[Prediction on the medical care system for the aged people in the new century].

Japan has become the country with the longest life expectancy in the world in about 25 years. Among many factors for this success, the medical care system, including the health insurance for everyone, played the important role, which has been evaluated as the best in the world. However, since the national economy in Japan has become recently suppressed it has become one of the big political problems to keep this system as same as before. In addition, the medical expenses for the elderly and aged people is now as high as 40% of all. In this meaning, we should create the better system by ourselves, based on ethical criteria, harmonized with the progress of medicine. In April of 2000, the new long term care system was introduced aiming the self independence of aged people. Now, the medical and long term care system has become unified into one toward the ideal society in the future. In this paper, the ideal medical care system, especially for the aged people was discussed. Needless to say, the medical care system should have widely view to the future. The progress of medicine, high technology and health promotion will play very important parts to create the ideal society in future. If any geriatric diseases including senile dementia will be settled in near future, the medical care system for the aged will change completely. In addition, the nationwide campaign of health promotion will induce excellent results. Thus the society in the future will become much brighter and happier. In this meaning, health promotion, medical care, and welfare systems should be unified into one system. The expenses for these systems should be regarded as the investments expecting the huge profit in health and happiness in the future.

Videofluorographic study of swallowing in Parkinson's disease.

We studied 16 patients with Parkinson's disease (PD) with dysphagia and 8 young and 7 elderly normal controls videofluorographically to evaluate the nature of swallowing disorders in PD patients. In 13 patients, abnormal findings in the oral phase were residue on the tongue or residue in the anterior and lateral sulci, repeated pumping tongue motion, uncontrolled bolus or premature loss of liquid, and piecemeal deglutition. Thirteen patients showed abnormal findings in the pharyngeal phase, including vallecular residue after swallow, residue in pyriform sinuses, and delayed onset of laryngeal elevation. Ten of these patients also showed abnormal findings in both the oral and pharyngeal phases. Aspiration was seen in 9 patients. The oral transit duration was significantly longer in the patients with and without aspiration than in the control subjects. The stage transition duration, pharyngeal transit duration, duration of the upper esophageal sphincter (UES) opening, and total swallow duration were significantly longer in the patients with and without aspiration than in the young controls, but were not longer than in the elderly controls. These durational changes in the pharyngeal phase of swallowing were similar to those in the elderly controls. The findings suggest that the disturbed motility in the oral phase of swallowing may be due to bradykinesia. Although PD patients with dysphagia evince a variety of swallowing abnormalities, the duration of pharyngeal swallowing may remain within the age-related range until the symptoms worsen.

[Organ transplant network in Japan: current status and its role].

The Role of Organ Transplant Network are the encouragement of the organ transplantation and fair organ sharing. Its principled are united, neutral open and nonprofit organization, so as to secure the fair and quick organ sharing based on the uniform allocation policy. Japan Kidney Transplant Network was established in 1995 nad reorganized into multi-organ sharing network, Japan Organ Transplant Network in 1997, when Japan Organ transplant Act was enacted. It consists of transplant coordinators, physicians, transplant surgeons, kidney banks, local administration, academic standings, other organization/associations and others. There are several committee, in which special subjects on organ transplantation and related matters are consulted, and review system in which each case is assessed and judged. And principal and essential items are decided by the board of members and then by the general assembly. The new computer system was introduced and registrants data are renewed every year, and recipient selection is done based on the latest registrants data. Standardized HLA examination tray was introduced and class II antigen was examined by means of DNA typing since 1997, which enabled more precise and accurate search. Hereafter, the education and encouragement of transplant coordinators to raise themselves and the more effective and extended distribution of donor cards are indispensable to promote organ donation/transplantation.

[Characteristics of bedridden elderly people living at home and in a hospital].

We compared bedridden elderly people living at home to others who were hospital inpatients. Questionnaires regarding medical status and care were returned by 85 of 116 people caring for a bedridden elderly person at home in Obu city, Aichi prefecture and by 62 of 64 nurses and family members caring for bedridden inpatients at Chubu National hospital. All subjects were at least 65 years old. The median age in both groups was 81 years, neither age distribution nor female sex predominance differed between both groups. The percentage of subjects with only one underlying disease was 62.5% among those living at home and 64.4% among inpatients. In both groups the most common disease was cerebrovascular disease (42.5% among those at home and 39.0% among inpatients), followed by dementia (31.3%), infirmity of old age (17.5%) and bone fracture (13.8%) among those at home, and by bone fracture (27.1%), dementia (20.3%) and infirmity of old age (16.9%) among inpatients. The median durations of bedridden status were 2 years and 3 months among those at home and 3 months among inpatients. The proportion of subjects bedridden for less than 6 months was greater among inpatients (p < 0.0001). The percentage who needed medical treatment was 60.0% among those at home and 67.7% among inpatients. The most common conditions for which drugs were taken were hypertension, dementia, chronic cerebrovascular dysfunction, and osteoporosis. Among inpatients, 54.8% were ambulatory before admission, 24.2% were almost completely bedridden, and 17.7% were completely bedridden. The most common cause rending the patients bedridden was infection (usually pneumonia). The degree of disability did not differ between groups. Decubitus ulcers were present in 25.9% of those at home and 17.7% of inpatients.

