[Role of Comprehensive Geriatric Assessment(CGA)in Elderly Cancer Treatment].

In the treatment of diverse elderly cancer patients, not only cancer progression and general condition but also social factors, comorbidities, and cognitive function have a great influence. Therefore chronological age and performance status(PS) alone, there is a possibility that under treatment that inappropriately lowers the treatment intensity and over treatment that performs the same treatment as young people without considering the risk of chemotherapy may be performed. Comprehensive geriatric assessment(CGA)evaluates individual health conditions such as physical function, comorbidities, cognitive function, psychological status, social support system, and nutritional status of the elderly from various aspects, and selects treatment. The goal is to be useful for treatment support. CGA results should be shared with other members of the medical team to intervene on issues. And it's important to do it over and over again. CGA may help optimize elderly cancer treatments and improve the quality of life of the limited elderly, not just prolonging their lives.

The Japan Geriatrics Society consensus statement "recommendations for older persons to receive the best medical and long-term care during the COVID-19 outbreak-considering the timing of advance care planning implementation".

Since the end of 2019, a life-threatening infectious disease (coronavirus disease 2019: COVID-19) has spread globally, and numerous victims have been reported. In particular, older persons tend to suffer more severely when infected with a novel coronavirus (SARS-CoV-2) and have higher case mortality rates; additionally, outbreaks frequently occur in hospitals and long-term care facilities where most of the residents are older persons. Unfortunately, it has been stated that the COVID-19 pandemic has caused a medical collapse in some countries, resulting in the depletion of medical resources, such as ventilators, and triage based on chronological age. Furthermore, as some COVID-19 cases show a rapid deterioration of clinical symptoms and accordingly, the medical and long-term care staff cannot always confirm the patient's values and wishes in time, we are very concerned as to whether older patients are receiving the medical and long-term care services that they wish for. It was once again recognized that it is vital to implement advance care planning as early as possible before suffering from COVID-19. To this end, in August 2020, the Japan Geriatrics Society announced ethical recommendations for medical and long-term care for older persons and emphasized the importance of conducting advance care planning at earlier stages. Geriatr Gerontol Int 2020; 20: 1112-1119.

Plasma orexin-A-like immunoreactivity levels and renal function in patients in a geriatric ward.

Orexin-A is a neuropeptide mainly produced by hypothalamic neurons with functions in the central nervous system such as regulation of the sleep-wake cycle. Recent studies suggest that orexin-A also plays major roles in peripheral tissues. Although a few studies have reported a role for the kidney in the dynamics of orexin-A, little is known about the association between plasma orexin-A-like immunoreactivity (orexin-A-LI) levels and renal function. We evaluated this association, and also explored other clinical characteristics associated with plasma orexin-A-LI levels. In this cross-sectional study, we included 70 consecutive patients aged ≥65 years admitted to the geriatric ward of Nagoya University Hospital from December 2017 to January 2018. Patients taking suvorexant (an orexin receptor antagonist) were excluded. On hospital days 2-4, fasting blood was collected in the morning. We evaluated associations between plasma orexin-A-LI levels and renal function and other clinical characteristics. Renal function was evaluated in two ways: the estimated glomerular filtration rate (eGFR) using serum creatinine, and estimated creatinine clearance (eCrCl) using the Cockroft-Gault formula. Pearson's correlation coefficient revealed that plasma orexin-A-LI levels were negatively correlated with the eGFR (r = -0.351, p = 0.003) and eCrCl (r = -0.342, p = 0.004). There were no significant associations between plasma orexin-A-LI levels and the primary diagnosis, body mass index, duration of fasting, or other clinical characteristics. In conclusion, plasma orexin-A-LI levels were negatively correlated with renal function in patients in a geriatric ward. Renal function may affect the study design and data interpretation in studies of plasma orexin-A-LI.

Polypharmacy and gait speed in individuals with mild cognitive impairment.

AIM: Polypharmacy has been reported to be associated with poor outcomes, including falls and frailty, in older populations. Past studies have found that slower walking speed is a good predictor of progression to frank dementia in mild cognitive impairment (MCI). Some studies of the general population reported that polypharmacy was associated with slower gait speed; however, it remains to be elucidated whether polypharmacy affects gait speed even in individuals with MCI, who already have some deterioration in gait compared with cognitively preserved individuals. The current study explored the association between the number of medications and gait speed in older adults with MCI who have a Clinical Dementia Rating score of 0.5. METHODS: A total of 128 individuals with MCI were included in the present study. The participants were divided into three groups according to the number of medications they were taking: up to four medications was non-polypharmacy; five to nine medications was polypharmacy; and ≥10 medications was hyperpolypharmacy. The background characteristics were compared by analysis of variance for numerical numbers, and by χ2 analysis for categorical factors. Multiple regression and logistic analysis were applied to investigate the association between gait speed and polypharmacy status or number of medications. RESULTS: Gait speed was significantly negatively associated with hyperpolypharmacy status and the number of medications. Slow gait speed (<1 m/s) was also significantly associated with polypharmacy status and the number of medications. CONCLUSIONS: We found that polypharmacy was associated with slow gait speed in older adults with MCI. Geriatr Gerontol Int 2019; 19: 730-735.

