assess the properties and volume of feces in three cases with different fecal properties. Case 1: In a 94-year-old man with normal feces (Bristol stool score: BS type 4), rectal US revealed a crescent-shaped high-echo area without acoustic shadow that was present until the next defecation. Case 2: In a 92-year-old woman with hard stool (BS type 1), rectal US showed a crescent-shaped strong-echo area with acoustic shadow that was present until the next defecation. The length of the high-echo area gradually increased during the observation period and decreased after defecation in Cases 1 and 2. Case 3: In a 67-year-old man with watery stool (BS type 7), rectal US revealed a low-peripheral-frequency-echo area without acoustic shadow. Rectal ultrasonography was able to demonstrate the presence or absence of hard stool, which was observed as a crescent-shaped a strong, high-echo area with acoustic shadow; the presence or absence of hard stool may be evaluated based on these findings. Furthermore, the fecal volume may be able to be evaluated based on the long diameter of the crescent-shaped high-echo area. Determining the best course of defecation care based on the fecal properties/volume evaluated using rectal US will likely be possible in the future.
Upon diagnosis of dementia, a 93-year-old woman was unable to manage her finances. Her nephew illegally spent her money, which was considered as financial abuse.
The public office forcibly admitted her to our hospital as a legal measure. After five years, she attained the terminal stage owing to eating disorders.
While the medical team was preparing for end-of-life care, the patient's guardian of adult had sent informed consent form to perpetrator who was accused of financial abuse because the guardian had no authority of decision-making.
On learning about the whereabouts of his aunt, the perpetrator contacted the medical team which then attempted to resolve the conflict of opinions.
However, obtaining the family's consent emerged into an exhaustive and stressful process for the staff.
In the present system, wherein the guardians of adult have no authority over medical treatment policy, they should, at least, participate in the discussion of future opinions and cooperate with a constructive attitude.
In contrast, the medical team should offer better information to the guardians of elderly patients to devise a proper treatment plan.
An 84-year-old male with dysphagia was referred to our hospital. Chest computed tomography (CT) showed a rectangular structure along with artificial air in the cervical esophagus. Endoscopy revealed a 'shogi' game piece in the same region shown in CT findings, which was recovered during the endoscopic procedure. From January 2006 to July 2017, we experienced a total of 84 cases of esophageal foreign bodies at our institution (49 males, 35 females; mean age 60 years). Among those cases, the most common foreign body in the esophagus was a food ball, though fish bones and pharmaceutical packaging materials have often been recovered from elderly patients. Chest CT was performed in 39 of those cases prior to an endoscopic examination, with a foreign body in the esophagus detected by CT in 37 (95%). In addition, the stopping portion, progression of inflammation, and presence of free air can be assessed with CT imaging, which provide important clinical information for a safer and faster subsequent endoscopic procedure. Recently, a report conducted outside of Japan noted that eosinophilic esophagitis (EoE) was the main cause of food stoppage in the esophagus. A second-look examination may be necessary to determine the presence of EoE causing such a foreign body blockage.
A 94 year old woman with a late-onset paraphrenia was referred to our clinic from a community care center. The patient showed symptoms of paranoia and auditory hallucination. The patient was in conflict with her neighbors regarding noise-related problems and was experiencing loss of appetite. Because the patient had a strong aversion to outpatient treatment due to difficulty in commuting, home visits were commenced. Improvements were observed after administration of 2.5 mg per day of olanzapine.
In home medical care, precise definitive diagnosis and determination of treatment approach is necessary under limited time and resources. The fact that elderly people often exhibit psychological symptoms such as hallucinations is well known among clinical professions. However, this is not well known among home care patients, families and other professionals, and, therefore, is often overlooked. As the population ages further, it can be predicted that cases of elderly patients requiring treatment for psychological symptoms will increase in home medical care situations. In Japan, with a super-aging society, understanding and continuously supporting late-onset paraphrenia among elderly people is a pressing issue for all communities in advancing home medical care and nursing.
Background: Whether or not immune checkpoint inhibitors are safe and effective for the elderly remains unclear, even though these drugs were approved two years ago for the treatment of advanced non-small cell lung cancer in Japan. Older cancer patients are vulnerable to chemotherapy, so their life function should be closely monitored before starting, continuing, or discontinuing cancer treatment.
Case: An 85-year-old man showed a wedge-shaped shadow in the apical portion of the left lung on chest computed tomography. Unfortunately, repeated bronchoscopy revealed no malignancy. The shadow progressed over about one year, so a third bronchoscopy was performed, leading to a diagnosis of squamous-cell carcinoma (cT3N2M1a, stage IVA). Because PD-L1 immunohistochemical staining was positive for 80%-90% of the tumor cells, the patient was treated with pembrolizumab as the first-line therapy, and the tumor dramatically regressed, notably without any decline in the patient's life functions.
Conclusion: An elderly case of squamous-cell lung cancer was treated continuously with pembrolizumab without any decline in the patient's life function.