Impact of Type 2 Diabetes and Glycated Hemoglobin Levels Within the Recommended Target Range on Mortality in Older Adults With Cognitive Impairment Receiving Care at a Memory Clinic: NCGG-STORIES

OBJECTIVE

To determine the impact of type 2 diabetes and glycated hemoglobin (HbA1c) levels within the recommended target range according to the Japan Diabetes Society/Japan Geriatrics Society Joint Committee on mortality in older adults with cognitive impairment.

RESEARCH DESIGN AND METHODS

This retrospective cohort study included 1,528 and 468 patients aged ≥65 years without and with type 2 diabetes, respectively, who were visiting a memory clinic. The 468 patients with type 2 diabetes were divided into three groups (within, above, and below the target range) based on their HbA1c levels, cognitive function, ability to perform activities of daily living, and medications associated with a high risk of hypoglycemia. The impact of diabetes and HbA1c levels on mortality was evaluated using Cox proportional hazards models.

RESULTS

Over a median follow-up period of 3.8 years, 353 patients (17.7%) died. Compared with individuals without type 2 diabetes, HbA1c levels above (hazard ratio [HR] 1.70, 95% CI 1.08-2.69) and below (HR 2.15, 95% CI 1.33-3.48) the target range were associated with a higher risk of death; however, HbA1c levels within the target range were not (HR 1.02, 95% CI 0.77-1.36).

CONCLUSIONS

HbA1c levels above and below the target range were associated with a higher risk of mortality, whereas patients with HbA1c levels within the target range did not exhibit a higher risk of mortality than individuals without type 2 diabetes. These results provide empirical support for the current target ranges among older adults with cognitive impairment.

Behavioral and psychological symptoms of dementia and mortality risk among people with cognitive impairment: an 8-year longitudinal study from the NCGG-STORIES

BACKGROUND

Behavioral and psychological symptoms of dementia (BPSD) are common among people with dementia from the early stages and can appear even in mild cognitive impairment (MCI). However, the prognostic impact of BPSD is unclear. This study examined the association between BPSD and mortality among people with cognitive impairment.

METHODS

This longitudinal study involved 1,065 males and 1,681 females (mean age: males = 77.1 years; females = 78.6 years) with MCI or dementia diagnosis, from the National Center for Geriatrics and Gerontology-Life Stories of People with Dementia (NCGG-STORIES), a single-center memory clinic-based cohort study in Japan that registered first-time outpatients from 2010-2018. Information about death was collected through a mail survey returned by participants or their close relatives, with an up to 8-year follow-up. BPSD was assessed using the Dementia Behavior Disturbance Scale (DBD) at baseline.

RESULTS

During the follow-up period, 229 (28.1%) male and 254 (15.1%) female deaths occurred. Cox proportional hazards regression analysis showed that higher DBD scores were significantly associated with increased mortality risk among males, but not females (compared with the lowest quartile score group, hazard ratios [95% confidence intervals] for the highest quartile score group = 1.59 [1.11-2.29] for males and 1.06 [0.66-1.70] for females). Among the DBD items, lack of interest in daily living, excessive daytime sleep, and refusal to receive care had a higher mortality risk.

CONCLUSIONS

The findings suggest a potential association between BPSD and poor prognosis among males with cognitive impairment.

Decision-making involvement and onset of cognitive impairment in community-dwelling older care recipients: a 2-year longitudinal study

BACKGROUND

The decision-making of older adults and people with dementia is attracting more attention among healthcare professionals. While cognitive impairment has been examined as a factor related to decision-making, it can also be assumed that involvement in decision-making leads to the maintenance of cognitive function. This study examined the association of the decision-making process with the onset of cognitive impairment.

METHODS

We analyzed data from a 2-year longitudinal panel survey of community-dwelling care recipients aged ≥65 years in Japan. The sample included 406 participants who responded to both baseline and follow-up surveys, were cognitively intact at baseline, and had no missing cognitive impairment data regarding onset at follow-up. The status of decision-making involvement was assessed using a single item and classified into four categories: 'very involved,' 'less involved,' 'unclear about desired care,' and 'having no one to share the decision.'

RESULTS

Among the participants (women, 65.0%; ≥75 years old: 68.2%), the incidence of cognitive impairment during the follow-up was 26.6%. Multivariable logistic regression showed that, compared with highly involved participants, those who lacked clarity about desired care were more likely to develop an onset of cognitive impairment (odds ratio: 5.49; 95% confidence interval: 1.63-18.54; P = 0.006).

CONCLUSION

Even among cognitively intact care recipients, those who are not able to formulate their desired care may be at risk of cognitive decline. Therefore, support for the decision-making process, not limited to the final decision, is essential to improving the prognosis of community-dwelling care recipients.

Development of a short form of the Japanese version of the Caregiver Reaction Assessment (CRA-J-10) among informal caregivers of older adults

AIM

To support informal caregivers, a simple assessment tool capturing the multidimensional nature of caregiving experiences, including negative and positive aspects, is required. We developed a short form of the Japanese version of the Caregiver Reaction Assessment (CRA-J), a multidimensional assessment scale for caregiver experiences.

METHODS

The internet survey involved 934 Japanese informal caregivers aged 20-79 years (mean age = 58.8 years; 50.2% women) who completed questionnaires, including the CRA-J 18 items (CRA-J-18), consisting of five domains, such as impacts on schedule and finances and positive experiences of caregiving. A 10-item short version of the CRA-J (CRA-J-10; 0-50 points), which was prepared by selecting the two items with the highest factor loadings from each domain, was tested for model fit by confirmatory factor analysis (CFA) and was analyzed for correlations with the CRA-J-18, Zarit Burden Interview (ZBI), Positive Aspects of Caregiving Scale (PACS), Patient Health Questionnaire-9 (PHQ-9), and WHO-Five Well-Being Index (WHO-5). The area under the curve (AUC) in the receiver operating characteristic was evaluated as discriminability for depressive symptoms (PHQ-9 ≥ 10 points).

