Nippon Ronen Igakkai Zasshi Japanese Journal of Geriatrics

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ISSN 0300-9173

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    ABSTRACT: Aim: To examine the causes of death in elderly patients with advanced dementia, we retrospectively investigated the medical records for death discharge cases hospitalized in the Department of Geriatric Medicine at Saiseikai-Nakatsu Hospital and examined death certificates issued throughout the hospital. Methods: (1) From 2010 to 2013, 31 patients with advanced dementia died in the hospital or were discharged to receive terminal care at home. We evaluated their medical records to examine the pathological background and disease with which they were diagnosed when admitted to and discharged from the hospital. (2) In order to assess the relationship between disease and dementia, we examined death certificates with "senility" or " (aspiration) pneumonia" recorded as the direct death cause issued throughout the hospital in the one-year period of 2013. Results: (1) There were many cases in which eating problems and dysphagia influenced the clinical course. A total of 21 patients died from eating problems and/or dysphagia. (2) All 13 cases with "senility" recorded as the direct death cause on the death certificate involved severe dysphagia. Investigating the medical records, 11 patients had advanced dementia and two patients had end-stage Parkinson's disease. In total, 46 cases were diagnosed as involving " (aspiration) pneumonia", whereas there were no cases in which the records mentioned dementia or dysphagia in another column on the death certification. Conclusions: Advanced dementia is a mortal illness, and most patients with advanced dementia have dysphagia. Clinicians should be aware of the fact that dysphagia may lead to aspiration pneumonia and is a significant cause of death. Understanding the clinical course of dementia is important for determining the cause of death.
    Preview · Article · Dec 2015 · Nippon Ronen Igakkai Zasshi Japanese Journal of Geriatrics
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    ABSTRACT: To evaluate the safety and efficacy of endoscopic therapy for bile duct stones in elderly patients aged over 80 years. We enrolled 20 elderly patients aged over 80 years and 50 patients who were younger than 79 years of age who had received their first endoscopic therapy for bile duct stones at our hospital from February 2012 to December 2013. A retrospective analysis was performed which included the following clinical parameters: the use of antithrombotic drugs; a past history of abdominal surgery; performance status (PS); the shortest diameter of the largest stone; and the total number of stones. The treatment outcomes of operations with endoscopic sphincterotomy, endoscopic papillary balloon dilation, or endoscopic papillary large balloon dilation were compared. The operative time, complete stone clearance rate, operative success rate (complete stone clearance or bile duct stent insertion), and adverse events were compared as treatment outcomes. There was no significant difference in the use of antithrombotic drugs, past history of abdominal surgery, number of stones, or treatment received between the age groups, while PS was significantly lower, and the diameter of the largest stone was significantly greater in the patients over 80 years of age. The operative time, complete stone clearance rate, operative success rate, and the number of adverse events did not differ significantly between the age groups. Endoscopic therapy for bile duct stones was found to be safe and effective in elderly patients over 80 years of age.
    Preview · Article · Aug 2015 · Nippon Ronen Igakkai Zasshi Japanese Journal of Geriatrics
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    ABSTRACT: We report a case of acute respiratory failure in a 77-year-old male with chronic obstructive pulmonary disease (COPD) who showed marked eosinophilia (61.5% of the peripheral total white blood cells [WBCs]; 13,200/mm(3)). The patient was an ex-smoker, but he had started smoking again one month previously, His forced expiratory volume in one second (FEV1) was low and dyspnea symptom was observed. Although rhonchi were detected, wheezing chest sounds were not detected. Chest X-radiography and computed tomography of the lung revealed diffuse bilateral pulmonary infiltrates and emphysematous changes. He was given intravenous methyl prednisolone (1,000 mg) for 3 consecutive days. The abnormal shadows on the chest X-ray film improved remarkably and the eosinophils in his peripheral blood were reduced. Furthermore, it was no longer necessary to administer oxygen to treat his hypoxemia. The symptomatic and clinical course mimicked to a case of acute eosinophilic pneumonia (AEP). However, transbronchial lung biopsy specimens did not reveal eosinophilic infiltration in the alveolar septa. The fraction of eosinophils in the patient's bronchoalveolar lavage was 4.4% and not greater than 25%. After hospitalization, 5-15 mg of prednisolone administered orally in combination with bronchodilators to better manage his clinical symptoms. This case was thus determined to correspond to elderly asthma-COPD overlap syndrome (ACOS).
