[The expected role of Dementia Support Doctors in dealing with complex cases of older people with dementia].

AIM: The present studyinvestigated the roles expected of Dementia Support Doctors (DSDs) in dealing with complex cases. METHODS: The participants were attendees of the education programs organised by the Center for Promoting Dementia Support and the Medical Center for Dementia at the Tokyo Metropolitan Geriatric Hospital from April 2021 to March 2022. A self-administered postal questionnaire survey was conducted. The questionnaire included items on the basic attributes of the participants, their experiences with the issues associated with complex cases, and role expectations of consulting/collaboration partners when dealing with complex cases. RESULTS: The valid response rate was 49.3%. DSDs were expected by primary physicians, Community General Support Center staff and administrative staff to diagnose dementia and give advice on support strategies for complex cases. Primary physicians further expected them to initiate pharmacotherapy with anti-dementia drugs and address the pharmacotherapy needs for managing Behavioral and Psychological Symptoms of Dementia. It was also found that DSDs' experience with complex cases was comparable to that of the staff at the Medical Centers for Dementia. Of note, DSDs were mentioned less frequently as consulting/collaboration partners than Medical Centers for Dementia and primary physicians. CONCLUSIONS: The study showed that DSDs play an important role in dealing with complex cases. The roles of DSDs and ways to collaborate with them need to be communicated through interprofessional education.

Association of functional and cognitive impairment severity with discharge to long-term care facilities in older patients admitted to a general acute care hospital from home.

BACKGROUND: The early recognition of hospitalized patients at risk of being discharged to long-term care facilities (LTCFs) may help to identify those who require transitional care programs and interventions that support discharge to home. We examined the association of functional and cognitive impairment severity with discharge to LTCFs among older hospitalized patients. METHODS: In this retrospective cohort study, we used an administrative claims database linked with geriatric assessment data from a general acute care hospital in Japan. We analyzed patients aged ≥65 years discharged between July 2016 and December 2018. The severity of functional and cognitive impairments was assessed using the Dementia Assessment Sheet for Community-based Integrated Care System 8-items (DASC-8) scale. Based on their DASC-8 scores, patients were designated as Category I (no impairment), Category Ⅱ (mild impairment), or Category III (moderate/severe impairment). We conducted logistic regression analyses to examine the association between the severity of impairments and discharge to LTCFs after adjusting for patient-level factors. RESULTS: We analyzed 9,060 patients (mean age: 79.4 years). Among the 112 patients (1.2%) discharged to LTCFs, 62.3%, 18.6%, and 19.2% fell under Category I, Category Ⅱ, and Category III, respectively. Category II was not significantly associated with discharge to LTCFs. However, Category III had a significantly higher odds of discharge to LTCFs than Category I (Adjusted odds ratio: 2.812, 95% confidence interval: 1.452-5.449). CONCLUSION: Patients identified as Category III by the DASC-8 on admission may benefit from enhanced transitional care and interventions that promote discharge to home.

Autopsy Validation of the Diagnostic Accuracy of 123I-Metaiodobenzylguanidine Myocardial Scintigraphy for Lewy Body Disease.

BACKGROUND AND OBJECTIVES: 123I-meta-iodobenzyl-guanidine (123I-MIBG) myocardial scintigraphy is used as a diagnostic imaging test to differentiate Lewy body diseases (LBDs), including Parkinson disease and dementia with Lewy bodies, from other similar diseases. However, this imaging test lacks validation of its diagnostic accuracy against the gold standard. Our aim was to validate the diagnostic accuracy of 123I-MIBG myocardial scintigraphy for LBD against autopsy, the gold standard. METHODS: This retrospective, cross-sectional study included consecutive autopsy patients from the Brain Bank for Aging Research who had undergone 123I-MIBG myocardial scintigraphy. We compared the 123I-MIBG myocardial scintigraphy findings with autopsy findings. Furthermore, the proportion of residual tyrosine hydroxylase (TH)-immunoreactive sympathetic fibers in the anterior wall of the left ventricle was investigated to assess the condition of the cardiac sympathetic nerves assumed to cause reduced 123I-MIBG uptake in LBDs. RESULTS: We analyzed the data of 56 patients (30 with pathologically confirmed LBDs and 26 without LBD pathology). Compared with the neuropathologic diagnosis, the early heart-to-mediastinum (H/M) ratio had a sensitivity and specificity of 70.0% (95% CI 50.6%-85.3%) and 96.2% (95% CI 80.4%-99.9%), respectively. The delayed H/M ratio had a sensitivity and specificity of 80.0% (95% CI 61.4%-92.3%) and 92.3% (95% CI 74.9%-99.1%), respectively. The washout rate had a sensitivity and specificity of 80.0% (95% CI 61.4%-92.3%) and 84.6% (95% CI 65.1%-95.6%), respectively. The proportion of residual TH-immunoreactive cardiac sympathetic fibers strongly correlated with the amount of cardiac 123I-MIBG uptake when assessed with early and delayed H/M ratio values (correlation coefficient 0.75 and 0.81, respectively; p < 0.001). DISCUSSION: This clinicopathologic validation study revealed that 123I-MIBG myocardial scintigraphy could robustly differentiate LBDs from similar diseases. Abnormal 123I-MIBG myocardial scintigraphy findings strongly support the presence of LBD and cardiac sympathetic denervation. However, LBD pathology should not necessarily be excluded by normal myocardial scintigraphy results, especially when other biomarkers suggest the presence of comorbid Alzheimer disease pathology. CLASSIFICATION OF EVIDENCE: This study provides Class II evidence that 123I-MIBG myocardial scintigraphy accurately identifies patients with LBD.

