The health and social system for the aged in Japan

Effect of in-patient cardiac rehabilitation at rehabilitation hospital for cardiology patients: two-center trial

The effectiveness of cardiac rehabilitation (CR) in patients with cardiovascular disease requiring continuous CR from an acute care hospital to a convalescent rehabilitation hospital is unknown. Therefore, we compared the effect of CR in a rehabilitation hospital for patients with cardiovascular disease with that of those who underwent cardiovascular surgery. Sixty-nine consecutive patients were admitted to two rehabilitation hospitals for CR. Patients were classified by primary disease into two groups: patients with cardiovascular disease (cardiology group, 26 patients) and patients who underwent cardiovascular surgery (surgery group, 43 patients). Clinical information, physical function, cognitive function, activities of daily living (ADL), quality of life (QOL), amount of CR, and length of hospital stay were compared between the two groups. Compared with clinical features, age was significantly higher in the cardiology group (P < 0.001), and the preadmission Barthel index was significantly lower in the cardiology group (P = 0.025). Physical function at the time of transfer was significantly lower in the cardiology group than in the surgery group for the short physical performance battery (P < 0.001), gait speed (P = 0.005), and 6-min walking distance (P = 0.042). No significant difference was found in the amount of CR performed or the length of hospital stay, and no interaction effects were observed in improvements in physical function, exercise tolerance, or QOL. In conclusion, in rehabilitation hospitals, patients with cardiovascular disease were older, had lower preadmission ADL, and had lower a physical function at transfer than those who underwent cardiovascular surgery, but CR improved physical function and QOL to the same extent. The results suggest that the recovery of patients with cardiovascular disease may be similar to those who undergo cardiovascular surgery.

Idobata-Nagaya: a community housing solution for socially isolated older adults following the great East Japan earthquake

Introduction

Following the Great East Japan Earthquake, the living environment of socially isolated older adults has become a pressing concern. In response, Nagaya, a collective housing program, was established in Soma City, Fukushima, Japan to address social isolation among older adults and support their long-term health. This study aimed to identify characteristics of individuals in Nagaya and examine the sustainability of this initiative.

Methods

We conducted a retrospective analysis of residents who were relocated to Nagaya, emphasizing their characteristics, the continuity of their stay in Nagaya, and their care certification levels, using data up to December 31, 2022. We employed Kaplan-Meier curves to analyze the duration for which residents continued to reside in Nagaya and the time leading up to the requiring care-level certification.

Results

Of 65 people who moved to Nagaya after the disaster, 30 people (46.2%) continued to live there, 21 (32.3%) died during their stay, and 14 (21.5%) moved out. The overall duration of occupancy averaged 6.39 years (SD 3.83 years). The proportion of requiring care-level certification occurrences per person-year was 0.0577 for those without care certification and 0.3358 for those with requiring support level at the time of moving in.

Conclusion

In summary, Nagaya-style communal housing may offer suitable living environments for older adults with diverse needs during disasters and serve as a valuable tool for developing public policies in aging societies.

Factors Affecting Care-Level Deterioration among Older Adults with Mild and Moderate Disabilities in Japan: Evidence from the Nationally Standardized Survey for Care-Needs Certification

This study aims to investigate the factors of care-level deterioration in older adults with mild and moderate disabilities using nationally standardized survey data for care-needs certification. We enrolled people aged 68 years or older, certified as support levels 1-2 (mild disability) or care levels 1-2 (moderate disability) with no cancer. The outcome was care-level deterioration after two years. The possible factors were physical and mental functions which were categorized as the following five dimensions according to the survey for care-needs certification: body function, daily life function, instrumental activities of daily living (IADL) function, cognitive function, and behavioral problems. A multivariate logistic regression analysis was conducted after stratifying the care level at baseline. A total of 2844 participants were included in our analysis. A low IADL function was significantly associated with a risk of care-level deterioration in all participants. In addition, low cognitive function was linked to care-level deterioration, except for those with support level 1 at baseline. Participants with more behavioral problems were more likely to experience care-level deterioration, except for those with care level 2 at baseline. Our study showed the potential utility of the care-needs certification survey for screening high-risk individuals with care-level deterioration.

