Influence of diabetes mellitus on caregiver burden in home care: a report based on the Nagoya Longitudinal Study of the Frail Elderly (NLS-FE).

BACKGROUND: Because little attention has so far been paid to the impact of diabetes mellitus (DM) on caregiver burden in community settings, we sought to confirm the influence of DM on perceived caregiver burden among caregivers providing care to a home elderly person using data from the Nagoya Longitudinal Study of the Frail Elderly (NLS-FE). METHODS: The NLS-FE is a large prospective study of 1875 community-dwelling elderly. A total of 1592 pairs of dependents and caregivers were included in the analysis. The data we used in this study included the Japanese version of the Zarit Caregiver Burden Interview (J-ZBI), characteristics of caregivers and dependents, and caregiving situation. The pairs were sorted into one control and three DM groups: (i) no DM; (ii) DM taking no medications; (iii) DM taking oral medication only; and (iv) DM taking insulin. The differences in dependent and caregiver characteristics among the groups were assessed. RESULTS: Two hundred and twenty-eight dependents from the NLS-FE study had DM. Of these, 25% took no medication to treat it, 55% took oral medications only, and 20% used insulin. No statistical differences were found in age, gender or kinship among caregivers. No differences were found among the DM categories in levels of caregiver burden according to the J-ZBI, before and after adjusting for these baseline variables. CONCLUSIONS: Among the community-dwelling frail elderly, DM is not an independent predictor of caregiver burden.

Regional variations in medical expenditure and hospitalization days for heart attack patients in Japan: evidence from the Tokai Acute Myocardial Study (TAMIS).

In Japan, the use of percutaneous transluminal coronary angioplasty (PTCA) for the treatment of acute myocardial infarction (AMI) is extraordinarily frequent, resulting in large medical expenditure. Using chart-based data and exploiting regional variations, we explore what factors explain the frequent use of PTCA, employing propensity score matching to estimate the average treatment effects on hospital expenditure and hospital days. We find that the probability of receiving PTCA is affected by the density of medical resources in a region. Moreover, expenditure is higher for treated patients while there are no significant differences in hospitalization days, implying that the frequent use of PTCA is economically motivated.

[Differences in cardiac management and in-hospital mortality between elderly patients with and without dementia after acute myocardial infarction: findings from TAMIS data].

AIM: In the United States, a study has shown that dementia is a significant factor negatively associated with medical treatment. Because the increasing number of the elderly has resulted in cause a rise in patients with dementia or acute myocardial infarction (AMI), or both, we need to know the differences in in-hospital mortality between patients with or without dementia in patients with AMI. METHODS: We used data from 13 acute care hospitals including in the data from the Tokai Acute Myocardial Infarction Study (TAMIS), a retrospective study of all patients admitted to these hospitals from 1995 to 1997 with a diagnosis of AMI. We abstracted the baseline and procedural characteristics from detailed chart reviews. A total of 22 patients with dementia and 1,030 with no dementia who were aged 65 and over were included in the present study, and were divided into two groups according to their diagnosis of dementia. We compared the baseline and procedure characteristics and clinical outcomes between the two groups. RESULTS: Patients with dementia were older and more likely to have either a lower body mass index score or ADL impairment. As for medical history, patients with dementia were more likely to have a history of cerebrovascular disease, and less likely to have a history of angina or smoking. Before and after multivariable adjustment, no significant difference was found in in-hospital mortality between patients with or without dementia. CONCLUSIONS: Our study demonstrates that AMI elderly patients with dementia were not less likely to be undertreated and did not have a higher in-hospital mortality rate than non-dementia patients.

Lack of body weight measurement is associated with mortality and hospitalization in community-dwelling frail elderly.

