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Keywords:

  • dementia;
  • medical psychiatry;
  • old age psychiatry;
  • physical complication;
  • psychogeriatrics

Abstract

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHODS
  5. RESULTS
  6. DISCUSSION
  7. REFERENCES

Background:  In the present study, we investigated the physical complications of elderly patients with senile dementia in the Department of Psychogeriatrics, Imaise Branch, Ichinomiya City Hospital.

Methods:  Physical complications that occurred in our ward in the 12 months from April 2007 to March 2008 were recorded. Our ward has 50 beds and, over the 12 months, the average occupation rate was approximately 90%. We subdivided physical complications into two categories: (i) serious emergencies occurring in the ward with a possible high risk of mortality within a few days (e.g. pneumonia and upper airway obstruction); and (ii) life-threatening complications arising in the ward that required diagnosis and treatment by specialists from other medical departments (e.g. bone fracture and cancer).

Results:  Serious emergencies with a high risk of mortality occurred 56 times. Six patients died. Life-threatening complications requiring diagnosis and treatment by specialists from other departments occurred 44 times. Both categories of physical complications in occurred at a high rate, with various types of diseases recorded.

Conclusions:  The present study confirms the high frequency of physical complications that require treatment in facilities for patients with senile dementia. It is necessary to diagnose and treat these various physical complications and to cooperate with specialists from other medical departments.


INTRODUCTION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHODS
  5. RESULTS
  6. DISCUSSION
  7. REFERENCES

Of the developed nations, Japan has the fastest aging population. The proportion of elderly people over 65 years of age in 2007 was 21.5% and this figure is expected to increase for several decades. The Ministry of Health, Labour and Welfare of Japan has estimated that there are currently approximately 1800 000 elderly people with dementia in Japan and that this number will increase to approximately 2500 000 by 2015 and 3500 000 by 2030 (see http://www.ipss.go.jp/).

Ichinomiya City is located in the Owari area of Aichi Prefecture in Central Japan, near metropolitan Nagoya. It has a population of approximately 380 000, with the 19.6% of the population over 65 years of age (see http://www.city.ichinomiya.aichi.jp/division/shimin/jinko/nenrei/2009/4.pdf).

The Imaise Branch of Ichinomiya City Hospital (IB-ICH) is a psychiatric hospital and the only facility with a ward for elderly patients with senile dementia (WED) in the Owari area. There are 50 beds in our WED, which proactively accepts patients with behavioral and psychological symptoms of dementia (BPSD) who have not responsed well to either pharmaceutical or non-pharmaceutical treatment.1–4

For example, on 1 February 2008, there were 27 men (61%) and 17 women (39%) in our WED. The average age of the patients was 76 years (men 75 years; women 76 years). There were 23 patients (52%) with Alzheimer's disease,5,6 six (14%) with vascular dementia,5,6 one (2%) with dementia with Lewy bodies,7 one (2%) with frontotemporal dementia,8 one (2%) with diffuse neurofibrillary tangles with calcification,9,10 two (5%) with mild cognitive impairment,11 two (5%) with dementia due to head injuries, two (5%) with Wernicke–Korsakoff syndrome, and six with other illnesses.

We also treat cases with serious physical complications in cooperation with other medical departments in Ichinomiya City Hospital (ICH), which is approximately a 5-min drive from IB-ICH (2 km).

Many studies suggest that physical complications are a common and serious problem in the elderly with senile dementia12–22 and although we previously reported on the state of the physical complications in our WED,18 there is very little concrete information available in the literature.

In the present study, we investigated the frequency and type of physical complications that occured in WED in the IB-ICH over a 12-month period to estimate the importance of diagnosing and treating physical complications arising in facilities for patients with senile dementia. The method and duration of this investigation were different from those of our previous study.18

METHODS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHODS
  5. RESULTS
  6. DISCUSSION
  7. REFERENCES

All physical complications occurring in our WED in the 12 months from April 2007 to March 2008 were recorded.

In the present study, physical complications were subdivided into two categories according to the degree of urgency and specialty: (i) serious emergencies occurring in the ward with a possible high risk of mortality within a few days (e.g. pneumonia and upper airway obstruction); and (ii) life-threatening complications arising in the ward that required diagnosis and treatment by specialists from other medical departments (e.g. bone fracture and cancer).

Ordinary diseases, such as the common cold, influenza, bronchitis, mild pneumonia, urinary tract infections, mild trauma, pressure ulcer, and tinea, were excluded from the investigation.

Chronic diseases, such as hypertension, angina, chronic heart failure, chronic obstructive pulmonary disease, chronic hepatitis, rheumatoid arthritis, chronic glomerulonephritis, diabetes mellitus, and hyperlipidemia, that had already been diagnosed before admission to the WED and for which patients were receiving treatment were also excluded because they were not first diagnosed in the WED.

Patient anonymity was carefully preserved and this retrospective study overviewing medical records was approved by the hospital director and department head.

