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Telemedicine has changed from a way to treat patients with limited access to hospitals to a necessary method of treatment for non-urgent conditions during the coronavirus disease 2019 pandemic. There are two styles of telemedicine, namely "hybrid medical care" and "gateway medical care," which take advantage of the characteristics of online medical care and might become important in the near future. During hybrid medical care, a patient and their primary care physician have face-to-face medical care while simultaneously being examined by a specialist physician through telemedicine, leading to an overall improvement in the level of local medical care and expansion in the number of treatable diseases. Gateway medical practice is a form of telemedicine used for patients who would otherwise refuse or not receive in-person medical care to engage in consultation with a physician. Telemedicine allows physicians to determine disease severity and triage patients, while reducing unnecessary home visits, emergency hospitalizations and the spread of infection. Telemedicine is less intense than in-person medical care, and allows for easier collaboration with other healthcare providers. However, telemedicine is not optimal for conditions requiring a definitive diagnosis and a comprehensive understanding of the patient's medical history. It is limited by the patient's ability to use telemedicine devices, and the risk of accidental treatments and fraud. The use of telemedicine might result in the development of new, online comprehensive geriatric assessment tools and technologies. Geriatr Gerontol Int 2022; 22: 913-916.

The present study aimed to investigate the impact of the coronavirus disease 2019 (COVID-19) pandemic on facility- and home-dwelling people with dementia (PWD).This observational study included two anonymous online survey questionnaires to explore the impact of the first wave of the COVID-19 pandemic in Japan and the long-term impact during the 2 years from the onset of the pandemic. The participants were medical and long-term care facilities representatives for older people (945 facilities in the first survey, 686 in the second), and care managers (751 in the first survey, 241 in the second). A χFor facility-dwelling PWD, activities that stimulate cognitive and physical functioning increased significantly compared with the first wave of the pandemic (P 0.05). Also, a decline in cognitive and walking functions and falls increased in the second survey compared with the first (P 0.01). For home-dwelling PWD, the broader impact of the pandemic on support for activities of daily living, social interaction and provision of medical care did not mitigate. The high prevalence of cognitive and physical functional decline in the first survey was similar in the second.The prolonged COVID-19 pandemic produced changes in the lives of home- and facility-dwelling PWD, with widespread negative consequences for them. Our findings are useful to consider preventive supports to mitigate or avoid functional decline and symptom exacerbation in PWD due to changes in their living environment and the care they receive in the COVID-19 era. Geriatr Gerontol Int 2022; 22: 832-838.

General muscle health declines with age, and in particular, sarcopenia-defined as progressive loss of muscle mass and strength/physical performance-is a growing issue in Asia with a rising population of community-dwelling older adults. Several guidelines have addressed early identification of sarcopenia and management, and although nutrition is central to treatment of sarcopenia, there are currently few guidelines that have examined this specifically in the Asian population. Therefore, the Asian Working Group for Sarcopenia established a special interest group (SIG) comprising seven experts across Asia and one from Australia, to develop an evidence-based expert consensus. A systematic literature search was conducted using MEDLINE on the topic of muscle health, from 2016 (inclusive) to July 2021, in Asia or with relevance to healthy, Asian community-dwelling older adults (≥60 years old). Several key topics were identified: (1) nutritional status: malnutrition and screening; (2) diet and dietary factors; (3) nutritional supplementation; (4) lifestyle interventions plus nutrition; and (5) outcomes and assessment. Clinical questions were developed around these topics, leading to 14 consensus statements. Consensus was achieved using the modified Delphi method with two rounds of voting. Moreover, the consensus addressed the impacts of COVID-19 on nutrition, muscle health, and sarcopenia in Asia. These statements encompass clinical expertise and knowledge across Asia and are aligned with findings in the current literature, to provide a practical framework for addressing muscle health in the community, with the overall aim to encourage and facilitate broader access to equitable care for this target population.

In current clinical practice, when a fall occurs in a long-term care facility, it is often treated as an accident. Falls are classified as one of the most commonly prevalent geriatric syndromes. As their causes are extremely diverse and complex, their occurrence rate depends on individual susceptibility, even if appropriate fall prevention measures are taken. Falls are common among older adults, and fractures and intracranial hemorrhage resulting from falls can lead to the deterioration of activities of daily living and death. For this reason, it is recommended that the risk of falls is assessed in the general population of older adults, and that appropriate interventions are carried out for those at high risk. In response to this situation, the Japan Geriatrics Society and the Japan Association of Geriatric Health Services Facilities have issued the following statements on falls as a geriatric syndrome based on scientific evidence, especially considering the frequent occurrence of falls in long-term care facilities. Geriatr Gerontol Int 2022; 22: 193-205.

Although frailty could be reversible by early diagnosis and interventions, it lacks definite diagnostic criteria. The Kihon Checklist is a 25-item questionnaire that diagnoses frailty with a cutoff score of 7/8. The Questionnaire for Medical Checkup of Old-Old (QMCOO) was recently established and used for medical checkups among Japanese older adults, but no method or cutoff score for diagnosing frailty has been established. Thus, we aimed to diagnose frailty using the QMCOO and to determine its cutoff score by comparing it with that of the Kihon Checklist.We recruited 223 older adults in Yasugi City and Yonago City to answer all the questions in the Kihon Checklist and the QMCOO at the same time. Those scoring ≥8 for the Kihon Checklist (n = 38) were diagnosed as frail. We also determined the cutoff score for frailty for the QMCOO and examined which questionnaire items affected the frailty status.The QMCOO and the Kihon Checklist score showed a significant positive correlation (r = 0.670, P 0.001). The area under the curve was 0.851. A cutoff score of 3/4 for the QMCOO represented the best results (sensitivity, 76.3%; specificity, 88.1%; and accuracy, 86.1%). Multiple linear regression analysis revealed that subjective health status, body weight loss, slowness, and forgetfulness still affected the frailty status.A cutoff score of 3/4 for the QMCOO might be effective in diagnosing frailty. Geriatr Gerontol Int 2022; 22: 127-131.

BACKGROUND Malnutrition of inpatients is often overlooked and remains a serious concern. However, there are few studies on the relations between infused energy and amino acid intakes and clinical outcomes in older patients on parenteral nutrition. OBJECTIVES We aimed to determine the short-term outcomes of infused energy and amino acid intakes in older patients receiving parenteral nutrition. METHODS We conducted a retrospective observational study using a national inpatient database covering >1000 hospitals in Japan. Participants were those who underwent central venous (CV) port insertion between 2011 and 2016, were aged ≥65 y, and did not have cancer. Based on the types and amounts of products used for enteral feeding and intravenous feeding on postoperative day (POD) 7 after CV port insertion, the infused energy and amino acid intakes were estimated. The primary end point was mortality on POD 90. Multivariable logistic regression was performed to investigate the relations of infused energy and amino acid intakes with mortality on POD 90. RESULTS A total of 10,153 patients aged ≥65 y who underwent CV port insertion were included. The mortality rates at 90 d after central venous port insertion were 14.9% and 14.0% (risk difference, 0.9%; 95% CI: -0.5%, 2.3%; P = 0.216) with infused energy intakes

Older adults at the end-of-life stage receiving home visits from physicians often experience symptoms such as dyspnea, pain and fatigue, among others. This study aimed to investigate the practices and opinions of physicians providing home visits regarding palliative care for older adults with respiratory symptoms due to non-malignant diseases in Japan.A nationwide questionnaire survey on home palliative care for non-cancer chronic respiratory diseases was sent to 2988 home-care physicians in 2020 through postal mail and/or email. The questions focused on their background, their use of rating scales to evaluate the intensity of dyspnea, and their practices and opinions regarding home palliative care for respiratory diseases or symptoms.Valid responses were collected from 592 physicians (19.8%). A total of 251 participants (43.1%) used a rating scale to evaluate the intensity of dyspnea. While 87.8%, 86.6%, 67.3%, and 60.0% of physicians considered pulmonary rehabilitation, morphine, sedative medications, and non-invasive positive pressure ventilation (NPPV), respectively, as effective in relieving respiratory distress, 73.0%, 66.9%, 57.3%, and 55.2% of those physicians, respectively, used each modality to relieve respiratory distress. Frequently involved physicians in the aforementioned care prescribed morphine or sedative medications and used NPPV more frequently.This study found a discrepancy between the proportion of physicians who considered palliative care as effective and those who prescribed it. Geriatr Gerontol Int 2022; 22: 943-949.

