Tokyo Metropolitan Geriatric Hospital Research Articles

The expected role of Dementia Support Doctors in dealing with complex cases of older people with dementia

The present studyinvestigated the roles expected of Dementia Support Doctors (DSDs) in dealing with complex cases. The participants were attendees of the education programs organised by the Center for Promoting Dementia Support and the Medical Center for Dementia at the Tokyo Metropolitan Geriatric Hospital from April 2021 to March 2022. A self-administered postal questionnaire survey was conducted. The questionnaire included items on the basic attributes of the participants, their experiences with the issues associated with complex cases, and role expectations of consulting/collaboration partners when dealing with complex cases. The valid response rate was 49.3%. DSDs were expected by primary physicians, Community General Support Center staff and administrative staff to diagnose dementia and give advice on support strategies for complex cases. Primary physicians further expected them to initiate pharmacotherapy with anti-dementia drugs and address the pharmacotherapy needs for managing Behavioral and Psychological Symptoms of Dementia. It was also found that DSDs' experience with complex cases was comparable to that of the staff at the Medical Centers for Dementia. Of note, DSDs were mentioned less frequently as consulting/collaboration partners than Medical Centers for Dementia and primary physicians. The study showed that DSDs play an important role in dealing with complex cases. The roles of DSDs and ways to collaborate with them need to be communicated through interprofessional education.

Retrospective Analysis of the Incidence of Drug-Induced Interstitial Lung Disease by Epidermal Growth Factor Receptor Tyrosine Kinase Inhibitors and Survival in Patients Aged 75 Years or Older with Lung Cancer.

To date, the appropriate epidermal growth factor receptor tyrosine kinase inhibitors (EGFR-TKIs) for patients aged ≥75 years with advanced EGFR mutation-positive, nonsmall cell lung cancer remain unknown. This study included a total of 89 patients aged ≥75 years who were diagnosed with EGFR mutation-positive, nonsmall cell lung cancer and treated with EGFR-TKIs at the Tokyo Metropolitan Geriatric Hospital and Nihon University ITABASHI Hospital from 2009 to 2020. The patients were classified into five groups based on their treatment: gefitinib (n = 23), erlotinib (n = 4), afatinib (n = 3), first-line osimertinib (n = 23), and TKI to TKI (n = 36). The efficacy and safety of each EGFR-TKI were analyzed. No significant differences in the overall survival and progression-free survival were observed among the groups. However, a significantly higher incidence of drug-induced interstitial lung disease (ILD) was detected with osimertinib than with the first-generation EGFR-TKIs (p = 0.008). In older patients with EGFR mutation-positive lung cancer, the incidence of drug-induced ILD was significantly increased during osimertinib treatment. This outcome should be noted when treating older patients with osimertinib who may not always want to live longer but want to live better.

Tokyo Metropolitan Geriatric Hospital and Institute of Gerontology

Tokyo Metropolitan Geriatric Hospital and Institute of Gerontology

Annual report of Japanese Brain Bank Network for Neuroscience Research.

All Japan Brain Bank Network (AJBBN) is in the process of establishment in close collaboration with the Japanese Society of Neuropathology (JSNP) AJBBN is the movement by patients, doctors and researchers for cure of intractable neurological and psychiatric disorders. We first established the Brain Bank for Aging Research at Tokyo Metropolitan Geriatric Hospital and Institute of Gerontology in 2001, formed the Japanese Brain Bank Network for Neuroscience Research (JBBNNR) funded by MEXT in 2001 and, then, the Japanese Brain Bank Net (JBBN) funded by AMED in 2016. In Japan, brain banking is based on general autopsy and general pathological and neuropathological diagnosis by pathologists and neuropathologists. The Brain Bank Committee, JSNP, supervises activity of each brain bank. In 2012, we established the Brain Bank for Neurodevelopmental, Neurological and Psychiatric Disorders (BBNNPD) at Osaka University, the first university brain bank in Japan. BBNNPD collaborates National Hospital Organization (NHO) organized by MHLW including Osaka Toneyama Medical Center and Utano University. BBAR accumulates postmortem resource of central and peripheral nervous system and published the epidemiological study of Lewy body (LB) pathology among a Tokyo suburban elderly cohort, showing that one third of the Japanese aged population contained LB somewhere in the body. We also conducted central diagnosis of corticobasal degeneration with morphological evaluation, genomic study and western blot analysis and supported research use. AJBBN steadily expands its territory and will cover all area in Japan.

