Characteristics of people seeking consultation after progressing to severe dementia: A mixed-method analysis.

OBJECTIVES: This explores the characteristics of patients with worsening dementia who did not receive a specialized medical examination or care. METHODS: This study utilized a mixed methods analysis. Of the 2712 people who received the Mini Mental State of Examination (MMSE) at the Community Consultation Center for Citizens with MCI and Dementia between December 2007 and December 2019, 1413 people who scored 23 points or less were included. Participants were categorized into mild, moderate, and severe groups, based on their MMSE scores. Participants' characteristics-gender, age, presence or absence of an escort, demographics, family type, and presence or absence of a family doctor-were compared between the groups. To further understand the severe group's characteristics, clinical psychologists recorded consultation forms were categorized. RESULTS: More than 80% of the patients in each group had a family doctor. Moreover, all the severe groups had escorts, and the role of family members and supporters was important for the consultation. In the severe group, 29 patients had never received specialized medical care. Their characteristics were coded "non-existence" (fewer people or opportunities to notice their needs), "connection failure" (a lack of access or connections to consultations), and "evaluation failure" (not recognized as a problem requiring consultation). CONCLUSIONS: It is necessary to improve primary physician education, disseminate knowledge, and raise awareness about dementia, besides building and strengthening networks to alleviate the isolation of dementia patients and their families. The psychological aspects of family members' denial regarding their family members with dementia must be addressed through intervention.

Encouraging death communication in a death-avoidant society: analysis of interviews with death café organizers.

BACKGROUND: Post-war Japanese tend to avoid discussion of death, resulting in a lack of death communication within clinical settings. However, with the aging of society, the significance of conversations and decisions related to end-of-life issues has grown. In 2007, the government established guidelines for decision-making in end-of-life care. Nonetheless, death communication remains a challenge for healthcare professionals in clinical settings. In contrast, death cafés have spontaneously emerged within communities as informal gatherings to openly discuss and explore death. Learning from death café organizers may help healthcare professionals encourage death communication in a death-avoidant society. Therefore, a qualitative study was conducted to describe death cafés by examining the underlying motivation and practices through interviews with death café organizers. METHODS: Individual in-depth interviews were conducted with death café organizers. Two key aspects were explored: 1) the underlying motivations of organizers; and 2) the practices and challenges encountered in running death cafés. The interviews were transcribed verbatim and analyzed using a qualitative descriptive approach. Thematic analysis was used. RESULTS: The study identified two themes representing the underlying motivation of death café organizers: individually-oriented and community-oriented. These themes exhibited contrasting orientations and were collectively termed "individual-community orientation". Regarding the practice of death cafés, the focus was on the "attitude towards having attendees with and without grief in the same session." Participants' attitudes towards this aspect fell into two categories with opposing orientations: "purification" and "inclusion." The "purification-inclusion orientation" was more prevalent among organizers who initiated death cafés due to their personal experiences. A matrix was created to categorize death cafés based on their underlying motivations (individual vs. community-oriented) and practices (purification vs. inclusion). This classification resulted in quadrant 1 (community-oriented, inclusive) and quadrant 3 (individually-oriented, purification). Notably, death cafés in quadrant 1 were often held in temples. CONCLUSIONS: Japanese death cafés can be classified into two categories: individually and purification-oriented and community and inclusive-oriented categories. Healthcare professionals can learn valuable insights from death café organizers, particularly in promoting death communication. Specifically, temple death cafés, with their inclusive practices and orientation towards community, can be particularly beneficial in fostering inclusivity and community engagement.

[Acute Aortic Dissection Complicated by IgA Deficiency].

Immunoglobulin A (IgA) deficiency is the most common type of primary immunodeficiency. When a patient receives a blood product transfusion, anti-IgA antibodies are formed. Second transfusion may sometimes cause an anaphylactic reaction, thus caution is necessary. Reported here is a case of Stanford type A acute aortic dissection performed in the patient with IgA deficiency with a history of blood transfusion. Red blood cells and platelet were washed and prepared, and flesh frozen plasma from IgA deficient donors was obtained. Thereafter, the surgery was safely performed.