Background As Japan's population continues to age, it is estimated that the number of people aged ≥75 years will exceed 20 million by 2025. Furthermore, over the past 10 years, we have not reduced the difference between life expectancy and healthy life expectancy. Therefore, the extension of healthy life expectancy and the development of a healthy society are the most urgent issues. In terms of medical care, the changing times have inevitably led to changes in disease structures and medical demands; therefore, the medical delivery system has had to be changed to meet these demands. As dementia rapidly increases, it is important to address "frailty," a condition in which people become more vulnerable to environmental factors as they age, and there is a need to provide services to older people, particularly the old-old, that emphasize quality of life in addition to medical care. To realize a super-aged society that will remain vigorous and vibrant for many years, we need to rethink the future of Japanese medicine and healthcare, and the state of society. Current situation and problems Disparity between healthy life expectancy and average life expectancy in the realization of a healthy society It is a challenge to build a society with a long and healthy life expectancy through comprehensive prevention and management of lifestyle-related diseases, as well as the elucidation of the factors that explain sex differences in healthy life expectancy, based on the recognition that lifestyle-related diseases in midlife are risk factors for frailty and dementia in old age. Challenges in medical care for building a super-aged and healthy society The challenges include promoting clinical guidelines suitable for older people, including lifestyle-related disease management, promoting comprehensive research on aging (basic research, clinical research and community collaboration research), and embodying a paradigm shift from "cure-seeking medical care" to "cure- and support-seeking medical care." Furthermore, the key to the future of integrated community care is the development of a comprehensive medical care system for older people in each region and the development of the next generation of medical personnel. Dissemination of frailty prevention measures in a super-aged society The concept of frailty encompasses the meaning of multifacetedness and reversibility; therefore, a comprehensive approach is required, including the renewal of conventional prevention activities in each region, such as the nutritional status of older people, physical activity including exercise, and various opportunities for social participation and participation conditions. Challenges of an unstable diet and undernutrition in older people According to the National Health and Nutrition Examination Survey of Japan, energy and protein intakes are low in Japanese people aged ≥75 years; particularly in people aged ≥80 years, low and insufficient intake of nutrients are prominent. Undernutrition in older people is increasing and is more pronounced in women. There are multiple factors behind this, including social factors, such as living alone, eating alone, poverty and other social factors, as well as problems with access to food security. Pharmacotherapy for older people: measures against polypharmacy In addition to the problems of adverse drug events, drug interactions, duplication of effects and the presence of drugs that "require particularly careful administration," it is also necessary to take measures against polypharmacy in older people, as well as medical economic issues, such as high drug costs and large amounts of remaining drugs. Barriers to this measure include multiple medical institution visits for each disease, lack of coordination between professions, and lack of understanding by patients and families. Role of local communities in a healthy society The decline in the working-age population is also a major challenge; however, we need to make a shift to use this declining birthrate and aging population as an opportunity rather than a crisis. As we look ahead to the coming of the 100-year age of life, we rethink the creation of a comprehensive society and community, and aim to create an age-free society where everyone can play an active role and live in peace, regardless of age. Contents of the proposal In this report, we have put together a vision for the future of an aging Japanese society from a broader perspective of how the environment and local communities should be, rather than simply from the perspective of individual health. We aim to convey this proposal to the Ministry of Health, Labor and Welfare, the Ministry of Education, Culture, Sports, Science and Technology, the Cabinet Office, and various professional organizations. The paradigm shift from "cure-seeking medical care" to "cure- and support-seeking medical care" should be promoted for the development of a healthy society While further promoting pre-emptive medical care in the medical care for older people, the development of multidisciplinary medical guidelines appropriate for older people should be promoted at the same time. In addition, we should promote basic aging research, clinical research (including the long-term care field) and transitional research that cover regional areas. Furthermore, while promoting the paradigm shift from "cure-seeking medical care" to "cure- and support-seeking medical care," the development of various comprehensive medical treatment systems for older people and the strengthening of integrated community care systems should be promoted. Development of the next generation of medical personnel to comprehensively deal with geriatric care, including training geriatric specialists, should be promoted As the number of older people with multimorbidities and frailty rapidly increases in the future, we should promote the development of the next generation of medical personnel who can comprehensively handle medical care for older people, including training leading geriatricians in cooperation with multiple professions in the integrated community care system to provide sufficient medical care. Countermeasures for frailty in older people should be promoted from medical and community planning perspectives To address frailty, which requires comprehensive evaluation and intervention, the three pillars of frailty prevention (nutrition, exercise and social participation) should be incorporated and addressed as part of community development within each municipality, taking into account local characteristics. In particular, it is necessary to revise the way of thinking about nutrition management in older people and the guidelines of the societies in the field. In addition, it is important to strengthen industry-academia-government-private partnerships in each region, taking into account not only medical issues, but also social factors, and encourage the development of momentum in the entire region regarding measures against undernutrition in older people. Polypharmacy measures should be promoted in pharmacotherapy for older people It is necessary to promote cooperation between physicians and pharmacists, establish other multiprofessional cooperation systems, and develop medical and long-term care insurance systems to support this. It is also essential to change the public's mindset, and awareness-raising activities at all levels are required, including the enhancement of educational materials for medical caregivers and the general public. In addition, the economic impact of healthcare using big data should be timely clarified. Innovation in medical and urban planning perspectives should be promoted In the future, it will be necessary to modify and update multidisciplinary approaches such as social participation (e.g. participation in a salon) with a view to innovation in both medical care and community development, especially on the idea of a symbiotic community. In addition, industry-academia-government-private partnership is necessary, including all aforementioned, such as places where people can play an active role in the rest of their lives (such as employment), promotion of human connections, promotion of technology to support older people and support for daily life. Geriatr Gerontol Int 2021; 21: 601-613.

Previous studies have shown temporal trends in the number of gastrostomies until 2016, but the recent trend is yet to be analyzed. This study aimed to evaluate temporal trends in gastrostomy (mostly percutaneous endoscopic gastrostomy) in older adults in Japan in more recent years.We extracted data on the numbers of gastrostomies and swallowing function assessment prior to gastrostomy, using the national aggregated open data (NDB Open Data) from 2014 to 2019.Adults in their 80s accounted for the largest portion of gastrostomy during the study period. A decreasing trend in the total number of gastrostomy was observed in older adults from 2014 to 2016, but became almost stable thereafter (57 103 in 2014, 47 228 in 2016, and 47 944 in 2019). The age group-stratified numbers of gastrostomy per 100 000 individuals decreased by -33.9% (≥90 years group) to -6.1% (65-69 years group) from 2014 to 2019. The implementation rate of the swallowing function assessment remained relatively low, despite a slight increase (21.4% in 2015 to 23.7% in 2019).We showed that the total number of gastrostomies remained almost stable after 2016 despite population aging. We considered that the avoidance of gastrostomy in frail or disabled older adults might explain the decrease, particularly for those aged over 80 years. Our findings would regain attention to appropriate decision-making for gastrostomy. Geriatr Gerontol Int 2022; 22: 648-652.

This study aimed to determine the prevalence and risk factors for brain white matter changes in normal young and middle-aged participants who underwent Brain Dock (brain screening). We analyzed 5,000 consecutive healthy participants from the Brain Dock registry between August to December 2018. Age, sex, body mass index (BMI), medical history, deep subcortical white matter high intensity (DSWMH), periventricular high intensity (PVH), and enlargement of perivascular space (EPVS) were investigated in relation to age. The prevalence of DSWMH, PVH, and EPVS were 35.3%, 14.0%, and 17.8%, respectively. Multivariate logistic regression analyses for brain white matter changes were conducted. The significant risk factors in participants aged < 50 years were: age (OR:1.09, 95% CI:1.07-1.12), the female sex (1.29, 1.03-1.60), BMI obesity (1.86, 1.12-3.08), and hypertension (1.67, 1.18-2.35) for DSWMH; age (1.08, 1.04-1.13) and the female sex (1.56, 1.03-2.36) for PVH; and age (1.07, 1.05–1.10) and the female sex (0.77, 0.60-1.00) for EPVS. In conclusion, age was consistently identified as a significant risk factor in young and middle-aged participants. Some risk factors for brain white matter changes were identified even in young and middle-aged participants in this study. Further longitudinal studies should be done in the future.

