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Background: Geriatric conditions (GCs) are common in the elderly population, but their clinical significance in acute care is not well understood. In this study, we first investigated the cross-sectional associations of GCs with frailty and polypharmacy at the time of admission to an acute care geriatric ward. Then, to clarify the clinical significance of GCs in acute care, we prospectively examined the association of GCs with the incidence of hospital-acquired complications and consequences after discharge.Methods: Participants were 184 patients (40.2% male: mean age, 85.0 ± 6.0 years) hospitalized in an acute care geriatric ward at a university hospital. We examined the cross-sectional associations of GCs with frailty and polypharmacy by multiple regression analysis, and then the associations of GCs with the incidence of hospital-acquired complications, falls, and death within 3 months of discharge by multiple logistic regression analysis.Results: GCs were associated with frailty and use of polypharmacy, independent of multiple morbidity. GCs were also associated with re-admission within 3 months of discharge; however, there was no significant association with the incidence of hospital-acquired complications, falls, or mortality after discharge.Conclusions: These findings suggest that GCs are clinically significant in the hospitalized elderly and further research on GCs is warranted.

Technological advances of hand-held ultrasound devices and educational programmes for their use, such as point-of-care ultrasonography (POCUS) training, have contributed to the increasing application of these devices in clinical practice. With the greater impact of frailty and sarcopenia in aging societies, attention is being focused on the use of ultrasound for skeletal muscle assessment. In this narrative review, we discuss how ultrasound can be applied to skeletal muscle assessment, especially that of the quadriceps muscle, in clinical practice. Muscle thickness by ultrasound has been shown to have good reliability and validity for the evaluation of muscle size, and echo intensity has been used to evaluate muscle quality. Muscle ultrasound has not only been useful to diagnose sarcopenia in various settings, but has also been validated to predict health-related outcomes such as death and functional disability. Recommended methods for muscle ultrasound was published recently, and the results of future studies are expected to be comparable. Although several challenging issues with muscle ultrasound remain, if it could be incorporated into educational programmes such as POCUS training, more clinicians may be able to use ultrasound for skeletal muscle assessment in the future.KEY MESSAGESThe evolution of hand-held ultrasound devices enables physicians to perform ultrasound at the bedside as part of regular medical examinations.Muscle ultrasound is considered an effective tool for evaluating muscle size and quality, and has been studied in various settings.More clinicians may be able to evaluate skeletal muscle assessment with the development of educational programmes on muscle ultrasound in the future.

Dehydration is highly prevalent in hospitalized older adults and has been linked to poor outcomes. It is considered a modifiable factor, so early identification and intervention may avoid adverse events and improve quality of life after discharge. Hospital-associated disability (HAD) is known to be a poor prognostic factor and can be categorized into mobility impairment and self-care impairment in setting goals for management. Few studies have directly examined the association between dehydration and HAD and therefore here we examined whether dehydration is a predictor of HAD categorized into mobility and self-care impairment among acute hospitalized older adults.Patients aged 65 years or older who were admitted to the geriatric ward of an acute hospital were recruited for this prospective cohort study. Estimated serum osmolarity 300 mOsm/kg was defined as current dehydration. HAD was assessed between baseline and discharge and at 3 months after discharge, and was evaluated separately for mobility and self-care impairments.In total, 192 patients (mean age, 84.7 years; male, 41.1%; dehydration, 31.3%) were analyzed. The occurrence of HAD was significantly higher in the dehydrated group than in the non-dehydrated group (42.4% vs 26.5%) from baseline to 3 months after discharge. In multiple logistic regression analysis, dehydration was significantly associated with HAD in self-care from baseline to 3 months after discharge (odds ratio, 2.25; 95% confidence interval, 1.03-4.94).Dehydration could predict the occurrence of HAD in acute hospitalized older adults. A multifaceted approach may be necessary to improve the management of dehydration in these patients.

