[A clinical analysis of elderly dementia patients with physical comorbidities].

AIM: To investigate the current status of elderly dementia patients with physical illnesses and identify optimal care strategies for this growing population. METHODS: This retrospective study included elderly dementia patients who (i) received in-patient treatment for a physical comorbidity at the dementia ward of the Juntendo Tokyo Koto Geriatric Medical Center, and (ii) who were discharged from April 2009 to March 2011. RESULTS: The study population was 390 patients (144 males, 246 females), with a mean [±SD] age of 80.5 [±8.1] years. Two hundred thirteen of the patients had Alzheimer's disease; the remaining 177 had other types of dementia. The comorbidities necessitating admission were: malignant neoplasms (n=65), respiratory conditions (n=57), genitourinary conditions (n=50), trauma or fracture (n=41), and other (n=177). Among the 239 subjects who were hospitalized from their homes and who were discharged alive, 157 (65.7%) returned to their homes. The hospital stays of patients who were discharged were significantly shorter (P<0.000) and their N-ADL scores were significantly better at admission (P<0.013) and at discharge (P<0.000). The proportion of subjects who were capable of oral ingestion was significantly higher among the patients who were discharged to their homes (P<0.025). The subjects who lived in their homes alone at the time of hospitalization were significantly less likely to be discharged to their homes (P<0.018). CONCLUSIONS: Elderly dementia patients should ideally return home after hospitalization for comorbid illnesses. This was facilitated by minimizing their hospital stay. During in-patient treatment, efforts should be made to maintain their N-ADL levels and support their oral intake.

[Blood culture results in elderly febrile patients].

AIM: We retrospectively evaluated blood culture results in elderly patients (≥65 years) with a fever due to infection. METHODS: We examined the bacteria isolated from blood cultures and compared them to bacteria detected in infected lesions that caused bacteremia. We compared the types of bacteria isolated in the two groups (the community-acquired group and the hospital-acquired group). RESULTS: Blood cultures were obtained from 638 patients. Bacteria were detected in 182 patients (28.5%), including 66 (36.3%) patients in the community-acquired group and 116 (63.7%) patients in the hospital-acquired group. There were 259 positive samples (25.1%). In arterial blood specimens, 153 (30.9%) samples were positive, while in venous blood specimens, there were 106 (19.8%) positive samples (P<0.001). In the community-acquired group, the most common bacteria identified were E. coli compared to S. epidermidis in the hospital-acquired group. More than 50% of the bacteria identified in the blood cultures were of the same species identified in the respective urine samples and central venous catheter tips. CONCLUSIONS: The bacteria detection rate in this study was 28.5% for blood cultures, which is higher than the 17.5% reported by the Japan Nosocomial Infections Surveillance Program conducted by the Japanese Ministry of Health, Labour and Welfare. These results suggest that in elderly patients from whom an insufficient volume of blood can be drawn from a vein, an arterial sample may increase the detection rate. A high percentage of bacterial species isolated from the blood cultures was also detected in urinary tract infections and central venous catheter-related infections, indicating that a blood culture is useful for detecting various infectious diseases, even in elderly febrile patients.

Clinical evaluation of percutaneous endoscopic gastrostomy tube feeding in Japanese patients with dementia.

AIM: The aim of this study was to clinically evaluate percutaneous endoscopic gastrostomy (PEG) tube feeding of elderly Japanese patients with dementia. METHOD: The records of the 155 patients with dementia who underwent PEG in Juntendo Tokyo Koto Geriatric Medical Center were reviewed for pertinent clinical data, including diagnosis of dementia, place of stay before and after hospitalization, as well as survival rate, albumin levels, and incidence of aspiration pneumonia (AP) before and 6 months after PEG feeding. The latter three data of these patients were compared with those of 106 patients with dementia fed through a nasogastric (NG) tube. RESULTS: Alzheimer's disease and vascular dementia were predominant. Fifty-three percent of the patients were admitted from their home; the number of discharges to homes decreased to 21.2%. The mean (SD) of the albumin levels was 2.9 (0.4) g/dl before feeding and 2.9 (0.6) g/dl after 6 months. Among the patients with AP before PEG tube feeding, 51.6% had an AP recurrence. Conversely, AP occurred in 9.4% of the patients without AP before feeding. The patient survival rate was higher by 27 months when using PEG tube than when using an NG tube. CONCLUSION: PEG tube feeding in patients with dementia leads to preservation of status for a few years. Compared with NG tube feeding, PEG tube feeding did not induce AP due to impairment of intact swallowing function, and was associated with higher survival rate of approximately 2 years. However, PEG tube feeding does not seem to promote home medical care.

