Clinical practice guidelines for nursing- and healthcare-associated pneumonia (NHCAP) [Complete translation]

Respiratory Investigation

Volumn 51, Issue 2, 2013, Pages 103-126

  Kohno, Shigeru ^a   Imamura, Yoshifumi ^a   Shindo, Yuichiro ^b   Seki, Masafumi ^c   Ishida, Tadashi ^d   Teramoto, Shinji ^e   Kadota, Junichi ^f   Tomono, Kazunori ^c   Watanabe, Akira ^g  

^a NAGASAKI UNIVERSITY   (Japan)

^b NAGOYA UNIVERSITY GRADUATE SCHOOL OF MEDICINE   (Japan)

^c OSAKA UNIVERSITY HOSPITAL   (Japan)

^d KURASHIKI CENTRAL HOSPITAL   (Japan)

^e UNIVERSITY OF TSUKUBA HOSPITAL   (Japan)

^f OITA UNIVERSITY   (Japan)

^g TOHOKU UNIVERSITY   (Japan)

Author keywords

[No Author keywords available]

Indexed keywords

AMOXICILLIN PLUS CLAVULANIC ACID; AZITHROMYCIN; BETA LACTAMASE INHIBITOR; CARBAPENEM DERIVATIVE; CEPHALOSPORIN DERIVATIVE; CLARITHROMYCIN; CLAVULANIC ACID; GARENOXACIN; INFLUENZA VACCINE; LEVOFLOXACIN; MACROLIDE; MOXIFLOXACIN; PENICILLIN DERIVATIVE; PNEUMOCOCCUS VACCINE; QUINOLINE DERIVED ANTIINFECTIVE AGENT; SULTAMICILLIN;

ANTIBIOTIC THERAPY; ARTICLE; ARTIFICIAL VENTILATION; ASPIRATION PNEUMONIA; COMMUNITY ACQUIRED PNEUMONIA; DIAGNOSTIC TEST; DIET THERAPY; DISEASE SEVERITY; EVIDENCE BASED MEDICINE; EXTENDED SPECTRUM BETA LACTAMASE PRODUCING ENTEROBACTERIACEAE; FLUID THERAPY; HEALTH CARE ASSOCIATED PNEUMONIA; HEALTH INSURANCE; HOME CARE; HOSPITAL ACQUIRED PNEUMONIA; HUMAN; MEDICAL CARE; METHICILLIN RESISTANT STAPHYLOCOCCUS AUREUS; MICROBIOLOGICAL EXAMINATION; MORBIDITY; NONHUMAN; NURSING CARE ASSOCIATED PNEUMONIA; NURSING HOME; OXYGEN THERAPY; PNEUMONIA; PRACTICE GUIDELINE; PSEUDOMONAS AERUGINOSA; RISK ASSESSMENT; RISK BENEFIT ANALYSIS; RISK FACTOR; SPUTUM CULTURE; THORAX RADIOGRAPHY;

ADOLESCENT; ADULT; AGED; AGED, 80 AND OVER; CHILD; CHILD, PRESCHOOL; CROSS INFECTION; FEMALE; HUMANS; INFANT; MALE; MIDDLE AGED; NURSING CARE; PNEUMONIA; PRACTICE GUIDELINES AS TOPIC;

EID: 84879272070     PISSN: 22125345     EISSN: None     Source Type: Journal    
DOI: 10.1016/j.resinv.2012.11.001     Document Type: Article

References (108)