RESULTS

The CFA indicated a good model fit in the CRA-J-10. The CRA-J-10 correlated well with the CRA-J-18 and other variables (CRA-J-18, r = 0.970; ZBI, r = 0.747; PACS, r = -0.467; PHQ-9, r = 0.582; WHO-5, r = -0.588) and showed good discriminant performance for the presence of depressive symptoms (AUC = 0.793, 95% confidence interval = 0.762-0.823).

CONCLUSIONS

The CRA-J-10 allows a simple assessment of caregiver experiences, helping support informal caregivers. Geriatr Gerontol Int 2024; 24: 290-296.

Relationship between mortality and vitality in patients with mild cognitive impairment/dementia: An 8-year retrospective study

AIM

The study aimed to investigate the association of vitality, as measured using the vitality index (Vix), with the survival outcomes of older adults with mild cognitive impairment (MCI) or dementia.

METHODS

We analyzed data from 3731 patients in the National Center for Geriatrics and Gerontology - Life Stories of Individuals with Dementia cohort from July 2010 to September 2018. The main focus was to correlate Vix scores with the time from the initial visit to death. Vix was categorized into "moderately to severely impaired" (0-7 points), "mildly impaired" (8-9 points), and "normal" (10 points) groups. Survival outcomes were assessed using a Cox proportional hazards model, adjusted for various factors. We conducted a mediation analysis to evaluate the effect of body mass index (BMI), instrumental activities of daily living (IADL), and basic activities of daily living (BADL) on the association between vitality and mortality. Stratified analysis was also conducted for the Mini-Mental State Examination groups.

RESULTS

We included 2740 patients with an average follow-up of 1315 days. The mortality rate was 15.7%. The Vix distribution was 16% at 0-7 points; 40%, 8-9 points; and 44%, 10 points. Patients in the "moderately to severely impaired" category, characterized by lower Vix scores, exhibited notably higher mortality rates. Mediation effects emphasized the significant roles of BMI, IADL, and BADL in influencing survival outcomes.

CONCLUSIONS

Vitality significantly influences patient survival rates. The association between vitality and mortality seems to be mediated by IADL and BADL, which has significant clinical implications. Geriatr Gerontol Int 2024; 24: 221-228.

Role of Interacting and Learning Experiences on Public Stigma Against Dementia: An Observational Cross-Sectional Study

Background: Overcoming dementia stigma is a global challenge. Contact and education on dementia may be promising approaches for reducing public stigma; however, the current evidence is insufficient. This study examined the moderating factors associated with the public stigma against dementia, focusing on experiences of interacting with and learning about people with dementia. Methods: This cross-sectional study recruited 710 adults aged 20-69 years who were not involved in any medical or care work. Participants were recruited via a web-based questionnaire survey for a large internet survey agency's panel in Japan. In terms of the public stigma about dementia, four domains were assessed using a multidimensional assessment scale: personal avoidance, fear of labelling, person-centredness, and fear of discrimination. We compared the stigma scores according to the participants' experiences of interacting with people with dementia ('none', 'talking or activities together', or 'living together') and learning about dementia ('yes' or 'no'), adjusted for demographic and socioeconomic factors.Results: Compared with those without interaction experiences, those with experiences of talking or activities with people with dementia had lower personal avoidance (p = .001), fear of labelling (p = .026), and fear of discrimination (p = .031); those with experiences of living together with people with dementia had lower personal avoidance (p = .014) and fear of discrimination (p = .031). Compared with those without learning experiences related to dementia, those with such experiences had lower personal avoidance (p < .001) and higher person-centredness (p = .048).Conclusions: The findings suggest that the promotion of interaction with and learning about people with dementia may be important for addressing the public stigma.

Developing a predictive model for mortality in patients with cognitive impairment

OBJECTIVES

We developed a predictive model for all-cause mortality and examined the risk factors for cause-specific mortality among people with cognitive impairment in a Japanese memory clinic-based cohort (2010-2018).

METHODS

This retrospective cohort study included people aged ≥65 years with mild cognitive impairment or dementia. The survival status was assessed based on the response of participants or their close relatives via a postal survey. Potential predictors including demographic and lifestyle-related factors, functional status, and behavioral and psychological status were assessed at the first visit at the memory clinic. A backward stepwise Cox regression model was used to select predictors, and a predictive model was developed using a regression coefficient-based scoring approach. The discrimination and calibration were assessed via Harrell's C-statistic and a calibration plot, respectively.

RESULTS

A total of 2610 patients aged ≥65 years (men, 38.3%) were analyzed. Over a mean follow-up of 4.1 years, 544 patients (20.8%) died. Nine predictors were selected from the sociodemographic and clinical variables: age, sex, body mass index, gait performance, physical activity, and ability for instrumental activities of daily living, cognitive function, and self-reported comorbidities (pulmonary disease and diabetes). The model showed good discrimination and calibration for 1-5-year mortality (Harrell's C-statistic, 0.739-0.779). Some predictors were specifically associated with cause-specific mortality.

CONCLUSIONS

This predictive model has good discriminative ability for 1- to 5-year mortality and can be easily implemented for people with mild cognitive impairment and all stages of dementia referred to a memory clinic.

Mortality Risks and Causes of Death by Dementia Types in a Japanese Cohort with Dementia: NCGG-Stories

BACKGROUND

Prognosis-related information regarding dementia needs to be updated, as changes in medical and long-term care environments for patients with dementia in recent decades may be improving the prognosis of the disease.

OBJECTIVE

We aimed to investigate the mortality, cause of death, and prognostic factors by types of dementia in a Japanese clinic-based cohort.

METHODS

The National Center for Geriatrics and Gerontology-Life Stories of People with Dementia consists of clinical records and prognostic data of patients who visited the Memory Clinic in Japan. Patients who attended the clinic between July 2010 and September 2018, or their close relatives, were asked about death information via a postal survey. A cohort of 3,229 patients (mean age, 76.9; female, 1,953) was classified into six groups: normal cognition (NC), mild cognitive impairment (MCI), Alzheimer's disease (AD), vascular dementia, dementia with Lewy bodies (DLB), and frontotemporal lobar degeneration. A Cox proportional hazards model was employed to compare the mortality of each type of dementia, MCI, and NC.

