Long-term care insurance in Japan: implications for U.S. long-term care policy

Caregiver Burdens, Health Risks, Coping and Interventions among Caregivers of Dementia Patients: A Review of the Literature

Over 55 million people reportedly suffer from dementia worldwide. In Japan, it is estimated that 1 in 5 people over 65 years old will have dementia by 2025, of which more than 20% will live with symptoms that require home/nursing care. Given the lack of effective medical treatments for dementia, informal caregivers play essential roles in allowing dementia patients to live with dignity. Our review focusing on caregiver burden showed that this burden has not been sufficiently addressed, despite having negative effects on caregivers' health, employment, and finances. It is important to consider non-pharmacological interventions that contribute to effective coping strategies for mitigating the caregiver burden. Online communication tools may be a viable intervention measure to educate caregivers on the importance of sharing resilient coping strategies to reduce their stress so that they can continue to provide care for their loved ones.

Machine Learning-Based Prediction of Functional Disability: a Cohort Study of Japanese Older Adults in 2013-2019

BACKGROUND

It is important to identify older adults at high risk of functional disability and to take preventive measures for them at an early stage. To our knowledge, there are no studies that predict functional disability among community-dwelling older adults using machine learning algorithms.

OBJECTIVE

To construct a model that can predict functional disability over 5 years using basic machine learning algorithms.

DESIGN

A cohort study with a mean follow-up of 5.4 years.

PARTICIPANTS

We used data from the Japan Gerontological Evaluation Study, which involved 73,262 people aged  ≥ 65 years who were not certified as requiring long-term care. The baseline survey was conducted in 2013 in 19 municipalities.

MAIN MEASURES

We defined the onset of functional disability as the new certification of needing long-term care that was ascertained by linking participants to public registries of long-term care insurance. All 183 candidate predictors were measured by self-report questionnaires.

KEY RESULTS

During the study period, 16,361 (22.3%) participants experienced the onset of functional disability. Among machine learning-based models, ridge regression (C statistic = 0.818) and gradient boosting (0.817) effectively predicted functional disability. In both models, we identified age, self-rated health, variables related to falls and posture stabilization, and diagnoses of Parkinson's disease and dementia as important features. Additionally, the ridge regression model identified the household characteristics such as the number of members, income, and receiving public assistance as important predictors, while the gradient boosting model selected moderate physical activity and driving. Based on the ridge regression model, we developed a simplified risk score for functional disability, and it also indicated good performance at the cut-off of 6/7 points.

CONCLUSIONS

Machine learning-based models showed effective performance prediction over 5 years. Our findings suggest that measuring and adding the variables identified as important features can improve the prediction of functional disability.

How the 2018 Japan Floods Impacted Nursing Home Admissions for Older Persons: A Longitudinal Study Using the Long-Term Care Insurance Comprehensive Database

OBJECTIVES

As disasters become more frequent because of global warming, countries across the world are seeking ways to protect vulnerable older populations. Although these conditions may increase nursing home admission (NHA) rates for older persons, we know of no studies that have directly tested this hypothesis.

DESIGN

This was a retrospective cohort study.

SETTING AND PARTICIPANTS

We analyzed data from long-term care insurance (LTCI) users in 3 Japanese prefectures that incurred heavy damage from the 2018 Japan Floods, which is the largest recorded flooding disaster in national history. Specifically, we extracted NHA data from the LTCI comprehensive database, both for disaster-affected and unaffected individuals.

METHODS

We employed the Cox proportional hazards model to calculate multivariate-adjusted hazard ratios (HRs) for NHAs within a 6-month period following the 2018 Japan Floods, with adjustments for potential confounding factors.

RESULTS

Of the 187,861 individuals who used LTCI services during the investigated period, we identified 2156 (1.1%) as disaster affected. The HR for NHA was significantly higher for disaster-affected (vs unaffected) individuals (adjusted HR 3.23: 95% CI 2.88‒3.64), and also higher than the HRs for older age (90-94 years vs 65-69 years: 2.29, CI 1.93‒2.70), cognitive impairment (severe impairment vs normal: 1.40, CI 1.25‒1.57), and physical function (bedridden vs independent: 2.27, CI 1.83‒2.70). According to our subgroup analyses, the adjusted HR for disaster-affected individuals unable to feed themselves was 6.00 (CI 3.68‒9.79), with a significant interaction between the 2 variables (P = .01).

