We undertook a comprehensive consideration of broncho-esophagological issues in Japan's super-aging society. Clearly, everyday clinical services should take into account the characteristics unique to the elderly. Also, as often stated in various quarters, for those of us in the medical profession, population issues are of importance in terms of the economic aspects of medical care. In addition, a rising ratio of elderly members is a serious issue for the Japan Broncho-esophagological Society also, and this problem should be addressed without delay.

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Recently, dysphagia has become a notable issue in both the medical and social spheres along with the aging of society. With aging swallowing functions deteriorate, resulting in increased risk of aspiration pneumonia, which in turn leads to high mortality rates. Here we describe the mechanisms and aspects of age-related swallowing impairments. In the elderly, age-related anatomical and physiological alterations of the pharyngolaryngeal organs result in swallowing disturbance. Especially critical factors are swallowing reflex delay, decrease in pharyngeal driving force on the bolus, and insufficient opening of the upper esophageal sphincter, which are caused by pharyngolaryngeal sensory impairment and physiological alteration of the inferior pharyngeal constrictor muscle. To treat or prevent these impairments, food texture modification, muscle training exercise maneuvers, and pharmacological sensory stimulation can be effective. Further clinical study and accumulation of evidence are desired.

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Qualitative and quantitative changes to the extracellular matrices occur in the vocal fold mucosa of the aged. Specifically, changes take place in the three-dimensional structure of the extracellular matrices, in the morphological structure of each extracellular matrix, and in the viscoelastic properties of the vocal fold mucosa. Histological changes in the aged larynx influence the viscoelasticity of the vocal fold mucosa as a vibrating tissue and vocal fold vibration, and are related to the geriatric changes in the voice. When we correlate the geriatric morphological changes of the vocal fold as a vibrating tissue with voice function of the aged, the pathophysiology of the voice function of the aged can be well explained. Significant differences in the histological changes of the aged larynx are found from one individual to another, just as there are individually recognizable differences in geriatric changes in the voice.

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Opportunities to treat head and neck cancer in elderly patients have increased year by year. Because of individual variations in physical and mental conditions in the elderly, it is difficult to routinely choose a guideline therapy depending on age alone. In our clinic, radical treatment is performed only in about 70% of cases of head and neck cancer in the elderly, and these cases showed outcomes substantially similar to those of the younger generation. Systematic use of sophisticated assessments (physical, mental) may allow physicians to select appropriate patients and reduce underutilization of aggressive treatment in the elderly. Elderly people are known to differ from other age groups in their treatment orientation, capacity to gather information, and ability to judge. However, these issues are often left undisguised in daily clinical practice. The usefulness of chemotherapy and use of molecular targeting drugs for the elderly have not yet been confirmed. Surgical treatment with a short treatment period should be accorded priority.

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The pathology of the aging lung is associated with reduced elastic tissues and an increased airspace diameter without inflammation or destruction of the alveoli. Compliance of the thoracic cage and the power of the respiratory muscles decrease with aging. These changes cause an increase in residual volume and decreases in FEV1/FVC, vital capacity, and DLCO in terms of pulmonary function. Pulmonary arterial pressure increases with aging, especially during exercise. Frequency of sleep breathing disorders also increases in the elderly. Furthermore, some studies have reported an increased prevalence of airway hypersensitivity in the aged population, and poorer airway clearance due to mucociliary dysfunction. During exercise, tidal volume does not increase sufficiently due to limitation of expiratory airflow in the elderly, which is a major cause of their decrease in exercise capacity. In addition to these physiological changes caused by aging, the pulmonary function of the elderly is influenced by various common comorbidities other than pulmonary diseases, such as severe scoliosis and low body weight. Compared to the dramatic decreases in pulmonary function caused by aging, arterial oxygen pressure at rest shows only a slight decrease with age, and arterial carbon dioxide pressure at rest is not affected by aging, showing that the pulmonary changes caused by aging affect the ability to resist extrinsic and intrinsic pulmonary injuries. These deteriorations of the pulmonary function induced by aging are associated with worsening of respiratory failure in patients with pulmonary tuberculosis sequelae, yearly decrease in the pulmonary function of patients with chronic obstructive pulmonary diseases, and the high prevalence of pneumonia in the elderly, which is frequently severe and long-lasting.

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Japan will become an aging society in the near future. To address problems faced by our hospital, which is located in an area where an aging society has already formed, should provide insight for solving the problems Japan as a whole will face as an aging society. COPD and bronchial asthma are common sicknesses among many pulmonary diseases. In particular cases of COPD, which is attributable mainly to smoking, are increasing in number and COPD is thought to be escalating as a cause of death as well. COPD is prevalent among the elderly with smoking histories, and cases are known to be complicated by many comorbidities. For this reason physicians are expected to see the COPD patient in a comprehensive context and not focus merely on the sickness alone. Likewise, as the aging society proceeds, elderly bronchial asthma patients are also increasing, even though this disease is typically prevalent among children or youngsters. Our findings show that such aged bronchial asthma patients also have many comorbidities. Aged persons sometimes have difficulties using the inhaler medication which is commonly prescribed for the treatment of COPD or bronchial asthma. This is another problem of aged societies. The aging society also suffers from transportation difficulties. Not only because of the impaired patient's ADL (activity in daily life) but also because of the family members' incapacity to take care of another aged, access to hospitals can be difficult. For the foregoing reasons, medical care in the aging society needs to focus not only on treatment of the sickness but also on the patient as a whole, including diverse aspects and backgrounds along with comorbidities. Furthermore, we need to be aware that medical care has to be provided taking into consideration not only the condition of the patient but also the situation of the patient's family members.

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Esophageal motility disorders are divided into primary disorders and secondary disorders. Primary esophageal motility disorders include achalasia, diffuse esophageal spasm, nutcracker esophagus, hypertensive lower esophageal sphincter and nonspecific esophageal motility disorders. Patients with hypocontraction of the esophageal body in nonspecific esophageal motility disorders are classified as an ineffective esophageal motility (IEM). Recently, a newly developed device for investigating esophageal motor functions, high-resolution manometry, was introduced and a new classification of esophageal motility disorder—the Chicago classification—was proposed. Some clinical differences in esophageal motility disorders exist between the elderly and young. We discussed these issues with references. Esophageal hiatus hernia and reflux esophagitis are common diseases in the elderly. In these cases, IEM is often recognized. Laparoscopic fundoplication with anti-reflux procedure is an effective treatment for these patients and IEM sometimes is improved. In patients with achalasia, insufficiency of LES relaxation and disorders of esophageal peristalsis are found ; here, laparoscopic Heller myotomy and Dor fundoplication is a very effective treatment for improving the patient's symptoms.

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Recent advances in treatment of esophageal cancer have led to significant improvement in survival during the past three decades in spite of the progress of our aging society. Here we re-evaluated our management and strategies including esophagectomy for elderly patients with esophageal cancer in order to obtain insights for further development of the treatment. Method : Between January 2000 and March 2013, we performed 579 radical esophagectomies for esophageal cancer under right thoracotomy or thoracoscopy. Patients were divided into two groups : elderly (n=56), aged 75 y/o or older ; and non-elderly (n=523), younger than 75 y/o. Results : Preoperative patient characteristics of the two groups were similar except for age. Hospital mortality rate was 3.6% in the elderly, 0.96% in the non-elderly. Overall 1-, 3-, and 5-year survival rates were 90.4, 73.2 and 61.7% in the elderly, and 88.2, 69.1 and 62.4% in the non-elderly. Conclusion : Advanced age itself should no longer be an absolute contraindication of radical esophagectomy in selected patients.

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