[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.

Diogenes syndrome in a 10-year retrospective observational study: An elderly case series in Tokyo.

OBJECTIVES: Supporting people suffering from Diogenes Syndrome (DS) is a challenge for geriatric psychiatry. However, there is a lack of knowledge about DS in Japan. Therefore, a systematic longitudinal study to clarify the factors associated with DS and its prognosis was conducted. METHODS/DESIGN: A retrospective study using data from case records of a municipal psychogeriatric service was conducted. The study population was socially isolated older adults with complex mental health and social care needs who had been referred to the service over 10 years. The participants were stratified into DS and non-DS groups, multivariate analysis was performed to identify factors associated with DS, and survival analysis was performed. RESULTS: Of the 270 participants, 61 with Environmental Cleanliness and Clutter Scale (ECCS) scores >12 were assigned to the DS group, and 209 with ECCS scores ≤12 were assigned to the non-DS group. On multiple logistic regression analysis, significantly more people in the DS group were living alone, had advanced dementia, and had reduced basic activities of daily living (BADL) compared to the non-DS group. Furthermore, survival analysis showed that the DS group had a higher risk of early death than the non-DS group. CONCLUSIONS: In the present study, social isolation, living alone, advanced dementia, and reduced BADL were found to be associated with DS. In addition, DS had a high risk of early death. Support for DS must take into account not only mental and social health, but also physical health from an early stage.

Middle-aged and older people with urgent, unaware, and unmet mental health care needs: Practitioners' viewpoints from outside the formal mental health care system.

BACKGROUND: Mental health challenges are highly significant among older individuals. However, the non-utilization of mental health services increases with age. Although universal health coverage (UHC) was reported to reduce unmet health care needs, it might not be sufficient to reduce unmet mental health care needs from a clinical perspective. Despite the existence of UHC in Japan, this study aimed to explore the factors related to the non-utilization of formal mental health care systems among middle-aged and older people with urgent, unaware, and unmet mental health care needs. METHODS: Purposeful sampling was used as the sampling method in this study by combining snowball sampling and a specific criterion. The interviewees were nine practitioners from four sectors outside the mental health care system, including long-term care, the public and private sector, as well as general hospitals in one area of Tokyo, where we had conducted community-based participatory research for five years. The interviews were conducted by an interdisciplinary team, which comprised a psychiatrist, a public health nurse from a non-profit organization, and a Buddhist priest as well as a social researcher to cover the broader unmet health care needs, such as physical, psychosocial, and spiritual needs. The basic characteristics of the interviewees were enquired, followed by whether the interviewees had case of middle-aged or older individuals with urgent, unaware, and unmet mental health care needs. If the answer was yes, we asked the interviewees to describe the details. The interviews pertinent to this study were conducted between October 2021 and November 2021. In this study, we adopted a qualitative descriptive approach. First, we created a summary of each case. Next, we explored the factors related to the non-utilization of formal mental health care systems by conducting a thematic analysis to identify the themes in the data collected. RESULTS: The over-arching category involving "the factors related to an individual person" included two categories, as follows: 1) "Individual intrinsic factors," which comprised two sub-categories, including "difficulty in seeking help" and "delusional disorders," and 2) "family factors," which comprised "discord between family members," "denial of service engagement," "multiple cases in one family," and "families' difficulty in seeking help." The over-arching category "the factors related to the systems" included four categories, as follows: 1) "Physical health system-related factors," which comprised "the indifference of physical healthcare providers regarding mental health" and "the discontinuation of physical health conditions," 2) "mental health system-related factors," which comprised "irresponsive mental health care systems" and "uncomfortable experiences in previous visits to clinics," and 3) "social service system-related factors," which comprised "the lack of time to provide care," "social service not allowed without diagnosis," and "no appropriate service in the community," as well as 4) " the lack of integration between the systems." Apart from the aforementioned factors, "the community people-related factor" and "factors related to inter-regional movements" also emerged in this study. CONCLUSIONS: The results of this study suggest a specific intervention target, and they provide further directions for research and policy implementation. The suggested solutions to the issues pertinent to this study are as follows: the recognition of the ways in which older people may inadequately understand their health or be unaware of available services, the building of a therapeutic alliance for "the individual intrinsic factors." Regarding the "family factors," the solutions include the provision of particularly intensive care for families with family discords, families with multiple cases, and families who find it difficult to seek help, as well as making intensive efforts for ensuring early involvement after contact with health care services. Regarding the "the factors related to the systems," the solutions include the implementation of mental health education campaigns aimed at enhancing mental health knowledge among non-mental health professionals, as well as formulating and implementing reforms ensuring that such professionals are increasingly responsible especially with regard to emergency inpatient care. It also include listening without ageism in clinical practice, the expansion of social services regarding human resources and the flexibility of use which increases the breadth of the types of care, as well as facilitating the integration between the associated health care systems. Further suggestions include encouraging community residents to join social security systems as well as the provision of particularly intensive care for people who have just moved in.

