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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

AIM: This study aimed to explore the perceptions of dementia experts on support for people with dementia (PWD) and their families, considering PWD's vulnerability regarding COVID-19 prevention. METHODS: A collaborative qualitative study was conducted, involving Hiroshima University, the Japan Geriatrics Society, the Japan Society for Dementia Research, and the Japanese Psychogeriatric Society. An anonymous, self-reported questionnaire survey was sent to dementia experts from 456 medical centers for dementia in Japan. The responses were categorized in a qualitative inductive manner. RESULTS: A total of 214 experts from 119 centers responded (facility recovery rate: 26.1%). Four core themes emerged from the data analysis. Of these themes, three were related to support for infection prevention and related issues and response to infection: (i) support for continuation of daily life while preventing infection; (ii) support to mitigate the unfavorable effects of infection prevention measures; and (iii) decision-making support and treatment for infected PWD. The remaining theme, (iv) community building for PWD living together, was extracted as a basis for facilitating themes (i) to (iii). Furthermore, in each theme, the roles of medical and long-term care facilities, administration, and the need for community collaboration were identified. CONCLUSIONS: Dementia experts strongly felt the need not only for short-term support to prevent the spread of infection to PWD and their families during the pandemic, but also for long-term support to enable them to maintain their daily lives and mitigate the impact of infection prevention measures. Geriatr Gerontol Int 2021; ••: ••-••.

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.

Severe cardiac dysfunction can manifest with diurnal breathing irregularity. However, it remains to be clarified whether or not diurnal breathing irregularity is observed in patients with heart diseases, including relatively mild chronic heart failure (CHF), compared to those without heart diseases. In this cross-sectional study, consecutive inpatients who were admitted for evaluation of sleep-disordered breathing were enrolled. We extracted 3.5 min of stable respiratory signals before sleep onset using polysomnography, analyzed the airflow data using fast Fourier transform, and quantified breathing irregularities using Shannon entropy S. A total of 162 subjects were evaluated. Among these, 39 subjects had heart diseases, including ischemic heart disease (IHD), atrial fibrillation (Af), CHF, and a history of aortic dissection. The values of Shannon entropy S of airflow signals in subjects with heart diseases were significantly higher than in those without heart diseases (p

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; ••: ••-••.

BACKGROUND: Implementation of appropriate oral anticoagulant treatment for the prevention of stroke in very elderly patients with atrial fibrillation is challenging because of concerns regarding bleeding. METHODS: We conducted a phase 3, multicenter, randomized, double-blind, placebo-controlled, event-driven trial to compare a once-daily 15-mg dose of edoxaban with placebo in elderly Japanese patients (≥80 years of age) with nonvalvular atrial fibrillation who were not considered to be appropriate candidates for oral anticoagulant therapy at doses approved for stroke prevention. The primary efficacy end point was the composite of stroke or systemic embolism, and the primary safety end point was major bleeding according to the definition of the International Society on Thrombosis and Haemostasis. RESULTS: A total of 984 patients were randomly assigned in a 1:1 ratio to receive a daily dose of 15 mg of edoxaban (492 patients) or placebo (492 patients). A total of 681 patients completed the trial, and 303 discontinued (158 withdrew, 135 died, and 10 had other reasons); the numbers of patients who discontinued the trial were similar in the two groups. The annualized rate of stroke or systemic embolism was 2.3% in the edoxaban group and 6.7% in the placebo group (hazard ratio, 0.34; 95% confidence interval [CI], 0.19 to 0.61; P

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; ••: ••-••.

The Japan Geriatrics Society has so far announced "The Japan Geriatrics Society Position Statement 2012" and "Guidelines for the Decision-Making Processes in Medical and Long-Term Care for the Elderly - Focusing on the Use of Artificial Hydration and Nutrition" related to end-of-life care for older adults. In 2018, the Ministry of Health, Labor and Welfare revised the "Guidelines for the Decision-Making Processes in Medical and Long-Term Care in the End of Life," recommending the practice of advance care planning (ACP). This was the first time when the Japanese government publicized its stance on ACP. Immediately after the government's announcement, the Japan Medical Association announced its committee report, "The Super-aged Society and the End-of-life Care," which also recommended the practice of ACP. The guidelines were published when the society was experiencing substantial changes related to geriatric care in Japan, and required timely and ethically appropriate decision-making processes. However, because ACP is a concept imported from English-speaking countries, some Japanese people could find it difficult to understand the role and methodology of ACP because of differences in culture and the medical/long-term care system. Therefore, the Japan Geriatrics Society has decided to publish the "Recommendations for the Promotion of Advance Care Planning" for medical and long-term care professionals nationwide with the aim of using the recommendations on a daily basis. The society recognizes ACP as indispensable to improve end-of-life care for individuals, particularly for older adults. We anticipate that the recommendations will provide practical guidance for those strenuously working toward this goal. Geriatr Gerontol Int 2020; 20: 1024-1028..

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.