Background Readmission is related to high cost, high burden, and high risk for mortality in geriatric patients. A scoring system can be developed to predict the readmission of older inpatients to perform earlier interventions and prevent readmission. Methods We followed prospectively inpatients aged 60 years and older for 30 days, with initial comprehensive geriatric assessment (CGA) on admission in a tertiary referral centre. Patients were assessed with CGA tools consisting of FRAIL scale (fatigue, resistance, ambulation, illness, loss of weight), the 15-item Geriatric Depression Scale, Mini Nutritional Assessment short-form (MNA-SF), the Barthel index for activities of daily living (ADL), Charlson Comorbidity Index (CCI), caregiver burden based on 4-item Zarit Burden Index (ZBI), and cognitive problem with Abbreviated Mental Test (AMT). Demographic data, malignancy diagnosis, and number of drugs were also recorded. We excluded data of deceased patients and patients transferred to other hospitals. We conducted stepwise multivariate regression analysis to develop the scoring system. Results Thirty-day unplanned readmission rate was 37.6 %. Among 266 patients, 64.7 % of them were malnourished, and 46.5 % of them were readmitted. About 24 % were at risk for depression or having depressed mood, and 53.1 % of them were readmitted. In multivariate analysis, nutritional status (OR 2.152, 95 %CI 1.151–4.024), depression status (OR 1.884, 95 %CI 1.071–3.314), malignancy (OR 1.863 95 %CI 1.005–3.451), and functional status (OR 1.584, 95 %CI 0.885–2.835) were included in derivation of 7 score system. The scoring system had maximum score of 7 and incorporated malnutrition (2 points), depression (2 points), malignancy (2 points), and dependent functional status (1 point). A score of 3 or higher suggested 82 % probability of readmission within 30 days following discharge. Area under the curve (AUC) was 0.694 (p = 0.001). Conclusions Malnutrition, depression, malignancy and functional problem are predictors for 30-day readmission. A practical CGA-based 7 scoring system had moderate accuracy and strong calibration in predicting 30-day unplanned readmission for older patients.

Aim We investigated the association between rehabilitation outcomes and polypharmacy, potentially inappropriate medications and potential prescribing omissions in older adults with fragility fractures. Methods In total, we registered 217 older adults with fragility fractures (hip or vertebral) retrospectively and examined the association between rehabilitation outcome and polypharmacy, potentially inappropriate medications and potential prescribing omissions. Polypharmacy was defined as five or more drugs. Potentially inappropriate medications and potential prescribing omissions were defined by the Beers criteria (2015) and the screening tool to alert to treatment criteria version 2, respectively. The outcome was functional independence measure gain (functional independence measure at discharge - functional independence measure at admission). Results Multiple regression analyses revealed no association between functional independence measure gain and polypharmacy (crude: β = 0.058, P = 0.858; adjusted model: β = 0.013, P = 0.869) or potentially inappropriate medications (crude: β = 0.100, P = 0.144; adjusted model: β = 0.084, P = 0.260). However, there was a significant association between functional independence measure gain and potential prescribing omissions (crude: β = 0.167, P = 0.014; adjusted model: β = 0.180, P = 0.016). Participants without potential prescribing omissions (in other words, participants who were prescribed anti-osteoporosis drugs) had a greater functional independence measure gain than participants with potential prescribing omissions (in other words, those that were not prescribed anti-osteoporosis drugs). Conclusion To the best of our knowledge, this study is the first to report that participants without potential prescribing omissions had significantly improved rehabilitation outcomes. Geriatr Gerontol Int 2021; ••: ••-••.

To elucidate recent prescription trends for older adults and the background underlying changes over time with a particular focus on the prevalence of polypharmacy and potentially inappropriate medications (PIMs).We cross-sectionally collected prescription data of patients aged ≧65 years who visited chain pharmacies dispensing prescribed drugs from all types of outpatient settings for one month in two sampling periods (October, 2014 and December, 2019), and the data were analysed. Prevalence of polypharmacy and factors associated with PIMs between the two periods were investigated.The average number of drugs prescribed decreased over time (4.05 ± 3.24 in 2014 vs. 3.98 ± 3.16 in 2019, p0.001), as did the prevalence of polypharmacy (50.1% in 2014 vs. 48.2% in 2019, p0.001). Meanwhile, the prevalence of PIMs exhibited a marked increase (overall: 26.8% in 2014 vs. 43.7% in 2019, aged 65-74: 25.6% in 2014 vs. 40.3% in 2019, aged 75-84: 27.4% in 2014 vs. 43.9% in 2019), which was the most pronounced in patients aged over 85 (29.4% in 2014 vs. 53.0% in 2019). The number of classes of drugs positively associated with PIMs in 2019 increased from that in 2014. The increasing trend was most prominently observed in the oldest age category (over 85 years, 2 in 2014 vs. 6 in 2019).The comparison of monthly prescribing data with an interval of 5 years suggested an increasing trend in the prevalence of PIMs, contrary to the declining prevalence of polypharmacy.

Older patients tend to have multimorbidity represented by multiple chronic diseases or geriatric conditions due to aging changes of organs, which require a variety of medical management. Currently, there are no sufficient disease treatment guidelines for older people with multimorbidity, therefore physicians have difficulty managing multimorbidity, such as which diseases should be treated intensively or to what extent the conditions should be improved. Furthermore, there are other points to be considered when initiating the treatment of diseases. For example, physicians must assess physical function. Some people have no difficulty with ambulation, but some are bedridden and have difficulty getting up on their own. As there are differences in disease severity, comorbid conditions and life expectancy, there should be differences in deciding treatment and prescribing drugs. It may be necessary to change the option for treatment depending on cognitive function, the living environment and the care environment, using comprehensive geriatric assessments. In addition, when treating multimorbidity, patients tend to have polypharmacy, which is a risk for adverse drug events. Because of this, it is necessary to consider dose reduction and drug discontinuation in patients with polypharmacy. Because of the global increase in older patients with multimorbidity, developing an essential method for managing multimorbidity is an urgent issue. More research and practices are necessary to achieve high-quality care in patients with multimorbidity. Geriatr Gerontol Int ••; ••: ••-•• Geriatr Gerontol Int 2020; ••: ••-••.

Aim Studies of medication use in patients with a percutaneous endoscopic gastrostomy (PEG) tube have not been conducted adequately. The aim of this study was to describe medication use of care-dependent older adults with PEG and evaluate whether potential prescribing omissions (PPO) would affect the cause of death or acute illness. Methods In a geriatric long-term care hospital, 116 inpatients aged ≥65 years with insertion of a PEG tube because of dysphagia were enrolled and followed for 2 years: 2016-2018. The patients were divided into two groups, i.e., group A (who died between 2016 and 2018) and group B (who continued to be hospitalized in 2018). Clinical data and prescribed medications were recorded. Logistic regression models were conducted to assess the associations between survival and variables: age, gender, serum albumin level, serum creatinine level, body mass index (BMI), number of drugs and PPO. Results The patients' mean age was 85.3 ± 10.2 years, 57.8% were women and the mean number of drugs was 6.8 ± 3.5. Medications for managing symptoms, such as constipation and gastrointestinal symptoms, were commonly prescribed. The most common PPO medications were antiplatelet agents and anticoagulants. On logistic regression analysis, PPO had no influence on the cause of death or acute illness. Lower age, higher serum albumin level and body mass index were associated with survival in both univariate and multivariate models. Conclusions Polypharmacy was prevalent in patients with PEG. Given the finding that PPO had no influence on health outcome, rational deprescribing could be warranted. Geriatr Gerontol Int 2020; 20: 961-966.