CONCLUSIONS AND IMPLICATIONS

Natural disasters increase the risk of NHA for older persons, especially those who are unable to feed themselves. Health care providers and policymakers should understand and prepare for this emerging risk factor.

Mapping the Global Landscape of Long-Term Care Insurance Research: A Scientometric Analysis

With the aging population increasing dramatically and the high cost of long-term care (LTC), long-term care insurance (LTCI) has expanded rapidly across the world. This review aims to summarize the status quo, evolution trends, and new frontiers of global LTCI research between 1984 and 2021 through a comprehensive retrospective analysis. A total of 1568 articles retrieved from the Web of Science Core Collection database were systematically analyzed using CiteSpace visualization software (CiteSpace 5.8. R2, developed by Dr. Chaomei Chen at Drexel University (Philadelphia, PA, USA)). The overall characteristics analysis showed that LTCI is an emerging research field in a rapid development stage—nearly 50% of articles were published in the past five years. The most productive LTCI research institutions and authors are located primarily in Japan and the USA. A rigorous analysis based on a dual perspective of references and keywords was applied to reveal that common LTCI hot topics include disability in the elderly, LTC financing, demand for and supply of LTCI, and LTCI systems. In addition, LTCI research trends have shifted from the supply side to the demand side, and from basic studies to practical applications. The new research frontiers are frailty in the elderly, demand for LTCI, and LTCI systems. These findings can provide help and reference for public health practitioners and researchers, as well as help with the sustainable development of LTCI research.

Potential causal effect of physical activity on reducing the risk of dementia: a 6-year cohort study from the Japan Gerontological Evaluation Study

Background

The causal effect of physical activity on reducing dementia risk has been questioned due to the possibility of reverse causation. This study examined the potential causal effects of physical activity on reducing dementia risk using residency in a snowy area as an instrumental variable (IV) representing the physical activity of older adults.

Methods

We used cohort data from the Japan Gerontological Evaluation Study, a longitudinal cohort enrolling people aged 65 or older who were physically and cognitively independent in 2013; study participants were followed for an average of 5.7 years. Participants in the present study included 73,260 individuals living in 19 municipalities in Japan. Physical activity was measured by self-report questionnaires and the incidence of dementia was ascertained by linking participants to the public registries of long-term care insurance. IV estimation was obtained from a piecewise Cox proportional hazard model using a two-stage regression procedure.

Results

During the study period, we ascertained 8714 cases (11.9%) of dementia onset. In the IV analysis, we found that the frequency of physical activity per week was negatively associated with dementia risk, though the association weakened over time (Year 1: hazard ratio = 0.53, 95% confidence interval: 0.39–0.74; Year 4: 0.69, 0.53–0.90; Year 6: 0.85, 0.66–1.10).

Conclusions

Our IV analysis indicated a potential causal effect of physical activity on reducing dementia risk that persisted for at least 4 years of follow-up. Thus, we conclude that physical activity should be recommended for older adults to reduce dementia risk.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12966-021-01212-w.

Shifting from Fragmentation to Integration: A Systematic Analysis of Long-Term Care Insurance Policies in China

Introduction

Long-term care is an effective intervention that help older people cope with significant declines in capacity. The growing demand for long-term care signals a new social risk and has been given a higher political priority in China. In 2016, 15 local authorities have been selected to pilot the long-term care insurance programme. However, the current implementation of these programmes is fragmented, with a measure of uncertainty. This study aims to investigate the principles and characteristics of long-term care insurance policies across all pilot authorities. It seeks to examine the design of local long-term care insurance systems and their current status.

Methodology

Based on the 2016 guidance, a systematic search for local policy documents on long-term care insurance across the 15 authorities was undertaken, followed by critical analysis to extract policy value and distinctive features in the delivery of long-term care.