[A case of intravascular large B-cell lymphoma with rapidly progressive cognitive impairment after cerebral infarction].

A 67-year-old man started to show symptoms of dementia and developed convulsions accompanied by presyncope. Since an old cerebral infarction was found, he was given a diagnosis of symptomatic epilepsy, treated with antiepileptics. Dementia progressed rapidly, resulting in admission to a dementia ward. There were no physical abnormalities, and only slight elevations of LDH and CRP were noted. He suddenly developed a fever between 38°C and 39°C. Only the serum concentration of soluble IL-2 receptor was elevated at 6,430 U/L. Although a malignant tumor of the lymphatic system was suspected, there was no swelling noted in the superficial lymph nodes. The patient suddenly developed hypoxemia, thrombocytopenia, and an increase in fibrin degradation products. Pulmonary thromboembolism was suspected, but contrast-enhanced chest CT did not reveal any abnormalities. Bone marrow aspiration did not detect any infiltrations of lymphoid cells but was suggestive of hemophagocytic syndrome. After that, a new cerebral infarction occurred. Based on the course, intravascular lymphoma, which causes microvascular occlusions in various organs, was considered probable. Prednisolone was administered at a dose of 60 mg daily and skin biopsy was scheduled. However, the patient experienced a sudden deterioration and died. In autopsy, immunostain with CD20 showed that the arteriolae, capillaries, and venulae of thoracic and abdominal organs were filled with cells of large B-cell lymphoma. The presence of similar cerebrovascular lesions was not confirmed, but can reasonably be speculated. Thus, the present case suggests that it is necessary to consider intravascular lymphoma when dementia rapidly progresses for unknown reasons.

[Death in geriatric pneumonia patients].

AIM: Pneumonia-associated deaths are the 4th leading cause of death in elderly people, and fatality tends to increase with age, especially after the age of 65. We aimed to further define convalescence in this patient population by examining the clinical characteristics of elderly pneumonia patients. METHODS: We retrospectively examined the data of 292 patients aged 65 years or older who had died of pneumonia. Analysis was performed according to the guidelines for the management of pneumonia of the Japanese Respiratory Society (JRSGMP), which retrospectively classifies pneumonia into a community-acquired type (c type) and hospital-acquired type (h type). In the present study, there were 110 cases of c type and 182 cases of h type. RESULTS: Among the factors that accurately predicted disease severity in the c type group, age was associated with the highest frequency (104; 94.5%). Furthermore, age was most frequently associated with a convalescence prediction factor in the h type group (150; 82.4%). The remaining factors collectively comprised approximately 50%. Except in mild cases in the c type group, deaths occurred in each of the disease severity groups for both pneumonia types. Dysphagia occurred in many cases in both groups, and in both pneumonia types the most common complication was dementia. In the h type group, cerebrovascular diseases were the second most common complication. CONCLUSION: When assessing disease severity in elderly pneumonia patients, the JRSGMP may not allow accurate judgment of convalescence. It is very likely that dementia and cerebrovascular diseases cause dysphagia. Furthermore, very elderly patients are frequently at risk of developing aspiration pneumonia during treatment. For these reasons, it may be necessary to add the condition of a patient with these complications to the disease severity rating or convalescence prediction factor when considering the outcome of pneumonia in very elderly patients. It is necessary to consider all these factors when treating such episodes.

[Study of discharge support in dementia cases].

