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Advance care planning (ACP) for people with dementia, as with other diseases, is a necessary process to realize medical treatment and care in the final stage of a person's life. On the other hand, dementia, a disease that is expected to make it difficult for people to make decisions on their own in the future, has a long course, and is characterized by uncertainty regarding the course of the disease, which may also be a limiting factor in the implementation of ACP for people with dementia. On the other hand, the uncertainties may also be a reason for implementing ACP. This paper reviews reports on ACP initiatives for people with dementia from many countries and presents their characteristics, cultural and customary influences, effects, facilitating and inhibiting factors, and recommendations for implementation, with the aim of promoting future ACP initiatives for people with dementia. The aim of the study was to promote future ACP initiatives for people with dementia.

In Japan, which has become a super-aged society, medical care for the elderly is more important than ever before. Geriatric education for medical students and young doctors is essential to ensure the best medical care possible for the elderly. In this paper, the Working Group for Education of the Japan Geriatrics Society collected and analyzed data and information on undergraduate education in the fields of geriatrics and gerontology at medical schools in various countries through the Internet, comparing the findings with those in Japan. Of the countries surveyed, 62% had undergraduate education in geriatrics and gerontology as mandatory subjects in medical school. Countries with advanced welfare programs, such as the United Kingdom, Germany, Austria, Denmark, Finland, Sweden, the Netherlands, Spain, Canada and New Zealand, performed substantial undergraduate education in geriatrics and gerontology. A lack of available staff and time for education was cited as a hurdle in many countries. The importance of education in geriatrics and gerontology is being emphasized in many countries, but few programs are satisfactory at present. The "struggle" to improve undergraduate education in geriatrics and gerontology therefore continues. We should endeavor to improve education in the fields of geriatrics and gerontology by working hand in hand with geriatricians and gerontologists around the world.

IgG4-related disease (IgG4-RD) which is characterized by an autoimmune abnormality and elevated serum IgG4 level often presents as swelling, nodules, and the thickening of multiple organs. It typically occurs in middle-aged to elderly patients, but its pathogenesis remains unclear. Lymphadenopathy is frequently seen in IgG4-RD, which clinically requires a differential diagnosis from malignant lymphoma. We herein report a case of malignant lymphoma with IgG4-RD arising in a very elderly man.An 85-year old man with a 6-year history of autoimmune pancreatitis was diagnosed as IgG4-related hypophysitis 13 months prior to admission. Hydrocortisone was prescribed for secondary adrenal insufficiency after this presentation. At 9 months before admission, he began to suffer from central diabetes insipidus, and desmopressin was also prescribed at that time. However, 9 months later, he presented with fever, weight loss, and systemic lymphadenopathy while demonstrating elastic hardness, flexibility, and no tenderness. A pathologic specimen obtained from a right axillary lymph node biopsy revealed diffuse large B cell lymphoma. Considering his age and performance status, palliative therapy was chosen, and thus prednisolone was administered. He was transferred to another hospital to receive palliative care on the 55 th day after hospitalization.We should consider the clinical course, pathological findings, serum IgG4 level, and other involved organs in order to differentiate malignant lymphoma from IgG4-related lymphadenopathy. To our knowledge, this case is the oldest known patient to have ever been reported. Both IgG4-RD and malignant lymphoma are frequently seen in elderly people, therefore, we should deepen our knowledge of these diseases.

Aim: We developed quality-of-life (QOL) scales for patients receiving home medical care. The objective of this study was to examine the agreement between the scores of the scales answered by patients and those answered by their proxy, as cognitive decline may interfere with one's ability to understand complex topics, such as the QOL., Methods: Participants were pairs of patients receiving home medical care and their proxy. The patients were asked to complete self-reported QOL scales (QOL-HC), and their proxies were asked to complete proxy-reported versions of the QOL scales (QOL-HC for caregivers). We then statistically examined the extent of agreement between the self- and proxy-reported QOL-HC scores using contingency tables and Spearman's rank correlation coefficient. The SPSS software program, version 24, was used for all statistical analyses., Results: The concordance rate between patients and caregivers for questions 1 ( "Do you have peace of mind?" ), 2 ( "Do you feel satisfied with your life when you reflect on it?" ), 3 ( "Do you have someone that you spend time talking with?" ), and 4 ( "Are you satisfied with the home care service system?" ) were 52.3%, 52.3%, 79.5%, and 81.8%, respectively. The total scores for the patients and caregivers were significantly correlated (Spearman's ρ=0.364*)., Conclusions: We created the first QOL scale for patients receiving home-based medical care and for caregivers. The findings of this study suggest that the QOL-HC can be used in clinical practice for the assessment of patients receiving professional home care.