RESULTS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHODS
  5. RESULTS
  6. DISCUSSION
  7. REFERENCES

The physical complications occurring in our WED and the bed occupation rate every month from April 2007 to March 2008 are given in Tables 1 and 2.

Table 1.  Cases of serious emergencies (n = 56) with a high risk of mortality from April 2007 to March 2008
DateBed occupation rateConditionOutcome
2007 April82%Pneumonia, refusal of food (terminal stage of Alzheimer's disease)Death
Pneumonia (Case 1)Recovery
Pneumonia (Case 2)Recovery
May81%Pneumonia (Case 3)Recovery
Pneumonia (Streptococcus pneumoniae) (Case 4)Recovery
Pneumonia (Case 5)Recovery
Pneumonia (Case 6)Recovery
Pneumonia (Streptococcus pneumoniae) (Case 7)Recovery
Pneumonia (Case 8)Recovery
Pneumonia (Case 9)Recovery
Pneumonia (Case 10)Recovery
Pneumonia (Case 11)Recovery
June87%Upper airway obstruction (boiled cauliflower)Recovery
July92%Aspiration pneumoniaRecovery
Enteritis, dehydrationRecovery
PneumoniaRecovery
Drug-induced cholinergic crisis (distigmine bromide)Recovery
Malignant syndrome (haloperidol)Recovery
PneumoniaRecovery
Upper airway obstruction (boiled meat)Recovery
August97%PneumoniaRecovery
PneumoniaRecovery
Upper airway obstruction, tracheobronchial foreign body (tofu)Recovery
September98%Upper airway obstruction (hanpen)Recovery
PneumoniaRecovery
Drug-induced hyperglycemia (olanzapine)Recovery
Upper airway obstruction (cookie)Recovery
Upper airway obstruction (sponge cake)Recovery
Pneumonia, refusal of food (terminal stage of Alzheimer's disease)Death
Bladder outlet obstruction (prostatic cancer)Operation
Aspiration pneumoniaRecovery
October95%Upper airway obstruction (crumbed pork cutlet)Recovery
Anemia (gastric cancer), melenaDeath
Refusal of food (terminal stage of Alzheimer's disease)Death
November85%Intracerebral hemorrhageRecovery
Intestinal obstructionRecovery
PneumoniaRecovery
PneumoniaRecovery
Malignant syndrome (quetiapine)Recovery
December81%Intracerebral hemorrhageDeath
Upper airway obstruction (tofu)Recovery
2008 January82%PneumoniaRecovery
Upper airway obstruction (cookie)Recovery
PneumoniaRecovery
February92%Aspiration pneumoniaRecovery
Pleuritis, pneumoniaRecovery
Convulsion (status epilepticus)Recovery
Subarachnoidal hemorrhage, sick sinus syndrome, syncopeTransference
PneumoniaRecovery
Acute exacerbation of chronic heart failure and renal failureDeath
March98%PneumoniaRecovery
Aspiration pneumonia, acute exacerbation of chronic respiratory failureTransference
Upper airway obstruction (sponge cake)Recovery
Toxicodermia (possibly drug eruption), pneumoniaRecovery
Pleuritis, aspiration pneumoniaRecovery
PneumoniaRecovery
Table 2.  Life-threatening complications requiring diagnosis and treatment by specialists from other departments (n = 44) from April 2007 to March 2008
TimeBed occupation rateConditionOutcome
2007 April82%Femoral neck fractureOperation
Femoral neck fractureOperation
HemoptysisRecovery
May81%Abnormal genital bleedingRecovery
June87%Oral injuryRecovery
July92%Fracture of nasal boneRecovery
Chest pain (possibly angina)Recovery
Ocular traumaRecovery
August97%Fracture of facial boneRecovery
Head injuryRecovery
Facial injuryRecovery
September98%Facial injuryRecovery
October95%Fever of unknown originRecovery
Liver cirrhosis, pancreatic tumorTransference
Femoral neck fractureOperation
Head injuryRecovery
November85%Fracture of nasal boneRecovery
Abnormal genital bleedingRecovery
Ligament injury (hip joint)Recovery
PseudogoutRecovery
Obstructive jaundiceTransference
December81%HypertensionRecovery
2008 January82%Low back pain attackRecovery
Duodenal ulcerRecovery
Facial injuryRecovery
Acute gastric mucosal lesionRecovery
HypertensionRecovery
February92%Subdural hematoma, facial injuryTransference
Hyponatremia (possibly SIADH)Recovery
AnemiaTreatment
Acute exacerbation of chronic renal failureTreatment
Vertebral fractureRecovery
Facial injuryRecovery
Acute exacerbation of chronic heart failureRecovery
Fracture of toothRecovery
Bladder outlet obstruction (prostatic hypertrophy)Recovery
March98%Femoral neck fractureOperation
Breast cancerOperation
Acute exacerbation of chronic heart failureRecovery
Peripheral facial nerve palsyTreatment
Gynecomastia (possibly tiapride)Observation
EpididymitisRecovery
Lung tumorObservation
Liver function disorderTreatment