AIM: The goal of this study was to clarify how the post-discharge support by a full time psychiatric social worker (PSW) in a dementia ward affected the discharge status of dementia patients. METHODS: Patients who were discharged from a dementia ward were examined for hospitalization, post-discharge status, nutrition methods, treatment drugs, and relationship with discharge support performed by the PSW. RESULTS: A total of 192 cases met the requirements for this examination, and approximately half (94, 49.0%) of these patients had Alzheimer disease. Fifty-two patients (32.3%) moved to home care. Forty-five patients visited our hospital for treatment, while 17 visited other medical institutions for treatment. Thirty-four patients (17.7%) moved to other medical institutions, and the remaining 96 patients (50.0%) entered other institutions. About half of these patients entered insurance care facilities for the elderly, and the number of entered cases decreased in the order of special elderly nursing homes, paid homes for the elderly, and group homes. The highest mean support frequency per case was more than 50 occasions and 800 minutes for a paid home for the elderly. This support decreased in the order of special elderly nursing homes, insurance care facilities, and group homes. Cases treated at other medical institutions had the shortest hospitalization, but these cases had a greater mean support frequency than the cases treated at our hospital. The lowest mean support frequency was for oral meal intake while the highest mean support frequency was for nourishment by gastrostomy, with a significant difference between both (P<0.01). Only for cases that entered insurance care facilities for the elderly was there significantly more support frequency for cases that took donepezil hydrochloride than cases that took other drugs (P<0.03). CONCLUSIONS: After discharge from a dementia ward, the PSW spent a significant amount of time on discharge support, and this discharge support was indispensable. Hospitalization at a medical institution or admission to facilities was associated with a higher degree of discharge support than home care. Furthermore, patients who were hospitalized at a long-term medical treatment institution, or those who entered an insurance care facility for the elderly, needed frequent support for drug administration.

[Clinical analysis of mortality in elderly patients with community-acquired pneumonia].

AIM: Community-acquired pneumonia remains a common and serious disease for elderly persons. The incidence and mortality rates of pneumonia are higher in the elderly. We analyzed the mortality and prognostic factors in 200 elderly patients with community-acquired pneumonia. METHODS: The subjects were 200 elderly patients aged 65 years or older who needed hospitalization after initial visit to Geriatric Medicine, Juntedo Tokyo Koto Geriatric Medical Center, between January 2005 and December 2006. The subjects were divided into two groups, those who died, and those who survived on admission, we examined mortality rates and compared the background, underlying disease, laboratory data, chest X-ray findings, severity classification using A-DROP, between the two groups. RESULTS: The mortality rate was 15.0%. Circulating diseases, cerebrovacscular diseases and dementia were the most common underlying diseases. It took a longer period to enter the hospital in the cases that died. In laboratory findings, total protein, serum albumin and percutaneous oxygen saturation were lower, and BUN was higher in the fatality group. There were many more patients who had extending infiltration shadow on chest X-ray films and severe condition on A-DROP classification in the fatality group. CONCLUSIONS: We concluded that delay of diagnosis and treatment, dehydration, low levels of protein and albumin were important prognostic factors. The extent of infiltration shadow in chest X-ray findings was also important. A-DROP might be useful for estimating the prognosis in elderly patients with community-acquired pneumonia. We should consider the prognostic factors and severity at the initial stage when treating elderly patients with pneumonia.

[Causes of death in hospitalized elderly patients].