Aim: This study aimed to investigate the effects of limited health literacy on arterial stiffness measured by the cardio-ankle vascular index (CAVI) in community-dwelling older adults., Methods: A total of 288 older adults (mean age, 72.4 years, men, n = 99) participated. The degree of arterial stiffness was assessed based on the CAVI using the VS-1500 device (Fukuda Denshi Co., Ltd., Tokyo, Japan). Arterial stiffness was defined according to a cut-off point of ≥9.0. Comprehensive health literacy was assessed using the 47-item European Health Literacy Survey Questionnaire (HLS-EU-Q47). Other potential confounding factors, such as demographics, number of prescribed medications, mini-mental state examination results, grip strength, gait speed, current smoking, alcohol consumption, and physical inactivity, were also assessed. An analysis of variance for continuous variables or chi-square test for categorical variables was used for group comparisons. A logistic regression analysis was performed to examine the association between quartiles of HLS-EU-Q47 and arterial stiffness in crude and multivariate models adjusted for age, gender, and other confounding factors., Results: The first quartile with the lowest health literacy showed a significantly higher CAVI and prevalence of arterial stiffness than the fourth quartile with the highest health literacy (p<0.05). In logistic regression, the crude model showed that the third quartile (odds ratio [95% confidence interval] = 0.48 [0.24-0.93]) and fourth quartile (0.39 [0.19-0.77]) were significantly associated with arterial stiffness, while the multivariate model showed that to fourth quartile was significantly associated with arterial stiffness (0.44 [0.19-0.98])., Conclusions: Older adults with limited health literacy might be at a higher risk of arterial stiffness after accounting for confounding factors.

Aim: The Japan Diabetes Society and The Japan Geriatric Society made a joint committee and published a new glycemic target in May 2016. Because reports on the state of glycemic control in elderly diabetic patients are insufficient, we investigated the state of glycemic control in this population before the new glycemic target was established., Methods: We enrolled patients older than 65 years of age who had been prescribed antidiabetic drugs and hospitalized in the geriatric department of Nagoya University Hospital from April 1, 2015, to March 31, 2016. We investigated the participants' HbA1c, prescription of antidiabetic drugs carrying risks of severe hypoglycemia (risk drugs) at hospitalization, cognitive function, basic activities of daily living, and instrumental activities of daily living., Results: A total of 63 patients were enrolled. Thirty-five patients were male, the mean age was 83.1±5.9 years old, and the average HbA1c was 7.6%±1.5%. The numbers of patients assigned to categories I, II, and III were 10, 12, and 41, respectively. For prescription of risk drugs, 6 participants were assigned to category I, 8 to category II, and 22 to category III. Prescription of risk drugs was associated with the HbA1c. Approximately one third of the patients using risk drugs had a lower HbA1c than the target value., Conclusions: Risk drugs was not significantly associated with the established categories or age. Many of the patients who were prescribed risk drugs had a lower HbA1c than the target values.