DASC-21: a novel geriatric assessment for discriminating best supportive care in older patients with inoperable advanced non-small cell lung cancer.

This study investigated whether the Dementia Assessment Sheet for the Community-based Integrated Care System is useful for decision-making or problem detection in the treatment and care of older patients with inoperable advanced non-small cell lung cancer compared with the current standard model using performance status. This study retrospectively examined 1595 cases admitted to the Department of Respiratory Medicine at the Tokyo Metropolitan Geriatric Hospital between 26 July 2016 and 28 January 2020. Among these, 29 and 31 patients who received pharmacotherapies and best supportive care were extracted, respectively. The performance in identifying best supportive care using the Dementia Assessment Sheet for the Community-based Integrated Care System was evaluated in comparison with performance status. The ability to detect impairments in each Dementia Assessment Sheet for the Community-based Integrated Care System domain was also assessed. The Dementia Assessment Sheet for the Community-based Integrated Care System total score had an area under the curve of 0.831 (95% confidence interval, 0.694-0.914), which was statistically equivalent to performance status. The discriminatory cut-off value for identification of best supportive care was set at 29 with a sensitivity and specificity of 0.742 and 0.897, respectively. Dementia Assessment Sheet for the Community-based Integrated Care System total score showed good concordance with performance status especially when reported by family members or caregivers. Deficits other than activities of daily living were recognized (2.8-19.4%) in patients with good performance status. Impairments were more frequently detected when reported by family members or caregivers. The Dementia Assessment Sheet for the Community-based Integrated Care System discriminates the best supportive care for older patients with inoperable advanced non-small cell lung cancer. Moreover, it can identify vulnerabilities especially when reported by family members or caregivers that cannot be detected by performance status.

Associations between sarcopenia and white matter alterations in older adults with diabetes mellitus: A diffusion tensor imaging study.

Aims/IntroductionOlder adults with diabetes mellitus are susceptible to sarcopenia. Diffusion tensor imaging studies have also shown that patients with diabetes have altered white matter integrity. However, the relationship between these structural changes in white matter and sarcopenia remains poorly understood.Materials and MethodsThe study included 284 older patients (aged ≥65 years) who visited the Tokyo Metropolitan Geriatric Hospital Frailty Clinic. We used diffusion tensor imaging to measure fractional anisotropy (FA) and mean diffusivity (MD) to evaluate changes in white matter integrity. We investigated the associations between sarcopenia, or its diagnostic components, and FA or MD in seven white matter tracts considered to be associated with sarcopenia according to the patients’ diabetes status.ResultsWe found significantly low FA or high MD values in the bilateral anterior thalamic radiations (ATR) and right inferior fronto‐occipital fasciculus (IFOF) of patients with Asian Working Group for Sarcopenia 2019‐defined sarcopenia, in all patients and those with diabetes. Using binominal regression analyses, we associated low FA values in the left ATR and right IFOF with sarcopenia in all patients and those with diabetes, after adjusting for age, gender, HbA1c, blood pressure, cognitive function, physical activity, depression, nutritional status, and inflammation.ConclusionsWhite matter alterations in left ATR and right IFOF are associated with the prevalence of sarcopenia in patients with diabetes. Specific changes to the left ATR and right IFOF tracts could play critical roles in the occurrence of sarcopenia in patients with diabetes.

Citrullinated histone H3 expression in anti-neutrophil cytoplasmic antibody-associated vasculitis in older Japanese autopsy patients.