Maximum gait speed is associated with a wide range of cognitive functions in Japanese older adults with a Clinical Dementia Rating of 0.5.

AIM: Physical and cognitive functions are mutually associated. However, it is unknown which markers of physical functions or body composition are most strongly associated with cognition. Here, we explored the association between body composition/physical performance and comprehensive neuropsychological assessments in an effort to identify reliable markers of cognition among factors in body composition/physical performance, including both usual and maximum gait speeds. METHODS: We examined a total of 161 Japanese individuals (71 men, 90 women; aged 76.3 ± 7.2 years) with a Clinical Dementia Rating of 0.5 and a Mini-Mental State Examination score >24. A battery of neuropsychological assessments, physical functional assessments and measurements of body composition was carried out. We conducted a multiple regression analysis to investigate the associations between cognitive performance and the factors in body composition and physical performance with adjustments for age, sex, and number of school years. RESULTS: Maximum gait speed was the factor most widely associated with cognitive performance among the factors of body composition and physical performance. CONCLUSION: Maximum gait speed might be the best marker for cognition in this population of older individuals. Geriatr Gerontol Int 2018; 18: 1323-1329.

The prevalence of homebound individuals in the elderly population: a survey in a city area in Japan.

Being homebound has been reported to be associated with a number of conditions. In the current study, the incidence of homebound individuals was surveyed in an urban city area in Japan. The city office randomly enrolled 5,000 residents of Nagoya City aged 65 and over. A questionnaire was sent to their principal caregivers by mail, and 3,444 (68.9 %) subjects returned the survey. The investigators obtained the totally anonymous data from the city office. This study was approved by the Ethics Committee of Nagoya University Graduate School of Medicine. In the present study, the data of 3,053 (61.1 %) subjects for whom complete sets of data were available were employed for statistical analysis. The questionnaire included the following items: age, sex, the status of public long-term care insurance certification (none, support-level, care-level), self-rated health (good, fair, poor, very poor), states of living (single living, with only spouse, with other family members), and the frequency of outside excursions per a week (every day, once in a few day, one a week, rarely). An individual was defined as being homebound if his or her frequency of outside excursions was less than once per week. he incidence of the homebound elderly in the elderly population over 65 years old was 14.4 % in the current study. The status of certification in public long-term care insurance was associated with being homebound. Self-rated health was significantly worse in homebound individuals than in those non-homebound. The current survey found 14.4 % of the elderly was home-bound in a large city in Japan.

Burden reduction of caregivers for users of care services provided by the public long-term care insurance system in Japan.

We surveyed the care burden of family caregivers, their satisfaction with the services, and whether their care burden was reduced by the introduction of the LTCI care services. We randomly enrolled 3000 of 43,250 residents of Nagoya City aged 65 and over who had been certified as requiring long-term care and who used at least one type of service provided by the public LTCI; 1835 (61.2%) subjects returned the survey. A total of 1015 subjects for whom complete sets of data were available were employed for statistical analysis. Analysis of variance for the continuous variables and χ(2) analysis for that categorical variance were performed. Multiple logistic analysis was performed with the factors with p values of <0.2 in the χ(2) analysis of burden reduction. A total of 68.8% of the caregivers indicated that the care burden was reduced by the introduction of the LTCI care services, and 86.8% of the caregivers were satisfied with the LTCI care services. A lower age of caregivers, a more advanced need classification level, and more satisfaction with the services were independently associated with a reduction of the care burden. In Japanese LTCI, the overall satisfaction of the caregivers appears to be relatively high and is associated with the reduction of the care burden.

Relationship between small cerebral white matter lesions and cognitive function in patients with Alzheimer's disease and amnestic mild cognitive impairment.

AIM: The main purpose of the present study was to investigate the influence of small cerebral white matter lesions on cognitive functions, and its difference by clinical stage. METHODS: A total of 160 patients with Alzheimer's disease and 40 older adults with amnestic mild cognitive impairment were enrolled in the present study. The Fazekas rating scale was used for the semi-quantitative measurement of white matter lesions. Participants whose scales were more than grade 2 were excluded. Associations between the degree of small white matter lesions and cognitive functions including memory, verbal fluency, working memory, processing speed, and executive function were examined. RESULTS: We found that small white matter lesions influenced the performances of neuropsychological tests differently between Alzheimer's disease and amnestic mild cognitive impairment. Analysis of covariance showed significant effects of interaction on a test that assessed categorical verbal fluency. In the amnestic mild cognitive impairment group, small periventricular white matter hyperintensities were significantly associated with poor performances in categorical verbal fluency; whereas in the Alzheimer's disease group, such associations were not observed. Deep white matter hyperintensities did not influence any cognitive functions examined in both groups. CONCLUSIONS: The results suggested the involvement of periventricular small white matter lesions on impairment in verbal fluency, and such influence might be different depending on an individual's clinical stage.