RESULTS

Patients with all types of dementia and MCI had higher mortality rates than those with NC (hazard risks: 2.61-5.20). The most common cause of death was pneumonia, followed by cancer. In the MCI, AD, and DLB groups, older age, male sex, and low cognitive function were common prognostic factors but not presence of apolipoprotein E ɛ4 allele.

CONCLUSION

Our findings suggest important differences in the mortality risk and cause of death among patients with dementia, which will be useful in advanced care planning and policymaking.

CHANGES IN LIFE SATISFACTION DURING THE FIRST YEAR OF THE COVID-19 PANDEMIC: A LONGITUDINAL STUDY OF JAPANESE ADULTS

The outbreak of the novel coronavirus (COVID-19) has exerted a major impact on daily life. Despite older adults being at a higher risk of severe illness from COVID-19, research has indicated that older adults experienced the same or even higher levels of well-being during the early phase of the pandemic than younger adults. To investigate adverse long-term effects, we examined how individuals’ well-being changed during the first year of the pandemic. A total of 5,281 Japanese adults aged 15—89 years participated in an online survey in February 2020 (before the first state of emergency) and were followed up in March 2021 (during the second state of emergency; follow-up rate 54.7%). Well-being was assessed as a one-item indicator of life satisfaction, with a range of 0－10. Counterintuitively, results of a latent change score model demonstrated that life satisfaction increased over time (unstandardized coefficient of 1.17, SE = 0.16, standardized coefficient of 0.58). Individuals aged 64 years and below, with low levels of education, living alone, and perceiving worse health and economic status showed less increase in life satisfaction. In an additional analysis, those more concerned about the pandemic at follow-up displayed less increase. The findings suggest that most people did not exhibit a decrease in life satisfaction during the first year of the COVID-19 pandemic. However, certain individuals could be vulnerable to the outbreak due to the lack of resources. Researchers should better understand the factors that drive the resilience of older adults in the face of adversity.

INVOLVEMENT IN CARE DECISION-MAKING AND ADVERSE OUTCOME ONSET IN COMMUNITY-DWELLING CARE RECIPIENTS IN JAPAN

The involvement of older adults in care decision-making may enhance their daily life motivation and quality of life. Furthermore, it could contribute to their better prognosis in long-term care. We examined the association between decision-making involvement and the onset of adverse outcomes, such as institutionalization and death, among older adults under long-term care. This study used two-year longitudinal survey data of Japanese community-dwelling care recipients aged 65 and above. The participants were followed regarding the onset of institutionalization and deaths. The status of involvement in decision-making was assessed based on one item and the selection among the following response options: “very much involved,” “fairly involved,” “not very involved,” “never involved,” “unclarified wishes,” and “absence of person supporting decision-making.” A multivariable logistic regression analysis estimated the odds ratios (OR) and 95% confidence intervals (CI) for the onset of adverse outcomes, composite of institutionalization and death. A total of 707 participants with no severe cognition disabilities (MMSE>12) and no missing variables at the baseline were included and responded to the follow-up survey. At the baseline, 36.5% reported being very much involved in decision-making. The onset of adverse outcomes was observed in 17.5% of participants (institutionalization, 5.1%; death, 12.4%). Compared to those with very high involvement in decision making, those who were not involved were more likely to have adverse events, even after adjusting for covariates (OR=2.86 [95% CI: 1.21-6.76], p=0.016). Our findings show the importance of decision-making involvement in daily care regarding better prognoses in long-term care.

INTERACTIONS WITH PEOPLE WITH DEMENTIA, LEARNING EXPERIENCES, AND PUBLIC STIGMA AGAINST DEMENTIA

Overcoming stigma around dementia is a global challenge. This cross-sectional study examined the association of experiences of interacting with people with dementia (PwD) and learning about dementia, with the public-stigma against dementia. We recruited—via an internet survey—710 Japanese adults (mean age = 46.3 years; 49.3% females) without any medical or welfare license, or dementia-related work experience. Public-stigma against dementia was assessed using the Japanese version of Phillipson et al.’s scale (2012) exploring dementia-related attitudes in the context of “personal avoidance,” “person centeredness,” “fear of labeling,” and “fear of discrimination.” Multivariable linear regression analysis was employed to examine the association of interacting with PwD and learning regarding dementia as explanatory variables with dementia stigma score, adjusting for sociodemographic variables. Regarding interactions with PwD, talking or activities with PwD were associated with low “personal avoidance” (β = -1.47, p = 0.002), “fear of labeling” (β = -0.96, p = 0.020), and “fear of discrimination” (β = -0.396, p = 0.043). Experiences of living with PwD were associated with low “personal avoidance” (β = -2.35, p = 0.002) and “fear of discrimination” (β = -0.789, p = 0.013). Learning experiences at school regarding dementia were associated with low “personal avoidance” (β = -4.01, p &lt; 0.001), and self-learning experiences were associated with low “personal avoidance” (β = -1.73, p = 0.049) and high “person centeredness” (β = 1.27, p = 0.037). However, workplace learning was not associated with any area. Interacting with PwD and learning about dementia might reduce associated public-stigma.

The role of social resources and trajectories of functional health following stroke

Stroke is a major cause of disability in old age. Research has revealed that social resources available after the onset of stroke can mitigate functional prognosis. However, most studies have conceptualized resources as static rather than dynamic and have not measured changes in social resources from the pre-to post-stroke periods. To better understand the recovery process following stroke, we examined how social resources available before its onset and changes from pre-to post-stroke were associated with trajectories of functional health following stroke. Data were derived from an up to 19-year longitudinal study of a nationally representative sample of Japanese adults aged 60 years and older. We identified 389 people who experienced self- or proxy-reported first stroke during follow-up (age at stroke onset: M = 75.9, SD = 6.8; 49.1% women). The average number of observations was 4.6 (SD = 1.6, range 2-7). Functional health was measured with self- or proxy-reported basic and instrumental activities of daily living. Social resources were indexed as residential status, contact with own non-coresident children, social participation, and perceived support. Analyses were adjusted for age at stroke onset, sex, education, health condition, and cognitive function. A multiphase growth model indicated that individuals who participated more frequently in social groups prior to stroke exhibited less functional deterioration post-stroke than those who participated less frequently. Whereas contact frequency with non-coresident children typically declined following stroke, the analysis further revealed that individuals who maintained contact frequency from pre-to post-stroke showed less steep functional decline over time in the post-stroke period despite minor individual differences. We found that social resources before stroke onset and changes in the resources following stroke may play a protective role against adverse prognoses. Inclusive communities may help older adults remain independent even after serious health events.