Aim: To clarify the routes of nutrition and types of diet and their relevance to the risk of mortality and hospitalization among community-dwelling dependent elderly provided various home care services under the long-term care insurance program., Methods: The present study consisted of the collection of baseline data of participants in the Nagoya Longitudinal Study of the Frail Elderly (NLS-FE) and data regarding mortality and hospitalization during a three-year follow-up period. The study population consisted of 1,872 subjects, and the baseline data included demographic characteristics, basic activities of daily living (ADLs), comorbidities, nutritional routes and types of diet, which were evaluated by trained visiting nurses., Results: Among the participants, 1,786 were on oral nutrition (solid regular-texture diet: 1,487 (79.5%); modified-texture diet (minced/pureed texture): 299 (16.0%), 82 (4.4%) were on enteral nutrition and four (0.2%) were on parenteral nutrition. During the three-year follow-up period, 453 participants died and 798 participants experienced admission to the hospital (pneumonia-related death and hospitalization: n=103 and 155, respectively). Cox regression models revealed that a modified-texture diet and tube feeding are associated with all-cause mortality and hospitalization. In particular, feeding tube use showed a high risk of pneumonia-related mortality and hospitalization, even after adjusting for potential confounders, including comorbidities and the ADL status.

Aim: This study aimed to identify factors associated with malnutrition in community-dwelling disabled elderly., Methods: A cross-sectional study of baseline data for 1,142 community-dwelling elderly (81.2±8.7 years) from of the KANAGAWA-AICHI Disabled Elderly Cohort (KAIDEC) study was conducted. The data included the participants' demographic characteristics, nutritional status (Mini Nutritional Assessment short-form: MNA-SF), dysphagia status (Dysphagia Severity scale: DSS), comorbidity, basic activities of daily living (bADL), hospitalization with in the past three months and care level according to the Long-Term Care Insurance program. The participants were considered to be in malnutrition or at risk of malnutrition if their MNA-SF score was 0-7 or 8-11, respectively. The chi square test, analysis of variance, Jonckheere-Terpstra trend test and logistic regression analysis were used for the statistical analysis., Results: A total of 16.7% of the participants were classified as having malnutrition. In addition, a higher prevalence of malnutrition was associated with a higher care level in the long-term care insurance program, and malnutrition was associated with a lower bADL score, the presence of dysphagia and dementia and hospitalization with in the past three months., Conclusions: The present study demonstrated that malnutrition in community-dwelling disabled elderly is associated with a lower bADL score, the presence of dysphagia and dementia and hospitalization with in the past three months.

Aim: To examine the place and cause of death in community-dwelling disabled elderly people., Methods: The baseline data of 1,875 participants and their caregivers in the Nagoya Longitudinal Study for Frail Elderly were used for the analysis. Cox proportional hazard models were used to assess the associations between the variables and the place of death during the 3-year follow-up period., Results: During the observation period of three years, 454 died (hospital death: 347, home death: 107). In total, the rates of pneumonia-, cancer- and heart failure-related death were 22.7%, 14.5%, and 13.2%, respectively. Among the home deaths, 22.4% were age-related deaths and 18.7% were heart failure-related deaths. Females, older, and participants with dementia were more likely to die at home, while those with cancer or a spouse caregiver were more likely to die in the hospital. There were no differences in the levels of caregiver burden or formal service use between the cases of home and hospital death. Multivariate Cox hazard models revealed that home death was associated with an older age and the absence of diabetes mellitus and cancer at baseline., Conclusions: We demonstrated that death at home among community-dwelling disabled elderly is associated with an older age, and the absence of diabetes mellitus and cancer. Due to the lack of important factors that should be addressed, a further study is required in the future.

Aim: In our aging society, the number of community-dwelling dependent elderly people is increasing. Many studies have shown that depression influences the health of older persons. In the present study, we examined whether depressive status is associated with mortality and hospitalization in community-dwelling dependent older people during a 3-year follow-up period., Methods: This study was a prospective cohort analysis of 1,409 community-dwelling disabled elderly (489 men, 920 women; average age 80.1, the Nagoya Longitudinal Study for Frail Elderly). Data included demographic characteristics, basic activities of daily living (ADL) scores, comorbidity, and depressive status as assessed by the short version of the Geriatric Depression Scale (GDS-15) at baseline. The participants were considered to have depression or severe depression if their GDS-15 score was 6-10 or above 10, respectively. The Cox proportional hazard model and the Kaplan-Meier method were used to assess any association with depressive status at baseline with mortality or hospitalization during a 3-year period., Results: During a 3-year observation, 284 participants died (53 at home, 231 at hospital), and 576 were admitted to hospitals. Univariate analysis revealed that the depressive status of participants was associated with mortality and hospitalization during a 3-year follow up. However, multivariate models used to adjust for potential confounders including gender, age, ADL status, and comorbidity, did not show any association between depressive status and mortality and hospitalization., Conclusions: Depressive status among community-dwelling disabled elderly was not associated with mortality or hospitalization in the present series.