    Preview · Article · Aug 2015 · Nippon Ronen Igakkai Zasshi Japanese Journal of Geriatrics
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    ABSTRACT: To determine factors associated with physical decline and a poor prognosis after hospitalization in physically dependent elderly patients with acute pneumonia. The subjects included 112 geriatric patients (86.8±5.5 years old) with acute pneumonia consecutively admitted to an inpatient unit of Geriatric Medicine, Kyorin University Hospital in the period from April 2012 to March 2013. All patients were generally treated with broad-spectrum antibiotics according to nursing- and healthcare-associated pneumonia (NHCAP) guidelines. The patients' baseline severity of pneumonia was evaluated according to the A-Drop score and their physical dependency was assessed according to the JABC score before and after admission. The patients were categorized into the community acquired pneumonia group (CAP) (n=29) and NHCAP group (n=83). The patients in the NHCAP group had a longer hospital stay (NHCAP vs. CAP: 33 vs. 21 days, p=0.02), higher A-Drop scores (2.88±0.80 vs. 2.45±0.87 points, p=0.02) and were more frequently diagnosed with aspiration pneumonia (89.2% vs. 42.9%, p<0.0001) than those in the CAP group. Three patients in the CAP group (10.3%) and 13 patients in the NHCAP group (15.7%) died during their hospital stay (p=0.69). Although the rest of the patients were successfully treated for pneumonia, their physical dependency progressed after admission in both groups (p<0.0001). After adjusting for age, gender and the JABC score before admission, NHCAP (risk ratio against CAP: 6.2, 95% CI 1.2-32.2, p=0.03) and a serum albumin lower than 2.5 g/dl (RR: 7.8, 95%CI 1.7-35.7, p<0.01) were significantly associated with the progression of physical dependency after admission. The diagnosis of NHCAP is a risk factor for the progression of physical dependency. Therefore, palliative care may be an optional approach for frail patients.
    Preview · Article · Aug 2015 · Nippon Ronen Igakkai Zasshi Japanese Journal of Geriatrics
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    ABSTRACT: Acquired hemophilia is a rare bleeding diathesis caused by autoantibodies against clotting factor VIII. Many cases are associated with autoimmune disease, malignancy and an elderly status. Acquired hemophilia is very rare, with a reported annual incidence of 1.48/million/y. However, it is necessary to consider this rare disease when encountering bleeding of unknown cause in elderly patients. An 84-year-old woman was referred to our hospital with subcutaneous bleeding and anemia. The patient had severe anemia and a prolonged activated partial prothrombin time (APTT). Despite the administration of red blood cell transfusions, the decline in hemoglobin continued. Since the activity of coagulation factor VIII was <1%, and the level of inhibitor against coagulation factor VIII (509 BU/ml) was >5 BU/ml, the patient was diagnosed with acquired hemophilia. No underlying diseases were found, and we concluded that this case was idiopathic. Although she was treated with prednisolone at a dose of 40 mg per day, the bleeding tendency did not improve. Therefore, she was given activated prothrombin complex concentrates (APCC) for four days. The subcutaneous bleeding and Hb decline stopped, and the dose of prednisolone was gradually reduced. The patient's clotting function and clinical course were satisfactory, and she was discharged on the 64th day. An early diagnosis and optimal treatment are critical for treating acquired hemophilia. The development of a bleeding tendency related to the appearance of coagulation factor VIII inhibitor is serious in many patients. Therefore, recognizing this disease and providing prompt management are necessary.
    Preview · Article · Aug 2015 · Nippon Ronen Igakkai Zasshi Japanese Journal of Geriatrics
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    ABSTRACT: This study had two objectives: to confirm the cross-sectional associations between the physical performance scale (PPS), skeletal muscle mass (SMM) and sarcopenia and cognition, and to examine whether PPS, SMM and sarcopenia are independent risk markers of cognitive decline (CD). Among 805 adults 65 years of age or older who participated in a baseline survey (2008-2011), 649 were reevaluated for their level of cognition at least once until 2012, and PPS, SMM, sarcopenia and cognition were assessed. CD was defined as a decrease of at least 0.5 points per year on the MMSE. After controlling for sex, age and years of education, PPS, SMM and sarcopenia were associated with cognition, respectively. During a median follow-up of 3.0 years, 201 adults (31.0%) had CD. After controlling for important confounders, PPS showed a significant association with CD [OR=0.75 (95%CI: 0.65-0.87)], whereas SMM showed no significant association with CD. As compared with the people who had normal PPS and SMM, people who had low PPS and normal SMM had 2.10 times higher risk for CD. We confirmed the cross-sectional associations between physical performance, SMM and sarcopenia and cognition in a general population of older adults. Although people had normal SMM, low physical performance was found to be a risk marker for subsequent CD.