Results

The results found that there were many inconsistencies in long-term care policies across local areas, leading to substantial variations in services to the beneficiaries, funding sources, benefit package, supply options and partnership working. Policy fragmentation has brought the postcode lottery and continued inequity for long-term care.

Discussion

Moving forward, local authorities need to have a clear vision of inter-organisational collaboration from the macro to the micro levels in directional and functional dimensions. At the national level, vertical governance should be interacted to outline good practice guidelines and build right service infrastructure. At the local level, horizontal organizations can collaborate to achieve an effective and efficient delivery of long-term care.

Influence of Living Alone or with a Spouse Only on the Short-Term Prognosis in Patients after an Acute Ischemic Stroke

Background—This study aimed to explore whether living alone or with a spouse only affects the short-term prognosis of acute ischemic stroke patients. Methods—We conducted a retrospective cohort study of patients with a diagnosis of acute ischemic stroke from April 2014 to February 2019 in Japan. The primary outcome was defined as worsening by at least one grade on the modified Rankin Scale (mRS). The secondary outcome was set as the degree of worsening on the mRS. The outcomes were compared between three groups of patients: (1) those living alone (ALONE), (2) those living with their spouse only (SPOUSE), and (3) OTHERs. Results—In total, 365 patients were included in this study: 111 (30%) ALONE, 133 (36%) SPOUSE, and 121 (33%) OTHERs. Cardiogenic embolisms were observed more frequently in ALONE than in OTHERs. The primary outcome occurred in 88 (79.3%) patients in ALONE and in 96 (72.2%) patients in SPOUSE, both of which were higher than the 72 (59.5%) in OTHERs. After adjusting with 19 variables, the risk of worsening was higher in ALONE (odds ratio (OR): 2.90, 95% confidence interval (CI): 1.50–5.58) and SPOUSE (OR: 1.83, 95% CI: 1.00–3.33) compared with OTHERs. Conclusions—In patients with acute ischemic stroke, not only living alone but also living with a spouse only may be associated with a worse short-term prognosis, independent of other cardiovascular risks.

Factors Associated With Discussions Regarding Place of Death Preferences Among Older Japanese: A JAGES Cross-Sectional Study

In Japan, many adults prefer to die at home; however, few have their preferences actually come true. While discussions regarding place of death preferences (DPDPs) are important for older adults, they are poorly documented. Therefore, we investigated the factors associated with older Japanese men and women having DPDPs. We used cross-sectional survey data collected for the Japan Gerontological Evaluation Study (JAGES). We applied multivariable logistic regression analysis to calculate the odds ratio (ORs) of having DPDPs separately between men (n = 2,770) and women (n = 3,038) aged ≥ 75 years. We considered 17 potential factors associated with having DPDPs, which were classified as either demographic, healthcare, family, or community factors. Among participants, 50.1% had DPDPs: 1,288 men (44.3%) and 1,619 women (55.7%). Older adults, DPDPs were associated with 5 additional factors; e.g. having a primary care physician (ORs = 1.47 [men] and 1.45 [women]), as were those who gave family and friends advice (ORs = 1.26 [men] and 1.62 [women]), and having people who listened to their concerns (ORs = 1.70 [men] and 1.81 [women]). Among men, DPDPs were associated with 3 additional factors; e.g. humorous conversations with their spouse (OR = 1.60). Among women, only one factor-reading newspapers (OR = 1.43) was associated with having DPDPs. Social networks with primary care physicians, family members, and friends may be important factors in promoting DPDPs. These gender-based differences in older adults relating to DPDPs should be considered when developing interventions to promote advance care planning that includes DPDPs.

