[Noninvasive positive-pressure ventilation in an elderly woman with acute respiratory failure caused by influenza a virus pneumonia].

A 79-year-old woman was admitted on January 18, 2000, with a lumbar compression fracture. Two days after admission, a chest X-ray film showed reticular infiltrates in the right lung field. She was diagnosed as having pneumonia and was treated with antibiotics. Despite this therapy, her symptoms did not improve and the infiltrates diffusely extended to involve both lungs on chest X-ray films. She was placed on noninvasive positive pressure ventilation (NIPPV) for progressive respiratory failure at 5 days after admission in order to avoid endotracheal intubation. Her hypoxemia was immediately improved by oronasal bilevel positive airway pressure ventilation (BiPAP) and chest X-ray films revealed improvement of the reticular infiltrates. Measurement of viral antibody titers showed that the cause of acute respiratory failure was influenza A virus pneumonia. In conclusion, NIPPV may reduce the need for intubation of elderly patients with acute respiratory failure, as well as chronic obstructive pulmonary disease (COPD) patients.

[Assessment of brain cell function using 123I-IMP SPECT of cerebral blood flow and visual evoked potential by photic stimulation in normal and demented elderly subjects].

Cerebral blood flow was quantitatively measured using 123I-IMP SPECT by photic stimulation and visual evoked potential (VEPs) in normal and dementia subjects: 8 with Alzheimer-type dementia, 9 with cerebrovascular dementia and 7 normal elderly subjects were divided into the three groups based on the Clinical Dementia Rating (CDR) grade: Group I (CDR 0), Group II (CDR 0.5-1), Group III (CDR 2-3). The 123I-IMP SPECT measurement was conducted at rest with the eyes closed and also during photic stimulation. VEPs were measured simultaneously. The results reveal prolongation of the P2 latency of the VEPs prolonged in accordance with the increasing severity of the dementia, and quantitative cerebral blood flow was lower in Group II and Group III than in Group I at rest, while during photic stimulation it significantly increased in Group I and II, but showed no change in Group III. The results suggest that quantitative measurement of cerebral blood flow using 123I-IMP SPECT by photic stimulation may enable more detailed assessment of brain cell function.

[Pathology and treatment of anemia in the elderly].

An important background characteristic of anemia in the elderly is decrease in hematopoiesis due to aging. Factors influencing hematopoiesis in the elderly include changes in the distribution of hematopoietic tissue, changes in hematopoietic stem cell density and changes in the hematopoietic inductive microenvironment. In the present study, in order to assess changes in the bone marrow with aging, the fat tissue area, uncleated cell-count and cellularity in the bone marrow, in addition to changes in the diameter of the vascular lumen which result primarily from sclerotic changes in the dorsomedial artery of the bone marrow were determined in different age groups. The results revealed that all of the aforementioned factors changed significantly with aging. We also describe on the results of assays of inflammatory cytokines (IL-1, IL-6, TNF-alpha), lactoferrin and transferrin receptors in cases of anemia of chronic disorders (ACD) which own secondary to chronic inflammatory diseases and is known to frequently afflict the elderly.

Treatment of insomnia by concomitant therapy with Zopiclone and Aniracetam in patients with cerebral infarction, cerebroatrophy, Alzheimer's disease and Parkinson's disease.

For insomniac patients, sleeping drugs are used: in addition, concomitant therapy with other drugs has been tried in an effort to prevent a decrease in the effects due to long-term continuous use. This report presents the results of a study on the sleeping effects in nine aged patients with insomnia associated with cerebrovascular and noncerebrovascular disorders who received concomitant therapy with Zopiclone and Aniracetam. The treatment in 7/9 cases (78%) was found to be effective, showing more than 50% prolongation of sleeping time, and in two cases (22%) was found to be ineffective. We discuss the mechanism of action referring to the literature.

[Deterrent factors in rehabilitation training following cerebral vascular disease--comparison of elderly and non-elderly patients].