Serious emergencies with a high risk of mortality within a few days occurred 56 times (Table 1). The most frequent disease occurring in our WED with a possibly high risk of mortality was pneumonia (57%), which occurred year round. An outbreak of pneumonia possibly related to Streptococcus pneumoniae occurred in the spring (Fig. 1). Upper airway obstructions occurred 10 times (18%), and also occurred year round. Six patients died in our WED over the 12-month period.

image

Figure 1. Cases of pneumonia among inpatients in our ward for the elderly with senile dementia according to the date of onset of illness. ‘Sputum isolate’ denotes that Streptococcus pneumoniae was isolated from the sputum. M, male; F, female. Numbers after M or F refer to the 11 cases presented in Table 1.

Download figure to PowerPoint

Life-threatening complications requiring diagnosis and treatment by specialists from other departments occurred 44 times (Table 2). There were 20 (45%) patients with orthopedic, neurosurgical, or oral and maxillofacial diseases that were possibly due to falls.

DISCUSSION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHODS
  5. RESULTS
  6. DISCUSSION
  7. REFERENCES

The present study confirmed the high frequency of physical complications requiring treatment in facilities for patients with senile dementia, as reported earlier.18 Both categories of physical complications in the present study occurred at a high rate and the types of disease varied. Over 365 days, 100 physical complications occurred in our WED, which breaks down to an average of 45 patients per day. These findings imply that geriatric psychiatrists must also be medical psychiatrists.12–18

The most frequent disease occurring in our WED with a possible high risk of mortality was pneumonia, which occurred year round. An outbreak of pneumonia possibly related to S. pneumoniae occurred from the middle of April to the middle of May (Fig. 1). Twenty-one of the 41 inpatients in our WED at the time of that outbreak had the illness and 11 of the 21 developed moderate or severe pneumonia (Fig. 1, Table 1); fortunately, no patient died. After this outbreak, we recommended pneumococcal vaccination of all WED inpatients with an unknown immunization history, as well as appropriate care for sufficient air ventilation etc.23,24 After these measures had been adopted, no outbreaks of pneumonia occurred.

Upper airway obstruction occurred 10 times, and also occurred year round. Fortunately, no patient died. These cases are difficult to prevent, despite various efforts of WED staff, including monitoring of the food condition and the position of patients at meal times.

Drug-induced emergencies with a possible high risk of mortality occurred five times (cholinergic crisis, hyperglycemia, toxicodermia and two patients with malignant syndrome). Older people are easily affected by drugs and frequently show severe side-effects, so geriatric psychiatrists must always pay attention to reducing both the dose and number of drugs used.

Six patients died in the WED during the 12-month period of investigation. Three patients were in the terminal stages of Alzheimer's disease and died from pneumonia and/or refusal of food. One of the six patients who died had advanced gastric cancer, which was detected on the basis of the presence of anemia and melena. However, he and his family declined surgical treatment. One patient succumbed suddenly to intracerebral hemorrhage, which had been diagnosed by a computed tomography (CT) scan. Another patient died of acute exacerbation of chronic heart failure and renal failure, presenting multiple organ failure in the end. We think these six deaths were unavoidable.

Twenty patients with orthopedic, neurosurgical, or oral and maxillofacial diseases that were possibly due to falls were recorded among 44 cases requiring diagnosis and treatment by specialists from other departments. Four of the 20 patients had femoral neck fractures and had to undergo surgery at the ICH. Although WED staff must at all times take precautions, it is very difficult to prevent fractures and/or trauma due to falls.

Four other patients (liver cirrhosis, obstructive jaundice, subdural hematoma, and breast cancer) were transferred to the ICH for treatment of their condition.

Two cases of hypertension arose suddenly in winter, but the cause in both cases was undetermined and both patients were diagnosed as idiopathic.

We often had to request assistance from other medical departments in the ICH (Internal Medicine, Surgery, Neurosurgery, Oral and Maxillofacial Surgery, Orthopedics, Urology, Dermatology, Otolaryngology, Ophthalmology, and Gynecology) to diagnose and treat physical complications. At facilities dedicated to dementia medicine, it is necessary and indispensable to diagnose and treat various physical complications that occur at a high rate. It is extremely important for all facilities to have the full cooperation of specialists in other medical departments.18–22

Because of the 2006 revision to the medical fee system, almost all hospitals in Japan have fallen into severe financial difficulties, especially municipal hospitals that operate unprofitable departments, such as those that diagnose and treat psychogeriatric physical complications of the elderly with BPSD. On 30 June 2008, the IB-ICH was closed by the Ichinomiya City government due to financial difficulties. The real concern is the growing difficulty in providing facilities for the treatment of patients with violent BPSD and/or physical complications in Japan.17,18 In light of the aging society in Japan, more financial support and appropriate medical policies are urgently needed.

REFERENCES

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHODS
  5. RESULTS
  6. DISCUSSION
  7. REFERENCES
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