Mitsunaga Iwata

Underuse of medications for chronic diseases in the oldest of community-dwelling older frail Japanese

OBJECTIVES: To test the following hypotheses: (1) the rate of polypharmacy, defined as six or more prescribing medications, is lower in the oldest old (≥85) than in younger older people (65–84); (2) beneficial medication use is lower in the oldest old; (3) the underuse of these medications in the oldest old is associated with physical or cognitive impairment or comorbid 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.

Prognostic value of serum albumin combined with serum C-reactive protein levels in older hospitalized patients: continuing importance of serum albumin

Background and aims: Although both serum albumin and C-reactive protein (CRP) levels are separately recognized as predictors of adverse outcomes in many illnesses, the predictive value of their combination for adverse outcomes has not been evaluated. We therefore sought to examine the prognostic value of serum albumin for in-hospital mortality in the presence or absence of severe inflammation, as indicated by high CRP levels. Methods: In this cohort study, we measured serum albumin and CRP levels in 1638 older patients (aged 65 years or older) hospitalized for medical problems, and examined their utility, both separately and in combination, for predicting in-hospital mortality. Results: In separate analyses of CRP and albumin, both high CRP levels (≥5 mg/dl) and hypoalbuminemia (<3.5 g/dl) were associated with risk of in-hospital death. After dividing participants into four groups based on CRP and albumin levels (<5 mg/dl CRP and <3.5 mg/dl albumin), subjects with severe inflammation (CRP ≥5 mg/dl) and hypoalbuminemia were associated with an adjusted relative risk (ARR) of 3.8 for in-hospital mortality when compared with the reference (high albumin and low CRP). Even in the absence of severe inflammation, the presence of severe hypoalbuminemia was associated with an ARR of 2.6 for in-hospital mortality, when compared with patients without hypoalbuminemia. Conclusions: Both serum CRP and albumin levels are predictors of in-hospital mortality. However, high serum albumin levels may have a protective effect in older patients, regardless of degree of inflammation. Serum albumin levels remain a useful predictor for in-hospital mortality in older hospitalized patients.

Mechanisms of the Inhibitory Effect of Epigallocatechin-3-Gallate on Cultured Human Vascular Smooth Muscle Cell Invasion

Objective—Although we recently showed that the administration of catechins reduced the neointimal formation in a rat balloon-injury model, the precise molecular mechanisms are largely unknown. In the present study, we tried to determine these mechanisms using an in vitro SMC invasion system. Methods and Results—Boyden chamber assay was used to examine the effect of catechins on the invasive behavior of SMCs. The invasive activity of SMCs through collagen gel was restrained by EGCG in a concentration-dependent manner. The data from gelatin and collagen zymography and Western blot revealed that EGCG blocks the activation of pro-matrix metalloproteinase (MMP)-2 during an invasion assay and in the conditioned medium of cultured SMCs as well as the activities of MMP-2 and membrane type 1-MMP (MT1-MMP) even at 0.1 to 0.3 &mgr;mol/L of EGCG. EGCG was found to restrain MT1-MMPcat–dependent pro–MMP-2 activation. EGCG upregulated the expression of tissue inhibitor of MMP-2 (TIMP-2) protein. Reverse zymography showed that the increased TIMP-2 to expression was validated by an increased activity. The data from decreased TIMP-2 activity using its siRNA suggested that upregulation of TIMP-2 expression may be one of the major mechanisms for inhibition of SMC invasion by EGCG. Conclusions—These results indicate that EGCG targets multiple MMP-mediated SMC cellular events and provides a new major mechanism for the SMC invasion through upregulation of TIMP-2 expression to modulate MMP activity.

Association Between Unmet Needs for Medication Support and All‐Cause Hospitalization in Community‐Dwelling Disabled Elderly People

OBJECTIVES: To clarify the association between unmet medication management need and 3‐year mortality and hospitalization for community‐dwelling older people with various levels of disabilities.