Aim The perceived age of older adults, as measured by their facial appearance, has been shown to be a robust biomarker of aging predictive of survival, telomere length and DNA methylation, and reportedly correlates with carotid atherosclerosis and bone status. This study aimed to determine whether metrics of dementia, including general cognition, vitality, depressive state and self-supportability, have stronger correlations with perceived age than with chronological age. Methods This study included 124 patients who were admitted to the Department of Geriatric Medicine, The University of Tokyo Hospital, on account of being suspected of cognitive decline. The Mini-Mental State Examination, Vitality Index, Geriatric Depression Scale-15, instrumental activities of daily living and Barthel Index were carried out. Five experienced geriatricians and five experienced clinical psychologists determined the perceived age of participants based on photographs. Results The average values of the 10 raters showed excellent reliability (intraclass correlation coefficient (3, 10) = 0.941). Steiger's test revealed that perceived age showed a significantly better correlation with the Mini-Mental State Examination (female) and Vitality Index (total, female) than did chronological age, but not with Geriatric Depression Scale-15, instrumental activities of daily living or the Barthel Index. Conclusions Perceived age was shown to be a reliable biomarker for cognitive assessment. Geriatr Gerontol Int 2020; 20: 779-784.

Aim To determine the patterns of concomitant drug use for chronic diseases and examine the risk factors of polypharmacy in older outpatients. Methods Data were extracted from an anonymized health insurance claims database of a public insurance program for older adults in Tokyo, Japan. We analyzed individuals aged ≥75 years who had visited an outpatient clinic, and were regularly prescribed orally administered drugs for chronic diseases for ≥14 days between May and August 2014. The prescription patterns for 16 main drug types were studied using exploratory factor analysis, and the risk factors of polypharmacy, defined as the concomitant prescription of five or more drugs, were identified using multivariate logistic regression models. Results A total of 1 094 199 outpatients were analyzed (mean age 81.8 years, 38.4% men). We identified five prescription patterns that explained almost 40% of all observed variance: edema/heart failure/atrial fibrillation-related drugs, insomnia/anxiety-related drugs, pain-related drugs, lifestyle disease-related drugs and dementia-related drugs. The significant risk factors of polypharmacy included men, octogenarians and nonagenarians, higher number of medical institutions visited, use of physician home visits, and hospitalization during the study period. The main drug types most strongly associated with polypharmacy were analgesics, diuretics and antidiabetics. Conclusions Polypharmacy was found to be prevalent in older outpatients aged ≥75 years in Tokyo. These findings might provide useful evidence that can contribute to the development of practical countermeasures against adverse events associated with polypharmacy in clinical practice. Geriatr Gerontol Int 2020; 20: 304-311.

To identify the dietary patterns among community-dwelling Japanese older adults and to explore the association between these patterns and sarcopenia. Cross-sectional study. Kashiwa city, Chiba prefecture, Japan. Community-dwelling older adults (n = 1241) aged 65 years and over who were not eligible for long-term care. Dietary intake was assessed using the brief self-administered diet history questionnaire (BDHQ). Dietary patterns were identified using both principal component analysis and the score on the Japanese diet comprising soybeans and soybean products, fish, vegetables, pickles, mushroom, seaweeds, and fruits. Sarcopenia was defined by the Asian Working Group for Sarcopenia (AWGS) criteria. A binary logistic regression analysis was performed with sarcopenia status as the dependent variable after adjusting for economic status, living alone status, BMI, energy intake, multimorbidity, and physical activity. Participants’ mean age was 74.6 years, and 52.1% were male. According to AWGS criteria, 5.1% had sarcopenia. Three dietary patterns were identified from the principal component analysis. Dietary pattern 1 (DP1), showed high loadings for fish, tofu, vegetables, and fruits which are similar to the side dishes in a typical Japanese diet. Dietary pattern 2 (DP2) had high factor loadings for fish, rice, and miso soup which are main dishes in a typical Japanese diet. Dietary pattern 3 (DP3) had a high factor loading for noodles. Men with the lowest tertile of DP1 score had a higher likelihood of being sarcopenic (Adjusted odds ratio (AOR) 3.67, 95% confidence interval (CI) 1.20∓11.2). Women with the lowest tertile of DP2 score had a moderate likelihood of being sarcopenic (AOR 2.71, 95%CI 0.99∓7.46). Low adherence to Japanese dietary pattern was associated with prevalence of sarcopenia in both genders. Adherence to a dietary pattern high in foods characteristic of a Japanese diet including fish, soybean products, vegetables, and fruits was associated with low prevalence of sarcopenia in both genders.

Aims: As the number of older people with dementia increases, safe pharmacotherapy in this population has attracted attention in recent years. The aims of this study were to clarify the prescribing patterns in older patients who were prescribed anti-dementia drugs and to investigate the association of potentially inappropriate medications (PIMs) with the use of anti-dementia drugs. Methods: Adults aged ≥65 years, who were prescribed anti-dementia drugs at 585 pharmacies across Japan (N = 7,953), were surveyed. The percentage of prescriptions of anti-dementia drugs and the effect of those prescriptions on PIMs were investigated. Results: Prescriptions of anti-dementia drugs were found in 4.4% of the entire study population. A multiple logistic regression analysis revealed that the use of anti-dementia drugs reduced the risk of prescribing psychotropic drugs, which represented PIMs, and that a combination of anti-dementia drugs (e.g., cholineesterase inhibitor with memantine) may reduce the risk of prescribing PIMs compared with monotherapy. Conclusion: The use of anti-dementia drugs was associated with fewer prescriptions of drugs considered as PIMs.

Aim To investigate the characteristics of adverse drug reactions (ADR) and their risk factors among very old patients in five geriatric wards in Japan. Methods A retrospective observational multicenter study was carried out to investigate factors related to ADR in older inpatients from geriatric wards of five university hospitals in Japan. Data including drugs profile and short-form comprehensive geriatric assessment were obtained from medical charts. ADR were identified from geriatrician's reports. For each ADR, symptoms and causal drugs were clarified, and factors associated with ADR were analyzed statistically. Results In 1155 patients (52.5% women, mean age 82.8 ± 7.0 years), the proportion with ADR was 15.4%. There was a great variety of signs and symptoms of ADR, and a great variety of drugs suspected to be the cause of ADR. On multiple logistic regression analysis, ADR was significantly associated with an increase in drugs (odds ratio 1.11, 95% CI 1.07-1.16) and emergency admission (odds ratio 2.76, 95% CI 1.82-4.15). Receiver operating characteristic curve analysis showed that the optimal cut-off number of drugs for predicting ADR was ≥7. Conclusions In geriatric inpatients, polypharmacy (especially ≥7 drugs) and emergency admission were associated with ADR. Because there was a great variety of ADR in the study, clinicians must consider reviewing all drugs to prevent adverse drugs reactions during admission in this vulnerable population. Geriatr Gerontol Int 2019; ••: ••-••. Geriatr Gerontol Int 2020; 20: 144-149.

To investigate the cross-sectional associations of nutrition-related, physical, and social factors and their combinations with frailty in community-dwelling older adults.The participants in this study were 1,161 adults (≥ 65 years). The outcome was frailty severity as assessed by the Cardiovascular Health Study index (score 0: no-frailty, score 1-2: pre-frailty, score ≥ 3: frailty). The independent variables included nutrition-related factors comprising a balanced diet and oral functions, physical factors including exercise habits and awareness of physical function, and social factors including social organizational participation, social support, and social networks. According to the quantity of factors the participants met, four groups were divided. An ordinal logistic regression analysis was conducted to evaluate the associations between frailty severity and the three factors individually and comprehensively.The mean age was 74.6 (±5.4) and the women is 47.8%. 47.7% and 8.7% of participants had pre-frailty or frailty respectively. Meeting no nutrition-related, physical, or social factors individually showed significantly associated with greater adjusted odds ratio (aORs) of frailty severity [aORs (95% confidence interval)]: nutrition-related factors: 1.58 [1.25-2.01]; physical factors: 2.53 [1.98-3.22]; social factors: 1.52 [1.19-1.93]. Referred to participants who met three factors, participants who met two, one, or none showed significantly associated with increased aORs of frailty severity: two: 1.88 [1.34-2.65]; one: 2.97 [2.09-4.23]; none: 7.52 [4.87-11.62].Meeting no nutrition-related, physical, or social factors individually showed higher risk of being (pre-)frailty. Meeting three factors showed lowest risk of being (pre-)frailty and this risk increased with the quantity decreasing of met factors.