The coronavirus disease 2019 (COVID-19) pandemic has casted a huge impact on global public health and the economy. In this challenging situation, older people are vulnerable to the infection and the secondary effects of the pandemic and need special attention. To evaluate the impacts of COVID-19 on older people, it is important to balance the successful pandemic control and active management of secondary consequences. These considerations are particularly salient in the Asian context, with its diversity among countries in terms of sociocultural heritage, healthcare setup and availability of resources. Thus, the Asian Working Group for Sarcopenia summarized the considerations of Asian countries focusing on responses and difficulties in each country, impacts of health inequity related to the COVID-19 pandemic and proposed recommendations for older people, which are germane to the Asian context. More innovative services should be developed to address the increasing demands for new approaches to deliver healthcare in these difficult times and to establish resilient healthcare systems for older people. Geriatr Gerontol Int 2020; 9999: n/a-n/a.

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.

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.

Sarcopenia is an age-related loss of skeletal muscle mass and strength. It has been widely recognized that low muscle mass was essential in the diagnosis of sarcopenia, whereas recent studies have emphasized the importance of muscle strength. In practice, muscle quality as well as muscle mass might determine the strength and physical performance. A new diagnostic algorithm of sarcopenia has recently been established, in which low muscle strength is a key characteristic factor for the diagnosis of sarcopenia. Although many factors are supposed to be involved in the pathology and development of sarcopenia, precise mechanisms remain to be elucidated. Recent studies have also focused on the crosstalk between muscles and bones, including functional involvement of myokines and osteokines.

Many studies use the global clinical dementia rating (CDR) of 0.5 as a criterion for mild cognitive impairment, but past studies have not fully discussed its validity. The authors developed the ABC Dementia Scale (ABC-DS) to accurately monitor the changes in activities for daily living, behavioral and psychological symptoms of dementia, and cognitive function. When we carried out a cluster analysis of ABC-DS scores of 110 individuals for whom global CDR was 0.5, there were three groups with different levels of activities for daily living and cognitive function. O'Bryant et al. proposed a new guideline to stage dementia using the CDR sum of boxes scores (CDR-SOB). We used their proposal and ABC-DS scores to evaluate the validity of CDR 0.5 as a definition of mild cognitive impairment (MCI). We concluded that the CDR-SOB scores and ABC-DS score are more accurate than global CDR of 0.5 for specifying individuals with MCI.

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.

Background Although the notion of percutaneous endoscopic gastrostomy (PEG) tube placement for patients with dementia has been changing, the number of cases of PEG placement remains high as Japan has become a super-aged society. However, there is insufficient research about the clinical course of dementia patients with PEG, especially regarding PEG extubation after regaining full oral intake. This case series aimed to reveal the demographic data of patients who successfully underwent PEG extubation and to identify clinical factors that might help predict eventual resumption. Methods This retrospective case series was identified in a private, community-based long-term care hospital in Sapporo, Japan. Inclusion criteria for the series were: 1) age, ≥75 years, 2) diagnosis of any type of dementia, and 3) resumption of full oral intake after removal of PEG tubes. Results Eight female patients were identified. Decreased oral intake was triggered by acute medical conditions, such as infectious enteritis. A trial of oral intake was initiated mostly by speech therapists. A majority of the patients ate pureed food. The patients aged ≥85 years with advanced dementia could be weaned from PEG tubes. Conclusion The series indicates that even patients with limited life expectancy could recover swallowing function by receiving appropriate guidance and care. Constant evaluation for swallowing function even after PEG insertion may be important for PEG extubation.

Inflammation is a critical feature of aging and its related diseases, including cardiovascular diseases. Recent epidemiological studies demonstrated that abdominal aortic aneurysm (AAA), an aging-related vascular pathological condition, is associated with cognitive decline. However, the underlying mechanism, especially the role of vascular inflammation, is largely unknown because of lack of an available animal model. In this study, we examined whether vascular inflammation affects synaptic and cognitive dysfunction, using an AAA mouse model. In young (3 months) and middle-aged (12 months) C57BL/6J mice, AAA was induced by angiotensin II infusion with calcium chloride application. After 4 weeks of induction, aortic diameter was significantly increased and excessive Mac3-positive inflammatory cells infiltrated the destroyed aorta in middle-aged mice. AAA-induced middle-aged mice further exhibited cognitive impairment. Neuronal loss was observed in the CA3 region of the hippocampus. IBA1/MHCII-double-positive microglia activation was also seen in the hippocampus, suggesting that vascular inflammation drives neuroinflammation and subsequent cognitive dysfunction. Furthermore, we found that senescence-accelerated mice prone 8 exhibited robust AAA formation and a marked decrease of cognitive and synaptic function in the hippocampus mediated by inflammation. In conclusion, this novel murine model convincingly suggested the occurrence of vascular inflammation-derived cognitive dysfunction.

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.

AIM The present study aimed to assess the interrater reliability and construct the validity of a novel, convenient informant-based Alzheimer's disease assessment scale to prepare its final version. METHODS For the assessment, site investigators, co-medicals and, if available, medical staff other than doctors or co-medicals interviewed study informants to assess individuals using this scale. We then analyzed the interrater reliability and construct validity using factor analysis and item response characteristics. RESULTS In this study, 427 eligible participants were enrolled. We first examined the interrater reliability, and found that the lower limit of the confidence interval of each item was never

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.