Aim: We compared gender differences in the sociodemographic characteristics of community-dwelling dependent elderly who use various community-based services under long-term care insurance programs, as well as in mortality, hospitalization, and institutionalization during a 3-year follow-up period., Methods: We conducted a cross-sectional study using the baseline data of 1,875 care recipients from the Nagoya Longitudinal Study for Frail Elderly (NLS-FE), and a prospective study using their 3-year follow-up data. The data, which were collected at the patients' homes or from care-managing center records, included the clients' and caregivers' demographic characteristics, living arrangements, community-based services used, depression as assessed by the Geriatric Depression Scale (GDS-15), a rating for basic activities of daily living (ADL), and comorbidities. The data included, at 3-year follow-up, all-cause mortality, hospitalization, and institutionalization., Results: Among 1,875 care recipients 66.3% were women. They had a higher rate of living alone (26.2% vs 14.6% in men), and a lower rate of receiving care by a spouse (22.1% vs. 73.6% of men). Although there were no differences in ADL levels or GDS-15 scores between genders, a higher Charlson comorbidity index, higher prevalence of cerebrovascular disease, chronic obstructive pulmonary disease (COPD), and cancer were observed in the male care recipients. Kaplan-Meier analysis demonstrated that during the 3-year follow-up, higher mortality, hospitalization, and lower institutionalization rates were observed in men., Conclusion: We observed that two thirds of care recipients were women. Compared with male recipients, female recipients were more likely to live alone, and to be cared for by non-spouse caregivers. Lower mortality and hospitalization, but higher institutionalization, were observed in female recipients.

Aim: As summer become hotter due to rapid climate change, older people suffering from heat illness are increasing. The aim of our study was to examine the characteristics of older people who suffered from heat illness., Methods: We analyzed the 65 years or older patients admitted for acute care of Nagoya Ekisaikai Hospital via the emergency department (ED) during the summer seasons of 2006 and 2007. Demographic data, functional status, use situation of care services, climate of the onset day, use of an air conditioners, and cognitive status, length of hospital stay and disposition following their discharge were recorded., Results: During the study period, 104 patients visited the ED because of heat illness. Twenty older patients were admitted for acute care. In hospitalized patients, the mean length of stay was 27.5+/-18.6 days. Sixty percent of patients were discharged to long-term care facilities (12/20). Sixteen patients suffered from heat illness inside their home. Most of the patients had characteristics such as living alone or with their spouses only (14/16), cognitive dysfunction (12/16), lack or no use of an air conditioner (11/16) , no use of care service (11/16) , and preserved functional status (10/16) ., Conclusions: Many older patients suffered from heat illness in their home, and their ED visits were associated with prolonged admissions and post-discharge institutionalizations. It is important to give education to prevent heat illness in older people.

Aim: In the United States, a study has shown that dementia is a significant factor negatively associated with medical treatment. Because the increasing number of the elderly has resulted in cause a rise in patients with dementia or acute myocardial infarction (AMI), or both, we need to know the differences in in-hospital mortality between patients with or without dementia in patients with AMI., Methods: We used data from 13 acute care hospitals including in the data from the Tokai Acute Myocardial Infarction Study (TAMIS), a retrospective study of all patients admitted to these hospitals from 1995 to 1997 with a diagnosis of AMI. We abstracted the baseline and procedural characteristics from detailed chart reviews. A total of 22 patients with dementia and 1,030 with no dementia who were aged 65 and over were included in the present study, and were divided into two groups according to their diagnosis of dementia. We compared the baseline and procedure characteristics and clinical outcomes between the two groups., Results: Patients with dementia were older and more likely to have either a lower body mass index score or ADL impairment. As for medical history, patients with dementia were more likely to have a history of cerebrovascular disease, and less likely to have a history of angina or smoking. Before and after multivariable adjustment, no significant difference was found in in-hospital mortality between patients with or without dementia., Conclusions: Our study demonstrates that AMI elderly patients with dementia were not less likely to be undertreated and did not have a higher in-hospital mortality rate than non-dementia patients.

