Toward the realization of a better aged society: messages from gerontology and geriatrics.

1. BACKGROUND: Recent medical advancements, and improvements in hygiene and food supply have led to Japan having the longest life expectancy in the world. Over the past 50 years, the percentage of the elderly population has increased fourfold from 5.7% in 1960 to 23.1% in 2010. This change has occurred at the fastest rate in the world. Compared with France, where the percentage of the elderly population has increased just twofold in the past 100 years, Japanese society is aging at an unprecedented rate. In addition, the percentage of the very elderly (aged 75 years and over), comprising more frail people, exceeded 10% of the nation's population in 2008. In such a situation, many elderly Japanese wish to spend their later years healthy, and wish to achieve great accomplishments in their lives. To achieve that, rather than considering an aging population as a negative social phenomenon, we should create a society where elderly people can enjoy a healthy, prosperous life through social participation and contribution. Factors that hamper the elderly from leading a healthy life include various psychological and social problems occurring in older age, as well as a high incidence of diseases. Therefore, gerontology, which focuses on health promotion of the elderly by encompassing the study of social welfare, psychology, environment and social systems; and geriatrics, which focuses on health care of elderly people and carried out research, education and practices to promote health in the elderly, are becoming more important. Furthermore, along with a need for multidisciplinary care to support geriatric medicine, the development of a comprehensive education system for aged-care professionals is awaited. Thus, we should now recognize the importance of gerontology and geriatrics, and a reform of medical-care services should be made in order to cope with the coming aged society. Population aging is a global phenomenon. The actions being taken by Japan, the world's most aged society, have been closely watched by the rest of the world. Japan's aged society has been posing not only medical, nursing and welfare problems, but also complex problems closely associated with economy, industry and culture. Therefore, to solve these problems, a macroscopic integration and cooperation among industries, education institutions, administration and community through an interdisciplinary approach including medical science, nursing science, nursing care, study of social welfare, social science, engineering, psychology, economics, religion and ethics should be made. Regarding the promotion of gerontology, the "Committee for Establishing a Scientific Community for Sustainable Aged Society" of the Science Council of Japan also prepared a proposal and this was announced on 20 April 2011. 2. CURRENT SITUATION AND PROBLEMS: (1) Promotion of social participation and contribution of elderly people In Japan, the overall labor force rate is expected to decrease in the near future as a result of the low birth rate and high life expectancy. In contrast, many elderly people, particularly the young-old, have sufficient physical strength to fulfil their job duties and make a social contribution. For these people, a social structure where elderly people can work should be developed through re-educating the elderly and providing various job types. Promotion of social participation and contribution of the elderly is expected to cause a substantial increase in the labor force. Furthermore, it is also expected to contribute to not only the upturn of national economic activity through an increase in total consumption, but also a decrease in the number of elderly people who are likely to be in need of care. Therefore, in order for elderly people to be engaged in various social activities, strategies for developing a social structure for re-education, various employment statuses and employment opportunities should be prepared. However, as the total number of jobs is fixed, consideration should also be given to young workers. (2) Fostering medical specialists for aging Older people often suffer from many diseases, together with geriatric syndromes with multiple etiologies. Signs and symptoms vary according to each individual, and are often atypical; therefore, the patients visit different hospitals and receive many screening tests and prescriptions at the same time. To solve this problem, an effective screening system carried out by a primary-care doctor, and privacy-preserving medical data sharing among hospitals and clinics are needed. In a geriatric clinical setting, health-care professionals should be aware of the physical traits of older people who often develop not only dementia, but also geriatric syndromes, such as depression, falls and urinary incontinence, so that a holistic approach with consideration of nursing care is required. However, the existing Japanese medical education system is not prepared for medical professionals enabled to respond to the aforementioned requirements. Thus, the fostering of medical professionals who can provide comprehensive care - especially for the oldest-old - such as geriatric specialists and medical professionals who understand the principles of elderly care, is urgently needed. (3) Diagnosis of elderly-specific diseases and reform of medical-care services In Japan, the diagnostic system for elderly-specific diseases, including dementia, and reform of medical care services are markedly delayed. The current status concerning diagnosis, care and nursing should be investigated to collect academic data. In order to accumulate evidence for providing safe elderly care and nursing, the promotion of clinical research and a marked expansion of geriatric medical centers with high-level medical services are eagerly awaited. (4) Promotion of home-based care and multidisciplinary care To reduce the length of stay in acute hospitals, to reduce the physical burden of health-care professionals working at acute hospitals and to meet the demand of older people who prefer to remain in their own homes, further promotion of home-based care is needed. In addition, "multidisciplinary care" is increasingly needed to meet various demands in the medical care and welfare of the elderly. It is considered important to share countermeasures against the problems of disease prevention, medicine, care and welfare among health-care professionals in medicine, care and welfare, and cooperate by making the best use of health-care professionals' specialties. 3. CONTENTS OF THE PROPOSAL: The subcommittee for aging, thus, provided the following proposal: 1 Development and promotion of systems that enable elderly people to participate socially and make a contribution using an interdisciplinary approach among the various areas, including nursing science, nursing care, study of social welfare, social science, psychology, economics, religion and ethics, as well as medical sciences; 2 Promotion of gerontology, reform and enhancement of geriatrics in undergraduate, postgraduate and lifelong education; 3 Building geriatric medical centers in each area, and accumulating large-scale evidence of geriatric diseases and geriatrics; and 4 Structural development and promotion of home-based care and multidisciplinary care. Through implementation of the above measures, Japan is expected to function as a successful example for the rest of the world.