BACKGROUND & AIMS: Although it is not uncommon for there to be frail older people living in the community, who do not know their weight and/or height, the health-related outcomes of those older remains unknown. We examined whether missing these anthropometries are a predictor of mortality or hospitalization during a 2-year follow-up period in community-dwelling older people using various community-based services. METHODS: This study was a prospective cohort analysis of 952 community-dwelling elderly. Data included the clients' demographic characteristics, basic activities of daily living (ADL), comorbidity, and anthropometric measurements at baseline. Analysis of mortality and hospitalization over the 2-year period was conducted using multivariate Cox proportional hazards models. RESULTS: Among the 952 participants, 342 and 292 had missing data for height and weight at baseline, respectively. Multivariate Cox proportional hazards models adjusting for potential confounders showed that the lack of data on weight was associated with 2-year mortality (hazard ratio, HR:1.54, 96% CI:1.09-1.79) as well as hospitalization (HR:1.34, 95% CI:1.01-1.79) during the 2-year follow-up, although the lack of height measurement was not associated with these adverse outcomes. CONCLUSIONS: Older people living in the community with unavailable weight data appear to be more likely to have a high risk of mortality and hospitalization.

[Decision-making factors regarding resuscitate and hospitalize orders by families of elderly persons on admission to a Japanese long-term care hospital].

BACKGROUND: Because long-term care facilities are being asked to care for more and more residents who are dying, the facilities require that new residents and families make decisions regarding their end-of-life care at the time of the admission process. An advance directive including "do-not resuscitate directives (DNR)" or "do-not-hospitalize directives (DNH)" is a written document that afford individuals the opportunity to determine the type and extent of end-of-life care when they are incapable of participation in medical decision making. It is expected that Japanese elderly and families make individual decisions regarding end-of-life care by a Japanese-style decision-making model including advance directives. The purpose of this study was to explore families' decision-making factors regarding cardiopulmonary resuscitate (CPR) and hospitalize orders in a long-term care hospital. METHOD: We assessed 70 admissions in a long-term care hospital in Aichi prefecture from April 2005 to September 2006. All residents were divided into two groups according to their CPR or hospitalize order. Data on the admission characteristics of the residents were collected from medical charts. RESULTS: The prevalence of older age, functional dependence, and illness did not vary significantly with CPR or hospitalize order recorded by families, however, significant variation among physicians existed in the CPR and hospitalize orders. CONCLUSION: Wide variation in the likelihood of having CPR and hospitalize orders among physicians who explain an advance directive suggests a need for standardized methods for eliciting the end-of-life preferences of residents and families on admission to long-term care hospitals.

Anthropometric measurements of mid-upper arm as a mortality predictor for community-dwelling Japanese elderly: the Nagoya Longitudinal Study of Frail Elderly (NLS-FE).

BACKGROUND & AIMS: It remains controversial whether mid-arm anthropometric measurements (MAAMs) are reflected with physical impairment or useful predictors of mortality in the frail elderly. We examined the following hypotheses: (1) MAAMs in frail community-dwelling elderly are lower than those of independent elderly, (2) the lower MAAMs are associated with physical function impairment, and (3) are independent predictors of 2-year mortality. METHODS: This study was composed of cross-sectional and prospective cohort analyses of 957 community-dwelling elderly. Data included the clients' demographic characteristics, comorbidity, activities of daily living (ADL), and MAAMs at baseline. The mean scores of MAAMs of participants were compared with Japanese Anthropometric Reference Data. Survival analysis of 2-year mortality was conducted using multivariate Cox proportional hazards models. RESULTS: Significantly lower arm muscle area (AMA) and higher triceps skinfold (TSF) levels were observed in most of the age groups of the study participants than those of the standard Japanese population. ADL function was correlated with AMA but not with TSF, both of which were independent risk factors for 2-year mortality in the participants (highest tertile versus lowest, AMA, HR:2.03, 95%CI:1.36-3.02; TSF, HR:1.89, 95%CI:1.30-2.75). CONCLUSIONS: AMA and TSF were independent risk factors for 2-year mortality in the community-dwelling frail elderly.

[End-of-life care in the curriculum in Japan: a national survey of senior medical students].