[Comprehensive health assessment of community-dwelling older people using mail method and its association with future transition to need for long-term care and dementia].

Objectives　We selected assessment items that can be used to evaluate the physical, mental, and social functions of community-dwelling older people comprehensively and easily, and examined whether these items could predict a future transition to the requirement for nursing care and dementia.Methods　We conducted a self-administered mail survey of 4,439 community-dwelling older people, who were not certified as requiring nursing care in 2011. The items for the survey were shortlisted out of a total of 54 items that were selected by referring to existing scales, and the evaluation items were determined by pass rate and factor analysis. The cut-off point of the total scores was estimated by ROC analysis using the certification of requiring long-term care (support level 1 or higher) and level of independence in the daily lives of older people with dementia (independence level I or higher) in 2014 as external criteria. The predictive validity was examined by binomial logistic regression analysis using the cut-off point of the total score and the score of the sub-domains as explanatory variables, and the requirement of nursing care and independence level of dementia in 2014 as objective variables.Results　A factor analysis of 1,810 subjects with no deficiencies in the 54 items identified 24 items in five domains (mental health, walking function, Instrumental Activities of Daily Living (IADL), cognitive function, and social support). During the ROC analysis, the cut-off point of the total score was estimated to be 20/21 points (nursing care: AUC 0.75, sensitivity 0.77, specificity, 0.56; dementia: AUC 0.75; sensitivity 0.79, specificity 0.55). The binomial logistic regression analysis showed that persons with a total score of less than 20 points in 2011 were significantly more likely to be certified as requiring nursing care (odds ratio 2.57, 95%CI 1.69-3.92, P<0.01) or show a decline in their independence level of dementia (odds ratio 3.12, 95%CI 1.83-5.32, P<0.01) in 2014. The scores of mental health, walking function, and IADL were significantly associated with certification of requiring nursing care, while walking function and cognitive function were significantly associated with dementia.Conclusion　We believe that the selected items in this study can successfully predict a transition to needing nursing care and dementia in the future. In the sub-domains, the results suggested an association with physical and mental function, as has been previously reported, but little association with social function.

Factors associated with inability to attend a follow-up assessment, mortality, and institutionalization among community-dwelling older people with cognitive impairment during a 5-year period: evidence from community-based participatory research.

BACKGROUND: The aim of the present study was to explore factors associated with (i) the inability to attend a follow-up assessment in the community-based participatory research (CBPR) framework; (ii) mortality; and (iii) institutionalization, across a 5-year period among older people with cognitive impairment identified via an epidemiological survey. METHODS: The participants were 198 older people whose score on the Mini-Mental State Examination was below 24, and who were living in our CBPR region in the Tokyo metropolitan area. Baseline data included sociodemographic factors, health-related factors, social factors, and assessments by healthcare professionals. Over the following 5 years we observed what happened to the subjects within the CBPR framework. Bivariate and stepwise multiple logistic regression analyses were performed to explore the factors associated with the inability to attend a follow-up assessment, 5-year mortality, and institutionalization. RESULTS: Participants who did not attend a follow-up assessment tended to live alone. Being older (>80), living with others, frailty, and the need for rights protection and daily living support were associated with increased mortality. Long-term care insurance certification was strongly associated with institutionalization as a natural consequence of the health-care system. Having dementia and low access to doctors were also positively associated with institutionalization. CONCLUSIONS: Older people with cognitive impairment who are living alone are at higher risk of being overlooked by society. To move toward more inclusive communities, the following are recommended: (i) more interventions focusing on older people living alone; (ii) social interventions to detect daily life collapse or rights violations; and (iii) more support to help people with dementia continue living in the community.