Evaluation of postural control in quiet standing using center of mass acceleration: comparison among the young, the elderly, and people with stroke.

OBJECTIVE: To determine center of mass (COM) acceleration usefulness in the evaluation of postural control during quiet standing. DESIGN: Three-group comparison design. SETTING: A research laboratory. PARTICIPANTS: Poststroke subjects (n=12), healthy elderly subjects (n=22), and healthy young subjects (n=25). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: With a force platform, postural sway was evaluated by using the standard deviations of COM acceleration and center of pressure (COP) and COM (COP-COM) in which COP-COM represents the distance between the COP and the COM. RESULTS: COM acceleration and COP-COM variables were greater in the poststroke group than in the healthy groups (elderly and young) in the mediolateral (ML) direction. Both variables in the anteroposterior (AP) direction were greater in the poststroke group and the elderly group than in the young group. Furthermore, the correlations between COM acceleration and COP-COM in each group in each direction were shown to be significantly high (r range, .906-.979; P<.001). CONCLUSIONS: COM acceleration was useful in the evaluation of postural control during quiet standing when comparing the young, the elderly, and poststroke patients. Additionally, COM acceleration and COP-COM in both the AP and ML directions during quiet standing were significantly and highly correlated. Thus, we proposed that COM acceleration can be an alternative and convenient measure instead of COP-COM in the evaluation of postural control.

Effects of passive leg movement on the oxygenation level of lower limb muscle in chronic stroke patients.

OBJECTIVE: To evaluate the effects of passive leg movements on the muscle oxygenation level and electromyographic (EMG) activity in the lower limbs in chronic stroke patients. METHODS: With a gait training apparatus, passive movements were imposed on the lower limbs of 15 chronic stroke patients at a frequency of 0.8 Hz for 10 minutes. During the passive leg movements, muscle oxygenation level and muscular EMG activity of the paretic and nonparetic calf muscles were assessed. RESULTS: The passive leg movements caused increases in the EMG activity and muscle oxygenation level in both paretic and nonparetic lower limbs. Although a significant difference was found in the concentration changes of the oxygenated hemoglobin (Oxy-Hb), both paretic and nonparetic sides of the muscle showed enhancement of the tissue oxygenation level (TOI). The degree of the changes of the Oxy-Hb depended on the level of motor recovery after stroke; subjects with good motor recovery showed less difference in the Oxy-Hb level between the paretic and nonparetic sides of the muscle. CONCLUSION: Passive leg movements have the capacity to induce muscular activity and enhance oxygen metabolism, even in the paretic lower limb muscle of chronic stroke patients. This type of exercise might be a useful and efficient method for the prevention of metabolic deterioration in the lower limb paretic muscles of chronic stroke patients.

Clinical status and dependency of the elderly requiring long-term care in Japan.

More than 4 million of the elderly receive long-term care services using the public long-term care insurance in Japan. In order to use the insurance system, the insured person needs to be classified in one of the six care levels according to his/her clinical status. Though each level is defined in terms of the total amount of estimated care time needed per day, the clinical status of each level is not precisely defined. This study aimed to compare the clinical status of the six levels in order to suggest indicators of deterioration for each care level. We analyzed the clinical status for 7,222 cases who applied for care-need certification in a rural area of Japan. Sixty-seven items were used to determine physical function, activities of daily living, and cognitive and sensory status. Even in the mildest care level (Support Required), more than 50% of the individuals were dependent with regard to standing and sitting, while weakness of the lower extremities and dependency in walking were identified in Care Level 1, dependency in dressing and toilet habits in Care Level 2, dependency in grooming and transferring in Care Level 3, dependency in communication and feeding in Care Level 4, and dependency in swallowing, orientation and limitations of joint movement in Care Level 5. Care providers should be tracking these changes to estimate and prevent the decline of care level because more than 20% of the individuals assessed in 2004 belonged to the worse care level one year later.