Background: Sarcopenia is a major cause of frailty, which relates to nutrition-related, physical, and social factors. In this study, we aimed to discuss the cross-sectional association of sarcopenia with the above three factors both individually and comprehensively. Methods: Overall, 1257 older adults (≥65 years old) participated in this study. Sarcopenia was determined via the Asian Working Group for Sarcopenia 2019 criteria. The independent variables for nutrition-related, physical, and social factors and especially their criteria for health condition were defined separately. Binomial logistic regression analysis was carried out to testify the associations of sarcopenia with three factors individually and in combination. Results: The mean age was 74.6 (±5.5), and women were 47.7%. Sarcopenia prevalence was 7.5%. Participants who did not meet the criteria of nutritional health, physical fitness, or social robustness independently had significant associations with a higher adjusted odds ratio (aOR) of sarcopenia or its indices of lower grip strength, muscle mass, or gait speed. In comparison to participants meeting three criteria, those who met two, one, or none showed (marginally) significant association with increased aOR for sarcopenia (aOR (95% confidence interval)): two: 1.97 (0.84–4.64); one: 2.35 (1.00–5.23); none: 5.52 (2.30–13.23). Conclusions: Comprehensive countermeasures with the above three factors are indispensable for sarcopenia prevention.

The prevalence of atrial fibrillation (AF) increases with age and is more common in frail patients. However, data are lacking on outcomes of oral anticoagulants (OACs) in very elderly patients with AF with frailty, who are ineligible for standard anticoagulant treatment.To compare very-low-dose edoxaban (15 mg daily) vs placebo across frailty status, including each of 5 frailty assessment parameters, among patients with AF involved in the ELDERCARE-AF (Edoxaban Low-Dose for Elder Care Atrial Fibrillation Patients) trial.This is a cohort study using data from ELDERCARE-AF, a multicenter, randomized, double-blind, placebo-controlled phase 3 study of Japanese patients with AF aged 80 years or older who were ineligible for OACs at doses approved for stroke prevention because of their high bleeding risks. Eligible patients were randomly assigned (1:1) to receive edoxaban or placebo. The study duration was from August 5, 2016, to November 5, 2019, with the last patient followed up on December 27, 2019. Data analysis was performed from February 2021 to February 2022.Edoxaban (15 mg) once daily or placebo.The primary efficacy end point was the composite of stroke or systemic embolism, and the primary safety end point was major bleeding.A total of 984 patients were randomly assigned to treatment (492 each to the edoxaban and placebo groups); 944 patients (402 frail patients [42.6%]; 542 nonfrail patients [57.4%]; mean [SD] age, 86.6 [4.3] years; 541 women [57.3%]) were included in this analysis. In the placebo group, the estimated event rates (SE) for stroke or systemic embolism were 7.1% (1.6%) per patient-year in the frail group and 6.1% (1.3%) per patient-year in the nonfrail group. Edoxaban was associated with lower event rates for stroke or systemic embolism with no interaction with frailty status or frailty assessment parameters. Major bleeding and major or clinically relevant nonmajor bleeding events were both numerically higher in the edoxaban group than in the placebo group, and no heterogeneity was observed with frailty status. Although both all-cause death and net clinical composite outcome occurred more frequently in the frail group than in the nonfrail group, there was no association with frailty status between the edoxaban and placebo groups.Regardless of frailty status, among Japanese patients with AF aged 80 years or older who were ineligible for standard OACs, once-daily 15-mg edoxaban was associated with reduced incidence of stroke or systemic embolism and may be a suitable treatment option for these patients.

To treat older patients with hypertension, it is important to detect cognitive impairment at an early stage because of its potential influence on treatment efficacy and functional prognosis. In this study, we aimed to identify the incidence and determinants of cognitive impairment in hypertensive patients aged 65 years and above who visited our outpatient clinic and were not previously diagnosed with cognitive impairment. Among 312 patients with hypertension, we found that 35% (n = 109) and 7.7% (n = 24) had cognitive impairment and dementia, respectively, as defined by the Mini-Mental State Examination (≤27 or ≤23, respectively). Patients with cognitive impairment were older, had lower levels of education, and had lower instrumental activities of daily living (IADL) scores than those without cognitive impairment. Multiple regression analysis revealed that age and IADL were associated with cognitive impairment in patients with hypertension. Regarding the treatment of hypertension, the office and home blood pressure levels, number of antihypertensive medications prescribed, and proportion of the use of each antihypertensive drug was equivalent between patients with and without cognitive impairment. Finally, patients with unrecognized cognitive impairment showed distinct clinical characteristics, including high antihypertensive medication burden and preserved IADL, when compared to hypertensive patients in the different cohorts of definitive mild cognitive impairment of a similar age. These findings suggest that older hypertensive patients are at a high risk of masked cognitive decline, even if they are functionally independent.

ObjectiveTo assess the association of coprescribed medications for chronic comorbid conditions with clinical dementia in older adults, as indicated by the initiation of a new prescription of antidementia medication (NPADM).DesignRetrospective enumeration cohort study.SettingA Japanese city in Tokyo Metropolitan Area.ParticipantsA total of 42 024 adults aged ≥77 years residing in Kashiwa City, a suburban city of Tokyo Metropolitan Area, who did not have any prscription of antidementia medication from 1 April to 30 June 2012.Main outcome measureThe primary outcome was NPADM during follow-up period until 31 March 2015 (35 months). Subjects were categorised into four age groups: group 1 (77–81 years), group 2 (82–86 years), group 3 (87–91 years) and group 4 (≥92 years). In addition to age and sex, 14 sets of medications prescribed during the initial background period (from 1 April 2012 and 31 June 2012) were used as covariates in a Cox proportional hazard model.ResultsIn a follow-up period of 1 345 457 person-months (mean=32.0±7.5 months, median 35 months), NPADM occurred in 2365 subjects. NPADM incidence at 12 months was 1.9%±0.1% (group 1: 0.9%±0.1%, group 2: 2.1%±0.1%, group 3: 3.2%±0.2% and group 4: 3.6%±0.3%; pConclusionsThis retrospective cohort study identified the associations of coprescribed medications for chronic comorbid conditions with NPADM in older adults. These findings would be helpful in understanding the current clinical practice for dementia in real-world setting and potentially contribute to healthcare policymaking.Trial registration numberUMIN000039040.

Background Poor oral health conditions are known to affect frailty in the older adults. Diabetes is a risk factor for both poor oral health and frailty, therefore, oral health status may affect frailty in diabetic patients more than in the general population. The purpose of this study was to evaluate the influence of oral health and other factors on frailty and the relationship among oral health, diabetes and frailty in older adult patients with type 2 diabetes. Methods Patients with type 2 diabetes aged 75 years or older were included in this cross-sectional study. Eligible patients were surveyed by questionnaire for frailty, oral health status, and cognitive and living functions. Factors influencing pre-frailty, frailty, and individual frailty screening index (FSI) classes were evaluated. Results Of the 111 patients analyzed, 66 cases (59.5%) were categorized as robust, 33 cases (29.7%) as pre-frailty, and 12 cases (10.8%) as frailty. The oral frailty index, the cognitive and living functions score, and BMI were found to be factors influencing pre-frailty or frailty. In the evaluation of individual FSI classes, BMI had an influence on those with a FSI ≤2. The cognitive and living functions score was a factor influencing those with FSI ≤3. The oral frailty index was found to have a significant influence on all FSI classes. Conclusions Poor oral health has an influence on frailty in patients with type 2 diabetes aged ≥75. In this patient population, as frailty progresses, the impact of oral health on frailty may increase. Trial registration: This study was retrospectively registered in UMIN-CTR (UMIN000044227).