Establishment of the Japanese version of the dementia stigma assessment scale

Aim

Reducing stigma against dementia is a global challenge, but the assessment scale is not well established. We examined the validity and reliability of the Japanese version of the assessment scale of public stigma against dementia.

Methods

This study recruited 819 adults aged 20–69 years (mean age = 45.9 years; 52.0% females) through an internet survey, and 34 community‐dwelling adults aged 20–78 years (mean age = 45.8 years; 55.9% females). Participants completed the Japanese version of the assessment scale of dementia stigma developed by Phillipson et al., with forward and back translations. In the internet survey sample, exploratory factor analysis was performed to verify factorial validity, and correlations with ageism and dementia attitudes were examined to test the concurrent validity. In the community sample, test–retest reliability was evaluated using intraclass correlation coefficients (ICCs) between two responses with a two‐week interval.

Results

Factor analysis revealed a four‐factor structure: “personal avoidance,” “fear of labeling,” “person centeredness,” and “fear of discrimination” (Cronbach's α = 0.892, 0.840, 0.879, 0.829, respectively). Personal avoidance, fear of labeling, and fear of discrimination were positively correlated with ageism (r = 0.598, 0.214, 0.369) and negatively correlated with dementia attitudes (r = −0.745, −0.453, −0.475); person centeredness was inversely correlated with ageism (r = −0.322), but positively correlated with dementia attitudes (r = 0.537), showing good concurrent validity. The scale showed acceptable test–retest reliability (ICCs = 0.67–0.80).

Conclusions

The Japanese version of the assessment scale of public stigma against dementia was established with good concurrent validity and adequate reliability. Geriatr Gerontol Int 2022; 22: 790–796.

Art and cultural activity engagement and depressive symptom onset among older adults: A longitudinal study from the Japanese Gerontological Evaluation Study

OBJECTIVES

Art and cultural activities can benefit mental health. However, there is insufficient evidence on active engagement in art and cultural activities for preventing depressive symptoms among older adults. Therefore, we examined the association of active engagement in art and cultural activities with depressive symptom onset among older adults using 3-year longitudinal data.

METHODS

This longitudinal study recruited non-institutionalised older adults independent in daily living from the Japan Gerontological Evaluation Study (JAGES) established in 2010, and those without depressive symptoms were followed for three years. Depressive symptoms were assessed using the 15-item Geriatric Depression Scale. Active engagement in nine art and cultural activities, including Japanese traditional cultural activities, were evaluated (musical performance, singing, dancing, handicrafts, painting, photography, poetry composition, calligraphy, and tea ceremony/flower arrangement).

RESULTS

Ultimately, 37,627 older adults without depressive symptoms at baseline were analysed. The participants' mean age (standard deviation) was 72.6 (5.5) years, and 51.5% were female. During the follow-up period, depressive symptoms occurred in 3844 participants (10.2%). Multivariable logistic regression analysis revealed that active engagement in art and cultural activities was inversely associated with depressive symptom onset (odds ratio = 0.80, 95% confidence interval = 0.73-0.87, p < 0.001). This association was confirmed regardless of age, gender, and socioeconomic status. Among the activities, especially dancing and photography were protective against depressive symptoms.

CONCLUSION

Active engagement in art and cultural activities may contribute to preventing depressive symptoms among older adults. Promoting art and cultural engagement could be important to protect their mental health.

Aging-in-place preferences and institutionalization among Japanese older adults: a 7-year longitudinal study

Background

In Asia, where autonomous decision-making is not well accepted, little is known about whether and how individuals’ preferences are considered when deciding where they receive care. This study examined whether individuals preferring to age in place if confined to bed were less likely to be institutionalized, using longitudinal data of Japanese older adults.

Methods

We analyzed nationally representative data of 1,290 community-dwelling older adults aged 70 and above. Baseline data were collected in 1999, shortly before the long-term care insurance system was introduced. The outcome was measured as self- or proxy-reported years of institutionalization over seven years. The explanatory variable was whether individuals preferred to age in place if they were confined to bed. Participants were asked about their desired place of care (facility, home, or other) if confined to bed. Covariates were sociodemographic and health-related factors. We used Cox proportional hazards models and calculated hazard ratios (HRs) with 95% confidence intervals (CIs) to evaluate the association of aging-in-place preferences if confined to bed with institutionalization. We applied multiple imputation to deal with missing data.

Results

Seventy-eight respondents (6.0%) were institutionalized during the follow-up period. Compared to individuals preferring to reside in long-term care facilities if confined to bed (48.7%), those preferring to stay in their homes (39.6%) were less likely to be institutionalized, even after adjusting for relevant covariates (HR = 0.47, 95% CI 0.27–0.79 for model 1 including residential status; HR = 0.45, 95% CI 0.27–0.76 for model 2 including marital status and co-resident children).

Conclusions

Our findings suggest that individuals’ aging-in-place preferences tend to be considered under the long-term care insurance system. Individuals’ preferences should be shared with families and clinicians when deciding the place of care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-02766-5.