Background: Because long-term care facilities are being asked to care for more and more residents who are dying, the facilities require that new residents and families make decisions regarding their end-of-life care at the time of the admission process. An advance directive including "do-not resuscitate directives (DNR)" or "do-not-hospitalize directives (DNH)" is a written document that afford individuals the opportunity to determine the type and extent of end-of-life care when they are incapable of participation in medical decision making. It is expected that Japanese elderly and families make individual decisions regarding end-of-life care by a Japanese-style decision-making model including advance directives. The purpose of this study was to explore families' decision-making factors regarding cardiopulmonary resuscitate (CPR) and hospitalize orders in a long-term care hospital., Method: We assessed 70 admissions in a long-term care hospital in Aichi prefecture from April 2005 to September 2006. All residents were divided into two groups according to their CPR or hospitalize order. Data on the admission characteristics of the residents were collected from medical charts., Results: The prevalence of older age, functional dependence, and illness did not vary significantly with CPR or hospitalize order recorded by families, however, significant variation among physicians existed in the CPR and hospitalize orders., Conclusion: Wide variation in the likelihood of having CPR and hospitalize orders among physicians who explain an advance directive suggests a need for standardized methods for eliciting the end-of-life preferences of residents and families on admission to long-term care hospitals.

Aim: We conducted a national survey of senior medical students' attitudes about end-of-life care teaching programs for undergraduate students of Japanese medical schools from April 2004 to May 2006., Methods: Our questionnaire survey focused on the students' attitudes towards the following end-of-life areas: 1) end-of-life topics, 2) teaching methods, 3) putting theories into practice, and 4) overall end-of-life issue., Results: Overall, 1,039 students from 16 medical schools responded to our survey. The students who took part in the program appreciated the class on communication techniques with dying patients or family members of dying patients. As for the students who did not participate in the program, they expressed the wish to join a class concerning these issues. These students also expressed an interest in visiting hospices or conducting interviews with dying patients as part of their training. Most of the students formulated good opinions toward end-of-life issues, but not toward end-of-life practices. Regardless of whether they joined the program or not, most of the students had a positive attitude towards end-of-life education programs., Conclusion: The survey highlighted the need to consider wider implementation and improvement of end-of-life care education in the Japanese curriculum.

Aim: We conducted a national survey to examine how programs to teach end-of-life care to medical students in Japanese medical schools influence their death attitude., Methods: Sixteen medical schools participated. We conducted a questionnaire survey on fifth- or sixth-year medical students' death attitude at each medical school. Attitude of death was analyzed by the Death Attitude Inventory formed by Hirai et al, which is composed of seven factors: Afterlife belief, Death anxiety, Death relief, Death avoidance, Life purpose, Death concern, and Supernatural belief. We studied how students' attitude to death relates to programs to teach end-of-life care., Results: Overall 1,017 of 1,510 students (67.4%) from the 16 medical schools participated. The students who took a program to teach end-of-life care presented Afterlife belief, Death concern and Supernatural belief score higher than those who did not participate in any program. Multiple logistic regression analysis was conducted and it was found that those trend disappeared, and the students who took a program had greater Death anxiety significantly higher than those who took no program., Conclusion: We concluded that the attitude of medical students to death was not related to programs to teach end-of-life care in medical schools. Our survey suggested that improving end-of-life care education is needed to mold the attitude of medical students to death.