The purpose of the present study was to clarify the deterrent factors for rehabilitation training (rehab) of chronic cerebral vascular disease (CVD) patients, and also to evaluate the influence of age on these factors. Sixty-five CVD impatients with sequelae treated at the Cerebral Vascular Center of Nanasawa Hospital were included in the study. Patients were classified into two groups using the Barthel index score: good effect group (n = 21) or no effect group (n = 22). The following factors were compared between the two groups in order to investigate which factor most affects the results of rehab: age, sex, the site of brain damage, extent of motor paralysis, character (Type A character or not), aphasia, hemispacial neglect, depression, and positive attitude toward training. A possible association between depression, and the site of brain damage and Type A character was investigated. Also, the difference in mood disorders was compared between elderly and non-elderly stroke patients. In the elderly group, hemispacial neglect, a negative attitude toward training, and depression all adversely affected the outcome of the rehab. In the non-elderly group, aging, hemispacial neglect, and a negative attitude toward training influenced the effect of the rehab, but there was no correlation with depression. Depression was seen in 64% of the patients (38/59). Of the 38 patients in a depressed state, 24 (63%) had right hemisphere brain damage, 13 (34%) had left hemisphere brain damage, and 1 (3%) had brain stem damage. Twenty-seven of the 38 depressed patients (71%) were Type A character, significantly more than in the non-depressed group (92/21, 43%). In addition, 14 of the 27 Type A patients were aged over 65 years (52%), which was more than in the non-depression group (11/38, 29%).

[Pleural-origin malignant lymphoma in an elderly patient with chronic empyema and infection with the Epstein-Barr virus].

A 73-year-old woman with a long-standing history of right-sided chronic empyema complained of lumbago. An artificial pneumothorax had been induced to treat pulmonary tuberculosis about 40 years previously. The year after she began to complain of lumbago, a tumor mass over the right anterior chest wall had grown rapidly. Pathologic examination revealed that it was a malignant lymphoma (Non-Hodgkin's lymphoma, diffuse large cell, B cell type). Chemotherapy with cyclophosphamide, adriamycin, vincristine, and prednisolone, and then radiation therapy were given. The patient responded very well. The tumor mass on the surface of the chest wall disappeared completely. She was alive and well and there was no evidence of recurrence at the seven-month follow-up examination. Analysis with the polymerase chain reaction showed that the tumor contained DNA of the Epstein-Barr virus. The chronic empyema and local infection with the Epstein-Barr virus might have been a factor in the development of the malignant lymphoma.

[Factors contributing to survival of elderly inpatients with chronic disease].

Clinical assessment and laboratory testing are important in predicting longevity and the outcomes of chronic diseases in the elderly. We therefore studied the prognostic utility of clinical and laboratory findings. A group of 168 elderly patients (70-97 years of age) with chronic diseases who were admitted to Kashiwazaki Kosei Hospital was studied. Data on 13 potentially prognostic factors were analyzed: dementia, being bedridden, anorexia, edema of the lower limbs, urinary incontinence, dyspnea fever, hepatic dysfunction, renal dysfunction, anemia, hypoalbuminemia, inflammation, and electrocardiographic abnormality. Kaplan-Meier survival curves were constructed, and either the log-rank or Wilcoxon method was used to look for significant differences in survival between patients with and without the factors listed above. Regression analysis was then done with the Coxproportional-hazards model to study the factors that contributed to the shortest survival. Patients lived longer if they were not bedridden, anorexic, incontinent of urine, hypoalbuminemic, or if they had no inflammation (p < 0.05): being bedridden, anorexia, urinary incontinence, hepatic dysfunction, hypoalbuminemia, inflammation, and electrocardiographic abnormalities. The survival curve obtained by using these factors as independent variables in the proportional-hazards model was similar to the Kaplan-Meier survival curve.

[Causes, diagnosis, and treatment of anemia in the elderly].