1. Ministry of Health, Labour and Welfare. Vital statistics of Japan 2007. Japan: Ministry of Health, Labour and Welfare; 2008 [Japanese].
2. Committee for the JRS Guidelines in Management of Respiratory Infections. The JRS Guidelines for the Management of Community-Acquired Pneumonia in adults. Japan: The Japanese Respiratory Society; 2007 [Japanese].
3. Committee for the JRS Guidelines in Management of Respiratory Infections. The JRS Guidelines for the management of hospital-acquired pneumonia in adults. Japan: The Japanese Respiratory Society; 2008 [Japanese].
4. American Thoracic Society and Infectious Diseases Society of America Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med 2005, 171:388-416.
5. Janssens JP, Krause KH. Pneumonia in the very old. Lancet Infect Dis 2004, 4:112-124.
6. Kollef MH, Morrow LE, Baughman RP, et al. Health care-associated pneumonia (HCAP): a critical appraisal to improve identification, management, and outcomes-proceedings of the HCAP Summit. Clin Infect Dis 2008, 46:S296-S334.
7. Kollef MH, Shorr A, Tabak YP, et al. Epidemiology and outcomes of health-care-associated pneumonia: results from a large US database of culture-positive pneumonia. Chest 2005, 128:3854-3862.
8. Shindo Y, Sato S, Maruyama E, et al. Health-care-associated pneumonia among hospitalized patients in a Japanese community hospital. Chest 2009, 135:633-640.
9. Seki M, Hashiguchi K, Tanaka A, et al. Characteristics and disease severity of healthcare-associated pneumonia among patients in a hospital in Kitakyushu. Jpn J Infect Chemother 2011, 17:363-369.
10. Maruyama T, Niederman MS, Kobayashi T, et al. A prospective comparison of nursing home-acquired pneumonia with hospital-acquired pneumonia in non-intubated elderly. Respir Med 2008, 102:1287-1295.
11. Brito V, Niederman MS. Healthcare-associated pneumonia is a heterogeneous disease, and all patients do not need the same broad-spectrum antibiotic therapy as complex nosocomial pneumonia. Curr Opin Infect Dis 2009, 22:316-325.
12. Ewig S, Welte T, Chastre J, et al. Rethinking the concepts of community-acquired and health-care-associated pneumonia. Lancet Infect Dis 2010, 10:279-287.
13. Carratalà J, Mykietiuk A, Fernández-Sabé N, et al. Health care-associated pneumonia requiring hospital admission: epidemiology, antibiotic therapy, and clinical outcomes. Arch Intern Med 2007, 167:1393-1399.
14. Seki M, Watanabe A, Mikasa K, et al. Revision of the severity rating and classification of hospital-acquired pneumonia in the Japanese Respiratory Society Guidelines. Respirology 2008, 13:880-885.
15. Fine MJ, Hough LJ, Medsger AR, et al. The hospital admission decision for patients with community-acquired pneumonia. Results from the pneumonia Patient Outcomes Research Team cohort study. Arch Intern Med 1997, 157:36-44.
16. Bartlett JG, Breiman RF, Mandell LA, et al. Community-acquired pneumonia in adults: guidelines for management. The Infectious Diseases Society of America. Clin Infect Dis 1998, 26:811-838.
17. Bartlett JG, Dowell SF, Mandell LA, et al. Practice guidelines for the management of community-acquired pneumonia in adults. Infectious Diseases Society of America. Clin Infect Dis 2000, 31:347-382.
18. Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis 2007, 44:S27-72.
19. El Solh AA, Pietrantoni C, Bhat A, et al. Indicators of potentially drug-resistant bacteria in severe nursing home-acquired pneumonia. Clin Infect Dis 2004, 39:474-480.
20. von Baum H, Welte T, Marre R, et al. Community-acquired pneumonia through Enterobacteriaceae and Pseudomonas aeruginosa: diagnosis, incidence and predictors. Eur Respir J 2010, 35:598-605.
21. Shindo Y, Hasegawa Y Healthcare-associated pneumonia among hospitalized patients. Applied technologies in pulmonary medicine 2011, 172-177. Karger Medical and Scientific Publishers, Basel. A. Esquinas (Ed.).