Pharmacokinetic study of aniracetam in elderly patients with cerebrovascular disease.

The clinical pharmacokinetics of the cognitive enhancer, aniracetam (200 mg), was studied in elderly patients with cerebrovascular disease (CVD) and compared with those of young healthy volunteers. Six female hospitalized patients (mean age 84.5 years) were used in this study. The serum level of anisic acid and p-methoxyhippuric acid, major metabolites of aniracetam, reached a peak at 2 h after oral administration, and returned to basal level by 6 h. Mean creatinine clearance was 20-30 ml/min. The t1/2 of metabolites was increased by 4- to 7-fold in the elderly patients compared with young volunteers. This study showed that tmax, t1/2, and AUC were enlarged in the elderly; however, no clinical side effects were observed.

Function of Ca2+ in phosphatidylcholine-hydrolyzing phospholipase D activation in osteoblast-like cells.

We investigated the function of Ca2+ in the activation of phosphatidylcholine (PC)-hydrolyzing phospholipase D (PLD) in osteoblast-like MC3T3-E1 cells. Fetal calf serum (FCS) stimulated the formation of choline in a dose-dependent manner in the range between 0.6% and 10%. The effect of a combination of FCS and 12-O-tetradecanoylphorbol-13-acetate, a protein kinase C (PKC) activator, on the formation of choline was additive. Staurosporine, an inhibitor of protein kinases, enhanced the formation of choline induced by FCS. BAPTA/AM, a chelator of intracellular Ca2+, inhibited the formation of choline induced by FCS. The depletion of extracellular Ca2+ by EGTA markedly reduced the FCS-induced formation of choline. SK&F 96365, an inhibitor of receptor-operated Ca2+ entry, significantly inhibited the choline formation induced by FCS. On the other hand, nifedipine, an inhibitor of L-type voltage-dependent Ca2+ channels, had little effect on the choline formation. TMB-8, an inhibitor of Ca2+ mobilization from intracellular Ca2+ store, significantly inhibited FCS-induced choline formation. These results strongly suggest that Ca2+ mobilization, through both the influx via receptor-operated Ca2+ channel and the release from intracellular Ca2+ store, plays an important role in the activation of PLD in osteoblast-like cells.

Pain-related somatosensory evoked potentials in dementia.

Pain-related somatosensory evoked potentials (pain SEPs) were examined in 25 demented and non-demented patients to investigate the cognitive function for pain in the progression of dementia. Pain SEPs by CO2 laser stimulation were recorded together with auditory event-related potentials (auditory ERPs). P340 in pain SEPs and P300 in auditory ERPs were analysed. The latency of P300 evoked in mildly demented patients was inversely correlated with the Mini-Mental state examination score, and the latency of P340 was also inversely correlated to that score but to a lesser extent. Pain SEPs were not recorded in 4 of 7 severely demented patients. These results indicate that the P340 component of pain SEPs is apparently different from the P300 component of auditory ERPs and suggest that the pain perception in severely demented patients may be abnormal.

[Clinical and physiological studies on senile tremor].

We examined 6 male and 10 female patients with senile tremor which started at 60 years of age or older. The patients' age on examination ranged from 66 to 82 years (mean: 73.4; SD: 5.4 years). The surface electromyogram (EMG) was recorded from the bilateral biceps brachii, triceps brachii, forearm flexor and forearm extensor muscles. The frequency of the tremor was counted and patterns of grouping discharges were analysed. The effect of mechanical perturbation to the affected muscle on tremor rhythm was also examined. The same investigations were performed in 15 male and 7 female patients with essential tremor with onset age before 60 years as control patients. The mean frequency was 6.2 Hz (SD: 1.3 Hz) in senile tremor and 7.3 Hz (SD: 1.5 Hz) in essential tremor. There was a significant difference between the two groups. The mean frequency in control patients whose age on examination was 60 years or over was, however, 6.0 Hz (SD: 0.8 Hz), and there was no difference from the mean frequency in senile tremor. The frequency in both groups was inversely correlated to the patient's age on examination. The antagonist muscles were reciprocally discharged in 15 patients in the senile tremor group and in 7 in the controls. Mechanical perturbation of the affected muscle re-set the tremor rhythm in all patients examined. Thus, senile tremor had characteristics resembling tremor in the control patients, suggesting that senile tremor may be a subtype of essential tremor.