Underappreciated predictors for postdischarge mortality in acute hospitalized oldest-old patients

Background: Although oldest-old, those aged 85 years and older, patients are the fastest growing segment, clinical evidences regarding the acute care of oldest-old patients are still lacking. Because acute medical conditions requiring emergent hospitalization is frequently followed by high rate of progressive physical decline and increased mortality after discharge in oldest-old patients, prognostic information collected during hospitalization can provide the basis for discussion about the goals of care and therapy. The aim of our study was to identify predictive factors for postdischarge mortality in oldest-old patients. Methods: The study included 403 oldest-old patients discharged from the acute care setting of a general hospital, who were followed-up for 1 year. Predictive values of the patients’ characteristics collected during their hospitalization for 1-year mortality were identified utilizing Cox proportional hazard regression analysis. Results: During 1-year follow-up, 104 patients (25.8%) died. The variables independently associated with 1-year mortality in multivariate analysis were the Charlson Comorbidity Index equal or greater than 2 [HR (hazard ratio) 4.71, 95%CI (confidence interval) 1.09–20.42], six or more prescribed medications at discharge (HR 3.12, 95% CI 1.39–6.99), benzodiazepines use (HR 1.64, 95% CI 1.04–2.60), nonsteroidal anti-inflammatory drugs use (HR 1.70, 95% CI 1.10–2.63), albumin less than or equaling 3.4 g/dl (HR 2.16, 95% CI 1.13–4.14), hemoglobin 10–12 g/dl (HR 2.32, 95% CI 1.22–3.56), hemoglobin less than 10 g/dl (HR 2.67, 95% CI 1.43–4.95), the presence of pressure sores (HR 1.84, 95% CI 1.14–2.97), and a history of delirium (HR 2.24, 95% CI 1.32–3.79). Functional impairment assessed by the Katz Index was only weakly associated with mortality (HR 1.24, 95% CI 0.53–2.91). Conclusion: Although often underappreciated, polypharmacy, particular medication use, anemia, the presence of pressure sores, and a history of delirium were important predictors for postdischarge mortality in oldest-old patients.

J-SHAPED RELATIONSHIP BETWEEN RESTING PULSE RATE AND ALL-CAUSE MORTALITY IN COMMUNITY-DWELLING OLDER PEOPLE WITH DISABILITIES

To the Editor: It has been demonstrated that a high resting heart (pulse) rate (PR), particularly in adult men, is associated with greater risk for cardiovascular and all-cause mortality. Although there have been only limited studies that have examined the relationship between PR and mortality in older people, conflicting results have been published. In older women, there is reported to be a linear relationship between heart rate and mortality, although others have been unable to confirm this association. In addition, the association between mortality and resting PR in disabled older people remains unknown. In the present study, we examined the influence of PR on the all-cause mortality of community-dwelling older people with disabilities. The study analyzed the baseline data of a subgroup of participants in the Nagoya Longitudinal Study of the Frail Elderly (NLS-FE) and mortality during a 3-year followup period. The study population consisted of 932 community-dwelling older people (347 men, 585 women; mean age standard deviation 80.4 7.9) who were provided with various home care services under a long-term care insurance program. The baseline data included the subjects’ demographic characteristics and a rating for basic activities of daily living (ADLs). Additional information obtained from records of care-managing centers included the following physician-diagnosed chronic conditions: ischemic heart disease, congestive heart failure, cerebrovascular dis-

Emergency department use by nonagenarian patients

Background:  In accord with the rapid growth of the nonagenarian population, their emergency departments (ED) visits are increasing. The aim of our study was to examine ED use by nonagenarian patients and their dispositions.

Transfer of elderly patients from health care facilities to emergency departments: Prospective observational study of the emergency department in Japan

Background:  The purpose of the present paper is to describe the current status of emergency departments (ED) that are used by health care facilities for elderly (HCFFE) residents in Japan.

Evaluation of gender differences in caregiver burden in home care: Nagoya Longitudinal Study of the Frail Elderly (NLS‐FE)

Background:  Japan is presently experiencing a growth in the number of male caregivers and this situation has given rise to some concerns over gender differences. Previous studies have suggested that there are gender differences in caregiver burden in home care, however, it is still unclear whether or not gender differences exist. We therefore conducted this study to attain a better understanding of the Japanese male caregiver burden in home care, using data from the Nagoya Longitudinal Study of Frail Elderly (NLS‐FE).