Background: Polypharmacy, usually defined as the use of 5 or more drugs, is associated with reduced quality of life, adverse events, and frailty. Slow gait speed is a component of physical frailty, and some studies have suggested an association between polypharmacy and slow gait speed. Objective: We aimed to determine the effects of polypharmacy on the gait difference according to stages of cognitive decline in a cross-sectional study of memory clinic patients. Methods: Participants were 431 outpatients aged 65 year or older who were cognitively normal (CN) or had mild cognitive impairment (MCI) or dementia due to Alzheimer’s disease. Participants were divided into a polypharmacy group and a non-polypharmacy group in each group. Multiple regression analysis and logistic analysis were used for data analysis. Results: There were 182 patients in the polypharmacy group and 249 patients in the non-polypharmacy group. Multiple regression analysis revealed that gait speed had significant negative associations with number of medications and polypharmacy status in the CN group (β: –0.026 [–0.041 to –0.0018] and –0.128 [–0.022 to –0.0033], respectively) and MCI group (–0.018 [–0.028 to –0.0009] and –0.100 [–0.166 to –0.0034]). Logistic regression analysis also showed that number of medications was associated with slow gait status (

Background: Homocysteine is a common risk factor for cognitive impairment and sarcopenia. However, very few studies have shown an association between sarcopenia and serum homocysteine levels after adjustment for cognitive function. Objective: The purpose of this study was to investigate the relationship between homocysteine and sarcopenia in memory clinic patients. Methods: This cross-sectional study investigated outpatients in a memory clinic. We enrolled 1,774 participants (≥65 years old) with measured skeletal muscle mass index (SMI), hand grip strength (HGS), and homocysteine. All participants had undergone cognitive assessments and were diagnosed with dementia, mild cognitive impairment, or normal cognition. Patient characteristics were compared according to sarcopenia presence, SMI level, or HGS. Multivariate logistic regression analysis was performed to determine the association of homocysteine with sarcopenia, low SMI, or low HGS. Next, linear regression analysis was performed using HGS as a continuous variable. Results: Logistic regression analysis showed that low HGS was significantly associated with homocysteine levels (p = 0.002), but sarcopenia and low SMI were not. In linear regression analysis, HGS was negatively associated with homocysteine levels after adjustment for Mini-Mental State Examination score (β= –2.790, p

Background: Few studies have investigated associations between types of clock drawing test (CDT) errors and cognitive impairment. Objective: To explore associations of qualitative errors in the CDT with comprehensive neurocognitive assessment scores and clinical diagnosis. Methods: Outpatients at a memory clinic were enrolled. Frequencies of errors determined by Cahn’s method were explored according to cognitive status (cognitively normal [CN] (n = 279), mild cognitive impairment [MCI] (n = 321), and Alzheimer’s disease [AD]) (n = 575). Neuropsychological assessment scores were compared between participants with and without errors. Results: Stimulus-bound response (SB) was relatively rare (6.8%) in the CN group but was markedly more common in the MCI (23.4%) and AD (33.2%) groups. Conceptual deficit (CD) was found in more than 20%of CN individuals, as well as about 50%of AD patients. Planning deficit (PD) frequencies were relatively similar among the groups. SB in both of CN and MCI individuals, and CD in both of CN and MCI individuals were associated with lower scores in several neuropsychological assessments. Meanwhile, PD was not associated with lower assessment scores in any of CN, MCI, or AD individuals. Conclusion: The frequencies of SB and CD increased from CN, MCI, to AD but showed somewhat different patterns. Both SB and CD were associated with lower cognition in all three cognitive stages.

Frailty is a dynamic status that can worsen or improve. However, changes in their frailty status that occur during hospitalization and their significance have not been comprehensively investigated. In this study, we explored the association between such changes and mortality 3 months after discharge in older adults hospitalized for acute care. In total, 257 participants (mean age 84.95 ± 5.88, 41.6% male) completed comprehensive geriatric assessments, including the Clinical Frailty Scale (CFS) at admission and discharge. Mean CFS score was 5.14 ± 1.35 at admission. CFS scores increased, indicating deteriorating frailty, in 29.2% of the participants (75/257) during hospitalization. Multiple logistic regression analysis demonstrated a positive association between increased CFS score during hospitalization and mortality (odds ratio, 2.987) independent of potential co-founding factors. This deterioration in frailty during hospitalization may be modifiable risk factor of poor prognosis in older adults who need acute care hospitalization.