Aim: This study aimed to evaluate the relationship between anthropometric measurements and mortality among community-dwelling frail elderly., Methods: This study was a prospective cohort analysis of 520 community-dwelling elderly registered in the Nagoya Longitudinal Study for Frail Elderly (NLS-FE). Data included the participants' demographic characteristics, body mass index (BMI), mid-arm circumference (MAC), triceps skinfold (TSF), and arm muscle area (AMA), basic activities of daily living, comorbidity. BMI and TSF values were categorized into three groups, respectively, according to above the 75th percentile, the 25-75th percentile, and below the 25th percentile of Japanese Anthropometric Reference Data (JARD 2001). Survival analysis of 21-month mortality was conducted using Kaplan-Meier curves and multivariate Cox proportional hazards models., Results: BMI and TSF were independent risk factors for 21-month mortality in the study participants. Significant higher risk of 21-month mortality was observed in participants below the 75th percentile of BMI or below the 25th percentile of TSF set in JARD 2001. A striking increase in the risk of 21-month mortality, adjusting for potential confounding factors, was observed in the below 75th percentile of the BMI group with a below 25th percentile TSF of JARD 2001, compared with the 75th or above percentile BMI group with the 25th or above percentile TSF., Conclusion: The combination of BMI and TSF is a predictor of 21-month mortality among older people with ADL dysfunction.

Aim and Methods: The cooperation of general practitioners and specialists is crucial to establish comprehensive medical services for demented older adults. In the current study we conducted a survey regarding the attitudes towards referrals between general practitioners and specialists by sending a questionnaire to 1,176 general practitioners., Results: The 39.1% of the general practitioners returned the questionnaire. Of the respondents, 68.8% answered that they did not want referrals of demented patients from specialists, however, when analysis was limited to those who had an internal medicine background, only 26.3% did not want referrals. Difference of subspecialties within internists did not affect the preference for referrals. Regarding the reasons for referring the demented patients to specialists, more than 70% of the general practitioners chose "accurate diagnosis of the cause of dementia" and "decision of therapeutic plans"., Conclusion: The majority of general practitioners in Japan may still be reluctant to follow patients with dementia mainly because they regard the practice of seeing demented patients as the subject outside of their specialty. Therefore providing general practitioners with opportunities to receive training programs regarding the practice and care of demented patients, as well as establishing support from specialists is necessary.

Aim: We examined the prevalence of depression and identified the factors associated with depression among community-dwelling Japanese frail elderly eligible for long-term care insurance., Methods: A cross-sectional study of the baseline data of 1,409 elderly from the Nagoya Longitudinal Study for Frail Elderly was conducted. The data, which were collected at the patients' homes or from care-managing center records, included the clients' demographic characteristics, care levels, depression as assessed by the short version of the Geriatric Depression Scale (GDS-15), a rating for basic activities of daily living (ADL), prescribing medications, and physician-diagnosed chronic diseases. The participants were considered to be in depression or severe depression if their GDS-15 score was 6 < or = or 10 < or =, respectively., Results: Although 57.2% or 23.1% of the participants had a GDS-15 score of 6 or higher, or 10 or higher, only 4.2% of sever depressive participants were taking an antidepressant. The higher prevalence of depression was associated with a higher care level in the long-term care insurance program. The depression was associated with 3 or more eligible care level, poor nutritional status, 3 or more prescribed medications, and nonuse of day-care/service., Conclusion: We observed a high prevalence of depression among community-dwelling Japanese frail elderly eligible for long-term care insurance. However, very few depressed elderly were taking an antidepressant.

Aim: The aim of this study was to assess the frequency of symptoms and end-of-life care received in advanced dementia and advanced cancer elderly patients dying at home during the last two days of their lives and to evaluate the differences observed between the two groups., Methods: We used data from the Dying Elderly at Home (DEATH) project, which was a prospective study of home elderly patients dying with end-stage illness. Consecutive deceased subjects aged 65 or older who were seen at 16 study clinics belonging to the Japanese Society of Hospice and Home-care with diagnoses of all illnesses including advanced dementia and advanced cancer and died at home from October 2002 to September 2004 were included in the study. We evaluated 36 deceased subjects with advanced dementia and 116 with advanced cancer. We collected the following information: sociodemographics, ADLs, cognitive impairment, observed symptoms and end-of-life care provided during the last 48 hours of life., Results: Deceased subjects with advanced dementia were less likely to show symptoms of pain, acute confusion, or nausea/vomiting and more likely to display fever or cough than advanced cancer patients. Also, those with advanced dementia were more likely to receive intravenous drip injection or narcotic analgesia and more likely to be given sputum suction, or antibiotics., Conclusion: We observed that the dying process and end-of-life care for advanced dementia elderly patients was different from that for advanced cancer elderly patients.