Governance of Assisted Living in Long-Term Care: A Systematic Literature Review

Assisted living (AL) is an emerging model of care in countries where long-term care needs are escalating, with emphasis given to promoting independence and autonomy among the residents to achieve active and healthy ageing. Unlike established nursing homes, the governance of AL is nebulous due to its novelty and diverse nature of operations in many jurisdictions. A comprehensive understanding of how AL is governed globally is important to inform regulatory policies as the adoption of AL increases. A systematic literature review was undertaken to understand the different levels of regulations that need to be instituted to govern AL effectively. A total of 65 studies, conducted between 1990 to 2020, identified from three major databases (PubMed, Medline, and Scopus), were included. Using a thematic synthesis analytical approach, we identified macro-level regulations (operational authorisation, care quality assessment and infrastructural requirements), meso-level regulations (operational management, staff management and distribution, service provision and care monitoring, and crisis management), and micro-level regulations (clear criteria for resident admission and staff hiring) that are important in the governance of AL. Large-scale adoption of AL without compromising the quality, equity and affordability would require clear provisions of micro-, meso- and macro-level regulations.

A descriptive study of pain treatment and its follow-up in primary care of elderly patients after orthopaedic care

Background

Pain treatment post orthopaedic care in the elderly is complicated and requires careful follow-up. Current guidelines state all patients prescribed opioids should have a plan for gradual reduction, with the treatment progressively reduced and ended if any pain remains after more than three months. How this works in primary care remains to be explored.

The aim was to describe pain treatment and its follow-up in primary care of elderly patients after orthopaedic care.

Methods

In this descriptive study, medical case histories were collected for patients ≥ 75 years, which were enrolled at two rural primary care units in southern Sweden, and were discharged from orthopaedic care. Pain medication follow-up plans were noted, as well as current pain medication at discharge as well as two, six and twelve weeks later.

Results

We included a total of 49 community-dwelling patients with medication aid from nurses in municipality care and nursing home residents, ≥ 75 years, discharged from orthopaedic care. The proportion of patients prescribed paracetamol increased from 28/49 (57%) prior to admission, to 38/44 (82%) after 12 weeks. The proportion of patients prescribed opioids increased from 5/49 (10%) to 18/44 (41%). Primary care pain medication follow-up plans were noted for 16/49 patients (33%).

Conclusions

Many patients still used pain medication 12 weeks after discharge, and follow-up plans were quite uncommon, which may reflect upon lacking follow-up of these patients in primary care.

Prevalence of burnout among public health nurses in charge of mental health services and emergency care systems in Japan

OBJECTIVES

The Community Health Act came into effect in 1997 in Japan. This act altered the work system for public health nurses (PHNs) in public health centers (PHCs) nationwide from region-specific to service-specific work. Such major changes to working environment in the new system seem to be exposing PHNs to various types of stress. The present study examined whether prevalence of burnout is higher among PHNs in charge of mental health services (psychiatric PHNs) than among PHNs in charge of other services (non-psychiatric PHNs), and whether attributes of emergency mental health care systems in communities are associated with increased prevalence of burnout.

METHODS

A questionnaire including the Pines burnout scale for measuring burnout was mailed to 525 psychiatric PHNs and 525 non-psychiatric PHNs. The 785 respondents included in the final analysis comprised 396 psychiatric PHNs and 389 non-psychiatric PHNs.

RESULTS

Prevalence of burnout was significantly higher for psychiatric PHNs (59.2%) than for non-psychiatric PHNs (51.5%). When prevalence of burnout in each group was analyzed in relation to question responses regarding emergency service and patient referral systems, prevalence of burnout for psychiatric PHNs displayed significant correlations to frequency of cases requiring overtime emergency services, difficulties referring patients, and a feeling of "restriction".

CONCLUSIONS

Prevalence of burnout is high among psychiatric PHNs, and inadequate emergency mental health service systems contribute to burnout among these nurses. Countermeasures for preventing such burnout should be taken as soon as possible.