22. Park HK, Song JU, Um SW, et al. Clinical characteristics of health care-associated pneumonia in a Korean teaching hospital. Respir Med 2010, 104:1729-1735.
23. Micek ST, Kollef KE, Reichley RM, et al. Health care-associated pneumonia and community-acquired pneumonia: a single-center experience. Antimicrob Agents Chemother 2007, 51:3568-3573.
24. Watanabe A, Yanagihara K, Kohno S, et al. Multicenter survey on hospital-acquired pneumonia and the clinical efficacy of first-line antibiotics in Japan. Intern Med 2008, 47:245-254.
25. Rikimaru T, Yonemitu J, Shimada A, et al. Comparison of nursing home-acquired pneumonia with community-acquired elderly pneumonia. Nihon Kokyuki Gakkai Zasshi 2007 Apr, 45:306-313. Japanese.
26. Tani S, Tomioka H, Kaneda T, et al. Hospitalized nursing home-acquired pneumonia: Comparison with community-acquired pneumonia in older adults. Nihon Kokyuki Gakkai Zasshi 2009 May, 47:355-361. Japanese.
27. Lim WS, Macfarlane JT. A prospective comparison of nursing home acquired pneumonia with community acquired pneumonia. Eur Respir J 2001, 18:362-368.
28. Polverino E, Dambrava P, Cilloniz C, et al. Nursing home-acquired pneumonia: a 10 year single-centre experience. Thorax 2010, 65:354-359.
29. Fukuyama H, Ishida T, Tachibana H, et al. [Clinical evaluation of bedridden patients with pneumonia receiving home health care]. Nihon Kokyuki Gakkai Zasshi 2010 Dec, 48:906-911. Japanese.
30. Maruyama T, Gabazza EC, Morser J, et al. Community-acquired pneumonia and nursing home-acquired pneumonia in the very elderly patients. Respir Med 2010, 104:584-592.
31. Yamanda S, Ebihara S, Ebihara T, et al. Bacteriology of aspiration pneumonia due to delayed triggering of the swallowing reflex in elderly patients. J Hosp Infect 2010, 74:399-401.
32. Zalacain R, Torres A, Celis R, et al. Community-acquired pneumonia in the elderly: Spanish multicentre study. Eur Respir J 2003, 21:294-302.
33. Chong CP, Street PR. Pneumonia in the elderly: a review of the epidemiology, pathogenesis, microbiology, and clinical features. South Med J 2008, 101:1141-1145.
34. Friedman ND, Kaye KS, Stout JE, et al. Health care-associated bloodstream infections in adults: a reason to change the accepted definition of community-acquired infections. Ann Intern Med 2002, 137:791-797.
35. Slinin Y, Foley RN, Collins AJ. Clinical epidemiology of pneumonia in hemodialysis patients: the USRDS waves 1, 3, and 4 study. Kidney Int 2006, 70:1135-1141.
36. Berman SJ, Johnson EW, Nakatsu C, et al. Burden of infection in patients with end-stage renal disease requiring long-term dialysis. Clin Infect Dis 2004, 39:1747-1753.
37. Wakino S, Imai E, Yoshioka K, et al. Clinical importance of Stenotrophomonas maltophilia nosocomial pneumonia due to its high mortality in hemodialysis patients. Ther Apher Dial 2009, 13:193-198.
38. Mermel LA, Eells SJ, Acharya MK, et al. Quantitative analysis and molecular fingerprinting of methicillin-resistant Staphylococcus aureus nasal colonization in different patient populations: a prospective, multicenter study. Infect Control Hosp Epidemiol 2010, 31:592-597.
39. Pop-Vicas A, Strom J, Stanley K, et al. Multidrug-resistant gram-negative bacteria among patients who require chronic hemodialysis. Clin J Am Soc Nephrol 2008, 3:752-758.
40. Vento S, Cainelli F, Temesgen Z. Lung infections after cancer chemotherapy. Lancet Oncol 2008, 9:982-992.
41. Chen CS, Boeckh M, Seidel K, et al. Incidence, risk factors, and mortality from pneumonia developing late after hematopoietic stem cell transplantation. Bone Marrow Transplant 2003, 32:515-522.
42. Rano A, Agusti C, Jimenez P, et al. Pulmonary infiltrates in non-HIV immunocompromised patients: a diagnostic approach using non-invasive and bronchoscopic procedures. Thorax 2001, 56:379-387.
43. Peleg AY, Hooper DC. Hospital-acquired infections due to gram-negative bacteria. N Engl J Med 2010, 362:1804-1813.