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

Quality of life (QOL) was assessed using the EQ-5D twice in 1 year in 57 older community-dwelling people (age 79.1±5.9 years) with mild cognitive impairment in a memory clinic. Screening for sarcopenia at the initial assessment revealed 40.1% of participants (23/57) were sarcopenic. QOL declined in 33.3% of participants (19/57) after around 1 year. Multiple logistic regression analysis showed that sarcopenia was associated with a decline in QOL around 1 year after initial assessment. Sarcopenia may be a risk factor for decline in QOL in older people with mild cognitive impairment.

Muscle ultrasound is a non-invasive technique that enables identification of the quantity and quality of muscle tissue. It has been used not only for diagnosis of sarcopenia but also for prediction of outcomes in clinical practice. There is now increasing awareness that muscle changes detected during acute hospitalization indicate acute sarcopenia leading to worse outcomes. However, to our knowledge, few studies have investigated this in hospitalized older adults. The aim of this study was to determine whether muscle changes on muscle ultrasound can predict poor outcomes in acute hospitalized older adults.This prospective, observational cohort study involved 145 acute hospitalized older adults. Bilateral anterior thigh thickness (BATT), echo intensity (EI), and corrected EI of the quadriceps were assessed on admission and 7 d later. The primary outcome was mortality, and the secondary outcomes were hospital-associated complications and decline in activities of daily living (ADLs) at 3 mo after discharge.Changes in BATT, EI, and corrected EI at 7 d after admission were found in 0.2%, 0.0%, and 0.2% of cases, respectively. The respective rates for mortality, hospital-associated complications, and ADL decline were 8.7%, 52.8%, and 43%, respectively. Multivariable logistic regression analysis showed that the BATT value at admission tended to be associated with mortality. Changes in BATT, EI, and collected EI were not associated with adverse outcomes.Acute muscle changes on muscle ultrasound were not associated with mortality, ADL decline, or hospital-associated complications in acute hospitalized older adults. More research in various settings is needed to clarify the value of muscle ultrasound in clinical practice.

Individuals with mild cognitive impairment (MCI) often make qualitative errors on the Clock Drawing Test (CDT), and these errors are reported to be associated with lower scores on neuropsychological assessments. Gait speed is also closely associated with cognitive dysfunction. However, the association between CDT errors and gait speed has not been investigated in individuals with MCI. Therefore, in this study, we explored the association between gait speed and qualitative errors on the CDT. Participants were 196 outpatients at a memory clinic with a clinical dementia rating of 0.5. The CDT was evaluated using the method of Cahn et al. The participants were divided into tertiles of normal and maximum gait speeds. The CDT error types of stimulus-bound response, conceptual deficit (CD), and planning deficit were found in 24.5%, 29.6%, and 30.1% of the participants, respectively. CD was found in 43.6% of the slowest tertile of maximum gait and in 22.2% of the fastest tertile. Multiple linear regression analysis gait speeds as objective continuous variables revealed that CD was significantly negatively associated with maximum gait, but not with normal gait. No other error types were associated with gait speeds. Only CD type error on the CDT was negatively associated with maximum gait speed, but not normal gait speed in the current study. The association between the qualitative error on the CDT and gait speed provides further basis of the clinical importance of qualitative assessments of CDT.