Association of cognitive impairment severity with potentially avoidable readmissions: A retrospective cohort study of 8897 older patients.

INTRODUCTION: Understanding the association between cognitive impairment severity and potentially avoidable readmissions (PARs) in older patients may facilitate the identification of at-risk individuals who would benefit from readmission prevention measures. METHODS: This retrospective cohort study was conducted using claims data linked with routinely collected cognitive impairment assessment results from a general acute care hospital in Tokyo, Japan. Patients were 65 years or age or older who were discharged from the subject hospital to home or a facility between July 2016 and September 2018. RESULTS: A multivariable logistic regression analysis adjusted for covariates showed that the odds of PARs within 90 days to the subject hospital for patients with moderate and severe cognitive impairment were 1.418 times (95% confidence interval: 1.005-2.002) and 2.212 times (95% confidence interval: 1.206-4.058) higher, respectively, that for patients with normal cognition. DISCUSSION: Older inpatients with later-stage cognitive impairment may represent a suitable target population for transitional care programs aimed at reducing readmissions.

Characteristics of detected and undetected dementia among community-dwelling older people in Metropolitan Tokyo.

AIM: Although a series of policies have been adapted to deliver an early diagnosis of dementia, many people living with dementia remain undetected and undiagnosed. The aim of this study is to investigate the characteristics of undetected dementia in community-dwelling older people in Metropolitan Tokyo. METHODS: We conducted a three-step survey. First, the questionnaires were mailed, in total, to 7614 residents aged ≥70 years in one area in Tokyo, and 5430 were retrieved. Secondly, 2020 individuals attended the face-to-face survey, including Mini-Mental State Exam (MMSE). Thirdly, 198 of 335 individuals who scored <24 on MMSE were visited. Diagnosis of dementia, Clinical Dementia Rating and need for social support were assessed by the interdisciplinary team at their home, and psychological variables, sociological variables and sociodemographic variables were evaluated. RESULTS: Among the 198 participants, 78 (39.4%) were assessed to have dementia. Among those who had dementia, 34 had received a previous diagnosis of dementia in a clinical setting, i.e., the rate of undetected dementia among our 198 participants was 56.4%. People living with dementia without a dementia diagnosis tended to have more complex social support needs, particularly in the domains of dementia diagnosis, medical check-ups for physical conditions, continuous medical care and housing support. In addition, they exhibited signs of frailty. CONCLUSIONS: Given that people living with dementia without a dementia diagnosis are at risk of losing housing or physical health, it is a threat to human rights. Geriatr Gerontol Int ••; ••: ••-•• Geriatr Gerontol Int 2020; ••: ••-••.

Prevalence of frailty, cognitive impairment, and sarcopenia in outpatients with cardiometabolic disease in a frailty clinic.