    Preview · Article · Aug 2015 · Nippon Ronen Igakkai Zasshi Japanese Journal of Geriatrics
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    ABSTRACT: The aim of this study was to develop a self-administered dementia checklist (SDC), in order to help community-residing older adults realize their declining functions and encourage them to begin using necessary services, and to examine its factorial validity and internal reliability. A panel of dementia clinical experts developed a questionnaire according to pre-selected items and conducted a self-administered survey with community-residing people aged 65 + (n=2,483). The team developed a scale through an exploratory factor analysis and item response theory (IRT) analysis (Study 1). Using this scale, they conducted a self-administered survey with community-residing people aged 65 + (n=5,199), conducted another exploratory factor analysis, and developed a 10-item scale. A confirmatory factor analysis was subsequently conducted and reliability coefficients were computed. The exploratory factor analysis of the proposed 37 items extracted 5 factors: Factor 1 was named "subjective decline in daily living functioning," and Factor 2 was "subjective cognitive decline" in the early stage of dementia. The team developed a 20-item scale by selecting 10 items from each factor which had high factor loadings and high slope values in the IRT analysis (Study 1). After the exploratory factor analysis of the 20-item scale, they developed a 10-item scale by selecting 5 items from each factor which had strong associations. The confirmatory factor analysis verified the 2-factor model. The Cronbach α coefficients for the subscales of Factors 1 and 2 were 0.935 and 0.834, respectively, and 0.908 for the overall 10-item scale. The authors developed a 10-item SDC with 2 factors and confirmed its factorial validity and internal reliability.
    Preview · Article · Aug 2015 · Nippon Ronen Igakkai Zasshi Japanese Journal of Geriatrics
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    Preview · Article · Aug 2015 · Nippon Ronen Igakkai Zasshi Japanese Journal of Geriatrics
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    ABSTRACT: To clarify the routes of nutrition and types of diet and their relevance to the risk of mortality and hospitalization among community-dwelling dependent elderly provided various home care services under the long-term care insurance program. The present study consisted of the collection of baseline data of participants in the Nagoya Longitudinal Study of the Frail Elderly (NLS-FE) and data regarding mortality and hospitalization during a three-year follow-up period. The study population consisted of 1,872 subjects, and the baseline data included demographic characteristics, basic activities of daily living (ADLs), comorbidities, nutritional routes and types of diet, which were evaluated by trained visiting nurses. Among the participants, 1,786 were on oral nutrition (solid regular-texture diet: 1,487 (79.5%); modified-texture diet (minced/pureed texture): 299 (16.0%), 82 (4.4%) were on enteral nutrition and four (0.2%) were on parenteral nutrition. During the three-year follow-up period, 453 participants died and 798 participants experienced admission to the hospital (pneumonia-related death and hospitalization: n=103 and 155, respectively). Cox regression models revealed that a modified-texture diet and tube feeding are associated with all-cause mortality and hospitalization. In particular, feeding tube use showed a high risk of pneumonia-related mortality and hospitalization, even after adjusting for potential confounders, including comorbidities and the ADL status.
    Preview · Article · Jul 2015 · Nippon Ronen Igakkai Zasshi Japanese Journal of Geriatrics
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    ABSTRACT: The purpose of this study was to investigate whether the degree of improvement in cognitive function achieved with an exercise intervention in community-dwelling older Japanese women is affected by the participant's baseline cognitive function and age. Eighty-eight women (mean age: 70.5±4.2 years) participated in a prevention program for long-term care. They completed the Square-Stepping Exercise (SSE) program once a week, 120 minutes/session, for 11 weeks. We assessed participants' cognitive function using 5 cognitive tests (5-Cog) before and after the intervention. We defined cognitive function as the 5-Cog total score and defined the change in cognitive function as the 5-cog post-score minus the pre-score. We divided participants into four groups based on age (≤69 years or ≥70 years) and baseline cognitive function level (above vs. below the median cognitive function level). We conducted two-way analysis of variance. All 4 groups improved significantly in cognitive function after the intervention. There were no baseline cognitive function level×age interactions and no significant main effects of age, although significant main effects of baseline cognitive function level (P=0.004, η(2)=0.09) were observed. Square-Stepping Exercise is an effective exercise for improving cognitive function. These results suggest that older adults with cognitive decline are more likely to improve their cognitive function with exercise than if they start the intervention with high cognitive function. Furthermore, during an exercise intervention, baseline cognitive function level may have more of an effect than a participant's age on the degree of cognitive improvement.