Trajectories of Functional Health Following Stroke: The Role of Social Resources

Stroke is one of the major causes of disability in old age. Predictors for the functional prognosis have been studied, but the role of social resources in recovery has not studied as much. We examined whether social resources available before and after stroke onset improved functional prognoses. Data was derived from longitudinal data collected between 1987 and 2006 from Japanese adults aged 60 years and older. We identified 396 people who had experienced their self- or proxy-reported first stroke during follow-up (age at stroke onset: M = 76.0, SD = 6.9; 74.2% women). Functional health was measured by self- or proxy-reported activities of daily living. Social resources were indexed as residential status, contact with non-coresident children, social participation, and perceived support. Analyses were adjusted for age at stroke onset, gender, and education. A multiphase growth model showed that functional health typically deteriorated surrounding stroke and gradually declined thereafter. There were also individual differences in the trajectories of functional health. Individuals who more frequently participated in social groups prior to stroke and those who came to participate more frequently thereafter exhibited less functional decline immediately following stroke. Our findings indicate that social participation plays a protective role against adverse prognoses following stroke regardless of when individuals start participating. Inclusive communities would enable older adults to remain independent. Our study was limited in that crucial information about stroke, such as objective measures of initial severity, was not available and that individuals with more severe stroke may have dropped out after the onset.

Involvement in Decision-Making for Daily Care and Cognitive Decline among Older Adults Who Need Care in Japan

Effective decision-making regarding daily care for older adults with needs could reduce the risk of dementia by preventing loss of motivation and improving care quality. However, empirical studies are scarce, particularly in non-Western countries with different socio-cultural backgrounds. By using 2-year longitudinal data of older Japanese adults aged 65 years and above who were receiving care at home, as well as of their family caregivers, we examined the association of involvement in decision-making with the onset of cognitive decline among older Japanese adults requiring care. The analysis included 219 cases of individuals with normal cognition and no missing variables at baseline and responded to the follow-up survey. An MMSE score of 23 or lower at follow-up was defined as the onset of cognitive decline. The level of involvement in decision-making was assessed by one item and dichotomized (not involved/involved). The covariates were age, gender, education, MMSE score, eligibility level for long-term care, and others at baseline. At baseline, 67.1% were 75 years or older, 58.9% were female, and 91.8% responded being “involved” in the decision-making. The incidence of cognitive decline at follow-up was 30.6%. The multivariable logistic regression analysis showed that involvement in decision-making (OR=0.298 [95% CI: 0.10-0.88], p=0.029) was negatively and significantly associated with the onset of cognitive decline. Our findings show the importance of involvement in the decision-making for daily care to reduce the risk of subsequent cognitive decline in older adults requiring care, even in a culture of familism.

Peripartum type B aortic dissection in patients with Marfan syndrome who underwent aortic root replacement: a case series study

OBJECTIVE

To investigate pregnancy outcomes, especially the risk of pregnancy-related aortic dissection (AD), in patients with Marfan syndrome (MFS) after prophylactic aortic root replacement (ARR).

DESIGN

Retrospective case series study.

SETTING

Tertiary perinatal care centre at a university hospital.

POPULATION

Pregnant women fulfilling the revised Ghent nosology (2010) criteria for MFS who were managed at our institute.

METHODS

The pregnancy outcomes of all patients with MFS managed at our institute between 1982 and September 2016 were reviewed retrospectively based on medical records.

MAIN OUTCOME MEASURES

Obstetrical management and complication including the incidence of AD throughout the peripartum period.

RESULTS

Among 22 patients (28 pregnancies) who had been managed as potential MFS or related disorders, 14 (17 pregnancies) fulfilled the revised Ghent nosology (2010) criteria for MFS and were enrolled in this study. Five patients (five pregnancies) had received ARR before conception: three (60%) developed type B aortic dissection [AD(B)] during the peripartum period, compared with only one of 10 patients (12 pregnancies) without ARR (P < 0.05, Chi-square test).

CONCLUSIONS

Our study results suggest that MFS patients after prophylactic ARR are still at high risk of AD(B) during the peripartum period. Careful pre-pregnancy counselling and multidisciplinary care throughout the peripartum period are essential for the management of MFS, even after surgical repair of an ascending aortic aneurysm.

TWEETABLE ABSTRACT

MFS patients after prophylactic ARR are still at high risk of type B aortic dissection during the peripartum period.

Subunit-specific and homeostatic regulation of glutamate receptor localization by CaMKII in Drosophila neuromuscular junctions

For the efficient transfer of information across neural circuits, the number of synaptic components at synapses must be appropriately regulated. Here, we found that postsynaptic calcium/calmodulin dependent protein kinase II (CaMKII) modulates the localization of glutamate receptors (GluRs) at Drosophila larval neuromuscular junctions (NMJs). Expression of an inhibitory peptide of CaMKII, Ala, in muscle cells enhanced the density of GluRIIA, which is a major and calcium-permeable subunit of GluR, at synapses of third instar larval NMJs. On the other hand, postsynaptic expression of a constitutively active form of CaMKII (T287D) reduced synaptic GluRIIA. These results suggest that CaMKII regulates GluRIIA at NMJs. Moreover, postsynaptic expression of T287D abolished the accumulation of the scaffolding protein discs large (DLG) at synapses, while exerting no significant effects on the presynaptic area and the localization of cell adhesion molecule fasciclin II (FasII). The amplitude of excitatory junctional potentials (EJPs) was enhanced in Ala-expressing larvae, whereas it was unaffected in T287D-expressing larvae in spite of the prominent loss of GluRIIA. The amplitude of miniature EJPs (mEJPs) was significantly reduced and quantal content was significantly increased in T287D-expressing larvae. Notably, another class of GluR containing GluRIIB was enhanced by the postsynaptic expression of T287D. These results suggest that the homeostatic mechanism in T287D larvae works to maintain the level of synaptic responses. Thus, the Drosophila larval NMJs have several regulatory systems to ensure efficient muscle excitability which is necessary for proper larval movement.

Bioactivation of titanium surfaces using coatings of TiO(2) nanotubes rapidly pre-loaded with synthetic hydroxyapatite

Apatite depositions from simulated body fluid (SBF) have been widely used for the in vitro assessment of the bioactivity of bone- and dental-implant materials. In previous work, we reported that titanium-based implant materials can be coated with an anodic TiO(2) nanotube layer which can significantly stimulate apatite formation. In the present work, we demonstrate that the tubular nature of such coatings makes them highly suitable for the application of a treatment called "alternative immersion method (AIM)", which preloads the coatings with synthetic hydroxyapatite. This treatment is indeed found to additionally promote natural apatite formation significantly. To study the AIM effect, layers of nanotubes with various diameters and crystal structures (amorphous, anatase/rutile) were produced, AIM-treated, and the formation of apatite in SBF10 (10mmol1(-1) HCO(3)(-)) was evaluated. The results show a drastic enhancement of apatite deposition rates (in some cases >20-fold acceleration) for AIM-treated TiO(2) nanotube layers in comparison with non-treated TiO(2) surfaces.