Postdisaster Changes in Social Capital and Mental Health: A Natural Experiment From the 2016 Kumamoto Earthquake

Levels of social capital can change after a natural disaster; thus far, no study has examined how changes in social capital affect the mental health of disaster victims. In this study, we examined how predisaster social capital and its changes after a disaster were associated with the onset of mental disorders. In October 2013, we mailed a questionnaire to participants in the Japan Gerontological Evaluation Study living in Mifune, a town in Kumamoto Prefecture, Japan, and measured predisaster social capital. In April 2016, the Kumamoto earthquake struck the region. Three years after the baseline survey, postdisaster social capital and symptoms of mental disorders were measured using the Screening Questionnaire for Disaster Mental Health (n = 828). Multiple Poisson regression indicated that a 1-standard-deviation change in predisaster social cohesion at the community level reduced the risk of depression among women (relative risk = 0.44, 95% confidence interval: 0.24, 0.78); a decline in social capital after the disaster elevated the risk (relative risk = 2.44, 95% confidence interval: 1.33, 4.47). In contrast to social cohesion, high levels of social participation at the community level were positively associated with the risk of depression among women. Policy-makers should pay attention to sex differences and types of social capital when leveraging social capital for recovery from disasters.

Evaluation of Long-Term Care Insurance Policy in Chinese Pilot Cities

Since 2016, 15 pilot cities in China have implemented a long-term care insurance (LTCI) policy. The aim of this research was to explore the outcomes and evaluate the performance of the LTCI policy in the Chinese pilot cities and estimate the willingness of Chinese citizens to expand the formal implementation of LTCI policy in China. We gathered data from 1500 elderly people aged over 60 years in 15 pilot cities (100 surveys for each city) and the effective response rate was 77.8% (1167/1500). We relied on statistical analysis to elicit the outcomes and performance of LTCI implementation and an ordinal logit regression to analyze the factors associated with the extension of the LTCI policy. We examined factors associated with the perception according to sex, age, degree of disability, choices of care, living location, number of children, and monthly income. Among these factors, the relationship between living location and number of children of the family and the outcomes and performance of the LTCI policy in the pilot cities was significant. The rest of the factors showed no significance with the implementation of the LTCI in Chinese pilot cities. This study is among the first to explore the attitudes of Chinese citizens among those who have benefited from the LTCI policy in the pilot cities and contributes to identifying the outcomes of the LTCI in pilot cities to assist policymakers in their further implementation in China.

The unlearning process of senior clinical nurses in rehabilitation wards

Aims

The aim of this study was to create a model and verify its fitness for focusing on unlearning of senior clinical nurses who transferred from acute to rehabilitation wards.

Background

The processes by which nurses with experience in acute wards acquire expertise in rehabilitation wards, the ‘process of unlearning’, have not yet been clarified.

Design

This research used a cross‐sectional study.

Methods

Content analysis of interview data of 23 senior clinical nurses was used to reveal factors constituting nurses’ unlearning and a base model was created. Data were collected between May ‐ September 2016. For its verification, categories extracted through content analysis were used as latent variables and subcategories as observation variables. The model's fit was confirmed through a survey of 5,435 senior clinical nurses from July to September 2017.

Results

We extracted six categories—‘awareness’, ‘conflict’, ‘discard’, ‘acquisition’, ‘acceptance’ and ‘establishment’—and 22 subcategories of the factors constituting unlearning and created a base model. The effective response rate in the survey for verifying the fitness of the base model was 20.2%. The base model generally fulfilled the fitness, but we further studied the model fit with the data and modified it to comprise five categories, excluding ‘acceptance’, with 16 subcategories. The fitness of the modified model further improved. Through revalidation, we confirmed that the modified model satisfies the goodness of fit.

Conclusion

Our findings add to the development of rehabilitation nursing skills of nurses transferred from acute to rehabilitation wards in a Japanese community‐based integrated care system.

Impact

This study revealed the unlearning process of senior clinical nurses. The unlearning process identified in this study contributes to knowledge and skills acquisition specific to nurses specializing in rehabilitation. It will be used for developing a re‐education programme for rehabilitation nurses in the future.

Usefulness of carer-held records to support informal caregivers of patients with dementia who live at home

AIM

It is unclear whether carer-held records (CHR) are useful for patients with dementia. In this study, we evaluated the usefulness of the CHR for patients with dementia at the municipal level.