Latent TGF-β binding protein 4 is an important factor that influences anti-inflammatory and cell-protective responses in the pathogenesis of pulmonary empysema Rationale: Deficiency of the extracellular matrix protein latent transforming growth factor-β (TGF-β)-binding protein-4 (LTBP4) results in lack of intact elastic fibers, which leads to pulmonary emphysema. However, how LTBP4 is involved in the pathogenesis of emphysema associated with elastic fiber assembly is largely unknown. Methods: To investigate the anti-inflammatory effects of LTBP4, we utilized human lung fibroblast cell lines (L299). L299 cells were transfected with LTBP4 siRNA. To evaluate the anti-inflammatory and cell-protective effects of LTBP4 in lungs, we analyzed the mRNA expression patterns of proinflammatory cytokines (MIP-1α, MCP-1, IP-10, and MIP-2), MMPs (MMP-1 and MMP-12) , TIMP-1, elastin and tropoelastin. The role of LTBP4 associated with elastic fiber assembly was evaluated in collagen-based cell contraction assay. Results: In the LTBP4-deficiency group, mRNA levels of MIP-1α, MCP-1, IP-10, MIP-2, MMP-1, MMP-12, and TIMP-1 were significantly decreased(p＜0.05) and elastin and tropoelastin were significantly increased (p＜0.05). The collagen-based cell contraction assay showed that the collagen gel size change was measured and LTBP4-deficiency is involved in the decreased level of elastic contraction(p＜0.05). Conclusion: Our results suggest a unique function for LTBP-4 that influences anti-inflammatory and cell-protective responses in elastic fiber assembly. These data are potentially useful for the treatment or prevention of pulmonary emphysema.

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.

Background: Comprehensive geriatric assessment (CGA) is a multidimensional and multidisciplinary method to identify geriatric conditions among older patients. The aim of the present study was to examine the associations between CGA and short-term outcomes among older adult inpatients with stroke. Methods: The study was a nationwide, retrospective cohort study. We used the Diagnosis Procedure Combination database, a national Japanese inpatient database, to identify older adult stroke patients from 2014 to 2017. The associations between CGA and in-hospital mortality, length of hospital stay, readmission rate, rehabilitation intervention, and introduction of home health care were evaluated using propensity score matching and instrumental variable analysis. Findings: We identified 338,720 patients, 21·3% of whom received CGA. A propensity score-matched analysis of 53,861 pairs showed that in-hospital mortality was significantly lower in the CGA group than in the non-CGA group (3·6% vs. 4·1%, p < 0·001). The rate of long-term hospitalization (> 60 days) was significantly lower in the CGA group than in the non-CGA group (8·7% vs. 10·1%, p < 0·001), and the rates of rehabilitation intervention (30·3% vs. 24·9%, p < 0·001) and home health care (8·3% vs. 7·6%, p = 0·001) were both higher in the CGA group than in the non-CGA group. Instrumental variable analysis showed similar results. Interpretation: CGA was significantly associated with the examined short-term outcomes. These findings from Japan, one of the most aged countries worldwide, highlight the possible benefits of CGA for short-term outcomes and can be of use for health policy in other international contexts. Funding: This work was supported by grants from the Ministry of Health, Labour and Welfare, Japan (19AA2007 and H30-Policy-Designated-004) and the Ministry of Education, Culture, Sports, Science and Technology, Japan (17H04141).

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

Context Previous research has shown a positive relationship between plasma leptin and sympathetic nervous activity. High plasma leptin activate inflammatory cytokines and lead to muscle wasting. However, studies have detected low sympathetic nervous activity and high plasma leptin in older adults with muscle wasting, sarcopenia, and frailty. High plasma leptin do not seem to correlate with high sympathetic nervous activity. However, their relationship in older adults remains unclear. Objective We investigated the relationship between plasma leptin and sympathetic nervous activity in older adults. Design, Setting, and Participants We conducted a cross-sectional study and analyzed the results from 69 participants aged ≥75 years. Sympathetic nervous activity was measured by heart rate variability, obtained from 24-hour Holter monitoring. A functional independence measure (FIM) and Barthel index were used to assess physical function. Results The plasma leptin was higher in women (men, 3.4 ± 2.8 ng/mL; women, 6.6 ± 6.5 ng/mL; P = 0.024). Plasma leptin was negatively and substantially related to the FIM (β = −0.233; P = 0.049) and Barthel index (β = −0.298, P = 0.018) after adjustment for covariates. However, the data showed no relationship between the plasma leptin and sympathetic nervous activity. Conclusions We could not detect an association between sympathetic nervous activity and plasma leptin in older adults. This might suggest a failure of the feedback system of the sympathetic nervous system, leading to muscle wasting in older adults., The relationship between plasma leptin and sympathetic nervous activity was diminished in older adults with physical dysfunction.

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.