44. Niederman MS. Hospital-acquired pneumonia, health care-associated pneumonia, ventilator-associated pneumonia, and ventilator-associated tracheobronchitis: definitions and challenges in trial design. Clin Infect Dis 2010, 51:S12-17.
45. Zilberberg MD, Shorr AF, Micek ST, et al. Epidemiology and outcomes of hospitalizations with complicated skin and skinstructure infections: implications of healthcare-associated infection risk factors. Infect Control Hosp Epidemiol 2009, 30:1203-1210.
46. Nseir S, Grailles G, Soury-Lavergne A, et al. Accuracy of American Thoracic Society/Infectious Diseases Society of America criteria in predicting infection or colonization with multidrug-resistant bacteria at intensive-care unit admission. Clin Microbiol Infect 2010, 16:902-908.
47. Shorr AF, Owens RC Quality pneumonia care: distinguishing community-acquired from health care-associated pneumonia. Am J Health Syst Pharm 2009, 66:S8-14.
48. Zilberberg MD, Shorr AF, Micek ST, et al. Antimicrobial therapy escalation and hospital mortality among patients with health-care-associated pneumonia: a single-center experience. Chest 2008, 134:963-968.
49. Zilberberg MD, Shorr AF. Epidemiology of healthcare-associated pneumonia (HCAP). Semin Respir Crit Care Med 2009, 30:10-15.
50. Venditti M, Falcone M, Corrao S, et al. Outcomes of patients hospitalized with community-acquired, health care-associated, and hospital-acquired pneumonia. Ann Intern Med 2009, 150:19-26.
51. Kollef MH. Health-care-associated pneumonia: not just a US phenomenon. Chest 2009, 135:594-596.
52. Shorr AF, Zilberberg MD, Micek ST, et al. Prediction of infection due to antibiotic-resistant bacteria by select risk factors for health care-associated pneumonia. Arch Intern Med 2008, 168:2205-2210.
53. Abrahamian FM, Deblieux PM, Emerman CL, et al. Health care-associated pneumonia: identification and initial management in the ED. Am J Emerg Med 2008, 26:1-11.
54. Craven DE. What is healthcare-associated pneumonia, and how should it be treated?. Curr Opin Infect Dis 2006, 19:153-160.
55. Zilberberg MD, Shorr AF. Healthcare-associated pneumonia: the state of evidence to date. Curr Opin Pulm Med 2011, 17:142-147.
56. Shindo Y, Sato S, Maruyama E, et al. Comparison of severity scoring systems A-DROP and CURB-65 for community-acquired pneumonia. Respirology 2008, 13:731-735.
57. El-Solh AA, Sikka P, Ramadan F, et al. Etiology of severe pneumonia in the very elderly. Am J Respir Crit Care Med 2001, 163:645-651.
58. Loeb M, Carusone SC, Goeree R, et al. Effect of a clinical pathway to reduce hospitalizations in nursing home residents with pneumonia: a randomized controlled trial. JAMA 2006, 295:2503-2510.
59. El Solh AA, Akinnusi ME, Pineda LA, et al. Diagnostic yield of quantitative endotracheal aspirates in patients with severe nursing home-acquired pneumonia. Crit Care 2007, 11:R57.
60. Blot F, Raynard B, Chachaty E, et al. Value of Gram stain examination of lower respiratory tract secretions for early diagnosis of nosocomial pneumonia. Am J Respir Crit Care Med 2000, 162:1731-1737.
61. Rello J, Luján M, Gallego M, et al. Why mortality is increased in health-care-associated pneumonia: lessons from pneumococcal bacteremic pneumonia. Chest 2010, 137:1138-1144.
62. Shorr AF, Haque N, Taneja C, et al. Clinical and economic outcomes for patients with health care-associated Staphylococcus aureus pneumonia. J Clin Microbiol 2010, 48:3258-3262.
63. Kett DH, Cano E, Quartin AA, et al. Implementation of guidelines for management of possible multidrug-resistant pneumonia in intensive care: an observational, multicentre cohort study. Lancet Infect Dis 2011, 11:181-189.
64. Teramoto S, Fukuchi Y, Sasaki H, et al. High incidence of aspiration pneumonia in community- and hospital-acquired pneumonia in hospitalized patients: a multicenter, prospective study in Japan. J Am Geriatr Soc 2008, 56:577-579.