METHODS

Candidates for CHR use in this study were informal caregivers of patients with dementia who lived at home in Kawanishi, Japan. CHR users were those who are involved in the patient's care and treatment, such as informal caregivers, family physicians, dementia specialists, care professionals, and care service coordinators, known as ‛care managers' in Japan. Collaborative meetings were held every month mainly to help users, especially care managers, learn how to effectively use CHR. We surveyed informal caregivers before and 1.5 years after the start of CHR use to evaluate whether CHR improved collaboration and information provision. The Zarit Caregiver Burden Interview and Dementia Behaviour Disturbance Scale were also administered. We divided the informal caregivers who continued CHR use for 1.5 years into two subgroups based on whether their care manager attended the collaborative meetings at least twice. In addition, we divided informal caregivers into three subgroups depending on their relationship to the patient: spouse, child, or daughter-in-law.

RESULTS

The study initially consisted of 201 informal caregivers. Among them, 74 informal caregivers continued CHR use for 1.5 years. The information provision score significantly improved after CHR use for all informal caregivers. The collaboration score significantly improved after CHR use only for informal caregivers whose care managers attended at least two collaborative meetings. The Zarit Caregiver Burden Interview score significantly improved after CHR use for daughter-in-law caregivers. The Dementia Behaviour Disturbance Scale scores did not significantly improve after CHR use.

CONCLUSIONS

CHR were useful for informal caregivers of patients with dementia. However, care managers need to teach informal caregivers how to properly use CHR.

Association between residual teeth number in later life and incidence of dementia: A systematic review and meta-analysis

Background

It has been suggested that tooth loss in later life might increase dementia incidence. The objective of this analysis is to systematically review the current evidence on the relationship between the number of remaining teeth and dementia occurrence in later life.

Methods

A search of multiple databases of scientific literature was conducted with relevant parameters for articles published up to March 25th, 2017. Multiple cohort studies that reported the incidence of dementia and residual teeth in later life were found with observation periods ranging from 2.4 to 32 years. Random-effects pooled odds ratios (OR) and 95% confidence intervals (CI) were estimated to examine whether high residual tooth number in later life was associated with a decreased risk of dementia. Heterogeneity was measured by I². The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system was used to assess the overall quality of evidence.

Results

The literature search initially yielded 419 articles and 11 studies (aged 52 to 75 at study enrollment, n = 28,894) were finally included for analysis. Compared to the low residual teeth number group, the high residual teeth number group was associated with a decreased risk of dementia by approximately 50% (pooled OR = 0.483; 95% CI 0.315 to 0.740; p < 0.001; I² = 92.421%). The overall quality of evidence, however, was rated as very low.

Conclusion

Despite limited scientific strength, the current meta-analysis reported that a higher number of residual teeth was associated with having a lower risk of dementia occurrence in later life.

Electronic supplementary material

The online version of this article (10.1186/s12877-018-0729-z) contains supplementary material, which is available to authorized users.

Validity of motor impairment scale in long-term care insurance system of Korea

OBJECTIVE

To validate the Motor Impairment Scale (MIS) of the Korean long-term care insurance (LTCI) system by comparing with the service time offered for aiding activities of daily living (ADL) and the ADL score.

METHODS

A total of 407 elderly subjects without dementia who had used LTCI services were included in this study. Spearman correlations and multivariate linear regression models were employed to determine the relationship of the upper and lower limb MIS (U-MIS and L-MIS, respectively) to the service time and ADL. Stratified analyses for the facility group (n=121) and the domiciliary group (n=286) were performed.

RESULTS

There were significant differences in characteristics between facility group and domiciliary group. The MIS was significantly correlated with service time in facility group (Spearman p=0.41 for U-MIS, Spearman p=0.40 for L-MIS). After adjusting for age, sex, and cognition score, U-MIS was an independent predictor for service time in facility group (p=0.04). In domiciliary group, no significant correlation was found between the MIS and service time. The MIS correlated with all of the ADL items and total ADL score in both groups. After adjusting for other factors including age, sex, and cognitive score, U-MIS and L-MIS were independent variables for explaining the total ADL score in both groups.

CONCLUSION

The validity of the MIS as an evaluation tool in the physically-disabled elderly is higher in facility group than in domiciliary group. As an easy, objective, and simple method, MIS can be a useful tool in the LTCI system of Korea.