Identification of quasi-in-need-of-care state (QUINOCS) among community dwelling elderly people using a seven-item subset of the Functional Independence Measure (FIM)

PURPOSE

To develop a screening test to identify community dwelling elderly people who are in need of assistive care but whose activities of daily living (ADLs) can be improved by appropriate rehabilitation intervention, so-called 'quasi-in-need-of-care state (QUINOCS)'.

METHOD

A total of 32 persons (mean age 77.3 years) from the metropolitan area and 51 persons (mean age 82.7 years) from a rural area were enrolled. Two physiatrists examined them and judged whether they could benefit from rehabilitation intervention while visiting nurses evaluated their ADLs using the Functional Independence Measure (FIM). A screening test to identify the QUINOCS was created using a seven-item subset score of the FIM (feeding, bathing, dressing lower-body, bladder management, bed/chair/wheel chair transfer, walking/wheel chair, stairs).

RESULTS

Fourteen in the metropolitan and 19 in the rural inhabitants were judged as the QUINOCS by the physiatrists. Persons whose subset scores included or ran across the intermediate range of independent levels (scores 3 and 4 of the FIM) showed tendency to be judged suitable for rehabilitation intervention. This finding was applied for screening algorism to identify the QUINOCS. Sensitivity and specificity of this test were 0.71 and 0.78 for the metropolitan, and 0.74 and 0.78 for the rural groups, respectively.

CONCLUSION

The screening method using the 7-item subset of the FIM can be used for identification of the QUINOCS among elderly people efficiently.

Difficulties experienced by care managers who are care workers managing elder abuse cases in the Japanese long-term care insurance system

The purpose of the present study is to describe the difficulties perceived by care managers in Japan when managing care in cases of abuse of elderly people in the home. Participants (n = 21) were female care managers who had handled an abuse case while working for an in-home care management service provider. Participants had a mean of 4.3 +/- 0.7 years of experience as a care manager. Interview data were collected from 2004 to 2005 and analysed according to the grounded theory approach. Seven categories and one core category of difficulties were extracted from the data. The core category was 'tacit control of care management by the abusive caregiver'. The other categories were as follows: the terrible situation of the people abused cannot be ignored; the long-term care insurance service is the only support for abused people; the abusive caregiver has the authority to cancel the contract; concerns that intervention might increase abuse; prioritising how to deal with the abuser rather than the abused is unavoidable; the abusive caregiver deciding the needs of the individual requiring care; and creating a care plan that is acceptable to the caregiver. Therefore, the present results suggest the necessity of not only treating the role of care managers as an important position within the care system that deals with elder abuse, but also highlight the need to establish a system that supports care managers in order to promote appropriate care management.

Palliative Care for the Older Adult

The majority of deaths in the United States occur in the geriatric population. These older adults often develop multiple chronic medical problems and endure complicated medical courses with a variety of disease trajectories. Palliative care physicians need to be skilled in addressing the needs of these frail elders with life-limiting illness as they approach the end of life. Although geriatrics and palliative medicine share much in common, including an emphasis on optimizing quality of life and function, geriatric palliative care is distinct in its focus on the geriatric syndromes and on the provision of care in a variety of long-term care settings. Expertise in the diagnosis and management of the geriatric syndromes and in the complexities of long-term care settings is essential to providing high-quality palliative care to the elderly patient. This paper is a practical review of common geriatric syndromes, including dementia, delirium, urinary incontinence, and falls, with an emphasis on how they may be encountered in the palliative care setting. It also highlights important issues regarding the provision of palliative care in different long-term care settings.

Day Care Service Use Is Associated with Lower Mortality in Community-Dwelling Frail Older People

OBJECTIVES

To clarify the association between day care service use and 21-month mortality in community-dwelling frail older people.

DESIGN

Prospective cohort study (the Nagoya Longitudinal Study for Frail Elderly).

SETTING

Community-based.

PARTICIPANTS

One thousand six hundred seventy-three community-dwelling older people (540 men, 1,133 women).