    No preview · Article · May 2015 · Nippon Ronen Igakkai Zasshi Japanese Journal of Geriatrics
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    ABSTRACT: A 70-year-old man with a 28-year history of type 2 diabetes mellitus was admitted due to persistent vomiting and neurological abnormalities in Nov 2012. He had developed gait disturbance and diplopia for six months during antiplatelet therapy, which was initiated following the diagnosis of a cerebellar infarction in June 2012. He had nystagmus, truncal ataxia and an ocular motility disorder, and the MRI study showed increased FLAIR and DWI signals in the peri-third ventricle and periaqueductal region, in addition to the cerebellar vermis. Wernicke encephalopathy was suspected according to his symptoms, and thiamine administration dramatically improved his condition. He did not have a history of alcohol abuse or poor eating habits; however, various coexisting factors, including diabetes mellitus, pyloric stenosis and the use of antiulcer drugs and insulin, were considered to be responsible for Wernicke encephalopathy. This case demonstrates the importance of distinguishing Wernicke encephalopathy from cerebrovascular disease in elderly patients.
    No preview · Article · May 2015 · Nippon Ronen Igakkai Zasshi Japanese Journal of Geriatrics
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    ABSTRACT: An increasing incidence of extended-spectrum β-lactamase (ESBL-) producing Escherihia Coli poses a difficult problem for clinicians to establish an optimal strategy for the effective antibiotic treatment of urinary tract infections (UTI). (1) Fosfomycin/minocycline (FOM/MINO) or rifampicin/sulfamethoxazole-trimethoprim (RFP/ST) combinations and (2) levofloxacin (LVFX) alone were used as an internal medication, and (3) cefoperazone/sulbactam (CPZ/SBT) and (4) meropenem (MEPM) were administered through intravenous injection. The selection of antibiotics was done empirically, according to the history and severity of illness and urinary findings, and the presence of comobidities. The efficacy of the treatment was determined by the absence of any pathogenic bacteria from a urinary culture after treatment. ESBL-producing and LVFX resistant non-ESBL producing E. coli were detected by an initial urinary culture in 33 and 10%, respectively, of the specimens before treatment. All the ESBL-producing E. Coli colonies were resistant against LVFX. The efficacy of the treatment was 9/11 (82%) in the FOM/MINO-RFP/ST group, 9/14 (64%) in the LVFX group, 9/16 (56%) in the CPZ/SBT group, and 19/27 (70%) in the MEPM group. In the FOM/MINO・RFP/ST group, ESBL-producing E. Coli were detected in the urine before treatment in 5 out of 16 patients and those E. coli disappeared after treatment in all 5 patients. In the LVFX group, the drug was changed to MEPM in 6 out of 15 patients soon after the presence of ESBL-producing/LVFX resistant E. Coli was identified by a urinary culture. In the CPZ/SBT group, ESBL-producing and/or LVFX-resistant E. coli disappeared in 4 out of 6 cases, while they were newly found in post-treatment urine cultures in 2 patients. In the MEPM group, 15 out of 28 patients initially had ESBL-producing/LVFX resistant E. Coli and those drug-resistant E. Coli disappeared from their urine after treatment in all patients. The drug susceptibility test of the urinary culture from all the patients with UTI showed CPZ/SBT-resistant colonies to be found in 19 out of 32 specimens, while AMPC/CVA-resistant ones were found in 9 out of 32 of ESBL-producing E. Coli. Our present study demonstrates that FOM/MINO or ST combinations were effective in the treatment of ESBL-producing E. Coli in mild cases of UTI and MEPM in severe cases. When using β-lactam/β-lactamase inhibitor combinations, the effect should be ascertained by examining post-treatment urinary specimens, because of the presence of ESBL-producing E. Coli strains which are resistant to those antibiotics.
    Preview · Article · May 2015 · Nippon Ronen Igakkai Zasshi Japanese Journal of Geriatrics
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    Preview · Article · Mar 2015 · Nippon Ronen Igakkai Zasshi Japanese Journal of Geriatrics
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    ABSTRACT: This study sought to investigate the influence of intervention by therapists at night on the patient's ADL's, number of falls, etc. On convalescent rehabilitation units in order to examine the efficacy of the intervention. The study subjects included patients hospitalized on 11 convalescent rehabilitation units. The period of intervention by the therapists at night and the period of no intervention were each set for three months. The improvements in the ADL scores during each period were compared, and the changes in the number of falls were examined. In addition, a questionnaire survey was conducted among the night shift staff in order to examine the need for intervention. The patients who received intervention by therapists at night showed higher scores for BI, FIM, etc. and fewer falls than those treated without intervention. The results of the questionnaire survey indicated differences between the therapists and other professionals regarding their attitude toward working the night shift. Our findings suggest that intervention by therapists at night results in favorable outcomes, e.g., improvements in the patient's ADL's and a reduction in the number of falls. Although there are issues to be discussed with respect to raising awareness among therapists and concerns regarding work-related problems, intervention by therapists at night has the possibility to be used as a new treatment strategy on rehabilitation units.
    Preview · Article · Mar 2015 · Nippon Ronen Igakkai Zasshi Japanese Journal of Geriatrics