Neutrophil extracellular traps play key roles in the necrotizing vasculitis associated with anti-neutrophil cytoplasmic antibody-associated vasculitis (AAV). However, the relationships between neutrophil extracellular traps formation and the distribution and phase of vasculitis are not well understood. In the present study, we clarified the clinicopathological characteristics of older AAV patients, as well as the expression of citrullinated histone H3 (citH3), a marker of neutrophil extracellular traps, in autopsied AAV patients. We reviewed autopsy cases that were carried out at Tokyo Metropolitan Geriatric Hospital, Tokyo, Japan, from 2001 to 2018. The expression of citH3 was determined by immunostaining. AAV patients (six cases) were elderly (aged 73-94 years; three men and three women; myeloperoxidase anti-neutrophil cytoplasmic antibody-positive, five cases; proteinase-3 anti-neutrophil cytoplasmic antibody-positive, one case; disease duration was 1.5-5.5 months; and patients were treated with steroids. All patients had necrotizing vasculitis in the medium-to-small-sized vessels in various organs, and also severe vasculitis-associated lesions including brain hemorrhage, alveolar bleeding, interstitial pneumonia, crescentic nephritis, acute pancreatitis and gastrointestinal bleeding. Expression of citH3 was associated with the activity of inflammation. We report severe clinicopathological characteristics of AAV in older patients. Expression of citH3 was a useful marker to evaluate vasculitis severity. Identification of these features might aid in the diagnosis of AAV. Geriatr Gerontol Int 2019; 19: 259-264.

Effects of EUS-guided intratumoral injection of oligonucleotide STNM01 on tumor growth, histology, and overall survival in patients with unresectable pancreatic cancer

Carbohydrate sulfotransferase 15 (CHST15) promotes tumor growth and invasion and is considered to be an emergent therapeutic target for pancreatic cancer. The aim of this study wasto evaluate the safety and efficacy of EUS-guided fine-needle injection (EUS-FNI) of STNM01, the double-stranded RNA oligonucleotide that specifically represses CHST15, for use in patients with pancreatic cancer. Six patients with unresectable pancreatic cancer, treated at Tokyo Metropolitan Geriatric Hospital, were used in this open-labeled, investigator-initiated trial. A total of 16 mL STNM01 (250 nM) was injected into the tumor through EUS-FNI. The study's primary endpoint was safety, with a secondary endpoint of tumor response 4 weeks after the initial injection. Some patients received a series of infusions as extensions. The local expression of CHST15 and overall survival (OS) were also evaluated. There were no adverse events. The mean tumor diameter changed from 30.7 to 29.3mm 4 weeks after injection. Four patients exhibited necrosis of tumor in biopsy specimens. CHST15 was highly expressed at baseline, with 2 patients showing large reductions of CHST15 at week 4. The mean OS of these 2 patients was 15 months, whereas it was 5.7 months for the other 4 patients. EUS-FNI of STNM01 in pancreatic cancer is safe and feasible. The CHST15 reduction could predict tumor progression and OS. Injections of STNM01 during the beginning of treatment may reduce CHST15 and warrants further investigation.

The brain bank for aging research project, Tokyo, Japan

Background: Tokyo Metropolitan Geriatric Hospital and Institute of Gerontology (TMGHIG) is supporting an elderly cohort who habituates in the northeastern suburban area of Tokyo.

Implementation of personalized medicine for fracture risk assessment in osteoporosis.

The present review summarizes our efforts to identify genetic polymorphisms associated with osteoporotic fractures and to establish a genetic risk score (GRS) to predict fracture risk in consecutive Japanese autopsy cases carried out at Tokyo Metropolitan Geriatric Hospital between 1995 and 2011. Three single nucleotide polymorphisms in transforming growth factor β-1, rs1800470; thrombospondin, type 1, domain-containing 7A, rs12673692; and formiminotransferase N-terminal subdomain-containing gene, rs7605378, showed a significant association with vertebral fracture prevalence, whereas five (α-l-iduronidase, rs3755955; C7orf58, rs190543052; homeobox C4, rs75256744; G patch domain-containing gene 1, rs2287679; and Werner syndrome, rs2230009) were significantly associated with femoral fracture. GRS values were calculated as the sum of risk allele counts (unweighted GRS) or of weighted scores estimated from logistic regression coefficients (weighted GRS). Both GRS values using the five single nucleotide polymorphisms adequately predicted femoral fracture prevalence for 924 male subjects; the areas under receiver-operating characteristic curves were 0.750 (95% confidence interval [CI] 0.660-0.840) and 0.770 (95% CI 0.681-0.859), respectively. Logistic regression analysis showed that the odds ratio for the association between fracture prevalence and unweighted GRS ≥3 (n = 124) was 8.39 (95% CI 4.22-16.69, P < 0.001) relative to GRS < 3 (n = 797). Likewise, the odds ratio for a weighted GRS of 6-15 (n = 135) was 7.73 (95% CI 3.89-15.36, P < 0.001) relative to GRS 0-5 (n = 786). Therefore, the GRS based on the risk allele profiles of these five single nucleotide polymorphisms could help identify at-risk individuals and enable implementation of preventive measures for femoral fracture.