Assessment of sensory neglect: a study using moving images.

A novel modified passive line-bisection test was performed using a computer display with a moving image. In the test, the subjects were required to give verbal responses instead of limb movements. The test, consisting of two subtasks, left-to-right and right-to-left tasks, was applied to patients with unilateral neglect and controls. The patient group showed an obvious mean deviation in both tasks, and showed greater rightward deviation in the right-to-left task than in the left-to-right task. The control group showed little differences between the two tasks. This paper discusses the results obtained from the two different conditions and their correlations. This method provides useful data for the assessment of unilateral neglect.

[Health-related quality of life factor in chronic hemodialysis patients].

AIM: The purpose of this study was to investigate the related factors of the health-related quality of life (HRQOL) measured by KDQOL-SF version 1.3 Japanese version) in chronic hemodialysis patients. METHODS: Using a cross-sectional survey design, we hand-delivered a self-administered questionnaire to the chronic hemodialysis patients and finally obtained 67 subjects' data to analyze. The response rate was 65.7%. Among the related factors, disease/dialysis-related factors and rehabilitation-related factors in addition to demographic factors were examined. The HRQOL was divided into a physical component summary (PCS) and a mental component summary (MCS). RESULTS: Multiple linear regression analysis revealed that the independent factors related to PCS were symptom score, serum albumin level, patients' satisfaction with dialysis care, and the work status. These four factors could explain 60% of PCS variance (adjusted R2 = 0.601). The independent factors related to MCS were revealed to be quality of social interaction and understanding of effectiveness of self-exercise. These two factors could explain only a quarter of MCS variance (adjusted R 2 = 0.223). CONCLUSION: These results suggest that highly satisfactory care of dialysis, improvement of dialysis-related symptoms, and good nutritional management are important for improving HRQOL in chronic hemodialysis patients, and that the promotion of social participation and interpersonal relationships as well as a positive attitude to self-exercise may lead to a beneficial outcome of rehabilitation for chronic hemodialysis patients.

Evaluation of diffusional anisotropy and microscopic structure in skeletal muscles using magnetic resonance.

The pulsed-gradient spin-echo (PGSE) nuclear magnetic resonance (NMR) method is used for detecting the diffusion of water molecules in biological tissues. Because tissues generally have diffusional anisotropy, their diffusion properties are denoted by a tensor. In this study, we evaluated the diffusional anisotropy and microscopic structure in atrophied skeletal muscles using the PGSE NMR method. The left sciatic nerve was severed in twelve 9-week-old rats. Neurotomy caused neurogenic muscular atrophy at the left gastrocnemius. At 2, 4 and 8 weeks after neurotomy, magnetic resonance signals were selectively acquired from a 2 x 2 x 2 mm(3) voxel, which was located on the left gastrocnemius. The diffusion tensor, the mean diffusivity (MD) and the fractional anisotropy (FA) were calculated from the signals. A theoretical model of the diffusion in muscles was derived from Tanner's equation. The muscle fiber diameter was estimated by fitting the model to the measured signals. The measurements were also performed for normal rats as controls. No significant difference was found in the MD and the estimated intracellular diffusion coefficient between the control group and the denervated group. The denervated group had significantly higher FA compared with the control group (P<.05). The estimated muscle fiber diameter of the denervated group was significantly smaller than the estimated value of the control group (P<.05). These differences were found at 8 weeks after neurotomy. The proposed method is effective for evaluating changes in the microscopic structure of skeletal muscles.

Laryngeal phonation after tracheoesophageal diversion.

When tracheoesophageal diversion is performed, laryngeal phonation is usually impossible. We, however, experienced the case of a 65 year-old female patient, who was able to do so. Fluoroscopic and videoendoscopic examinations elucidated her mechanism of phonation. This is the first detailed report describing the mechanism of laryngeal phonation after the procedure. Our case is compared with a few other similar cases found in available literature.

A simple method to dissociate sensory-attentional and motor-intentional biases in unilateral visual neglect.

A variant of a line bisection test was devised. Patients with unilateral visual neglect and control subjects were asked to perform the test, which consisted of two subtasks: a verbal and a manual task. The verbal task was newly designed and did not require manual responses from the subjects. The manual task was similar to conventional line bisection tasks. This paper reports and discusses the results obtained from each task and their correlations. This technique is compatible with bedside examinations, does not require a complex apparatus, and provides useful data for the assessment of unilateral visual neglect.