MEASUREMENTS

Data included the clients' demographic characteristics; depression as assessed using the short version of the Geriatric Depression Scale; a rating for basic activities of daily living (ADLs); comorbidity; number of prescribed medications and physician-diagnosed chronic diseases; use of home-care services, including day care, visiting nurse, and home-help services; and number of regular medical checkups. Survival analysis of 21-month mortality was conducted using Kaplan-Meier curves and multivariate Cox proportional hazards models.

RESULTS

Of the 1,673 participants, 726 were day care service users at baseline, and 268 (94 day care service users, 174 nonusers) died during the 21-month follow-up. Multivariate Cox regression models adjusting for potential confounders showed that day care service use was associated with reduction in mortality. Subgroup analysis demonstrated that day care service use was associated with less risk of mortality in subjects who were female; were in the youngest age group (65-74); had higher ADL scores, lower comorbidity, depression, no dementia; and used a visiting nurse service. Participants using day care service two and three times or more a week had 63% or 44% lower relative hazard ratios, respectively, than participants not using the service.

CONCLUSION

Among community-dwelling frail older people, day care service use two or more times per week was associated with 44% to 63% lower 21-month mortality.

The effect of a subsidy policy on the utilization of community care services under a public long-term care insurance program in rural Japan

This cross-sectional study investigated the effect of an interim subsidy policy for low-income beneficiaries to buy home help services under Japanese long-term care insurance (LTCI) for the service utilization of home help and other community care services. Claims records during the period from October to December 2001 were reviewed to compare the monthly amounts for each service and out-of-pocket copayment for subsidized (n = 137) and non-subsidized (n = 124) beneficiaries. A multivariable linear regression analysis was conducted to control for age, gender, household size, length of care, and care eligibility level. Compared with the non-subsidized beneficiaries, the subsidized beneficiaries used 1.53 times as much home help service (p < 0.001), and spent 0.70 times as much on out-of-pocket copayments (p < 0.001), while they used fewer adult daycare services (0.71 times as much as the non-subsidized did, p = 0.063). The results strongly indicated that the interim subsidy for low-income beneficiaries alleviated the economic burden, but also resulted in service overuse and the substitution of home help services for other community care services. The policy implications of these findings were discussed.

Health measurement using the ICF: test-retest reliability study of ICF codes and qualifiers in geriatric care

Background

The International Classification of Functioning, Disability and Health (ICF) was published by the World Health Organization (WHO) to standardize descriptions of health and disability. Little is known about the reliability and clinical relevance of measurements using the ICF and its qualifiers. This study examines the test-retest reliability of ICF codes, and the rate of immeasurability in long-term care settings of the elderly to evaluate the clinical applicability of the ICF and its qualifiers, and the ICF checklist.

Methods

Reliability of 85 body function (BF) items and 152 activity and participation (AP) items of the ICF was studied using a test-retest procedure with a sample of 742 elderly persons from 59 institutional and at home care service centers. Test-retest reliability was estimated using the weighted kappa statistic. The clinical relevance of the ICF was estimated by calculating immeasurability rate. The effect of the measurement settings and evaluators' experience was analyzed by stratification of these variables. The properties of each item were evaluated using both the kappa statistic and immeasurability rate to assess the clinical applicability of WHO's ICF checklist in the elderly care setting.

Results

The median of the weighted kappa statistics of 85 BF and 152 AP items were 0.46 and 0.55 respectively. The reproducibility statistics improved when the measurements were performed by experienced evaluators. Some chapters such as genitourinary and reproductive functions in the BF domain and major life area in the AP domain contained more items with lower test-retest reliability measures and rated as immeasurable than in the other chapters. Some items in the ICF checklist were rated as unreliable and immeasurable.

Conclusion

The reliability of the ICF codes when measured with the current ICF qualifiers is relatively low. The result in increase in reliability according to evaluators' experience suggests proper education will have positive effects to raise the reliability. The ICF checklist contains some items that are difficult to be applied in the geriatric care settings. The improvements should be achieved by selecting the most relevant items for each measurement and by developing appropriate qualifiers for each code according to the interest of the users.