Healthy elderly people are mildly anemic peripheral blood data on 3,583 healthy elderly people (1,590 men and 1,993 women aged 65 years or older) from among those undergoing medical examinations at our hospital in the 8 years from 1988 to 1995 were compiled into 5-year age groups. For both men and women the mean values of red blood cell count, hemoglobin, and hematocrit were slightly lower among older subjects. The main causes of this apparent reduction may be a decrease in the number of hematopoietic stem cells and regression of the hematopoietic microenvironment. Observation of arteries in specimens of hematopoietic bone marrow obtained from the spines of elderly people showed arteriosclerotic changes such as greater hypertrophy of the media than of the intima, and adventitial fibrous hypertrophy. The number of venous sinuses was low and the amount of adipose tissue was high compared to the bone marrow of younger people. The cell density and the ratio of hematopoietic tissue to fat tended to be lower in older subjects. The number of erythroid burst-forming units formed after 14 days in culture medium containing erythropoietin was 28 +/- 19 in 32 healthy elderly people, which was significantly lower than the number in 30 young people 54 +/- 30, (p < 0.005). The value for erythroid colony-forming units was 170 +/- 67 in eight healthy people, which was much lower than in young people, 276 +/- 54. In the elderly subjects, the plasma iron disappearance time (PIDT/2) was 60-80 min (mean: 71.9 min), which was similar to that in the young, but the percent red cell iron utilization was 67.6%-84.9% (mean: 79.7%), which was slightly lower than in younger people. When the diagnostic criterion for anemia in the elderly was set at a hemoglobin value of 11.0 g/ dl, about 13% of outpatients who came to our Geriatrics department were found to have anemia, and in most of them the anemia had resulted from another disease. In conclusion, anemia in the elderly is likely to be affected by reduction in the function of various organs and by the decreased reserves associated with aging. The causes of anemia are complex and diagnosis is often difficult. The present article gives a general outline of the diagnosis and treatment of common types of primary and secondary anemia in the elderly.

[Serum sodium imbalance in the bedridden elderly. Part One: Realities and problem of management].

Symptoms and other abnormalities associated with serum sodium imbalance were studied in bedridden elderly and healthy elderly subjects. 1. A significantly higher number of the bedridden elderly suffered from chronic wasting disease. 2. The average serum sodium concentration in bedridden elderly subjects was significantly lower than in healthy subjects, as was the sodium intake and the sodium content in urine, which indicate that the bedridden elderly subjects suffered from chronic sodium deficiency. 3. The bedridden elderly subjects had high levels of plasma PRA and antidiuretic hormone, and their aldosterone levels were low, which indicate that their condition was associated with a decrease in available circulating plasma, hypersecretion of antidiuretic hormone, and a decline in the ability to retain sodium. 4. Measurement of 24-hr creatinine clearance, albumin, and beta 2-microglobulin in urine revealed that bedridden elderly subjects had high levels of renal dysfunction, the result of which may a disturbance in water excretion. Abnormalities in serum sodium levels in the bedridden elderly subjects were related to a chronic deficiency in sodium intake, which reduced their ability to maintain sodium levels and impaired their renal function. Iatrogenic factors are likely to play an important role in the genesis of this condition, and should be taken into account in during management.

[Clinical analysis of elderly patients with malignant lymphoma].

An epidemiological study on 173 consecutive elderly malignant lymphoma patients age 65 years or over was performed and the clinical outcome of chemotherapy is reported. Of there, 131 patients (75.7%) had non-Hodgkin's lymphoma (NHL) and 21 patients had Hodgkin's disease (HD). As for clinical staging, 58.9% of patients were in stage 3 or 4. The initial sites were nodal in 61.8% of the patients the most common sites of involvement in superficial lymph nodes being cervical, inguinal and axillar. The most frequent site of extranodal involvement was the gastrointestinal tract. The cases were treated with CHOP/COPP, BACOP or COP-BLAM combination chemotherapy. The clinical efficacy of these modalities was similar, with complete remission rates being about 50%. However, the total response rate (CR+partial remission) by the COP-BLAM regimen were 88.1%. The median survival time of cases achieving CR, was longer than 47 months. The most frequent cause of death was infection, especially pneumonia and septicemia. Many elderly ML patients were found and diagnosed when the disease developed to an advanced stage. Therefore it is necessary to make efforts to find early ML patients by screening apparently healthy elderly people. Improvement of the complete remission rate should be obtained if vigorous and intensive chemotherapy is carried out with careful supportive therapy concerning the general condition and complications in patients.

[Cardiac function in elderly patients with dementia].