[Awareness and feelings of elderly patients and their families concerning disease during terminal hospitalization--malignancy versus non-malignancy].

We conducted a questionnaire survey on the awareness and feelings of elderly patients and their families concerning their diseases and prognosis during terminal hospitalization. Sixty-five families of 177 patients who died at our hospital in 1992 answered questions concerning estimation of the prognosis, understanding of the disease, satisfaction regarding explanation of the disease, wish to be informed of the diagnosis, feelings during hospitalization, and whether the family revealed the diagnosis to the patient. Patients with malignancy were not informed of the true diagnosis at this time. As to estimation of the prognosis, patients aged 70 or older who did not expect "cure" of their diseases at first were significantly fewer, and those anticipating "death" just before dying were significantly more frequent than those under age 70. In patients with malignancy, those aged 70 or older foresaw "incurability" at first significantly more frequently than those under age 70. Patients with malignancy knew the diagnosis in significantly fewer cases, believed the false diagnosis significantly more frequently, and showed dissatisfaction with the explanation of the disease significantly more frequently, than those with non-malignancy. Proportions of the family who told the diagnosis to the patient were 11.8% in malignancy and 38.8% in non-malignancy with statistical significance. These data indicate that medical care during terminal hospitalization should be modified principally based on informed consent, if that is the wish of the patient.

[Videofluorographic analysis of the swallowing disorders in spinocerebellar degeneration].

Clinical and videofluorographic (VF) studies of swallowing were performed in 11 patients with spinocerebellar degeneration (SCD). Eight patients had a subjective symptom of dysphagia. In VF study, seven patients represented abnormal findings in an oral phase such as residue on the tongue (2 patients), reduced tongue control (3 patients), uncontrolled bolus or premature loss of liquid (6 patients), and piecemeal deglutition (4 patients). Seven patients showed abnormality in a pharyngeal phase such as vallecular residue after swallow (5 patients), residue in pyriform sinuses after swallow (4 patients), delayed onset of laryngeal elevation (5 patients), and aspiration during swallow (5 patients). Aspiration was more obvious when barium liquid was swallowed. When the patients aspirated, techniques such as the chin down posture and the supraglottic swallow were tried in 4 of the 5 patients with the evidence of aspiration. The aspiration was prevented in 2 patients. It was suggested that in SCD the change in the form and volume of food is recommended for prevention of aspiration and that the rehabilitation techniques such as the chin down posture and the supraglottic swallow may also improve the dysphagia.

Pain-related and electrically stimulated somatosensory evoked potentials in patients with stroke.

BACKGROUND AND PURPOSE: Pain-related somatosensory evoked potentials (SEPs) were applied to study abnormality of pain sensation in stroke, together with electrically stimulated SEPs for deep sensation. METHODS: We recorded pain-related SEPs after CO2 laser stimulation to the dorsum of the hand and electrically stimulated SEPs after median nerve stimulation at the wrist in 12 patients with stroke. We analyzed P340 in pain-related and parietal N20 in electrically stimulated SEPs. RESULTS: In 5 patients with a putaminal lesion, P340 was absent or its latency was delayed, and N20 was absent or reduced in amplitude. In 3 patients with a thalamic lesion, P340 and N20 showed various patterns according to the involved sites. In 4 patients with a lesion in the corona radiata, P340 and N20 were normal. CONCLUSIONS: Abnormalities of P340 and N20 in the stroke location were related to impairment of the pain and vibration senses, respectively. Thus, pain-related and electrically stimulated SEPs were useful to investigate the sensory function of each structure in the central nervous system in patients with stroke.

[A survey on elderly patients' knowledge of management of health care].

We conducted a questionnaire survey on the awareness of elderly patients in our hospital concerning medical management. As to the recognition of their own diseases, patients aged 80 or older, showed a lower degree of understanding than those under age 80. The proportion of patients who wished to known about their diagnosis decreased with age, although no statistical significance was recognized. Those who wished to known about their diagnosis, even if it were malignant, reduced significantly depending on the increase in age. In addition, the proportion of patients who would not like to know their diagnosis, if it were malignant, increased significantly as age increased. Proportions of patients who wanted to know other information, such as prognosis, the aims, methods and results of medical examination, the methods and adverse effects of treatment, and the names, effects and side effects of drugs, also decreased significantly as age increased. However, there were no statistical significant differences in the proportion of answers between cases of malignant and non-malignant disease. These data show that elderly patients had more anxiety or fear about malignancy, and wished to know less about medical management than non-elderly patients.