Increase of mild disability in Japanese elders: a seven year follow-up cohort study

Background

Japan has the highest life expectancy in the world. In a 2002 census government report, 18.5% of Japanese were 65 years old and over and 7.9% were over 75 years old. In this ageing population, the increase in the number of dependent older persons, especially those with mild levels of disability, has had a significant impact on the insurance budget. This study examines the increase of mild disability and its related factors.

Methods

All community-dwelling residents aged 65 and over and without functional decline (n = 1560), of Omishima town, Japan, were assessed in 1996 using a simple illustrative measure, "the Typology of the Aged with Illustrations" to establish a baseline level of function and were followed annually until 2002. The prevalence and incidence of low to severe disability, and their association with chronic conditions present at the commencement of the study, was analyzed. A polychotomous logistic regression model was constructed to estimate the association of each chronic condition with two levels of disability.

Results

An increase in mild functional decline was more prevalent than severe functional decline. The accumulation of mild disability was more prominent in women. The major chronic conditions associated with mild disability were chronic arthritis and diabetes in women, and cerebrovascular accident and malignancy in men.

Conclusion

This study showed a tendency for mild disability prevalence to increase in Japanese elders, and some risk factors were identified. As mild disability increasingly prevalent, these findings will help determine priorities for its prevention in Japanese elders.

Burnout and work environments of public health nurses involved in mental health care

AIMS

(1) To examine whether prevalence of burnout is higher among community psychiatric nurses working under recently introduced job specific work systems than among public health nurses (PHNs) engaged in other public health services. (2) To identify work environment factors potentially contributing to burnout.

METHODS

Two groups were examined. The psychiatric group comprised 525 PHNs primarily engaged in public mental health services at public health centres (PHCs) that had adopted the job specific work system. The control group comprised 525 PHNs primarily engaged in other health services. Pines' Burnout Scale was used to measure burnout. Respondents were classified by burnout score into three groups: A (mentally stable, no burnout); B (positive signs, risk of burnout); and C (burnout present, action required). Groups B and C were considered representative of "burnout". A questionnaire was also prepared to investigate systems for supporting PHNs working at PHCs and to define emergency mental health service factors contributing to burnout.

RESULTS

Final respondents comprised 785 PHNs. Prevalence of burnout was significantly higher in the psychiatric group (59.2%) than in the control group (51.5%). Responses indicating lack of job control and increased annual frequency of emergency overtime services were significantly correlated with prevalence of burnout in the psychiatric group, but not in the control group.

CONCLUSIONS

Prevalence of burnout is significantly higher for community psychiatric nurses than for PHNs engaged in other services. Overwork in emergency services and lack of job control appear to represent work environment factors contributing to burnout.

Effect of long-term care insurance on communication/recording tasks for in-home nursing care services

The purpose of this research was to clarify the possible changes brought about by the introduction of the long-term care insurance system in terms of number of communication/recording tasks, related nursing services in use, and when and where these tasks were performed. By examining the detailed content of communication/recording tasks, this study also sought to explore the advantages of introducing information technology (IT) systems in nursing service settings. The study was designed before-and-after study in two sessions, February 2000 and August 2000, namely before and after the introduction of Japan's long-term care insurance system. Participants were clients using the institution's in-home nursing services and all staff in a medical institution located in the Mikawa region of Aichi Prefecture, Japan. Following measurements were performed: (1). nursing service in use, (2). type of job, (3). date and time, (4). from whom, (5). to whom, (6). communication tool and (7). content, related to a particular communication. Communication/recording tasks were frequently performed around the starting and closing time of services. Following the adoption of the new system, these tasks tended to occur mostly around the starting time of services. As for the staff, the involvement of the professional carers increased. Regarding content of communication/recording, reports, confirmation and instruction increased. In conclusion, the use of IT driven devices is recommended to streamline the performance of communication/recording tasks as well as to ease the rush of these tasks thereby improving the quality of nursing services.