[Lipomatous Hypertrophy of Interatrial Septum in Patient with Venous Thrombus:Report of a Case].

A 64-year-old female underwent a computed tomography (CT) examination of the chest because of pneumonia, which revealed lipomatous hypertrophy of the atrial septum. During medical treatment for pneumonia, venous thrombus of the superior vena cava occurred and then disappeared following apixaban administration. The patient refused surgery at that time, thus follow-up examinations include CT scans were conducted at the outpatient clinic. Two years later, the tumor became larger, and this time she accepted surgery. Under total cardiopulmonary bypass with beating heart a 5.0×3.5 cm tumor was resected. Because of its location very close to superior vena cava, upper area of the right atrium was augmented using a bovine pericardium. Following surgery, sick sinus syndrome developed and pacemaker implantation was performed. Thereafter, the patient had a smooth recovery and no recurrence is noted one year since.

[Off-pump Coronary Artery Bypass Grafting in Jehovah's Witness Patient on Hemodialysis;Report of a Case].

Cardiac surgery in Jehovah's witnesses is challenging due to their refusal of blood transfusion. Furthermore, dialysis patients often suffer from anemia and are also prone to bleeding. We performed offpump coronary artery bypass grafting (CABG) [OPCAB] on a Jehovah's witness male patient on hemodialysis. His preoperative hemoglobin level was around 10.0 g/dl. We used cell saver-collected blood as much as possible during operation. His postoperative course was uneventful with the lowest hemoglobin level of 7.2 g/dl using iron supplements and erythropoietin. This case indicates that intraoperative blood salvage and perioperative management of anemia make OPCAB without blood transfusion possible even in Jehovah's witness hemodialysis patients, when their preoperative hemoglobin levels are maintained greater than 10.0 g/dl.

Distribution of Mini-Mental State Examination scores among urban community-dwelling older adults in Japan.

OBJECTIVES: The Mini-Mental State Examination (MMSE) is widely used as a cognitive screening test for older adults; however, cognitive performance can be affected by age, education, and sample selection bias, including time and place. The aims of this study were to examine the distribution of scores on the Japanese version of the MMSE in an urban community sample and to provide normative data for older Japanese adults. METHODS: A questionnaire survey was conducted on all residents aged 65 years and older living in an urban district in Tokyo (N = 7682). From among this population, 3000 residents were randomly selected to receive visits from trained nurses and to have their health status checked and their cognitive function examined using the MMSE. RESULTS: Of the 2786 eligible residents, the MMSE was administered to 1341 (47%) and successfully completed by 1319 (mean age, 74.4 ± 6.4 years; mean years of formal education, 12.6 ± 2.9). The median score was 28. A total of 143 residents (10.8%) had scores below the traditional 23/24 cutoff point. Younger age and higher education were associated with better performance. Greater variation was seen among the oldest and least educated residents, especially among women. CONCLUSION: The results of this study confirm that age and education affect MMSE scores. To ensure the effective use of the MMSE, it is recommended to examine scores corresponding to age and education. The normative data presented are expected to be useful for assessing MMSE scores in older individuals both in and out of the clinical setting. Copyright © 2016 John Wiley & Sons, Ltd.

Underweight and hypoalbuminemia as risk indicators for mortality among psychiatric patients with medical comorbidities.