Background Female sex is an important factor predisposing individuals to frailty. Appropriate nutrition is one of the most effective ways to prevent older adults from developing frailty; Sex-related differences have also been detected in the association between nutritional intervention and health-related outcomes. However, few studies have discussed these sex-related differences. The aim of the present study was to investigate the sex-related differences in the association between frailty and dietary consumption. Methods We conducted a cross-sectional study which investigated community-dwelling older adults aged ≥65 years. We surveyed age, sex, body mass index, family arrangement (living alone, living with a partner or living with parent(s) and/or child (ren)), dietary consumption and frailty status. Dietary consumption was surveyed using a food frequency questionnaire that included 13 major food categories (fish, meat, eggs, dairy products, soybean products, vegetables, seaweeds, potatoes, fruits, fats or oils, snacks, salty foods and alcohol). Frailty was defined by the Kihon Checklist score. The Kihon Checklist is composed of 25 simple yes/no questions, and it has been validated as a metric for frailty. A higher score indicates a greater degree of frailty. Multinomial regression analysis was performed to clarify the association between frailty and dietary consumption for each sex. Results We analyzed 905 older adults (420 (46.4%) were male). After adjusting for cofounders, a low frequency of meat consumption (less than twice/week) was associated with a high prevalence of frailty in men (odds ratio: 2.76 (95%CI: 1.12–6.77), p = 0.027). In contrast, in women, low frequencies of consumption of fish, meat, vegetables, potatoes and snacks were associated with a higher prevalence of frailty compared with those who consumed foods from those categories daily (odds ratios: fish 2.45 (1.02–5.89), p = 0.045; meat 4.05 (1.67–9.86), p = 0.002; vegetables 5.03 (2.13–11.92), p

Aim The present study aimed to evaluate drug costs per resident at Japanese intermediate care facilities for older adults (called Roken) in relation to drug utilization after admission to these facilities. The payment, including coverage of drugs, is mainly determined by the resident's long-term care needs. Methods A nationwide drug utilization survey was carried out. The participants were 1324 residents of 350 Roken (up to five individuals per facility) who were admitted in 2015 and agreed to participate in this study. Drug costs per resident per month at admission and 2 months later were calculated for drugs prescribed for regular use. Associations between characteristics of the residents and drug costs were examined. Results A wide variation in drug costs with a long right tail was observed. Median drug costs were $77 (interquartile range $34-147) at admission, and $46 (interquartile range $19-98) in month 2. There was no apparent association between the level of long-term care needs and drug costs, adjusting for sex, age and main place of residence before admission. Anti-dementia drugs accounted for the largest portion of total drug costs at admission (15.4%) and in month 2 (12.4%). The average drug cost per user was also the highest for anti-dementia drugs ($90.2 per user per month), followed by drugs for Parkinson's disease ($70.3). The proportion of generic drugs across all drug classes examined increased after admission. Conclusions These findings might suggest that implementation of the bundled payment scheme would be effective for the reduction of medication costs in institutional long-term care. Geriatr Gerontol Int 2019; 19: 667-672.

In patients with overlap syndrome (OVS), the pathophysiologies of obstructive sleep apnea (OSA) and chronic obstructive pulmonary disease can interact with one another. Focusing on low arousal threshold, the authors evaluated polysomnographic features of OVS patients. This retrospective, multicenter study was conducted at three hospitals in Japan. Patients aged ≥ 60 years who underwent polysomnography and pulmonary function testing were reviewed. Severity of airflow limitation (AFL) was classified according to the Global Initiative for Chronic Obstructive Lung Disease criteria. Low arousal threshold was predicted based on the following polysomnography features: lower apnea-hypopnea index (AHI); higher nadir oxygen saturation, and larger hypopnea fraction of total respiratory events. These features were compared among patients with only OSA (n = 126), OVS with mild AFL (n = 16), and OVS with moderate/severe AFL (n = 22). A low arousal threshold was more frequently exhibited by OVS patients with moderate/severe AFL than by those with OSA only (p = 0.016) and OVS with mild AFL (p = 0.026). As forced expiratory volume in 1 s/forced vital capacity (FEV1/FVC) decreased in OVS patients, the mean length of apnea decreased (r = 0.388, p = 0.016), hypopnea fractions increased (r = − 0.337, p = 0.039), and AHI decreased (r = 0.424, p = 0.008). FEV1/FVC contributed to low arousal threshold independent of age, sex, smoking history, hospital, or body mass index in all subjects (OR 0.946 [95% CI 0.909–0.984]) and in OVS patients (OR 0.799 [95% CI 0.679–0.940]). This study first described peculiar polysomnographic features in OVS patients with moderate/severe AFL, suggesting a high prevalence of low arousal threshold.

Objectives: Eating alone is related to depression, nutritional risk, and mortality. These effects are also influenced by living status. However, little is known about the relationship between eating alone despite living with family and frailty. This study explores the relationship of eating alone and living status with frailty in community-dwelling older adults. Design: Cross-sectional study. Setting and Participants: Kashiwa city, Chiba prefecture, Japan; randomly selected community-dwelling older adults (aged 65 years and over). Measurements: Eating status was assessed by the question, “Do you eat meals with anyone, at least once a day: yes or no?” Frailty was defined by Kihon Checklist (KCL) score 8 or over. Domains of frailty were divided into instrumental activities of daily living (IADL), physical strength, nutrition, eating, socialization, memory, and mood, based on KCL categories. Binary logistic regression analysis was used, adjusting for age, years of education, chronic diseases, number of teeth and cognitive function. Results: Among the total of 1,914 participants, 49.8% were male, and the overall mean age was 72.9 ± 5.5 years. Of all participants, 56 (5.9%) of men and 112 (11.7%) of women were frail. Older adults who ate alone despite living with others were more likely to be frail (OR 2.49, 95%CI 1.1–5.5 for men and OR 2.16, 95%CI 1.0–4.5 for women). Of particular note, eating and living status were associated with lower physical strength and mood in men, whereas in women these statuses were associated with lower scores for IADL, socialization, memory, and mood. Conclusions: Eating alone despite living with others was associated with high frailty in both genders; however, the pathways were different between genders. These results might help yield a simple, fundamental intervention approach to multifaceted frailty, reflecting gender and associated high-risk domains.

We aimed to determine the proportion of frail patients among older adults with non-valvular atrial fibrillation (NVAF), characterize them and their use of anticoagulant therapy, and examine the association between frailty and clinical outcomes in a real-world setting using the ANAFIE Registry dataset.The target population consisted of more than 30,000 adults aged ≥75 years definitively diagnosed with NVAF by electrocardiogram. For this sub-cohort study, patients who answered the Kihon Checklist were registered prospectively. Patients were classified into robust, pre-frail, and frail groups based on the Kihon Checklist score.Of the 32,275 patients in the ANAFIE Registry, 2951 were enrolled in this subanalysis and responded to the Kihon Checklist: 959 (32.5%) patients were robust; 924 (31.3%), pre-frail; and 1068 (36.2%), frail. In the robust, pre-frail, and frail groups, respectively, the 2-year cumulative incidence rates of stroke/systemic embolic events were 2.4%, 3.3%, and 4.5%, (P = .025); all-cause death, 2.9%, 5.1%, and 13.7%, (P.001); major bleeding, 1.5%, 1.2%, and 2.9%, (P = .029); and net clinical outcomes, 5.5%, 8.2%, and 17.1% (P.001). Results were similar when comparing the robust+pre-frail vs frail groups. In multivariate analyses, cardiovascular death, all-cause death, and net clinical outcomes were significantly associated with frailty. In the robust+pre-frail vs frail groups, major bleeding was also associated with frailty.Frailty was associated with cardiovascular and all-cause death, net clinical outcomes, and major bleeding but not stroke or intracranial hemorrhage in older Japanese adults with NVAF.