Cognitive impairments and functional declines in older adults at high risk for care needs.

AIM: Functional status of those who have very mild cognitive impairment have not been sufficiently investigated. In the current study, we analyzed the characteristics of functional awareness in older adults who had cognitive impairment and were at high risk of requiring support/care (termed as specified elderly at high risk for care needs in the long-term care insurance scheme). METHODS: The answers of a health check, which is provided by the local municipal government for those aged 75 years or older who have not been certified as eligible for care services, were analyzed. The differences of the variables between the two groups regarding yes/no answers to each of three cognition-related questions were analyzed. Then, a multiple logistic analysis was carried out to investigate the association of yes/no answers of the three cognition-related questions and the awareness of functional decline. RESULTS: The participants who had cognitive impairment had greater awareness of functional declines. Multiple logistic regression analysis showed that subjective memory impairment and disorientation were significantly associated with a wider range of awareness of functional decline. CONCLUSIONS: Subjective cognitive impairment was associated with a wide range of awareness of functional decline in older adults at high risk for care need.

Cognitive dysfunction: an emerging concept of a new diabetic complication in the elderly.

The incidence of type 2 diabetes mellitus (T2DM) has risen, and this trend is likely to continue. Recent advances suggest that T2DM is a risk factor for cognitive decline. We are now encountering novel complications of T2DM, namely cognitive dysfunction and dementia. Although the treatment strategy for diabetic patients with neurocognitive dysfunction has received a great deal of attention, the appropriate level of glycemic control for the prevention of the development and/or progression of cognitive decline in elderly diabetic patients remains to be elucidated. Another issue in diabetic treatment in patients with cognitive dysfunction is the selection of medicines. The best choice and combination of antidiabetic medications for the preservation of cognition should also be studied. Ample studies suggest that exercise helps to preserve cognitive function, although existing evidence does not necessarily indicate its effectiveness exclusively in diabetic patients. Exercise is a helpful non-pharmacological therapy. Considering the progressive aging of the worldwide population, more research to investigate the best way to manage this population is important.

Association between improvements in insulin resistance and changes in cognitive function in elderly diabetic patients with normal cognitive function.

AIM: The number of elderly with cognitive dysfunction has been increasing in developed countries. Several studies have shown that diabetes is a risk factor for declines in cognitive function and, recently, numerous studies have demonstrated that exercise improves insulin resistance (IR). However, no studies have been undertaken to examine the relationship between IR and cognitive dysfunction. METHODS: Sixteen elderly diabetic patients participated in this study (mean age 70.9 ± 3.7 years). They were divided into control and training groups, and the training group was instructed to exercise 4 days per week for 12 weeks using horse riding simulation equipment (JOBA). Insulin sensitivity was measured by the euglycemic clamp technique and several tests to assess cognitive function, such as the Mini-Mental State Examination (MMSE), were performed. RESULTS: There were no statistically significant differences between the control and training groups in the baseline data. The differences of glucose infusion rate values and delayed word list scores, between baseline and the follow up, were significantly correlated (P = 0.024). In addition, changes in fasting blood sugar (FBS) and in the Trail Making Test B (TMT-B) score were also correlated (P = 0.035). CONCLUSION: The current study showed that a 12-week exercise intervention program did not significantly improve IR in elderly diabetic patients. However, changes in IR were associated with improvements in memory function, and reduced FBS was associated with improvements in TMT-B.

Association of lower hemoglobin level with depressive mood in elderly women at high risk of requiring care.

AIM: Despite the high prevalence of anemia and depression in the elderly, there have been few studies exploring the association between these two conditions. In the current study, we analyzed the association of hemoglobin level and depressive mood in a group of community-dwelling elderly at high risk of requiring care. METHODS: All participants at a health check in a group of community-dwelling elderly (1163 men and 2651 women) filled out a basic yes/no questionnaire consisting of simple assessments of their instrumental activities of daily living (7 items), memory problems (3 items), walking status (5 items), dysphagia (3 items), nutritional status (2 items) and depressive mood (5 items). Other examinations, including blood testing, were also performed. Multiple regression analysis with the score of depressive mood in the basic checklist was performed. The hemoglobin level was set for an explanatory value after adjustment for age, blood pressure, electrocardiogram abnormality, instrumental activities of daily living, walking status, nutritional status, dysphagia and memory problems. RESULTS: It was found that 30.5% of women and 31.8% of men had anemia. When the subjects were divided with depressive score of 2 points or more (the highest possible score was 5) and less, those with a higher depressive score had significantly lower hemoglobin levels than those with a lower score. Multiple regression analysis showed that lower hemoglobin level was significantly associated with depressive mood only in women (P=0.046) but not in men (P=0.579). CONCLUSION: Lower hemoglobin level was significantly associated with depressive mood in elderly women at high risk for care, but not in elderly men at high risk for care.