65. El-Solh AA, Pietrantoni C, Bhat A, et al. Microbiology of severe aspiration pneumonia in institutionalized elderly. Am J Respir Crit Care Med 2003, 167:1650-1654.
66. Japanese Society of Chemotherapy, Japanese Association for Anaerobic Infection Research. Guidelines for diagnosis and treatment of anaerobic infections. Japan: KYOWA KIKAKU Ltd.; 2007 [Japanese].
67. Ito I, Kadowaki S, Tanabe N, et al. Tazobactam/piperacillin for moderate-to-severe pneumonia in patients with risk for aspiration: comparison with imipenem/cilastatin. Pulm Pharmacol Ther 2010, 23:403-410.
68. Yamaguchi K, Ohno A, Ishii Y, et al. In vitro susceptibilities to levofloxacin and various antibacterial agents of 12,919 clinical isolates obtained from 72 centers in 2007. Jpn J Antibiot 2009 Aug, 62:346-370. Japanese.
69. Matsuo S, Imai E, Horio M, et al. Revised equations for estimating glomerular filtration rate (GFR) from serum creatinine in Japan. Am J Kidney Dis 2009, 53:982-992.
70. Japanese Society of Nephrology. Clinical practice guidebook for diagnosis and treatment of chronic kidney disease 2009. Japan: Tokyo Igakusha; 2009 [Japanese].
71. Gilbert DN, Moellering RC, Eliopoulos GM, et al. The Sanford guide to antimicrobial therapy 2000 2010, Antimicrobial Therapy Inc., Virginia.
72. Niederman MS, Bristo V. Pneumonia in the older patient. Clin Chest Med 2007, 28:751-771.
73. Japanese Study Group on Aspiration Pulmonary Disease. Diagnosis and treatment of aspiration pulmonary disease. Japan: Pfizer Japan Inc.; 2003 [Japanese].
74. Riquelme R, Torres A, El-Ebiary M, et al. Community-acquired pneumonia in the elderly: a multivariate analysis of risk and prognostic factors. Am J Respir Crit Care Med 1996, 154:1450-1455.
75. Woo J, Ho SC, Mak YT, et al. Nutritional status of elderly patients during recovery from chest infection and the role of nutritional supplementation assessed by a prospective randomized single-blind trial. Age Ageing 1994, 23:40-48.
76. Marrie TJ. Community-acquired pneumonia in the elderly. Clin Infect Dis 2000, 31:1066-1078.
77. Hedlund J, Hannson LO, Ortqvist A. Short- and long-term prognosis for middle-aged and elderly patients hospitalized with community-acquired pneumonia: impact of nutritional factors. Scand J Infect Dis 1995, 27:32-37.
78. Marrie TJ. Epidemiology of community-acquired pneumonia in the elderly. Semin Respir Infect 1990, 5:260-268.
79. Loeb M, McGeer A, McArthur M, et al. Risk factors for pneumonia and other lower respiratory tract infections in elderly residents of long term care facilities. Arch Intern Med 1999, 159:2058-2064.
80. Muder RR. Pneumonia in residents of long-term care facilities: epidemiology, etiology, management and prevention. Am J Med 1998, 105:319-330.
81. Teramoto S, Kawashima M, Komiya K, et al. Health-care-associated pneumonia may be primary due to aspiration pneumonia. Chest 2009, 136:1702-1703.
82. Teramoto S, Matsuse T, Fukuchi Y, et al. Simple two-step swallowing provocation test for elderly patients with aspiration pneumonia. Lancet 1999, 353:1243.
83. Maruyama T, Taguchi O, Niederman MS, et al. Efficacy of 23-valent pneumococcal vaccine in preventing pneumonia and improving survival in nursing home residents: double blind, randomized and placebo controlled trial. Br Med J 2010, 340:c1104.
84. Yoneyama T, Yoshida M, Ohrui T, Oral Care Working Group, et al. Oral care reduces pneumonia in older patients in nursing homes. J Am Geriatr Soc 2002, 50:430-433.
85. Pick N, McDonald A, Bennett N, et al. Pulmonary aspiration in a long-term care setting: clinical and laboratory observations and an analysis of risk factors. J Am Geriatr Soc 1996, 44:763-768.
86. Dennis MS, Lewis SC, Warlow C FOOD Trial Collaboration. Effect of timing and method of enteral tube feeding for dysphagic stroke patients (FOOD): a multicentre randomised controlled trial. Lancet 2006, 365:764-772.