Aim: We conducted a national survey to examine the current status of programs to teach end-of-life care to undergraduates of Japanese medical and nursing schools in 2004., Methods: Our survey focused on the following areas: (1) the present status of curricula to teach end-of-life care, (2) topics covered in the curricula, (3) details of the timing of existing end-of-life care teaching programs and of departments responsible for it, (4) teaching methods, (5) education assessment tool, (6) reading list of textbooks., Results: 50.6% of the medical schools and 40.9% of the nursing schools participated. Most of the schools offered end-of-life care education programs, and 45% of the medical schools and 68.9% of the nursing schools offered education concerning end-of-life care for elderly. The most frequent teaching timing was the fourth year of medical school and the third year of nursing school. Broader end-of-life topics were covered in the curriculum in the nursing schools than the medical schools. One fourth of the nursing schools offered a separate course in end-of-life care. The mean number of teaching hours was 7.6 in the medical schools and 35.5 in the nursing schools. More nursing schools offered educational programs in which students can gain experience with end-of-life care than medical schools. A few institutions used practiced examinations to evaluate students' learning. A reading list of end-of-life care textbooks was provided in 10% of the medical schools and 35.6% of the nursing schools., Conclusion: Our survey suggested that systematizing end-of-life care education and improvement in text content are on the way.

A byproduct of the aging of the population has been a dramatic rise in patients with dementia. The aim of the present study is to clarify the use of aggressive and palliative treatments, artificial nutrition and sedation in long-term care hospitals in Japan. We assessed 123 deaths in people aged 65 and older who died in two long-term care hospitals in and around Nagoya from January 2001 to December 2002. All deceased were divided into two groups according to their diagnosis of dementia. Data on the particular characteristics of the deceased, diagnosis of dementia, aggressive treatments (including CPR, intubation, mechanical ventilation, the use of systemic antibiotics and blood transfusion), palliative treatments (including oxygen, narcotic and nonnarcotic pain medication) artificial nutrition (including hyperalimentation and tube feeding) and sedation during the last six months of their lives were collected from medical charts. The prevalence of aggressive and palliative interventions did not vary significantly with the diagnosis of dementia except for the use of vasopressors. Artificial nutrition was prevalent and few patients received sedatives in either group. Patients with and without dementia received similar treatments in the end-stage. A greater understanding of the course of dementia is needed to further discussions on the terminal care of people with dementia. A national consensus on how to treat end-stage demented patients is also needed.

Providing elderly people with nutritional care has become important. The aim of the present study is to clarify the factors limiting the widespread adoption of home visits by dietitians. From September to November 2002, we conducted a questionnaire survey of 211 dietitians belonging to the "Houeiken", a group devoted to the study of dietician's home visits. We examined the following factors: characteristics of the study subjects, result of the home visits, factors limiting the widespread adoption of home visits by dietitians, and the future of home visits by dietitians. Among the dietitians, 49.7% did nutrition management, 30.5% catering management and 12.8% performed home visits (12.8%). In total, 53.5% of the dietitians had experience with home visits, having visited an average of 1 to 5 people. Typical visits included cooking lessons (27.5%), advice on energy intake (25.3%), sharing new recipes (23.6%), and anthropometric examinations (13.3%). A total of 76.8% thought their guidance was effective and noted significant improvements in terms of caregiver's cooking skills (30.0%), patient's understanding of diet (24.0%), and dietary intake (21.5%). The factors preventing more widespread home visits by dietitians are: few people are aware that this service exists, few people believe that they need this type of assistance, it is largely unprofitable, and the number of qualified dieticians is insufficient. We believe that more medical staff should become involved in dietitian's home visits. Public policies should be implemented to lower dietitian's nutritional care fees and increase the education and number of dietitians.