Presence of functional domains in NADPH-dependent cytosolic 3,5,3'-Triiodo-L-thyronine (T3)-binding protein (p38CTBP) molecule: analyses with deletion mutants

Functional domains required for NADPH-binding, T(3)-binding, protein dimerization and cytosolic retention were analyzed in NADPH-dependent cytosolic 3,5,3'-triiodothyronine (T(3))-binding protein (p38CTBP) by using the deletion mutants. Wild-type p38CTBP (amino acids; 1-314) and a series of deletion mutants (amino acids; 1-79, 1-128, 1-146, 1-216, 37-314, and 1-145 with 270-314) were bacterially induced. NADPH-dependent T(3)-binding activity was not observed in all mutant p38CTBPs studied, although wild-type p38CTBP showed high-affinity T(3)-binding activity. Wild-type p38CTBP was able to bind a CL-6B column, none of the mutant p38CTBPs showed any binding activity. Pull-down analyses demonstrated that two regions between amino acid 128 and 146, and between 216 and 270, both of which possess helical structures, were required for homodimeric p38CTBP binding. In fluoroscopic studies, GFP-tagged p38CTBP was preferentially observed in cytoplasm. However, C-terminal region-deleted p38CTBP(1-216) was not only observed in cytoplasm, but also in nucleus. These results suggest that 1) multiple regions in p38CTBP molecule are required for T(3)-binding and NADPH binding, 2) two helical structures in p38CTBP molecule may be important in the homodimer formation, and 3) C-terminal region of p38CTBP contains the function to preserve the protein in cytoplasm.

Cloning and expression of CitPDS1, a gene encoding phytoene desaturase in citrus

A cDNA clone encoding phytoene desaturase (PDS) was isolated from citrus (Citrus unshiu Marc.). The transcript of the isolated PDS (CitPDS1) was not detected by conventional RNA gel-blot analysis; instead, it was detected by a sensitive reverse transcription-PCR (RT-PCR). The CitPDS1 transcript in the juice sacs/segment epidermis (edible part) was at a low level in the young fruit, and it increased toward maturation like citrus phytoene synthase (CitPSY1). In the peel, in contrast to CitPSY1, the transcript of which was induced toward maturation, the level of the CitPDS1 transcript remained constant after an increase in July, indicating non-coordinate regulation of CitPDS1 and CitPSY1 in the peel.

Structure, expression, and conserved physical linkage of mouse testicular cell adhesion molecule-1 (TCAM-1) gene

Isolation and characterization were performed for cDNA encoding mouse testicular cell adhesion molecule-1 (TCAM-1) using 2908 bases coding for a protein having 548 amino acids (60 kDa). Mouse TCAM-1 protein was found to consist of seven domains for signal sequence, five immunoglobulin (Ig) domains, and the transmembrane plus cytoplasmic domain. TCAM-1 gene and the region linking it to growth hormone (GH) gene located downstream from the TCAM-1 gene were then analyzed. The mouse TCAM-1 gene was 11.6 kb in length with 8 exons; the same as for the 12.0 kb rat gene. The distance from the TCAM-1 to GH gene was 12.5 kb in the mouse genome, and 7.6 kb in the rat. By Northern hybridization, 3.1-kb TCAM-1 mRNA was detected in 17-day testis and would appear present in pachytene spermatocytes and round spermatids.

Selective inhibition of cyclooxygenase-2 with antisense oligodeoxynucleotide restricts induction of rat adjuvant-induced arthritis

The effects of cyclooxygenase (COX)-2 antisense oligodeoxynucleotide (ODN) in induction of adjuvant-induced arthritis were investigated. Female Lewis rats were injected with Mycobacterium butyricum intradermally at the base of tails to induce arthritis. Synthetic 18 mer phosphorothioate ODNs corresponding to the translation initiation site of rat COX-2 mRNA were prepared. The antisense (AS), sense (S), and "scrambled" (Sc) ODNs were intraperitoneally administered. Arthropathy was evaluated with arthritis score, paw edema, and histological examination. Expression of COX-1 and -2 protein and mRNA were examined with immunostaining and reverse-transcription polymerase chain reaction, respectively. COX-2 AS ODN significantly suppressed induction of arthritis in a dose-dependent manner without severe adverse effects, whereas S and Sc ODNs did not show significant inhibitory effects. COX-2 mRNA and protein expression were also suppressed only by COX-2 AS ODN without any alteration of COX-1 expression. These data suggest that selective inhibition of COX-2 with AS ODN may have a therapeutic potency in the treatment of rheumatoid arthritis.

A tyramine receptor gene mutation causes a defective olfactory behavior in Drosophila melanogaster

We characterized molecular profiles of a new olfactory mutant line, honoka (hono), which was found among 500 viable P-element insertion lines screened first by 5-bromo-4-chloro-3-indrolyl-beta-D-galactopyranoside (X-gal) staining on the third segment of the antenna, and then by behavioral assays to several pure chemicals. The behavioral responses of hono mutants to repellents such as ethyl acetate (EA), benzaldehyde (BZ) and 4-methylcycrohexanol (MCH), were reduced compared with those of a control strain. The location of the P-element insertion was determined to be about 100bp) upstream of the first exon of the tyramine receptor gene. The level of 3.6kb tyramine receptor mRNA expression was reduced in hono compared with that of wild-type flies. The tyramine receptor cDNA hybridized to the chromosomal division 79C-D, the same locus as the P-element insertion point in hono, and not to 99A-B, previously reported by Arakawa et al. (1990. Neuron 2, 343-354). Electrophysiological responses to octopamine and tyramine were examined by measuring the excitatory junctional potential (EJP) amplitude from larval body-wall muscles of the hono mutant. The hono was impaired with responding to tyramine, while displaying normal response to octopamine. These results indicate that tyramine has a functional role in the Drosophila olfactory system as a neurotransmitter or a neuromodulator, and hono is the first tyramine receptor mutant. This study provides the first step toward understanding of the molecular genetics of tyramine-mediated neural functions in Drosophila.