Hemodynamic and hormonal responses to a short-term low-intensity resistance exercise with the reduction of muscle blood flow.

We investigated the hemodynamic and hormonal responses to a short-term low-intensity resistance exercise (STLIRE) with the reduction of muscle blood flow. Eleven untrained men performed bilateral leg extension exercise under the reduction of muscle blood flow of the proximal end of both legs pressure-applied by a specially designed belt (a banding pressure of 1.3 times higher than resting systolic blood pressure, 160-180 mmHg), named as Kaatsu. The intensity of STLIRE was 20% of one repetition maximum. The subjects performed 30 repetitions, and after a 20-seconds rest, they performed three sets again until exhaustion. The superficial femoral arterial blood flow and hemodynamic parameters were measured by using the ultrasound and impedance cardiography. Serum concentrations of growth hormone (GH), vascular endothelial growth factor (VEGF), noradrenaline (NE), insulin-like growth factor (IGF)-1, ghrelin, and lactate were also measured. Under the conditions with Kaatsu, the arterial flow was reduced to about 30% of the control. STLIRE with Kaatsu significantly increased GH (0.11+/-0.03 to 8.6+/-1.1 ng/ml, P < 0.01), IGF-1 (210+/-40 to 236+/-56 ng/ml, P < 0.01), and VEGF (41+/-13 to 103+/-38 pg/ml, P < 0.05). The increase in GH was related to neither NE nor lactate, but the increase in VEGF was related to that in lactate (r = 0.57, P < 0.05). Ghrelin did not change during the exercise. The maximal heart rate (HR) and blood pressure (BP) in STLIRE with Kaatsu were higher than that without Kaatsu. Stroke volume (SV) was lower due to the decrease of the venous return by Kaatsu, but, total peripheral resistance (TPR) did not change significantly. These results suggest that STLIRE with Kaatsu significantly stimulates the exercise-induced GH, IGF, and VEGF responses with the reduction of cardiac preload during exercise, which may become a unique method for rehabilitation in patients with cardiovascular diseases.

[A longitudinal study of cognitive function and the relationship between cognition and activities of daily living in the elderly].

AIM: To describe fundamental cognitive function and change in the elderly and examine interaction between cognition and ADL. METHODS: We investigated the mental and physical condition of 12,140 persons aged 65 years or over in 2000 and 2002 according to the Eligibility Survey Questionnaire for Long-term Care Insurance. The percentage correct and correlation coefficients of six items in the Questionnaire concerning "Understanding" : "Understands daily activities", "Answers date of birth and age", "Remembers what the subject did before interview", "Says own name", "Knows what season it is now", "Knows the place where the subject is" were determined. The interaction between these six items and ADL were also examined. RESULTS: The percentage correct of "name" was .89, "date of birth and age" .78, "place" .75, "season" .66, "daily activities" .59, "Remembers before interview" .58. The item with high percentages of correct answer in 2000 higher tended to remain high in 2002. Those who were not impaired physically but unable to understand cognitive items tended to require significantly more support for ADL such as "Dressing and undressing", and "Personal hygiene", "Taking medication". CONCLUSION: The percentage correct of each item was considered to be associated with a classical model of memory process: encoding, retention and retrieval. It seemed to require the whole memory process to "Understand daily activities" and "Remember before interview", since the contents were changeable. On the other hand, "name" and "date of birth and age" were relatively well preserved, since these items were encoded and stored in the early stage of life and retrieved repeatedly. "Place" and "Season" were between these two groups.

[A new portable communication test (mini-communication test) for dementia].

To evaluate verbal communication ability in the elderly, we developed a new portable "mini-communication test (MCT)" with 13 sub-scales, which was constructively validated based on 45 items from other reported scales. Clinical reliability and validity were tested in 354 inpatients in a long-term care hospital (81.9 +/- 8.3 years old) and 124 inpatients (80.39 +/- 8.1 years old) and 34 outpatients (76.5 +/- 7.0 years old) in Kyorin University Hospital. All patients were evaluated in approximately 7 minutes each. The test-retest correlation coefficient was 0.99. Inter-rater coefficient of variation was 0.107. The Cronbach alpha value of the test was 0.93. MCT positively correlated with the Barthel Index (r = 0.65, p < 0.01). Hasegawa Dementia Scale Revised version (r = 0.93, p < 0.001) and Vitality Index (r = 0.66, p < 0.01). MCT could be a new tool to assess communication ability in elderly patients with or without dementia.