AIM: We conducted a national survey of senior medical students' attitudes about end-of-life care teaching programs for undergraduate students of Japanese medical schools from April 2004 to May 2006. METHODS: Our questionnaire survey focused on the students' attitudes towards the following end-of-life areas: 1) end-of-life topics, 2) teaching methods, 3) putting theories into practice, and 4) overall end-of-life issue. RESULTS: Overall, 1,039 students from 16 medical schools responded to our survey. The students who took part in the program appreciated the class on communication techniques with dying patients or family members of dying patients. As for the students who did not participate in the program, they expressed the wish to join a class concerning these issues. These students also expressed an interest in visiting hospices or conducting interviews with dying patients as part of their training. Most of the students formulated good opinions toward end-of-life issues, but not toward end-of-life practices. Regardless of whether they joined the program or not, most of the students had a positive attitude towards end-of-life education programs. CONCLUSION: The survey highlighted the need to consider wider implementation and improvement of end-of-life care education in the Japanese curriculum.

[Anthropometric measurements as a predictor of mortality of community-dwelling Japanese elderly: the Nagoya Longitudinal Study of Frail Elderly (NLS-FE)].

AIM: This study aimed to evaluate the relationship between anthropometric measurements and mortality among community-dwelling frail elderly. METHODS: This study was a prospective cohort analysis of 520 community-dwelling elderly registered in the Nagoya Longitudinal Study for Frail Elderly (NLS-FE). Data included the participants' demographic characteristics, body mass index (BMI), mid-arm circumference (MAC), triceps skinfold (TSF), and arm muscle area (AMA), basic activities of daily living, comorbidity. BMI and TSF values were categorized into three groups, respectively, according to above the 75th percentile, the 25-75th percentile, and below the 25th percentile of Japanese Anthropometric Reference Data (JARD 2001). Survival analysis of 21-month mortality was conducted using Kaplan-Meier curves and multivariate Cox proportional hazards models. RESULTS: BMI and TSF were independent risk factors for 21-month mortality in the study participants. Significant higher risk of 21-month mortality was observed in participants below the 75th percentile of BMI or below the 25th percentile of TSF set in JARD 2001. A striking increase in the risk of 21-month mortality, adjusting for potential confounding factors, was observed in the below 75th percentile of the BMI group with a below 25th percentile TSF of JARD 2001, compared with the 75th or above percentile BMI group with the 25th or above percentile TSF. CONCLUSION: The combination of BMI and TSF is a predictor of 21-month mortality among older people with ADL dysfunction.

[Effect of end-of-life care teaching on the attitude of medical students to death].

AIM: We conducted a national survey to examine how programs to teach end-of-life care to medical students in Japanese medical schools influence their death attitude. METHODS: Sixteen medical schools participated. We conducted a questionnaire survey on fifth- or sixth-year medical students' death attitude at each medical school. Attitude of death was analyzed by the Death Attitude Inventory formed by Hirai et al, which is composed of seven factors: Afterlife belief, Death anxiety, Death relief, Death avoidance, Life purpose, Death concern, and Supernatural belief. We studied how students' attitude to death relates to programs to teach end-of-life care. RESULTS: Overall 1,017 of 1,510 students (67.4%) from the 16 medical schools participated. The students who took a program to teach end-of-life care presented Afterlife belief, Death concern and Supernatural belief score higher than those who did not participate in any program. Multiple logistic regression analysis was conducted and it was found that those trend disappeared, and the students who took a program had greater Death anxiety significantly higher than those who took no program. CONCLUSION: We concluded that the attitude of medical students to death was not related to programs to teach end-of-life care in medical schools. Our survey suggested that improving end-of-life care education is needed to mold the attitude of medical students to death.

Impact of gender on in-hospital mortality of patients with acute myocardial infarction undergoing percutaneous coronary intervention: an evaluation of the TAMIS-II data.