Mo1493 EUS-Guided Intratumoral Injection of CHST15 Dsrna for Unresectable Pancreatic Cancer: an Investigator-Initiated Trial

Mo1493 EUS-Guided Intratumoral Injection of CHST15 Dsrna for Unresectable Pancreatic Cancer: an Investigator-Initiated Trial

Communication with important others regarding their preferences for end-of-life care

Our aim in this study was to explore individual factors that make it likely for Japanese older adults to engage in communication with important other persons regarding their preferences for end-of-life care. We conducted a questionnaire survey of outpatients at Tokyo Metropolitan Geriatric Hospital in the last six days of March 2012. Nine-hundred and sixty-eight outpatients consented in writing to participate in this survey. Two items on the questionnaire concerned the participants' attempts to communicate their preferences regarding end-of-life care; that is, whether they had discussed this issue with their significant others and whether they had written notes indicating how they want to be cared for in the final days of their lives. The participants who had designated a surrogate decision-maker were more likely to report answers of both than only discussion (OR=2.52) and less likely to reports answers of no communication than only discussion (OR=0.37). In addition, (a) those who did not wish to rely on artificial nutrition or hydration (OR=0.68) and (b) those who often thought about their death were more likely to be in the only discussion group than in the no communication group, although these factors were not significantly associated with whether the participants were likely to be in the both or only discussion groups. Our findings indicate that individuals often attempt to clarify their preferences in order to make it easier for their significant others to make end-of-life care decision on their behalf, so that they may receive their desired care.

Sternalock plating system for elderly post-sternotomy patients.

Sternal nonunion after median sternotomy is very stressful for patients and is counted as one of the major postoperative complications reducing quality of life. Conventionally, sternal fixation using metallic wires, sutures, etc., has long been performed. However, postoperative intermittent stress on these fixative materials can cause breakdown of the materials. There are also cases in which the sternum itself rather than the fixative materials is broken. Such events can lead to mediastinal hematoma, necessitating a second thoracotomy or resulting in nonunion in some joints or sternal osteomyelitis [1]. Possible risk factors for sternal nonunion include severe obesity, insulin-dependent diabetes mellitus, chronic obstructive pulmonary disease, steroid therapy, coronary artery bypass grafting with the bilateral internal thoracic arteries, and the necessity of loading body weight onto the arms at the time of standing up or walking. Recently, the Sternalock plating system was developed for use in such cases, and favorable clinical outcomes have increasingly been reported primarily from Western countries [2]. This system is composed of a titanium plate (for crosslinking between the right and left stumps of the sternum) and screws for fixation of the plate onto the sternum. Six plate shapes are available, and the screws come in 7 sizes (8–20 mm) to accommodate different sternal thicknesses. In 2013, reimbursement from the insurer for use of the Sternalock plating system was started in Japan, allowing treatment with this system under the national health insurance scheme of this country. This system is currently used for patients at high risk for sternal nonunion. For patients with a fragile sternum due to aging, many surgeons still use wires or other materials for sternal closure (the conventional method). Because of postoperative sternal nonunion in elderly patients has a risk for severe worsening during postoperative course, many surgeons still employed the familiar conventional method. Moreover, as demerits of the Sternalock plating system usage, there are the higher costs and the requirement of the special tool for emergent re-open chest. The present study was undertaken to retrospectively review patients in whom the Sternalock plating system had been used and to examine whether or not this system can be safely and effectively employed in elderly patients. Of the patients who underwent surgery on the heart or large thoracic vessels via a median sternotomy at the Department of Cardiac Surgery, Tokyo Metropolitan Geriatric Hospital between December 2012 and March 2014, 60 seemingly at high risk for sternal nonunion, satisfying at least one of the following requirements, were enrolled in this study: (1) severe obesity (body mass index C130), (2) insulin-dependent diabetes mellitus, (3) chronic obstructive pulmonary disease, (4) having undergone coronary artery bypass grafting employing the bilateral internal thoracic arteries, (5) requirement for loading body weight onto the arms at the time of standing up or walking, (6) receiving hemodialysis, (7) having undergone a second thoracotomy, and (8) taking steroids or other immunosuppressant agents. For the 30 patients who had undergone surgery before September 2013 when the Sternalock plating system was introduced, sternum fixation was achieved T. Nishimura (&) C. Kurihara Y. Sakano S. Kyo (&) Department of Cardiac Surgery, Tokyo Metropolitan Geriatric Hospital, 35-2, Sakae-cho, Itabashi-ku, Tokyo 173-0015, Japan e-mail: takashin-tky@umin.ac.jp