AIM: Medical comorbidities are a major cause of death among patients with mental illness. The purpose of this study was to clarify the risk factors for mortality among psychiatric patients with medical comorbidities. METHODS: We retrospectively reviewed the clinical files of patients transferred to Tokyo Metropolitan Matsuzawa Hospital from a psychiatric hospital to treat medical comorbidities during the 3-year period from January 2014 to December 2016. We analyzed the clinical differences between the expired and alive patients. RESULTS: Of the 287 patients included, 29 (10.1%) had expired at the time of hospital discharge, while 258 (89.9%) were living. A multivariable analysis to determine the prognostic factors related to mortality from medical comorbidities showed that body mass index <18.5 had the highest odds ratio among the predictive factors (5.1; 95% confidence interval, 1.5-17.1; P < 0.05), followed by a serum albumin level < 3.0 mg/dL (3.0; 95% confidence interval, 1.1-8.1; P < 0.05). CONCLUSION: We found that underweight and hypoalbuminemia were risk factors for mortality among psychiatric patients with medical comorbidities. Physicians at psychiatric hospitals should consider transferring patients with medical comorbidities to a general medical hospital in the presence of underweight and/or hypoalbuminemia.

[Acute Type B Aortic Dissection Complicated with Malperfusion of Celiac Artery Alone;Report of a Case].

Malperfusion of the superior mesenteric artery(SMA) in acute type B aortic dissection is potentially fatal. Revascularization should therefore be aggressively considered in a proactive way. However, this is not the case with the celiac artery malperfusion. We present a case of malperfusion of isolated malperfusion of the celiac artery due to acute type B aortic dissection. Although the collateral blood flow from the SMA via the pancreatic arcade was identified, ischemic gastric ulcer and pancreatitis developed later on. At present, there is a general agreement that catheter intervention is the 1st treatment of choice for complicated acute type B aortic dissection. In the present case, however, even a guide wire did not pass through the orifice of the celiac artery and revascularization was not successful.

[Emergency Mitral Valvoplasty for Papillary Muscle Rupture].

We experienced 2 emergency surgical cases of severe mitral valve regurgitation due to papillary muscle rupture. Case 1:a 69-year-old man presented with respiratory and cardiac failure due to mitral regurgitation. He had no history of myocardial infarction. Mitral valve repair with artificial cords was performed. The papillary muscle of the anterior leaflet was ruptured. The postoperative course was uneventful. Case 2:a 80-year-old man came to our hospital with cardiac arrest. Emergency coronary intervention was performed to the right coronary and intraaortic balloon pumping was inserted. However his condition remained unstable. Severe mitral regurgitation was found by teansesophageal echo cardiography, and he underwent emergency mitral valve repair and single coronary bypass grafting. His cardiac function recovered quickly, but severe brain damage remained.

Excessive daytime sleepiness is related to subjective memory impairment in late life: a cross-sectional community-based study.

AIM: The aim of this study was to determine whether daytime sleepiness is related to subjective memory impairment among community-dwelling elderly people, after adjustment for psychosocial variables. METHODS: Questionnaires were mailed to all 5199 elderly residents living in one area of Tokyo. The questionnaires collected information about sociodemographic variables, subjective memory impairment, and excessive daytime sleepiness, which was measured by the Japanese version of the Epworth Sleepiness Scale. Information was also collected on sleep hygiene, health-related variables, and psychosocial variables, including perceived social support, social withdrawal, and work status. RESULTS: Of the 4783 questionnaires that were returned (92.0%), 4185 participants were included in the analysis (valid response rate: 80.5%), after the exclusion of questionnaires with missing data. The average score on the Japanese version of the Epworth Sleepiness Scale was 5.0 ± 3.9 for men and 4.5 ± 3.7 for women. The frequency of excessive daytime sleepiness was 8.3% for men, 5.8% for women, and 7.0% in total. Stepwise multivariate logistic regression revealed the odds ratio of excessive daytime sleepiness as a predictor of subjective memory impairment was 6.06 (95% confidence interval; 3.06-12.03). CONCLUSIONS: Elderly people who complain of daytime sleepiness are potential candidates for interventions related to dementia care after careful consideration of other possible causes of sleepiness.

[Development of a self-administered dementia checklist (SDC) (1): Examination of factorial validity and internal reliability].

AIM: 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. METHODS: 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. RESULTS: 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. CONCLUSION: The authors developed a 10-item SDC with 2 factors and confirmed its factorial validity and internal reliability.