The purpose of this study was to examine the relationship of the serum creatinine/cystatin C ratio (CCR) with hand grip strength (HGS), total body muscle mass, trunk muscle mass, and skeletal muscle mass index (SMI) in patients attending a memory clinic.This cross-sectional study enrolled outpatients of a memory clinic in Japan from October 2010 to July 2017.We enrolled 1945 participants aged 60 years or older with measured skeletal muscle mass, HGS, and serum creatinine and serum cystatin C levels.Linear multiple regression analysis was performed for men and women using total body muscle mass, trunk muscle mass, and SMI as objective variables. The exposure variables were selected from previous reports if they were strongly linked to muscle mass. Total body muscle mass and trunk muscle mass were corrected by dividing by body weight. Multiple regression analysis was also conducted for men and women using HGS as an objective variable. Because cognitive function and HGS are strongly related, we also conducted sensitivity analysis by excluding participants with a Mini-Mental State Examination score 24 to alleviate any concern that we did not fully adjust for the effect of cognitive dysfunction.In men, CCR was significantly associated with total body muscle mass, trunk muscle mass, and SMI (P = 0.013, P = 0.008, and P 0.001, respectively). In women, CCR was significantly associated with total body muscle mass and trunk muscle mass (P = 0.013 and P 0.001, respectively), but not with SMI (P = 0.932). On the other hand, CCR was significantly associated with grip strength in both men and women (P 0.001 and P 0.001, respectively).CCR was associated with both muscle mass and muscle strength. This study suggests that CCR is a useful marker not only for muscle mass but also for muscle strength.

Chronic dehydration mainly occurs due to insufficient fluid intake over a lengthy period of time, and nursing home residents are thought to be at high risk for chronic dehydration. However, few studies have investigated chronic dehydration, and new diagnostic methods are needed. Therefore, in this study, we aimed to identify risk factors for chronic dehydration by measuring serum osmolality in nursing home residents and also to evaluate whether examining the inferior vena cava (IVC) and determining the IVC collapsibility index (IVC-CI) by ultrasound can be helpful in the diagnosis of chronic dehydration. A total of 108 Japanese nursing home residents aged &ge, 65 years were recruited. IVC measurement was performed using a portable handheld ultrasound device. Fifteen residents (16.9%) were classified as having chronic dehydration (serum osmolality &ge, 295 mOsm/kg). Multivariate logistic regression analysis showed that chronic dehydration was associated with dementia (odds ratio (OR), 6.290, 95% confidential interval (CI), 1.270&ndash, 31.154) and higher BMI (OR, 1.471, 95% CI, 1.105&ndash, 1.958) but not with IVC or IVC-CI. Cognitive function and body weight of residents should be considered when establishing a strategy for preventing chronic dehydration in nursing homes.

To evaluate the predictability of progression of cognitive impairment to dementia using qualitative clock drawing test (CDT) scores, we administered both the CDT using Cahn et al.’s qualitative scoring system and the Mini-Mental State Examination (MMSE) to assess cognitive function in non-demented older individuals attending a memory clinic at a university hospital. Patients visiting the clinic for assessment of cognitive function between January 2015 and December 2019 were enrolled, and only those who were diagnosed as not having dementia at the time of initial assessment completed a follow-up assessment at 1 y (n = 163). To examine any association of qualitative CDT score with progression to dementia, multiple logistic regression analysis was conducted with the change in diagnosis from non-dementia to dementia at 1 y as the dependent variable. A total of 26 participants (16.0%) were diagnosed as having converted to dementia. Multiple logistic regression analysis revealed that both the qualitative CDT score using Cahn et al.’s scoring system and the existence of conceptual deficits were significantly associated with progression to dementia at 1 y after initial assessment of cognitive function, irrespective of the MMSE score, among non-demented older individuals. The CDT may be a useful predictor of progression to dementia in primary care settings.