FRI0187 The benefit-risk balance of treatment with tumor necrosis factor inhibitors has been improved with the change of time: a report from the real database

BackgroundThe introduction of tumor necrosis factor inhibitors (TNFI) has dramatically improved treatments for rheumatoid arthritis (RA) during the last decade. To identify optimal use of TNFI in clinical practice, various...

P5-17-04: Association between Breast Cancer and Osteoporosis among Women 85 Years or Older.

Abstract Background: The pathogenesis of breast cancer in very elderly women is of interest, because estrogen levels are likely to be extremely low during the development of the disease. Estrogens have opposing effects on the pathogenesis of breast cancer and osteoporosis. In an effort to understand the significance of estrogens in the pathogenesis of breast cancer in this group, we examined the association between breast cancer and osteoporosis in women at least 85 years old, taking body mass index (BMI) and hormone receptors status into consideration. Methods:Clinical records of consecutive elderly women (≥ 85 y/o) who underwent breast cancer surgery at Tokyo Metropolitan Geriatric Hospital (BC) and control women of the same age group (Cont) were reviewed; osteoporosis and BMI status in both groups were recorded and compared. The status of estrogen receptor (ER) and progesterone receptor (PR) of breast cancers was examined immunohistochemically and compared between BC with and without osteoporosis (BC-OP and BC-nonOP, respectively). Results:Frequency of osteoporosis was significantly lower among BC than Cont. There was no difference in BMI measured after 85 y/o between BC and Cont; however, percentage of women, whose BMI measured when they were in their sixties or seventies was ≥ 20% higher than BMI measured when they were 85 y/o or older, was significantly higher among BC than Cont (31% and 2%, respectively. P = 0.0001). ER positivity of breast cancer did not differ between BC-OP and BC-nonOP, whereas PR positivity was significantly higher among BC-nonOP than BC-OP (P = 0.0359). Discussion: The inverse relationship between the incidence of breast cancer and osteoporosis suggests an important role for estrogens in the pathogenesis of breast cancer in the very elderly women. Our finding that one third of BC had ≥ 20% higher BMI when they were in their sixties or seventies suggests they may also had elevated serum estrogens during these earlier years, because increased BMI has been reported to be associated with increased serum estrogens in postmenopausal women. Expression of PR is regulated by estrogen-ER signaling, and PR positivity is considered to reflect the effectiveness of estrogen-ER pathway. Significant difference of PR positivity between BC-nonOP and BC-OP suggests the more importance of estrogens in BC-nonOP than BC-OP. Conclusion:Estrogens seem to play an important role in the pathogenesis of breast cancers in very elderly women, especially without osteoporosis. With increasing aging population in developed countries, those findings may have implications for breast cancer prevention in this age group. Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P5-17-04.

Gene expression profiling in postmortem brains classified by Braak neurofibrillary tangle staging

Alzheimer's disease (AD) is the most common form of dementia in the elderly. Molecular mechanism of progression in the AD brain remains to be resolved. A high-dense microarray technology allows us to profile gene expression in every exon level. In this study, we used 213 postmortem brain tissues (entorhinal, temporal and frontal cortices [EC, TC and FC, respectively]) from 71 brain donors in the Tokyo Metropolitan Geriatric Hospital and Institute of Gerontology Brain Bank. According to Braak neurofibrillary tangle (NFT) stage criteria, these donors were classified into four groups: Braak NFT stages 0 (N = 13), I - II (N = 20), III (N = 19) and V - VI (N = 19). Total RNA was isolated from these tissues and purified with an on-column DNaseI treatment, using the TRIzol® plus RNA purification system (Invitrogen). An RNA integrity number (RIN, 1 [degraded] - 10 [intact]) was computed to evaluate RNA quality by a 2100 BioAnalyzer system (Agilent). Whole exons transcribed in the brain were analysed by an Affymetrix GeneChip® platform (Human Exon 1.0 ST Array). We determined APOE genotypes by means of both sequencing and a TaqMan® assay. The statistical significance was set at P < 0.05. The genotypic distribution of the APOE is as follows: e2*3 = 4, e3*3= 55, e3*4 = 9, e4*4 = 3. In three brain regions, there were no significant differences of mean RIN values between Braak NFT stages: EC, P = 0.8684; TC, P = 0.8490; FC, P = 0.7141. No correlation between postmortem interval and RIN was observed. We selected more than 50 genes which were differentially expressed among Braak NFT stages and evaluated by independent statistical analyses. We identified candidate genes involved in AD pathogenesis depending on the brain regions. Several genes responsible for clinical manifestation of AD could be elucidated through gene expression profiling.