AIM: The Juntendo Tokyo Koto Geriatric Medical Center (JTKGMC) is a community hospital catering for the health care needs of senior citizens, and 37.5% (120 beds) of its beds are psychiatric beds mostly for those with cognitive impairment. The purpose of this study was to analyze cause of death in a hospital like ours with its particular case mix. METHODS: All patients who passed away in our hospital between June 1st 2002 and November 30th 2007 were surveyed with regard to their age distribution and causes of death were analyzed and compared with available national statistics. RESULTS: The over 65 age group accounted for 93.5% of the total and consisted of 815 patients, including 461 men (56.6%) and 354 women (43.4%). The most common cause of death was malignant neoplasm, followed by pneumonia, cardiovascular diseases, cerebrovascular accidents, and renal failure. Among those who died from the primary disease diagnosed on admission, malignancy was most common (288 cases, 61.3%), followed by pneumonia, cerebrovascular accidents, cardiovascular diseases and renal failure. As for those who died from non-primary diagnosis on admission (patients dying due to any condition, not the direct reason of their admission), pneumonia was the most common diagnosis on admission (95 cases, 27.5%), followed by cardiovascular diseases, malignant neoplasm, sepsis and renal failure. In the general wards, above half of those who died due to the primary cause of admission was malignant neoplasm. On the other hand, 1/4 of those who died from causes other than the primary diagnosis on admission was pneumonia. In the mental health wards the most common cause of death due to the primary diagnosis was malignant neoplasm, followed by dementia of Alzheimer's type. The most common cause of death other than the primary reason for admission was pneumonia. More non-primary diagnosis deaths occurred in the mental health wards than in the general wards. CONCLUSION: In our hospital, malignancy and pneumonia were the most common causes of death, rather than cerebrovascular or cardiovascular diseases, but otherwise, the ranking order of the causes of death was very similar to those in other areas of Japan. Causes of the both in our hospital were closely linked with the high incidence of in-hospital mortality in Japan, accounting for 80% of all deaths. Although the case mix of our in-patients is influenced by a particular distribution of health care institutions and nursing care facilities in our catchment area for secondary care, the study demonstrated that our geriatric service responds to the needs of a wide spectrum of indications suffered by elderly citizens at the end of their life.

[Clinical study on lung disease caused by non-tuberculous mycobacteriosis in the elderly].

AIM: This study was done to clarify the characteristics of elderly patients with nontuberculous mycobacteriosis. METHODS: We investigated the clinical features of 10 patients at an advanced age who had been given diagnosis of nontuberculous mycobacteriosis. RESULTS: Mycobacterium avium intracellulare complex (MAC) were detected in all cases. The age of the patients ranged from 65 to 92. Four cases had underlying respiratory diseases (old pulmonary tuberculosis in 3 cases, pulmonary emphysema in 1 case, bronchiectasia in 1 case). Six cases suffered from dementia. The symptoms were relatively nonspecific, such as low grade fever, fatigue, appetite loss in almost all cases in this study. On computed tomography (CT) scans of the chest, mainly small nodular infiltrates were seen. MAC was detected in clinical samples such as sputum, gastric juice and bronchial lavage. The examination of gastric juice was performed in 6 out of the 10 cases. Gastric juice samples were smear-positive for acid-fast bacilli in 5 of 6, and culture-positive for MAC in 5 of 6. The detection of MAC in gastric juice samples was higher than that in sputum samples on admission. CONCLUSION: Gastric juice might be useful to differentiate infection from casual isolation of MAC in elderly patients.

Clinical characteristics of 8 sporadic cases of community-acquired Legionella pneumonia in advanced age.

Legionella spp are well recognized as one of the etiologic factor in pneumonia, but it is difficult to distinguish the clinical features of Legionella infection from pneumonia due to other causes. The objective of the present study was to examine the clinical characteristics of community-acquired Legionella pneumonia in elderly patients. We reviewed the clinical, laboratory and radiographic findings in 8 patients diagnosed as having pneumonia caused by Legionella. The diagnosis was confirmed by the presence of urinary antigen, bacterial culture, polymerase chain reaction (PCR) and serum antibody. There were 6 men and 2 women, whose ages ranged from 76 to 85 years. All patients had fever and hypoxia, four patients had respiratory symptoms. The initial chest X-ray findings were varied--consolidation, ground glass opacity, pleural effusion and linear shadow. Urinary antigen was positive in 4 patients, bacterial culture in 2, PCR on the sputum in 3 and serum antibody in 2 patients. As pneumonia caused by Legionella often becomes life-threatening, especially in elderly people, it is imperative to diagnose it at the initial stage. In this study, urinary antigen proved to be the most useful diagnostic means. However, it is important to confirm the diagnosis through plural examinations.