OBJECT: It is a matter of concern that women have higher in-hospital mortality rates than men with percutaneous coronary intervention (PCI), however, it is not yet clear whether significant gender differences exist. We studied the influence of gender on the characteristics and in-hospital mortality among patients with acute myocardial infarction (AMI) undergoing percutaneous coronary intervention (PCI). METHODS: We used data from 15 acute care hospitals included in the sample from the Tokai Acute Myocardial Infarction Study II (TAMIS-II), a prospective study of all patients admitted to these hospitals from 2001 to 2003 with a diagnosis of AMI. We abstracted the baseline and procedural characteristics from detailed chart reviews which included not only physician notes but also nursing notes, and a questionnaire which included baseline characteristics, procedural course and in-hospital mortality. Multivariate analysis was performed, controlling for age and other variables which were found to be significantly different between men and women by chi-square test or unpaired t test. PATIENTS: A total of 566 women and 2,048 men were included in the present study. RESULTS: There were gender differences in age, comorbid conditions, smoking status, body mass index, activities of daily livings, heart failure on presentation, duration of stay, angiographic data, transfer to ICU/CCU, and thrombolytic drugs. In univariate analysis, women had a higher in-hospital mortality rate than did men; however, this gender difference disappeared after adjustment for age and other variables. CONCLUSION: Our study demonstrated that women with AMI who undergo PCI do not have a higher in-hospital mortality rate than men.

Influence of diabetes mellitus on in-hospital mortality in patients with acute myocardial infarction in Japan: a report from TAMIS-II.

BACKGROUND: The relation between diabetes mellitus (DM) and mortality among patients with acute myocardial infarction is still controversial. We evaluated the influence of DM on the in-hospital mortality of acute myocardial infarction (AMI) patients using data from the Tokai Acute Myocardial Infarction Study-II, a multi-hospital prospective study performed in Japan. METHODS: All of the study subjects were patients hospitalized for newly diagnosed AMI at 1 of 13 acute care hospitals between January of 2001 and December of 2003. We abstracted the baseline and procedural characteristics from detailed chart reviews. Multivariate analysis was performed, controlling for the variables found to be significantly different between AMI patients with and without DM by chi-square test or unpaired t-test. We evaluated a total of 940 DM and 2284 non-DM patients. RESULTS: DM patients had roughly twice the in-hospital mortality rate of non-DM patients, with an unadjusted odds ratio of 1.77 (95% CI, 1.37-2.30). However, according to the multivariate analysis, DM was not identified as an independent predictor of in-hospital death, with an adjusted odds ratio of 5.73 (95% CI, 0.97-33.88). CONCLUSIONS: DM is not an independent predictor of in-hospital mortality, and that there is a need for additional studies to confirm our conclusion.

Effect of emergency percutaneous coronary intervention on in-hospital mortality of very elderly (80+ years of age) patients with acute myocardial infarction.

It is still controversial whether percutaneous coronary intervention (PCI) is effective in improving in-hospital survival in very elderly patients. Therefore, using data from the Tokai Acute Myocardial Infarction Study II, we studied the effect of emergency PCI on the in-hospital mortality of very elderly (80+ years of age) patients with acute myocardial infarction (AMI). The study was a prospective study of all consecutive patients admitted to the 15 acute care hospitals in the Tokai region with the diagnosis of AMI from 2001 to 2003. A total of 211 patients undergoing emergency PCI and 176 patients not undergoing PCI were included in the present analysis. We compared the baseline and procedural characteristics and the clinical outcomes between the 2 groups. Patients without emergency PCI were older and had an increased prevalence of female gender, ADL impairment, and dementia in comparison with those with PCI. They also showed poorer clinical conditions. They were less likely to be transferred to intensive care or coronary care units and to be given intra-aortic balloon pumps. The patients with emergency PCI had nearly one-third the in-hospital mortality rate of the patients without emergency PCI. According to multivariate analysis, emergency PCI was still identified as an independent predictor of in-hospital death, with an adjusted odds ratio of 0.26 (95% CI, 0.07-0.97). The results indicated that emergency PCI has a preventative effect on in-hospital mortality in Japanese AMI patients 80 years of age and older.

Association of renal insufficiency with in-hospital mortality among Japanese patients with acute myocardial infarction undergoing percutaneous coronary interventions.