Evaluation of cardiac function is very important in elderly patients because it is closely related to the prognosis. Appropriate evaluation is especially important to treat and prevent the progression of dementia since its pathology differs greatly depending on type. In the present study, we evaluated the cardiac function of patients with senile dementia using echocardiography. Included in the present study were 11 patients with Binswanger-type dementia (BD), 12 with cerebrovascular dementia (VD) of other types, 16 with senile dementia of Alzheimer-type (SDAT) and 15 controls. Left ventricular function was assessed by Mode M based on left ventricular end-diastolic dimension (LVDd), left ventricular end-systolic dimension (LVDs), left ventricular dimension shortening (FS), left ventricular ejection fraction (EF) and cardiac output (CO). LVDd was significantly larger in the BD group than in the control, and LVDs was also significantly larger in the BD group than in the three other groups. FS was significantly decreased in the BD group compared to the SDAT and controls. FS was also significantly decreased in the VD group compared to the control. EF was significantly decreased in the BD group compared to the three other groups, and it was also significantly decreased in the VD group compared to the controls. There was no significant inter-group difference in SV or CO. FS and EF were found to be decreased in patients with cerebrovascular dementia, especially BD, indicating the presence of latent left ventricular hypofunction in these patients. This finding is important in predicting the prognosis of patients and conducting treatment and prevention.

Clinical-study of multiple-myeloma in the elderly.

From January 1989 until December 1992, 120 elderly patients over 65 years old with multiple myeloma (MM) were enrolled with the Elderly Hematology Study Group (EHSG) with 14 institutions participating. Several courses of chemotherapy were conducted in 103 of the 120 patients, 33 patients with alpha-interferon (IFN) and 70 patients without IFN. The response rate (CR+PR) was 24.0% of all 120 cases, 24.2% of the group treated with IFN and 25.7% of those treated without IFN. Similarly, the efficacy rate (CR+PR+MR) of these groups were 78.8%, 81.8% and 78.8%, respectively. The 50% survival time was 31 months in the 120 cases as a whole, 44 months in the group treated with IFN and 38 months in the group treated without IFN. No significant difference was observed either in response rate (p=0.243) or survival time (p=0.262) in the groups treated with or without IFN.

[Abnormality of bone mineral metabolism in elderly female patients with dementia].

In order to clarify the relationship between dementia and osteoporosis, bone mineral metabolism was studied in elderly female patients with dementia. We measured bone mineral densities of the vertebral body and the femoral neck using DEXA, and evaluated Ca-related factors in 22 patients with dementia of the Alzheimer type (DAT), 23 patients with vascular dementia (VD), and 22 age-matched controls (C). Activity of daily living was significantly poorer in VD patients than controls, but no difference was shown between DAT and C groups. Bone mineral density values of the vertebral body and the femoral neck were significantly decreased in both DAT and VD groups when compared to C group. DAT patients showed significant decreases in serum Ca and Ca2+ ion, increase in serum parathyroid hormone, and decrease in serum 1,25-dihydroxyvitamin D, a tendency towards decrease in serum calcitonin, and a tendency towards increase in urinary Ca. However, VD patients showed only significant increase in urinary Ca and a tendency towards decrease in serum 1,2-dihydroxyvitamin D, without showing other changes of Ca-regulating hormones. These results suggest that patients with dementia are more often associated with osteoporosis, and that in DAT several abnormalities of Ca-regulating factors play an important role in the development of osteoporosis, while in VD limited physical activities contribute to bone mineral loss.

[A case of binswanger-type dementia with bilateral temporoparietal hypoperfusion in SPECT].

We report a case of Binswanger-type dementia demonstrated bilateral temporoparietal hypoperfusion in SPECT with 123I-IMP. The perfusion pattern in the present case was different from those previously obtained in SPECT or PET studies of patients with Binswanger-type dementia, and was similar to regional abnormalities in patients with Alzheimer-type dementia. Temporoparietal hypoperfusion in this case is likely to be mediated by neuronal mechanisms via projection fibers as a result of the deep white matter lesions in the temporoparietal area. A decreased perfusion or metabolism in the temporoparietal area is considered to be a characteristic in patients with Alzheimer-type dementia, however, we should keep in mind that other cerebral disorders may also show a similar perfusion pattern.