Purpose Chronic inflammation is a pathophysiological cause of age-related diseases including sarcopenia. However, limited data are available on the association between the diet-derived inflammation and sarcopenia. Here, using the Dietary Inflammatory Index (DII), we examined the associations between inflammatory potentials of the diet, sarcopenia/its components, and serum inflammatory markers. Materials and methods This cross-sectional study was performed in 2014 among 1,254 community-dwelling older adults. Energy-adjusted DII score (E-adjusted DII) was calculated using a self-administered diet history questionnaire. Sarcopenia/its components was determined according to the Asian Working Group for Sarcopenia. Serum interleukin (IL)-1β, IL-4, IL-6, IL-10, tumor necrosis factor (TNF)α, and high-sensitivity C-reactive protein (hsCRP) were measured. Results The mean of E-adjusted DII was 0.13±2.1 (-4.92~5.29) in participants (74.6±5.5 y). After adjustment of confounders, men in the highest tertile of the E-adjusted DII showed a 2.89-times (95% CI: 1.04-8.04) higher risk of sarcopenia than those in the lowest tertile. Regarding its components (low muscle mass/strength/function), men in the highest tertile did not have significantly greater odds, respectively. Intriguingly, when the E-adjusted DII was calculated only based on anti-inflammatory food parameters, men who did not consume food with anti-inflammatory properties scored high E-adjusted DII and were significantly associated with sarcopenia in the highest tertile (OR: 2.96; 95% CI: 1.06-8.93). Higher serum hsCRP levels were seen in sarcopenic men with the highest E-adjusted DII (p=0.036). Conclusions These results suggest that a diet with pro-inflammatory potential is associated with the risk of sarcopenia. Further investigations whether anti-inflammatory diet could reduce its risk are needed.

ObjectivesTo evaluate the prescription and discontinuation of psychotropic drugs (PD) and drugs with anticholinergic properties (DAP) in residents with dementia admitted to Roken, a major type of long-term care facility in Japan.DesignCohort study.SettingA nationwide questionnaire survey across 3598 Roken in Japan in 2015 (up to five randomly selected residents per facility).ParticipantsThis study included 1201 residents from 343 Roken (response rate: 10%). We determined the presence and severity of dementia using a nationally standardised measure.Primary and secondary outcome measuresPrescriptions of PD and DAP at admission and 2 months after admission were evaluated. Multivariable logistic regression was used to evaluate the associations of residents’ baseline characteristics with prescriptions or discontinuation.ResultsPrescription rates decreased for antidementia drugs (19.4% to 13.0%), hypnotics (25.1% to 22.6%) and anxiolytics (12.3% to 10.7%), whereas those for other PD, such as antipsychotics (13.2% to 13.6%), antidepressants (7.4% to 6.7%), antiepileptic drugs (7.1% to 7.8%) and DAP (35.2% to 36.6%) did not statistically significantly decrease. Some factors were associated with the prescriptions, for example, for antipsychotics, older age (≥85 years) (adjusted OR (aOR), 0.60; 95% CI 0.43 to 0.85) and being bedridden (aOR 0.67; 95% CI 0.47 to 0.97) were associated with a lower use of antipsychotics, whereas severe dementia was associated with a higher use of antipsychotics (aOR 3.26; 95% CI 2.26 to 4.70). At an individual level, a quarter of residents prescribed PD or DAP at admission had discontinued at least one PD or DAP, respectively, 2 months after admission. Antidementia drug use in severe dementia (aOR 1.86; 95% CI 1.04 to 3.31) and PD use in older age (aOR 1.61; 95% CI 1.00 to 2.60; in residents with disabling dementia) were associated with discontinuation.ConclusionsThere is possible scope for deprescribing PD and DAP in Roken residents with dementia to mitigate the risks of adverse events.

Background: Atrial fibrillation (AF) in patients aged ≥75 is one of the major risk factors for stroke, and prescription of oral anticoagulants (OACs) should be considered in these patients. We investigated the use of OAC' for patients certificated for long-term care (LTC) insurance, who have a high risk of bleeding among older patients. Methods and Results: From 1169 consecutive inpatients aged 75 or older who were admitted to the geriatric ward of The University of Tokyo Hospital between 2012 and 2017, we identified 175 patients (men 48%, mean age 85.5 years) who had AF during admission. The patients’ background, prescription of OACs on discharge, and the level of LTC insurance were checked. Patients were followed up for 1 to 5 years. Major bleeding, stroke, and all-cause mortality were investigated as outcomes. Among patients with AF, 63.4% were taking OACs. In multivariate analysis, older age, low BMI and no history of stroke were significant factors for not prescribing OACs. Care level patients with OACs had a higher incidence of stroke than others. There was no difference, irrespective of OAC prescription and disability level, in incidence of major bleeding. Care level patients without OACs had higher mortality than others. Conclusions: These results suggest that older care level patients with AF may benefit less from OACs.

Metabolic syndrome (MetS) is an important predictor of mortality in older adulthood, but it is not reliably related to measures of body composition such as body mass index in older adults, as opposed to those in earlier life stages. Previous research suggests that skeletal muscle mass is related to cardiovascular risk in older adulthood, but it is difficult to measure muscle mass accurately and independently of body fat. This study aimed to examine the relationship between body composition and cardiovascular risk factors among women in older adulthood. A cross-sectional observational clinical study was conducted at a single medical clinic in Tokyo, Japan. Participants included 90 healthy Japanese women aged 65 years and older. MetS risk factors were assessed. Appendicular skeletal muscle mass (ASM) was assessed using dual-emission X-ray absorptiometry. Visceral fat area (VFA) was measured using computed tomography. VFA positively correlated with ASM and MetS, whereas ASM and MetS did not correlate with each other. Using VFA and ASM data in a MetS multiple linear regression model, the association between VFA and MetS remained positive, whereas a significant negative relationship emerged between ASM and MetS. Lower muscle mass was independently associated with higher cardiovascular risk after controlling for VFA. Clinical interventions to reduce muscle loss in older adulthood may be beneficial for reducing the risk of MetS and improving cardiovascular health.

Despite the increasing incidence and high morbidity associated with dementia, a simple, non-invasive, and inexpensive method of screening for dementia is yet to be discovered. This study aimed to examine whether artificial intelligence (AI) could distinguish between the faces of people with cognitive impairment and those without dementia.121 patients with cognitive impairment and 117 cognitively sound participants were recruited for the study. 5 deep learning models with 2 optimizers were tested. The binary differentiation of dementia / non-dementia facial image was expressed as a "Face AI score". Xception with Adam was the model that showed the best performance. Overall sensitivity, specificity, and accuracy by the Xception AI system and AUC of the ROC curve were 87.31%, 94.57%, 92.56%, and 0.9717, respectively. Close and significant correlations were found between Face AI score and MMSE (r = -0.599, p < 0.0001). Significant correlation between Face AI score and chronological age was also found (r = 0.321, p < 0.0001). However, MMSE score showed significantly stronger correlation with Face AI score than chronological age (p < 0.0001). The study showed that deep learning programs such as Xception have the ability to differentiate the faces of patients with mild dementia from that of patients without dementia, paving the way for future studies into the development of a facial biomarker for dementia.

Since the end of 2019, a life-threatening infectious disease (coronavirus disease 2019: COVID-19) has spread globally, and numerous victims have been reported. In particular, older persons tend to suffer more severely when infected with a novel coronavirus (SARS-CoV-2) and have higher case mortality rates; additionally, outbreaks frequently occur in hospitals and long-term care facilities where most of the residents are older persons. Unfortunately, it has been stated that the COVID-19 pandemic has caused a medical collapse in some countries, resulting in the depletion of medical resources, such as ventilators, and triage based on chronological age. Furthermore, as some COVID-19 cases show a rapid deterioration of clinical symptoms and accordingly, the medical and long-term care staff cannot always confirm the patient's values and wishes in time, we are very concerned as to whether older patients are receiving the medical and long-term care services that they wish for. It was once again recognized that it is vital to implement advance care planning as early as possible before suffering from COVID-19. To this end, in August 2020, the Japan Geriatrics Society announced ethical recommendations for medical and long-term care for older persons and emphasized the importance of conducting advance care planning at earlier stages. Geriatr Gerontol Int 2020; 20: 1112-1119.