Although percutaneous endoscopic gastrotomy (PEG) has been widely acknowledged as a safer method for enteral feeding, its long-term impact on prognosis and quality of life (QOL) in elderly patients is not sufficiently understood. Regarding the indications of PEG, there still exist issues to be studied due to lack of convincing evidence for reduction of expected complications such as aspiration pneumonia or for improvement of prognosis in patients with severe dementia. In this study we investigated the survival rate after PEG placement and family satisfaction retrospectively in 78 elderly inpatients who underwent PEG, by sending questionnaires to the patients or their caregivers. The results of 68 cases (88%) recovered showed that the 1-year survival rate was 64.0%, and the 2-year survival rate was 55.5%. Fifty-three percent of families of patients showed overall satisfaction regarding the induction of PEG. The survival rate was relatively higher than that from previously reported studies. The differences we observed may be attributed to variations in patients' backgrounds (clinical, socio-economic, cultural) in therapeutic interventions. We recognized the importance of clarifying factors which would affect the prognosis and QOL in elderly patients who undergo PEG. The indication for PEG can be made based on comprehensive assessment of the relevant factors in individual cases, taking patient's or caregiver's wishes into consideration.

An 85-year-old woman was receiving enteral feeding via percutaneous endoscopic gastrostomy (PEG). The patient exhibited symptoms of gastro-esophageal reflux, leakage of nutrient from the PEG insertion point, vomiting, pyrexia, dyspnea when given nutrients and recurrent pneumonia. We therefore gave a half-solid nutrient, which was made by a mixture of agar powder and conventional liquid nutrient Immediately after starting the half-solid nutrient feeding via PEG, the patients no longer exhibited the above symptoms apart from mild pyrexia, which also vanished two weeks later. This case suggested that simply changing the fluidity of nutrients can contribute to a reduction of complications expected to occur in patients on PEG tube feeding.

Clinical trials have shown that beta-blockers can produce symptomatic improvement and decrease the risk of death in chronic heart failure patients. However, the side effects of beta-blockers including worsening heart failure, AV-block, contracting peripheral vessels and unfavorable effects on glucose and cholesterol metabolism tend to make physicians hesitate to prescribe beta-blockers for elderly patients. Carvedilol is a novel non-selective beta-blocker without intrinsic sympathomimetic activity (ISA) and has vasodilating effect through blocking alpha 1 receptor. We examined the effects of carvedilol on cardiac parameters in order to clarify whether beta-blocker may affect left ventricular function in elderly Japanese patients with hypertension, angina pectoris, or both. We examined the hemodynamic effect of carvedilol in 16 patients with hypertension, angina patients or both, aged 65 and over (75.5 +/- 5.6 y.o.). After 12 weeks treatment with 10-20 mg daily oral administration, echocardiography was performed and hemodynamic parameters were calculated to evaluate their cardiac functions. Blood pressure was significantly decreased, especially in systolic pressure (163.8/87.6 +/- 15.6/11.2 mmHg to 141.6/76.9 +/- 16.6/11.7 mmHg, p < 0.001/p < 0.01, respectively). Ejection fraction increase (65.8 +/- 11.8% to 71.2 +/- 11.4%, p < 0.05) accompanied heart rate decrease (72.0 +/- 16.1 bpm to 63.9 +/- 11.4 bpm, p < 0.05). Carvedilol increased ejection fraction and decreased blood pressure safely in elderly patients with hypertension, angina pectoris, or both. Taking the condition of each patient into consideration, alpha-beta-blocker can be beneficial in elder patients.

To determine the factors related to the destination on discharge from the geriatric ward of Nagoya University Hospital, we analyzed the relationship between the scores of comprehensive geriatric assessment at admission and the destination in patients who had dwelled in home. The scores of basic activity of daily living (Barthel index), instrumental activity of daily living (Lowton scale), and cognitive function (Mini-Mental State Examination) were significantly lower in the patients who moved to institutions than those in the patients who returned home. The proportion of disabilities in all items, except eating, in the Barthel index, and all items but washing in the Lowton scale were significantly higher in patients who moved to institutions than in patients who returned home. Space orientation, calculation, and drawing in the Mini-Mental State Examination were related to the destination. In items for social life communication and group behavior were related to the destination. In multiple logistic regression models, it was suggested that activity of daily living, specifically independence of excretion, and ability in communication were significantly related to the destination on discharge.