Cerebrocerebellar relationships in normal subjects and patients with dementia of the Alzheimer type: a SPECT study.

The relationships between blood flow in the cerebrum and the cerebellum was investigated in 21 normal subjects and 21 patients with dementia of the Alzheimer type (DAT). In normal subjects, only asymmetry in the frontal cortical blood flow was significantly correlated with asymmetry in the contralateral cerebellar blood flow. However, a significant correlation between asymmetry in the cerebral cortical blood flow in many areas and the blood flow in the contralateral cerebellum in DAT patients was observed. These results suggest the existence of a functional relationship between the cerebrum and the cerebellum in both normal and DAT groups, mediated by neuronal mechanisms through crossed fiber pathways. However, there are regional differences in the cerebrocerebellar relationship in normal resting and pathological states.

[Pharmacokinetics of oral alminoprofen (Minalfen) in elderly patients with rheumatoid arthritis and spondylosis deformans].

The pharmacokinetics of oral Alminoprofen, a nonsteroidal anti-inflammatory drug, were studied in five elderly patients with rheumatoid arthritis and spondylosis deformans after 200 mg (three times a day) repeated dose for 5 days. The pharmacokinetic parameters after oral administration of Alminoprofen were analyzed by the one-compartment open model method. The maximum plasma concentrations (Cmax) were 16.1 +/- 2.5 micrograms/ml, after dosing on day 1, 25.2 +/- 1.6 micrograms/ml on day 3 and 21.6 +/- 2.7 micrograms/ml on day 5. The maximum time (Tmax) were about 2 hours after the medication in al cases. The area under the curve in drug concentration in plasma versus time (AUC) were 58.5 +/- 6.3 micrograms hr/ml on day 1, 58.5 +/- 3.1 micrograms hr/ml on day 3 and 58.1 +/- 8.5 micrograms hr/ml on day 5. The biological half-lives (t1/2) were 2.45 +/- 0.35, 2.09 +/- 0.82 and 2.49 +/- 0.63 hours, after dosing on day 1, day 3 and day 5, respectively. The analysis of moment in pharmacokinetics revealed that the mean residence time (MRT) on day 1, day 3 and day 5 observed were 2.31 +/- 0.03, 2.15 +/- 0.09 and 2.15 +/- 0.07 hours, respectively. The variance residence times (VRT) observed were 0.95 +/- 0.05 hour2 on day 1, 0.88 +/- 0.09 hour2 on day 3 and 1.06 +/- 0.07 hour2 on day 5. The ratios of accumulation calculated were 1.16 +/- 0.05 in both the morning medication on day 3 day 5, and it therefore appears that the steady-state equilibrium is established within 3 days after commencement of dosage.(ABSTRACT TRUNCATED AT 250 WORDS)

[Cerebral hemodynamic difference between early- and late-onset Alzheimer's disease by circumferential profile analysis with 123I-IMP brain SPECT].

We conducted investigation to determine whether early- and late-onset Alzheimer's disease differ pathophysiologically. Five patients with the early-onset (65 years and under) of the disease and 11 with the late-onset (65 years and over) of the disease were studied by single photon emission CT (SPECT) with N-isopropyl-p-[123I]iodoamphetamine (IMP). Circumferential profile analysis (CPA) was performed to examine differences in the predominant hypoperfusion in the temporoparietal lobe, which is considered to be functionally damaged the most in Alzheimer's disease. The Xm values, calculated from gradients between the motor sensory or occipital cortices and temporoparietal cortex in the circumferential profile curve, were compared in both groups. The Xm values for the patients with early- and late-onset Alzheimer's disease were 6.81 +/- 2.10 (count/degree) and 3.28 +/- 1.58, respectively, the difference being significant. Our results suggest that functional abnormalities in the temporoparietal area severer in early- than late-onset Alzheimer's disease and that the application of CPA to IMP SPECT is useful to elucidate the pathophysiological difference between each of the disease.

[A clinical study in elderly patients with Parkinson's disease using MRI and SPECT--Parkinson's disease and the lacunar state].