Both conventional indices of cognitive function and frailty predict levels of care required in a long-term care insurance program for memory clinic patients in Japan

AIM

To delineate relationships among cognitive function, frailty and level of care required in the Japanese long-term care insurance program (LTCIP) in outpatient memory clinic patients.

METHODS

This was a cross-sectional study carried out at an outpatient memory clinic. Participants were 201 cognitively impaired patients. Cognitive function was measured by the Mini-Mental State Examination (MMSE). Frailty was measured by Timed Up & Go (TUG) and grip strength. Waist circumference, body mass index, living arrangement and level of care required in the LTCIP (rank 1 minor disability to rank 7 severe disability) were also assessed.

RESULTS

Mean age, MMSE score, TUG score and grip strength were 78.8 ± 6.9 years, 19.6 ± 6.1, 14.6 ± 6.7 s and 16.9 ± 7.5 kg, respectively. A total of 70 patients (34.8%) had not applied for the certification, at least in part because of their younger age and existence of family caregivers. LTCIP rank was correlated both with MMSE score (β: -0.49, P = 0.001), grip strength (β: -0.27, P = 0.005) and living alone (β: -0.18, P = 0.03), but not with TUG score (β: 0.14, P = 0.105).

CONCLUSION

In outpatients of a memory clinic, care ranks, which define the upper limit of monthly benefit in the Japanese LTCIP, were influenced by age, cognitive function, frailty and living arrangements. Understanding the relationship among these parameters would be useful in predicting the needs of cognitively impaired patients and important when comparing the possible services provided by long-term care systems for them worldwide.

Population ageing and wellbeing: lessons from Japan's long-term care insurance policy

Japan's population is ageing rapidly because of long life expectancy and a low birth rate, while traditional supports for elderly people are eroding. In response, the Japanese Government initiated mandatory public long-term care insurance (LTCI) in 2000, to help older people to lead more independent lives and to relieve the burdens of family carers. LTCI operates on social insurance principles, with benefits provided irrespective of income or family situation; it is unusually generous in terms of both coverage and benefits. Only services are provided, not cash allowances, and recipients can choose their services and providers. Analysis of national survey data before and after the programme started shows increased use of formal care at lower cost to households, with mixed results for the wellbeing of carers. Challenges to the success of the system include dissatisfaction with home-based care, provision of necessary support for family carers, and fiscal sustainability. Japan's strategy for long-term care could offer lessons for other nations.

Factors influencing home death in a Japanese metropolitan region

To examine factors influencing home death, an anonymous survey was mailed to 998 home care supporting clinics (HCSCs) in the 23 wards of Tokyo, Japan. We classified the HCSCs into two types (single physician practice and multiple physician practice) and identified factors of each type of practice that predict home death. The factors associated with a greater probability of dying at home were as follows: in the multiple physician practices, collaboration with hospitals and teaching coping skills to the family members and, in the single physician practices, collaboration with clinics. Our findings suggest that home end-of-life care services are unlikely to be achieved without cooperation among service providers and without improvement of the family members' coping skills.

Gender differences in spousal caregiving in Japan

BACKGROUND

Gender differences in spousal caregivers and their relationship to care experiences, social demographics, and caregivers' depression were examined.

METHODS

A stratified random sample of 2,020 users of public long-term care insurance in a city of Osaka prefecture, Japan, participated in this study. Responses from 308 spouses (56.2% wives, 43.8% husbands) were analyzed. Variables relating to care experiences, social demographics, and caregivers' depression were compared by conducting simultaneous analyses of multiple populations.

RESULTS

Wives caring for husbands had higher depression scores than husbands caring for wives. Wives tended to adopt "emotional support seeking" and "willing commitment" as coping strategies for their caregiving experience. Husband caregivers used more home-care services; however, increased service use had no effect on husbands' depression. The availability of secondary caregivers reduced depression for caregivers, regardless of gender.

CONCLUSIONS

The effects on depression differed related to the caregiver's gender. Husbands relied more on family or home-care services when caring for their wives, whereas wives provided higher levels of care, positively accepted their role, and did not seek to share caregiving, but sought emotional support.