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1 70 Dementia Japan 27 : 70-80, ±7.1 53% 70 HDS - R 14.3±6.4 80% Kazuhiro Niizato 1), Gen Ohi 2) 1) Department of Psychiatry, Tokyo Metropolitan Matsuzawa Hospital Kamikitazawa, Setagaya - ku, Tokyo , Japan 2) Professor Emeritus of the University of Tokyo percutaneous endoscopic gastrostomy PEG PEG , ,

2 ; 2011 PEG Finucane et al., 1999 ; Gillick, 2000 ; Dharmarajan et al., HDS - R ± ± ± % 11 16% mild cognitive impairment MCI 6 8% 5 7% 2 3% 2 3% 7 10% Grain 1 HDS - R 14.3±6.4 mini - mental state examination MMSE 17.7±5.9 1

3 72 Dementia Japan Vol. 27 No. 1 January % No. 9, 16, 30, 48 No. 50 No. 8, 15, 18, 19, 27, 32, 33, 36, 46, 49, 51, 55 A B B 13 3 No. 59, 62, 65 No. 59 No. 62 No HDS - R A B % B 7 No. 61, 63, 64, 66, 68, 69, 70 No. 61, 70 No. 64 No. 68 No. 63 B 3 58, 60, 67 No. 58 No. 60 No % 8 5% A B HDS - R 14.1± ± ± ±0.9

4 73 No. HDS - R MMSE A 1 F F 67 AD F 67 VD F F 69 AD M 71 AD M 71 VD F 72 VD F 72 AD M 73 AD F 74 AD F 74 AD M 75 VD M 76 DLB F 76 AD M 76 AD M 76 AD M M 78 AD F 78 MCI F 79 VD F 79 AD F 79 VD M 80 AD F F 81 AD F 81 AD M 82 AD F 82 MCI F 82 Grain M 82 AD M 82 DLB F 82 AD M 83 VD M 83 AD F 83 AD F M F 85 AD F 85 AD F 86 AD 7 11

5 74 Dementia Japan Vol. 27 No. 1 January 2013 No. HDS - R MMSE A B 42 F 86 AD F 86 MCI M 87 VD F 87 AD F 87 AD F 87 AD M 87 VD M 89 MCI F 89 MCI M 90 AD F 90 AD F 90 AD F 91 AD 9 55 M 94 AD F 95 AD 7 57 F 96 MCI F 71 AD M 74 AD M M 76 VD F 76 AD M F 80 AD F M 82 AD F 84 PSP M 85 VD M M 89 AD 6 10 : AD ; VD ; DLB ; MCI ; PSP ; 80% 9.3% 8.7% 39% 42% 8.7% 2.7% 6.0% ,

6 % 7.4% Seckler et al., 1991 IC IC 1970 IC IC IC IC IC IC Rational

7 76 Dementia Japan Vol. 27 No. 1 January 2013 Darwinism Alexander & Sherman, P. Gage P. Gage Bechara et al., 1995 ; Damasio, A 推論戦略決定図 1. 事実決定のための選択肢将来の結果の表象情動状況意思決定のための 2 つのルート何らかの反応が求められる状況から意思決定に至るルートには,2 つのものが想定されている. 2 つは互いに相補的なものである. ルート A は費用便益分析ともいえる決定経路である. 推論の戦略が練られ, その結果のもたらす益を天秤にかけ決定を行う. ルート B は並行的に作用する. 過去の類似した状況における情動経験が活性化され, 危険な選択肢を決定から遠ざけ, 好ましそうな選択肢を近づけることで, 情動は決定に大きな影響を及ぼす. ときおりルート B がじかに決定をもたらすことがある. それは本能的感情によって即応の反応が求められる場合である. その決定のスピードは非常に速く, 決定の過程が意識に上ることはない.(Damasio, 2003 の図を改変 ) A ( 時に情動が直接の意志決定をもたらす ) B

8 77 B B? Lakoff & Johnson, 1999 B B B

9 78 Dementia Japan Vol. 27 No. 1 January Alexander RD, Sherman PW 1977Local mate competition and parental investment in social insects. Science 196 : R Bechara A, Tranel D, Damasio H, Adolphs R, Rockland C, Damasio AR 1995Double dissociation of conditioning and declarative knowledge relative to the amygdala and hippocampus in humans. Science 269 : Damasio AR 2003Looking for Spinoza : Joy, Sorrow, and the Feeling Brain. Mariner Books, Florida 1997 Dharmarajan TS, Unnikrishnan D, Pitchumoni CS 2001Percutaneous endoscopic gastrostomy and outcome in dementia. Am J Gastroenterol 96 : Finucane TE, Christmas C, Travis K 1999Tube feeding in patients with advanced dementia : a review of the evidence. JAMA 282 : Gillick MR 2000Rethinking the role of tube feeding in patients with advanced dementia. N Engl J Med 342 : PHP Kosslyn SM, Thompson WL, Ganis G 2006The Case for Mental Imagery. Oxford University Press, London Lakoff G, Johnson M 1999Philosophy in the Flesh. Basic Books, New York

10 : Dementia Japan 25 : songenshi - kyokai.com/ 2008 Seckler AB, Meier DE, Mulvihill M, Paris BE 1991Substituted judgment : how accurate are proxy predictions? Ann Intern Med 15 : A tokyo.ac.jp/dls/cleth/ahn/pdf/processnote_all.pdf ,

11 80 Dementia Japan Vol. 27 No. 1 January 2013 Responses of the elderly with dementia to suggestion of gastrostomy Kazuhiro Niizato 1), Gen Ohi 2) 1) Department of Psychiatry, Tokyo Metropolitan Matsuzawa Hospital 2) Professor Emeritus of the University of Tokyo More than 560,000 patients in Japan are currently placed with percutaneous endoscopic gastroscopy PEG, a controversial treatment for the elderly with advanced dementia. As their preference for PEG installment seems routinely ignored, we asked 70 demented elderly 29 males, 41 females ; 37 Alzheimer s Disease, 11 vascular dementia, 22 other types ; MMSE 17.7 points ; HDS - R 14.3 points if they would have gastrostomy installed as a life - prolonging measure. Eighty % promptly rejected the idea with frequent shows of disgust and the remaining 20% were unable to answer. None responded affirmatively. Their instant and emotional rejections may represent activation of a prior emotional experience in comparable situations. We believe that asking the intent of the demented elderly regarding initiating gastrostomy is an ethically valid and practical precaution to avert the controversial issue. Address correspondence to Dr. Kazuhiro Niizato, Department of Psychiatry, Tokyo Metropolitan Matsuzawa Hospital Kamikitazawa, Setagaya - ku, Tokyo , Japan

606 Dementia Japan Vol. 29 No. 4 October 2015 Table 1. The day care for people with severe dementia Outline Subjects Personal distribution Medical man

606 Dementia Japan Vol. 29 No. 4 October 2015 Table 1. The day care for people with severe dementia Outline Subjects Personal distribution Medical man Dementia Japan 29 : 605-614, 2015 605 原著要旨 1. はじめに 1 26 4.2 80 2 3 A survey of daycare facilities for dementia people in Japan Tohmi Osaki, Kiyoshi Maeda 1 650-0017 7-5 - 2 Medical Center for Dementia,