Background The aim of our study was to evaluate the influence of changes of nutritional status and body composition on the results of comprehensive geriatric assessment (CGA) in inpatients of a geriatric ward. Sex differences in these relationships were also investigated. Methods A total of 212 elderly patients (>65 years old) admitted to the geriatric ward at the University of Tokyo hospital between 2012 and 2019 were enrolled in this study. CGA (ADL, IADL, MMSE, GDS, Vitality Index) was performed, along with assessment of body compositions (appendicular muscle mass, abdominal muscle mass, body fat mass) and blood malnutrition biomarkers (serum albumin, pre-albumin, 25-hydroxy vitamin D, zinc, hemoglobin concentrations). Results Multiple linear regression analysis showed that upper, lower limbs and abdominal muscle masses were significantly associated with the score on ADL in men. On the other hand, abdominal muscle mass was negatively associated with the scores on GDS. Body fat mass was also negatively associated with the score on IADL. In contrast, in women, multiple linear regression analysis failed to show any significant associations between body composition parameters and scores on any domains of CGA. Unlike in men, however, blood malnutrition biomarkers were significantly associated with ADL, IADL, MMSE, and Vitality Index in women. Conclusions Our study findings revealed that the association of the nutritional status and body composition with the functional status in the elderly differs by sex. These results suggest that intensification of exercise in men and improvement of the nutritional status in women are particularly useful to maintain the functional status.

Chronic obstructive pulmonary disease (COPD) often accompanies type 2 diabetes mellitus (T2DM). However, background factors affecting these diseases in the elderly remain unclear. Eligible patients with T2DM were divided into two age groups-non-elderly (65 years) and elderly (≥65 years); COPD, ratio of forced expiratory volume in one second to forced expiratory volume (FEV1/FVC ratio), and percent predicted forced expiratory volume in one second (FEV1% predicted) were examined, and factors related to reduced respiratory function according to age group were evaluated. In total, 371 patients with T2DM were analysed. COPD was found in 9 patients (5.3%) in the non-elderly group and 45 (22.5%) in the elderly group. In the elderly, male sex, low body mass index (BMI), insulin therapy, and high C-peptide immunoreactivity levels were factors related to COPD. In the non-elderly, age, female sex, high BMI were factors related to decreased FEV1% predicted. Female sex was factor related to decreased FEV1% predicted in both age groups. Low BMI was a factor related to reduced respiratory function in elderly patients and high BMI was a factor related to reduced respiratory function in non-elderly patients. Thus, BMI needs to be managed according to the age and general condition of T2DM patients.

Background Although anticoagulation effectively prevents stroke in patients with atrial fibrillation (AF), it has been underused in elderly AF patients for many reasons, mainly because of knowledge gaps regarding cardiovascular treatment of these populations with multiple comorbidities and poor prognosis. The objectives of the All Nippon AF In the Elderly (ANAFIE) Registry are to collect real-world information about the clinical status of patients with non-valvular AF (NVAF) aged ≥75 years, current status of anticoagulant therapy, and prognosis with/without anticoagulation to establish a database for this specific patient population that is increasing remarkably worldwide. Methods and design The ANAFIE Registry is an observational, multicenter, prospective study of Japanese patients with NVAF aged ≥75 years that will include 30,000 patients and have the primary endpoint of composite of stroke and systemic embolism over a 2-year follow-up period. In parallel with the main study, seven sub-cohort studies will be conducted with assessments including coagulation-fibrinolysis markers, echocardiography, heart rate, hypertension, cognitive function, frailty, and medication adherence. Subgroup analyses will be performed, and stratified by renal function, HbA1c, and maximum number of drugs used. The study was started in October 2016, with a planned 2-year recruitment period. As of January 31, 2018, 33,213 patients were enrolled; the recruitment was therefore ended 8 months earlier than the original plan. Conclusions The ANAFIE Registry will provide a valuable database for the clinical status, management, and outcomes of mortality, stroke, systemic embolism, and hemorrhagic events with/without anticoagulation in the increasing population of elderly NVAF patients, and will identify risk factors associated with these clinical events.

AIM The present study aimed to: (i) examine the reliability and validity of the Dementia Assessment Sheet for Community-based Integrated Care System 21-items for classifying patients to the appropriate categories for glycemic targets in older patients; and (ii) develop a short version of the tool and examine its reliability and validity. METHODS A total of 410 older individuals were recruited for this multicenter cross-sectional study. We classified them into three categories used for determining the glycemic target in older patients in Japan based on cognitive functions and activities of daily living. Exploratory factor analyses were used to select the eight items of the shorter version. The reliability and validity of the assessment tools were assessed using Cronbach's alpha coefficients and receiver operating characteristic analyses, respectively. RESULTS The Dementia Assessment Sheet for Community-based Integrated Care System 21-items had three latent factors: cognitive function, instrumental activities of daily living and basic activities of daily living. The Dementia Assessment Sheet for Community-based Integrated Care System 8-items was developed based on each factor load quantity and was confirmed to have a strong correlation with the original version (r = 0.965, P

The course of Alzheimer's disease (AD) varies between individuals, and the relationship between cognitive and functional decline and the deterioration of behavioral and psychological symptoms of dementia (BPSD) is still poorly understood. Until recently, it was challenging to monitor subsequent changes in these symptoms because there was no single composite scale available that could simultaneously evaluate activities of daily living (ADL), BPSD, and cognitive function (CF) states. The present authors developed a new, brief assessment scale, the "ABC Dementia Scale" (ABC-DS), which is based on item response theory and facilitates concurrent measurement of ADL, BPSD, and CF states. We previously presented the reliability, construct validity, concurrent validity, and responsiveness of the ABC-DS. We obtained the evidence through three clinical trials featuring 1,400 subjects in total. In the present study, we performed a secondary analysis of the data obtained in the previous study. We conducted hierarchical cluster analyses that allowed us to classify 197 AD patients in terms of similarities regarding ADL, BPSD, and CF domain scores, as measured by the ABC-DS. Consequently, the scale identified subgroups of patients with global clinical dementia ratings of 1, 2, and 3. Considering our results in conjunction with the clinical experiences of the AD expert among the present authors regarding longitudinal changes in ADL, BPSD, and CF, we were able to propose potential progression pathways of AD in the form of a hypothetical roadmap.

BackgroundAlthough research indicates that a physically active lifestyle has the potential to prevent cognitive decline and dementia, the optimal type of physical activity/exercise remains unclear. The present study aimed to determine the cognitive benefits of a golf-training programme in community-dwelling older adults.MethodsWe conducted a randomised controlled trial between August 2016 and June 2017 at a general golf course. Participants included 106 Japanese adults aged 65 and older. Participants were randomly assigned to either a 24-week (90–120 min sessions/week) golf-training group or a health education control group. Postintervention changes in Mini-mental State Examination (MMSE) and National Centre for Geriatrics and Gerontology-Functional Assessment Tool scores were regarded as primary outcome measures. Secondary outcome measures included changes in physical performance and Geriatric Depression Scale (GDS) scores.ResultsA total of 100 participants (golf training, n=53; control, n=47) completed the assessments after the 24-week intervention period. The adherence to the golf programme was 96.2% (51/53 participants). Analysis using linear mixed models revealed that the golf training group exhibited significantly greater improvements in immediate logical memory (p=0.033), delayed logical memory (p=0.009) and composite logical memory (p=0.013) scores than the control group. However, no significant changes in MMSE, word memory, Trail Making Test or Symbol Digital Substitution Test scores were observed. In addition, no significant changes in grip strength, walking speed or GDS were observed.ConclusionsGolf-based exercise interventions may improve logical memory in older adults, but no significant changes in other cognitive tests. Further follow-up investigations are required to determine whether the observed effects are associated with delayed onset of mild cognitive impairment or Alzheimer’s disease in older adults.Trial registration numberUMIN-CTR UMIN000024797; Pre-results.