Parkinson's disease (PD) is often associated with dementia in elderly patients, and sometimes PD coexists with senile dementia of the Alzheimer type (SDAT) or cerebrovascular disease (CVD) in the elderly. However, since there are few previous clinical studies on the coincidence of, or relationship between PD and CVD, the authors evaluated these aspects in 34 elderly patients with PD using MRI and SPECT. All the patients were over 70 years old. The diagnosis of PD was based on the presence of three symptoms (resting tremor, cogwheel rigidity and bradikinesia) which are characteristic of PD, and the effectiveness of L-DOPA therapy. We therefore believe that patients with vascular Parkinsonism were excluded from our study. In 34 cases, 24 (71%) had MRI evidence of CVD (mainly the lacunar state). In the 10 cases who had no CVD, 2 (20%) had severe dementia and the decrease of regional cerebral blood flow (rCBF) in the temporal and parietal lobes bilaterally correlated with the SPECT findings commonly found in SDAT. A comparison of the rCBF and the results of Hasegawa's dementia score (HDS) (verbal intelligence score) was made between the patients with PD associated with CVD and the patients with PD who had no CVD and no SPECT findings which correlated with SDAT. The rCBF in the frontal lobes and the results of the HDS of the former group were significantly lower than those of the latter. As mentioned above, elderly patients with PD often had CVD, leading to dementia.(ABSTRACT TRUNCATED AT 250 WORDS)

[Decreased cerebral blood flow in remote areas in deep-seated cerebrovascular lesions].

Recent positron or single photon emission computed tomographic studies have demonstrated that the impairment of regional hemodynamics or metabolism in cerebrovascular disease is not limited to the focal lesion, but also involves more remote areas. The present study evaluated cerebral blood flow in areas remote from the primary lesion in patients with subcortical cerebrovascular disease, and assessed correlations with the clinical features. Twenty patients aged 61-89 (mean, 74.7 +/- 6.7 years) were divided into the L group (lacunar infarction in deep penetrating arterial territory, n = 7), the NL group (non-lacunar subcortical infarction caused by main trunk occlusion or severe stenosis, n = 6), and the H group (putaminal or thalamic hemorrhage, n = 7). Ipsilateral cortical and contralateral cerebellar blood flow were assessed using single photon emission computed tomography with 123I-IMP. Although only some patients of the L group showed a mild reduction of ipsilateral cortical blood flow, most of the patients in the NL and H groups showed a moderate or severe flow reduction. The cortical blood flow reduction was suggested to be caused by several mechanisms, including brain edema, a decreased perfusion pressure associated with disease of large arteries, partial cortical neuronal damage, and deactivation. The degree of the flow reduction was considered to depend on the relative contribution of each of these factors. Contralateral cerebellar blood flow reduction, i.e., crossed cerebellar diaschisis, was observed more frequently and prominently in the NL and H groups than in the L group.(ABSTRACT TRUNCATED AT 250 WORDS)

[The functional relationship between the cerebral cortex and deep brain areas in normal individuals].

Recent PET or SPECT studies have demonstrated a reduction of blood flow and metabolism in the cortex ipsilateral to a deep-seated lesion, and in the thalamus and/or basal ganglia ipsilateral to a cortical lesion. A close relationship between the cerebral cortex and deep areas of the brain has been shown in pathological conditions, presumably because of functional interconnections between the cortex and deeper area. The present study was designed to investigate the relationship of cerebral blood flow in the cerebral cortex to that in the deep gray matter including the basal ganglia and the thalamus in normal subjects. Twenty-two healthy subjects were studied using SPECT with N-isopropyl-p[123I]iodoamphetamine while in a resting state. The asymmetry index (AI) of blood flow in both the cerebral cortex and deep gray matter was calculated as follows; AI = (R-L)/(R+L)/200 (%) (R: right side, L: left side). The AI in deep gray matter was significantly correlated with the AI values in the upper frontal cortex (r = 0.54, p less than 0.01), and parietal cortex (r = 0.58, p less than 0.01), as well as the mean cortical hemispheric AI (r = 0.48, p less than 0.05). Our results suggest the existence of a functional relationship between the cerebral cortex and deep areas not only in pathological conditions but also in the resting state in normal subjects. This functional relationship is likely to be mediated by neuronal mechanisms through the projectional fiber connections between the cortex and the deep gray matter.