BACKGROUND: Although frailty and cognitive impairment are critical risk factors for disability and mortality in the general population of older inhabitants, the prevalence and incidence of these factors in individuals treated in the specialty outpatient clinics are unknown. METHODS: We recently established a frailty clinic for comprehensive assessments of conditions such as frailty, sarcopenia, and cognition, and planned 3-year prospective observational study to identify the risk factors for progression of these aging-related statuses. To date, we recruited 323 patients who revealed symptoms suggestive of frailty mainly from a specialty outpatient clinic of cardiology and diabetes. Frailty status was diagnosed by the modified Cardiovascular Health Study (mCHS) criteria and some other scales. Cognitive function was assessed by Mini-Mental State Examination (MMSE), Japanese version of the Montreal Cognitive Assessment (MoCA-J), and some other modalities. Sarcopenia was defined by the criteria of the Asian Working Group for Sarcopenia (AWGS). In this report, we outlined our frailty clinic and analyzed the background characteristics of the subjects. RESULTS: Most patients reported hypertension (78%), diabetes mellitus (57%), or dyslipidemia (63%), and cardiovascular disease and probable heart failure also had a higher prevalence. The prevalence of frailty diagnosed according to the mCHS criteria, cognitive impairment defined by MMSE (≤27) and MoCA-J (≤25), and of AWGS-defined sarcopenia were 24, 41, and 84, and 31%, respectively. The prevalence of frailty and cognitive impairment increased with aging, whereas the increase in sarcopenia prevalence plateaued after the age of 80 years. No significant differences were observed in the prevalence of frailty, cognitive impairment, and sarcopenia between the groups with and without diabetes mellitus, hypertension, or dyslipidemia with a few exceptions, presumably due to the high-risk subjects who had multiple cardiovascular comorbidities. A majority of the frail and sarcopenic patients revealed cognitive impairment, whereas the frequency of suspected dementia among these patients were both approximately 20%. CONCLUSIONS: We found a high prevalence of frailty, cognitive impairment, and sarcopenia in patients with cardiometabolic disease in our frailty clinic. Comprehensive assessment of the high-risk patients could be useful to identify the risk factors for progression of frailty and cognitive decline.

Short- and long-term evaluation of cognitive functions after electroconvulsive therapy in a Japanese population.

AIM: While electroconvulsive therapy (ECT) is a well-established, safe, and effective treatment for mental illnesses, the potential for adverse effects on cognitive functions remains controversial. We aimed to evaluate multiple cognitive functions in different time periods before and after ECT in a Japanese population. METHODS: A battery of five neurocognitive tests was administered to patients who underwent a course of ECT treatment at three time points: before, immediately after, and 4 weeks after ECT. RESULTS: A transient but significant decline in letter fluency function was observed immediately after ECT, but had recovered well by 4 weeks. We also observed a significant improvement in the trail-making task at 4 weeks after ECT. CONCLUSION: In a Japanese population, adverse effects of ECT on verbal fluency function-related and other cognitive impairments were transient. Over the longer term, we detected significant improvements in the performance of tasks that presumably reflected information processing speed and executive functions.

[A clinical case of progressive supranuclear palsy with long-term frontal presentation preceding the onset of gaze palsy].

Progressive supranuclear palsy (PSP) is a neurodegenerative disorder with diverse clinical phenotypes characterized by supranuclear gaze palsy, parkinsonism with postural instability, and frontal dementia. The early and accurate diagnosis of PSP remains difficult because of the variable combination of symptoms and frequent lack of gaze abnormalities early in the disease course. Moreover, a subset of PSP shows behavioral changes as the initial presentation, which considerably overlaps with the clinical picture of frontotemporal dementia (FTD). Thus, this subgroup possibly needs psychiatric assessments. Here, we describe a clinical case of PSP difficult to differentiate from FTD because the frontal presentation persisted without gaze palsy until the late stage of the clinical course. A 58-year-old man was admitted to our hospital for the reconsideration of a diagnosis of FTD. Disinhibited and gambling behaviors inconsistent with his previous personality first appeared at around the age of 45, with gradual progression, followed by memory deficits, executive dysfunction, and a slowing of mental processes. Recurrent sexual disinhibition led him to undergo psychiatric consultation at the age of 57. Downward gaze palsy and postural instability with recurrent falls emerged 8 months after the first psychiatric examination, and he was clinically diagnosed with PSP 13 years after the initial frontal presentation. PSP should be considered in the differential diagnosis of patients presenting with frontal lobe symptoms, even in psychiatric practice.

A prospective naturalistic multicentre study of intravenous medications in behavioural emergencies: haloperidol versus flunitrazepam.

A prospective naturalistic multicentre study for deep sedation was conducted in intensive care with continuous electrocardiogram (ECG) monitoring. Clinical purpose was enough sedation, which made uncooperative and disrupted patients receive brain computed tomography (CT), magnetic resonance imaging (MRI), or fluid therapy, with minimum drug doses. A first infusion was either haloperidol (HAL group) or flunitrazepam (FNP group). If enough sedation was not achieved, a second infusion, which was the opposite drug to the first infusion, was given. The proportion requiring a second infusion was higher in the HAL group than in the FNP group (82% vs. 36%, P<0.0001). The mean reduction of the Excited Component for Positive and Negative syndrome scale at 15 min was greater for the FNP first group (FNP+HAL group) than the HAL first group (HAL+FNP group) (68% [S.D. 17] vs. 54% [S.D. 31], P=0.02). The mean dose of flunitrazepam in the HAL+FNP group was significantly lower than that in the FNP+HAL-group (1.3 mg vs. 3.5 mg, P=0.0003). Thus, in terms of monotherapy and speed of action, flunitrazepam has advantages over haloperidol as a first infusion for deep sedation. Regarding drug dosages, haloperidol has an advantage over flunitrazepam as a first infusion in safety.