Erratum: Magic ARB, or magic trial?

Correction to: Hypertension Research (2010) 33, 414; doi:10.1038/hr.2010.34 The authors of the above article noted an error in publication of this paper (AOP and in the May 2009 issue) in the affiliation address. The correct address is shown below. Dr I Kuwajima is at the Division of Cardiology, Tokyo Metropolitan Geriatric Hospital, 35-2 Sakaecho, Itabashi-ku, Tokyo 173-0015, Japan.

Brief screening tool for mild cognitive impairment in older Japanese: Validation of the Japanese version of the Montreal Cognitive Assessment

The Montreal Cognitive Assessment (MoCA), developed by Dr Nasreddine (Nasreddine et al. 2005), is a brief cognitive screening tool for detecting older people with mild cognitive impairment (MCI). We examined the reliability and validity of the Japanese version of the MoCA (MoCA-J) in older Japanese subjects. Subjects were recruited from the outpatient memory clinic of Tokyo Metropolitan Geriatric Hospital or community-based medical health check-ups in 2008. The MoCA-J, the Mini-Mental State Examination (MMSE), the revised version of Hasegawa's Dementia Scale (HDS-R), Clinical Dementia Rating (CDR) scale, and routine neuropsychological batteries were conducted on 96 older subjects. Mild Alzheimer's disease (AD) was found in 30 subjects and MCI in 30, with 36 normal controls. The Cronbach's alpha of MoCA-J as an index of internal consistency was 0.74. The test-retest reliability of MoCA, using intraclass correlation coefficient between the scores at baseline survey and follow-up survey 8 weeks later was 0.88 (P < 0.001). MoCA-J score was highly correlated with MMSE (r = 0.83, P < 0.001), HDS-R (r = 0.79, P < 0.001) and CDR (r = -0.79, P < 0.001) scores. The areas under receiver-operator curves (AUC) for predicting MCI and AD groups by the MoCA-J were 0.95 (95% confidence interval [CI] = 0.90-1.00) and 0.99 (95% CI = 0.00-1.00), respectively. The corresponding values for MMSE and HDS-R were 0.85 (95% CI = 0.75-0.95) and 0.97 (95% CI = 0.00-1.00), and 0.86 (95% CI = 0.76-0.95) and 0.97 (95% CI = 0.00-1.00), respectively. Using a cut-off point of 25/26, the MoCA-J demonstrated a sensitivity of 93.0% and a specificity of 87.0% in screening MCI. The MoCA-J could be a useful cognitive test for screening MCI, and could be recommended in a primary clinical setting and for geriatric health screening in the community.

Report of Home Visit Dental Treatment in Toshima, Tokyo by Oral Health Center, and Tokyo Metropolitan Geriatric Hospital Dentistry and Oral Surgery

Report of Home Visit Dental Treatment in Toshima, Tokyo by Oral Health Center, and Tokyo Metropolitan Geriatric Hospital Dentistry and Oral Surgery

Reviewing the definition of “elderly”

Conventionally, “elderly” has been defined as a chronological age of 65 years old or older, while those from 65 through 74 years old are referred to as “early elderly” and those over 75 years old as “late elderly.” However, the evidence on which this definition is based is unknown. We have attempted to review the definition of elderly by analyzing data from long‐term longitudinal epidemiological studies, and clinical and pathological studies that have been accumulated at the Tokyo Metropolitan Geriatric Hospital and the Tokyo Metropolitan Institute of Gerontology. Our recommendation might be a starting point in developing a strategy for a successful society by reviewing the definition of elderly based on comprehensive evidence in all aspects of social, cultural and medical sciences.