Molecular cloning of a homologue of dad-1 gene in citrus: distinctive expression during fruit development

A cDNA homologue to the human defender against apoptotic death gene (dad-1), which is involved in programmed cell death, was isolated from satsuma mandarin (Citrus unshiu Marc.) fruit. It (Citdad-1-1) was 345 bp long, with a deduced protein sequence of 115 amino acids. Southern hybridization suggests that dad-1-related sequences are present as a small gene family in the citrus genome. Expression of Citdad-1-1 was progressively down-regulated in leaves as they matured, but not in juice sac/segment epidermis (edible part) towards fruit ripening. The role of dad-1 during citrus development is also discussed.

Neural expression of hikaru genki protein during embryonic and larval development of Drosophila melanogaster

Hikaru genki (HIG) is a putative secreted protein of Drosophila that belongs to immunoglobulin and complement-binding protein superfamilies. Previous studies reported that, during pupal and adult stages, HIG protein is synthesized in subsets of neurons and appears to be secreted to the synaptic clefts of neuron-neuron synapses in the central nervous system (CNS). Here we report the analyses of distribution patterns of HIG protein at embryonic and larval stages. In embryos, HIG was mainly observed in subsets of neurons of the CNS that include pCC interneurons and RP5 motorneurons. At third instar larval stage, this protein was detected in a limited number of cells in the brain and ventral nerve cord. Among them are the motorneurons that extend their axons to make neuromuscular junctions on body wall muscle 8. Immunoelectron microscopy showed that these axonal processes as well as the neuromuscular terminals contain numerous vesicles with HIG staining, suggesting that HIG is in a pathway of secretion at this stage. Some neurosecretory cells were also found to express this protein. These data suggest that HIG functions in the nervous system through most developmental stages and may serve as a secreted signalling molecule to modulate the property of synapses or the physiology of the postsynaptic cells.

Cloning and expression analysis of vacuolar H+-ATPase 69-kDa catalytic subunit cDNA in citrus (Citrus unshiu marc.)1

To investigate the mechanism of sugar accumulation in fruit vacuoles, a full length cDNA (CitVATP-A) encoding the vacuolar H+-ATPase 69-kDa catalytic subunit was isolated from a cDNA library constructed from citrus fruit (Citrus unshiu Marc.). A 2304-bp insert of CitVATP-A was coded for a 623 amino acid polypeptide with a predicted molecular mass of 68.68 kDa. The deduced amino acid sequence for CitVATP-A showed a 96.5% homology with the carrot homologue. Genomic Southern blot analysis suggested that CitVATP-A is a low-copy number gene. Northern blot analysis of leaves and fruits during the developing stages showed that the level of expression is high in young leaves and is low in mature leaves, and that it increased in both the edible parts and the peel, during fruit growth and maturity.

[Hansen's disease and nephropathy as its sequence]

Nephropathy as the sequences of Hansen's disease before and after the introduction of chemotherapy was compared referring to the report by Hayashi in 1943 and the summary of the autopsy reports from 1978 to 1981 at National Hansen's disease hospital Zenseien. Unlike the high rates of tuberculosis as the cause of death before the introduction of chemotherapy (41.3%) those thereafter decreased to be negligible. On the other hand the comparison of the rates of nephropathy with the same way as that of tuberculosis was impossible since the description about nephropathy by Hayashi was not sufficient to characterize each nephropathy since he included arteriolitis, glomerulonephritis and interstitial nephritis together in the term of nephritis. Death rate due to nephritis among Hansen's disease patients according to Hayashi at that time was 21.2% which was twice as many comparing to that in the other cases. According to the report about the cases of Zenseien those reported to have glomerulonephritis was 37.3% though those were not necessarily listed as the cause of death. Also the nephropathy including fibrinoid angitis with occasional microaneurysmal dilatation of afferent arteries, glomerulitis, sclerosis and stricture of efferent arteries likewise ischemic acute tubular necrosis possibly as the result of these angiopathy seemed to be present. These vascular changes partially resemble to that of microscopic periarteritis nodosa but seems to be common in the smaller arteries. In conclusion, unlike the case of tuberculosis the rate of nephritis including glomerulitis, arteriolitis and interstitial nephritis as Hayashi used as his criteria does not seem to have decreased. Therefore, the critical analysis of the nephropathy especially of that relating to the arteriolitis should be done to obtain the knowledge to suppress its occurrence.

Genetic dissection of sexual behavior in Drosophila melanogaster

Mating of Drosophila melanogaster is a sterotypically patterned behavior consisting of a fixed sequence of actions that are primarily under genetic control. Mutations that disrupt specific aspects of mating activities offer a starting point for exploring the molecular machineries underlying sexual behavior. Several genes, identified as causing aberrant sexual behavior when mutated, have been isolated and cloned, providing molecular probes for expression and mosaic analyses that can be used in specifying the cells responsible for the behavior. This review presents current understandings of mating behavior obtained by such molecular and cellular approaches and provides an overview of future directions of research in behavioral genetics.

Cloning and molecular analysis of cDNAs encoding three sucrose phosphate synthase isoforms from a citrus fruit (Citrus unshiu Marc.)

Three partial cDNA clones (pSPS1, pSPS2 and pSPS3) encoding sucrose phosphate synthases (SPS) were isolated by Reverse Transcription (RT)-PCR using first-strand cDNA prepared from the leaf or fruit of citrus (Citrus unshiu Marc.). The nucleotide and deduced amino acid sequences of the three clones showed significant similarities to SPS previously isolated in other plants. A full-length, cDNA clone, CitSPS1, was isolated from a fruit (juice sacs and pulp segment) cDNA library using one (pSPS1) of the three partial clones as a probe. The 3539-bp CitSPS1 clone coded for a 1057-amino acid polypeptide with a predicted molecular mass of 117.8 kDa. The amino acid sequence deduced from the CitSPS1 clone showed homology with SPS from maize (55.8% identity) and spinach (74.0% identity). Genomic Southern blot analysis suggested that CitSPS1 clone represents a lowcopy-number gene. RNA blot analysis of leaf, flower and fruit showed that CitSPS1 and pSPS2 were expressed in all organs. However, the levels of expression of CitSPS1 in young leaves, flowers and immature fruits were low, but high in mature leaves, and fruit. pSPS2 transcripts were barely detectable in young leaves and immature fruits, low in mature leaves, and high in flowers and mature fruits. pSPS3 transcripts were only detected in young and in mature leaves.