Olanzapine orally disintegrating tablet vs. risperidone oral solution in the treatment of acutely agitated psychotic patients.

OBJECTIVE: Efficacy and tolerability of risperidone oral solution (RIS-OS) and olanzapine orally disintegrating tablet (OLZ-ODT) were compared for the treatment of acute psychotic agitation. METHOD: During a 2-month period, patients scoring > or =15 on the Excited Component for Positive and Negative Syndrome Scale (PANSS-EC) were assigned to treatment with OLZ-ODT (n=34) or RIS-OS (n=53) on psychiatric emergency situations, and assessed every 15 min. RESULTS: Two (OLZ-ODT and RIS-OS) by five (0-, 15-, 30-, 45- and 60-min time points) repeated-measures analysis of variance revealed only a significant main effect of time course on PANSS-EC (F=82.2, P<.0001). No differences in the number of patients receiving additional injection due to worsening were found (OLZ-ODT, 11.8%; RIS-OS, 9.4%). No differences in rate of extrapyramidal symptoms and patient satisfaction with assigned treatment were found. However, patients in the OLZ-ODT group recovered significantly more from tachycardia than those in the RIS-OS group (t=2.17, P=.03). CONCLUSION: OLZ-ODT and RIS-OS treatments yielded similar improvements in acutely agitated patients who accepted oral medication. However, on one physiological parameter (i.e., tachycardia) OLZ-ODT might be superior to RIS-OS. Physiological indicators may also be useful for measuring levels of agitation.

Perospirone in the treatment of patients with delirium.

Perospirone is a recently developed atypical antipsychotic with potent serotonin 5-HT2 and dopamine D2 antagonist activity. Other atypical antipsychotics including risperidone, quetiapine and olanzapine have been widely used for treatment, not only for schizophrenia symptoms but also for delirium, because of their low potential to induce extrapyramidal disturbances. In the present study the effectiveness and safety of perospirone in patients with delirium are described. Thirty-eight patients with DSM-IV delirium were given open-label perospirone. To evaluate the usefulness of perospirone, scores from 13 severity items of the Delirium Rating Scale-Revised-98 were assessed. Data were gathered from October 2003 to September 2004. Perospirone was effective in 86.8% (33/38) of patients, and the effect appeared within several days (5.1 +/- 4.9 days). The initial dose was 6.5 +/- 3.7 mg/day and maximum dose of perospirone was 10.0 +/- 5.3 mg/day. There were no serious adverse effects. However, increased fatigue (15.2%), sleepiness (6.1%), akathisia (3.0%) and a decline in blood pressure (3.0%) were observed. It is proposed that perospirone may be another safe and effective atypical antipsychotic drug for the treatment of delirium symptoms in hospitalized patients. This is a preliminary open trial, and further randomized double-blind placebo-controlled tests are needed.

Average size of random polygons with fixed knot topology.

We have evaluated by numerical simulation the average size R(K) of random polygons of fixed knot topology K=,3(1),3(1) musical sharp 4(1), and we have confirmed the scaling law R(2)(K) approximately N(2nu(K)) for the number N of polygonal nodes in a wide range; N=100-2200. The best fit gives 2nu(K) approximately 1.11-1.16 with good fitting curves in the whole range of N. The estimate of 2nu(K) is consistent with the exponent of self-avoiding polygons. In a limited range of N (N greater, similar 600), however, we have another fit with 2nu(K) approximately 1.01-1.07, which is close to the exponent of random polygons.

Antidiabetic effect of nitobegiku in KK-Ay diabetic mice.

In the past, nitobegiku (the herb of Tithonia diversifolia (Hemsl) A. Gray) has been used as a medicinal plant for diabetes. Antidiabetic effect of the water extract of Nitobegiku (NG) was investigated in KK-Ay-mice--one of the animal models of type 2 diabetes. NG (1,500 mg/kg body weight) reduced the blood glucose of KK-Ay mice from 509 +/- 22 mg/dl to 340 +/- 14 mg/dl (p < 0.001) and also lowered the plasma insulin (p < 0.05) 7 hours after single oral administration. No change in blood glucose of NG-treated normal mice (ddY) was seen. These results support that NG improve glucose metabolism by reducing insulin resistance. Therefore, NG may be useful for treatment of type 2 diabetes.