Background Hospital-associated complications are associated with adverse outcomes after discharge, and a method to help predict the occurrence of these complications needs to be established. Sarcopenia is thought to be one of the factors associated with hospital-associated complication, but sarcopenia assessment in hospitalized patients is often difficult. Focus has recently been placed on morphological and qualitative evaluation of muscle by ultrasound as an index of sarcopenia. Therefore, in this study, we sought to clarify the association of hospital-associated complication with muscle thickness or echo intensity measured by ultrasound and with commonly used sarcopenia-related parameters. Methods This is a prospective observational cohort study with 156 hospitalized older patients recruited over a year. Bilateral thigh muscle thickness of rectus femoris and vastus intermedius, echo intensity and corrected echo intensity of rectus femoris were measured by ultrasound. Also measured were the sarcopenia-related parameters of handgrip strength, skeletal muscle index, and maximum calf circumference. Hospital-associated complication was defined as the occurrence of any of the following complications: delirium, functional decline, incontinence, falls, pressure injuries, and nosocomial infections. Results Of 156 patients enrolled at admission, hospital-associated complication was observed in 70 (54.3%). With-hospital-associated complication group had a higher prevalence of emergency admission and a higher corrected echo intensity than without-hospital-associated complication group. Multivariate logistic regression analysis showed that only higher corrected echo intensity was associated with hospital-associated complication (odds ratio 1.036; 95% confidence interval, 1.001–1.072), while handgrip strength, bilateral thigh muscle thickness, skeletal muscle index, and maximum calf circumference were not. Conclusions Corrected echo intensity might be a useful parameter to help predict hospital-associated complication in acute hospitalized older patients and might contribute to establishing a strategy to prevent hospital-associated complication.

A 61-year-old man presented with pain in the abdomen and right lower limb. He had a history of hepatitis B virus-induced liver cirrhosis, but had not been visiting the outpatient clinic and did not receive any medication. Cutaneous necrosis and bulla were observed on his abdomen and right lower limb. The necrotic skin was incised, and he was diagnosed with necrotizing fasciitis. A nonfermentative Gram-negative bacillus infection was confirmed from aspirated fluid and blood cultures. Therefore, meropenem and immunoglobulins were administered. Because necrosis was widespread, surgical debridement was performed. Thereafter, Acinetobacter calcoaceticus infection was confirmed by semi-quantitative PCR using the bullous fluid and blood cultures. Meropenem was administered for 3 weeks, followed by levofloxacin alone for 1 week. The patient's condition improved; therefore, skin grafting was performed as planned and yielded a favorable response. After rehabilitation, the patient could walk without support and infection did not recur. However, he had severe liver cirrhosis and large esophageal varices, and he eventually died from sudden varix rupture. Necrotizing fasciitis is an uncommon soft tissue infection, associated with high morbidity and mortality, and early recognition and treatment are crucial for survival. Acinetobacter is rarely associated with necrotizing fasciitis. Although this is a very rare case of the occurrence of necrotizing fasciitis due to A. calcoaceticus infection, we believe that this organism can be pathogenic in immunocompromised patients such as those with liver cirrhosis by reporting this case.

Introduction Severe fever with thrombocytopenia syndrome (SFTS) is an emerging infectious disease that was first reported in China in 2011. However, it is now endemic in Japan, and the SFTS viruses in Japan and China have evolved independently. Its fatality rate is 26.5 % in Japan, and the viral load is related to morbidity. Case description We encountered two patients with SFTS. Case 1 is a 72-year-old woman who visited our hospital owing to severe fatigue, diarrhea, and nausea. Her consciousness level score on the Glasgow Coma Scale was 14 points, and her serum lactate dehydrogenase level was 646 IU/L. Case 2 is an 82-year-old woman who visited our hospital owing to diarrhea and general fatigue. Her consciousness level score on the Glasgow Coma Scale was 11 points, and her serum lactate dehydrogenase level was 935 IU/L. Discussion and evaluation Both patients had hemophagocytic syndrome and presented with similar symptoms. Although both were treated with similar drug regimens, their clinical courses were different: after treatment, the 72-year-old woman survived whereas the 82-year-old woman died. In addition to age, the two patients differed in terms of time between symptom onset and treatment initiation, consciousness level, viral load, and extent of elevation of liver enzyme levels. Conclusions The viral load, which is a predictor of morbidity, was associated with the level of consciousness and the serum lactate dehydrogenase level, both of which might be useful for predicting death in patients with SFTS.