87. Sekizawa K, Matsui T, Nakagawa T, et al. ACE inhibitors and pneumonia. Lancet 1998, 352:1069.
88. Shinohara Y. Antiplatelet cilostazol is effective in the prevention of pneumonia in ischemic stroke patients in the chronic stage. Cerebrovasc Dis 2006, 22:57-60.
89. Sims R, Steinmann WC, McConville JH, et al. The clinical effectiveness of pneumococcal vaccine in the elderly. Ann Intern Med 1988, 108:653-657.
90. Shapiro ED, Berg AT, Austrian R, et al. The protective efficacy of polyvalent pneumococcal polysaccharide vaccine. N Engl J Med 1991, 325:1453-1460.
91. Jackson LA, Neuzil KM, Yu O, et al. Effectiveness of pneumococcal polysaccharide vaccine in older adults. N Engl J Med 2003, 348:1747-1755.
92. Dominguez A, Salleras L, Fedson DS, et al. Effectiveness of pneumococcal vaccination for elderly people in Catalonia, Spain: a case control study. Clin Infect Dis 2005, 40:1250-1257.
93. de Roux A, Lode H. Pneumococcal vaccination. Eur Respir J 2005, 26:982-983.
94. Musher DM, Rueda-Jaimes AM, Graviss EA, et al. Effect of pneumococcal vaccination: a comparison of vaccination rates in patients with bacteremic and nonbacteremic pneumococcal pneumonia. Clin Infect Dis 2006, 43:1004-1008.
95. Vila-Córcoles A, Ochoa-Gondar O, Hospital I, et al. Protective effects of the 23-valent pneumococcal polysaccharide vaccine in the elderly population: the EVAN-65 study. Clin Infect Dis 2006, 43:860-868.
96. Moderley SA, Holden J, Tatham DP, et al. Vaccines for preventing pneumococcal infection in adults. Cochrane Database Syst Rev 2008, 1:CD 000422.
97. Haglund LA, Istre GR, Pickett DA, et al. Invasive pneumococcal disease in central Oklahoma: emergence of high-level penicillin resistance and multiple antibiotic resistance. Pneumococcus Study Group. J Infect Dis 1993, 168:1532-1536.
98. Quick RE, Hoge CW, Hamilton DJ, et al. Underutilization of pneumococcal vaccine in nursing home in Washington State: report of a serotype-specific outbreak and a survey. Am J Med 1993, 94:149-152.
99. Centers for Disease Control and Prevention (CDC). Outbreaks of pneumococcal pneumonia among unvaccinated residents of chronic-care facilities-Massachusetts, October 1995, Oklahoma, February, 1996, and Maryland, May-June 1996, MMWR Morb Mortal Wkly Rep 1997; vol. 46. p. 60-2.
100. Nuorti JP, Butler JC, Crutcher JM, et al. An outbreak of multidrug-resistant pneumococcal pneumonia and bacteremia among unvaccinated nursing home residents. N Engl J Med 1998, 338:1861-1868.
101. Jefferson T, Di Pietrantonj C, Al-Ansary LA, et al. Vaccines for preventing influenza in the elderly. Cochrane Database Syst Rev 2010, 2:CD004876.
102. Christenson B, Lundbergh P, Hedlund J, et al. Effects of a large-scale intervention with influenza and 23-valent pneumococcal vaccines in adults aged 65 years or older: a prospective study. Lancet 2001, 357:1008-1011.
103. Christenson B, Hedlund J, Lundbergh P, et al. Additive preventive effect of influenza and pneumococcal vaccines in elderly persons. Eur Respir J 2004, 23:363-368.
104. Nichol KL. The additive benefits of influenza and pneumococcal vaccinations during influenza seasons among elderly persons with chronic lung disease. Vaccine 1999, 17:S91-93.
105. Chiba H, Ohrui T, Matsui T, et al. Benefits of pneumococcal vaccination for bedridden patients. J Am Geriatr Soc 2004, 52:1410.
106. Kawakami K, Ohkusa Y, Kuroki R, et al. Effectiveness of pneumococcal polysaccharide vaccine against pneumonia and cost analysis for the elderly who receive seasonal influenza vaccine in Japan. Vaccine 2010, 28:7063-7069.
107. Healthy people 2010 (). http://www.healthypeople.gov/2010/document/tableofcontents.htm.
108. Cai L, Uchiyama H, Yanagisawa S, et al. Cost-effectiveness analysis of influenza and pneumococcal vaccinations among elderly people in Japan. Kobe J Med Sci 2006, 52:97-109.