A study of the development of atherosclerosis in childhood and young adults: risk factors and the prevention of progression in Japan and the USA. The Pathobiological Determinants of Atherosclerosis in Youth (PDAY) Research Group

Coronary heart disease (CHD), one of the prevalent results of atherosclerotic disease, has been a leading cause of death in many Western countries for several decades, and now is the second most prevalent cause of death in Japan. Thus attention must also be paid to atherosclerosis in Japan. While there has been a remarkable reduction in the mortality rate from CHD in some Western countries, an undesirable stabilized mortality rate has recently been reported by the government of Japan. This report emphasises the importance of preventing atherosclerosis at an early stage from the viewpoint of cardiovascular pathology, using evidence from statistical data derived from autopsied cases in Japan and the USA.

On the beta-glucuronidase binding protein (BGBP) of microorganisms. Its purification, the antiserum preparation against that and its localization in leproma and the other infectious lesions shown by immunohistologic method

Our previous studies suggested that M. leprae (ML) grow in peripheral nerves and lepra cells because ML metabolize hyaluronic acid (HA), and use its component for their growth by the aid of host enzyme combined to the bacilli derived beta-glucuronidase binding protein (BGBP). In this study, therefore, we examined the method to purify BGBP from a mycobacterium HI-75 originally separated from a leproma and cultured by modified Ogawa's medium containing split products of HA (glucuronic acid and N-acetylglucosamine). The distribution of BGBP in leproma and the other lesions consisting of hepatitis B virus infected liver and M. avium-intracellulare infected lung tissue were also immunohistologically examined. As the result, the best method to get BGBP was preparatory electrophoresis in the final step of the purification and not the molecular sieving. The BGBP was actually proven in leproma and the other infected tissues as described, indicating the abilities of these microorganisms to utilize the metabolic machinery of the host with the similar ways to that of ML.

Purification and characterization of two lectins from the sea cucumber Stichopus japonicus

Two Ca(2+)-dependent lectins were purified from the sea cucumber Stichopus japonicus by affinity chromatography on lactosyl-Sepharose 4B and ion-exchange chromatography on Q-Sepharose. Their molecular masses were estimated to be 13kDa (SJL-I) and 15 kDa (SJL-II) on SDS-PAGE. SJL-I agglutinated rabbit erythrocytes as well as human A, B, and O-type erythrocytes, but SJL-II agglutinated only rabbit erythrocytes. Hemagglutination by SJL-I was competitively inhibited by N-acetyl-D-galactosamine and galactose-containing carbohydrates. On the other hand, only lactose, melibiose, and raffinose gave weak inhibition of hemagglutination by SJL-II, suggesting that SJL-II may have high specificity for particular complex carbohydrate(s) on the surface of rabbit erythrocytes. SJL-II was activated at ten times lower Ca2+ concentration than SJL-I. Both lectins lost activity in acidic pH, while SJL-I appeared more stable down to pH 4.5.

[The interaction between neural activity and intracellular pH]

The regulation of intracellular pH (pH(i)) in the nervous system has been vigorously studied using a variety of animal cells in the last decade, through advances in techniques for measuring pH(i) accurately in living cells. These studies have elucidated the mechanisms of pH(i) regulation, such as intracellular buffering and acid transport across the cell membrane, in neurons and glial cells. Following an outline of pH(i) regulation, the interaction between neural activity and acid-base balance is discussed. The dynamic change of pH(i), produced by neural activity, and the effect of pH(i) on the electrical properties of neurons and other excitable cells is emphasized.

[Gross anatomical study of veins in the orbit]

The aim of this study is to clarify the major route of venous return in the orbit. Minute dissections were performed in 10 adult cadavers (5 males and 5 females) after being fixed in a 10% formalin solution. The superior ophthalmic vein (SOV) and its ascending anastomotic branch were consistently well-developed (the average maximum diameter: 6.2mm and 3.2mm, respectively) and these two veins formed the main venous channel from the orbital contents. The ascending anastomotic branch ran between the optic nerve and the medial rectus just behind the eyeball and joined the SOV. A large number of veins, including the inferior ophthalmic vein, which originated from the inferior contents of the orbit, drained into the ascending anastomotic branch. Arteries and/or nerves did not accompany their respective veins in the orbit, except for the lacrimal and ethmoidal veins. The posterior end of the SOV was severely narrowed lateral to the aponeurosis of the lateral rectus, while being conspicuously dilated just behind the eyeball. The above findings suggested that the dilated portion of SOV may act as a reservoir of the venous return of the orbit.

[Radiation therapy for unresected gastric lymphoma]

Six consecutive patients with unresected gastric lymphoma which were treated by radiation therapy between November, 1976 and March 1989 were reviewed. Radiation therapy was performed using involved fields, total radiation dosages of which ranged from 25.2 to 36 Gy (mean, 29.3 Gy). Five out of the 6 patients were treated with chemotherapy combined with radiation. Regimen of the chemotherapy was CHOP (cyclophosphamide, adriamycin, vincristine and prednisone) in most cases. Three out of the 6 underwent probe laparotomy, but the tumors were diagnosed as unresectable due to locally invading the adjacent structures. They were treated by chemo-radiotherapy and 2 of them are surviving as of the present study (40 and 116 months). The other 3 patients were diagnosed as with clinical stage IV disease and 2 of them were successfully treated with chemo-radiotherapy (21 and 66 months, surviving). These data suggest that unresected gastric lymphomas, which are locally advanced or stage IV disease, are treated by chemoradiotherapy with high curability without any serious complications.