It is not yet clear whether a difference in in-hospital morality between patients with and without renal insufficiency undergoing percutaneous coronary intervention (PCI) exists. Therefore, the aim of the present study was to investigate if such as association exists in Japan. Data from the Tokai Acute Myocardial Infarction Study II were used. This was a prospective study of all 3274 patients admitted with acute myocardial infarction (AMI) to the 15 participating hospitals from 2001 to 2003. We abstracted the baseline and procedural characteristics as well as in-hospital mortality from detailed chart reviews. Patients were stratified into 2 groups according to the estimated creatinine clearance on admission. The creatinine clearance values were available in 2116, 107 of whom had renal insufficiency. The patients with renal insufficiency were more likely to be older, female, not independent in their daily activities, have lower body mass index and higher heart rate values on admission, lower prevalences of hypercholesterolemia and peptic ulcers, greater prevalences of diabetes, angina, previous heart failure, previous renal failure, previous cerebrovascular disease, aortic aneurysm, worse clinical course such as bleeding, and a multivessel coronary disease. Vasopressors, an intra-aortic balloon pump, and mechanical ventilation were frequently used in the patients with renal insufficiency, while thrombolytics were used less frequently. The patients with renal insufficiency had a higher in-hospital mortality rate than those without. Multivariate analysis identified renal insufficiency as an independent predictor of in-hospital death. The results suggest that renal insufficiency is an independent predictor of in-hospital death among AMI patients undergoing PCI.

Japanese patients with acute myocardial infarction who present without chest pain.

Previous studies have suggested that patients with acute myocardial infarction (AMI) who presented without chest pain had an unfavorable prognosis due to undertreatment. Despite this, few studies have been conducted on the topic, particularly in Japan. The present analysis aimed at determining whether Japanese AMI patients without chest pain are undertreated and experience higher mortality during hospitalization. Data from the Tokai Acute Myocardial Infarction Study II sample were used, which is a prospective study of all consecutive patients admitted to the 15 acute care hospitals in the Tokai region with the diagnosis of AMI from 2001 to 2003. Data on baseline and procedural characteristics and hospital outcome were collected. Differences in the baseline and procedural characteristics and clinical outcomes between patients presenting with and without chest pain were assessed. We evaluated a total of 1,769 patients who presented with chest pain and 452 who did not. The patients with AMI in the absence of chest pain were older and were more likely to have worse clinical conditions than those with chest pain. They were more likely to be undertreated, although the probability of vasopressor use was higher. The patients without chest pain had a significantly higher in-hospital mortality rate than those with chest pain. According to multivariate analysis, however, chest pain was not identified as an independent predictor of in-hospital death. The results suggest that the higher in-hospital mortality rate among Japanese AMI patients without chest pain could be accounted for by differences in clinical conditions.

Day care service use is associated with lower mortality in community-dwelling frail older people.

OBJECTIVES: To clarify the association between day care service use and 21-month mortality in community-dwelling frail older people. DESIGN: Prospective cohort study (the Nagoya Longitudinal Study for Frail Elderly). SETTING: Community-based. PARTICIPANTS: One thousand six hundred seventy-three community-dwelling older people (540 men, 1,133 women). MEASUREMENTS: Data included the clients' demographic characteristics; depression as assessed using the short version of the Geriatric Depression Scale; a rating for basic activities of daily living (ADLs); comorbidity; number of prescribed medications and physician-diagnosed chronic diseases; use of home-care services, including day care, visiting nurse, and home-help services; and number of regular medical checkups. Survival analysis of 21-month mortality was conducted using Kaplan-Meier curves and multivariate Cox proportional hazards models. RESULTS: Of the 1,673 participants, 726 were day care service users at baseline, and 268 (94 day care service users, 174 nonusers) died during the 21-month follow-up. Multivariate Cox regression models adjusting for potential confounders showed that day care service use was associated with reduction in mortality. Subgroup analysis demonstrated that day care service use was associated with less risk of mortality in subjects who were female; were in the youngest age group (65-74); had higher ADL scores, lower comorbidity, depression, no dementia; and used a visiting nurse service. Participants using day care service two and three times or more a week had 63% or 44% lower relative hazard ratios, respectively, than participants not using the service. CONCLUSION: Among community-dwelling frail older people, day care service use two or more times per week was associated with 44% to 63% lower 21-month mortality.