「老年社会科学」 Vol. 14/Supplement

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長谷川和夫

Currently there are estimated about one million elderly people afflicted with dementia in Japan and they are expected to increase to about two million after 30 years because of the aging of the populations. Dementia is defined as the intellectual disorder occurring in adult without the impairment of consciousness. There are four characteristics.
１．The degree of the intellectual dysfunction seen in dementia has the severity sufficient to interfer with social or occupational functioning.
2．The presence of causative organic lesions in the brain.
3．The presence of various staging in the progressive course.
4．The concomitant behavioral disturbances.
  The author reviews the diagnostic procedures, especially evaluation of dementia state by various psychological or behavioral instruments. Lastly the author reviews the current situation of pharmacological treatments, the principle of care, especially his day-care experiences.
  The usual crises of dementia in the long course of illness are of different origin and they demand the immediate and adequate actions from different agencies. In order to meet the need of dementia sufferers and their caregivers, there should be various institutions, hospitals and homecare services in the community.
  We have various kinds of menus in the services but not in quantity. What is more important is the integration of different services. There should be the evaluation and counseling service center which has a role of integrating various agencies. In addition, the education of caring professionals should be enhanced.
  The importance of basic research to Alzheimer’s dementia should be emphasized in order to obtain medical strategies such as the development of objective diagnostic markers as well as anti-dementia pharmacological agencies.
  How to cope with age-associate dementia is really challenging issues. We need constant endeavors and wisdoms to promote effective strategies and improve quality and quantity of caring demented patients and their caregivers.

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　A general deterioration of physical and mental functions is observed among many of the demented elderly with advancement of dementia and the mortality rate is significantly higher in the demented elderly compared with non-demented. Families caring for demented elderly wished to have them admitted to an institution or hospital if they manifested marked behavioral problems and psychiatric symptoms. Dementia sufferers may encounter with those crisis in the long course of their disorder. I classified two types of crisis in this article. One of the crisis is the primary crisis that has caused by demented elderly themselves such as their deterioration, health problems and behavioral disturbance. Another crisis is the secondary crisis that have caused by sudden change of environment which result in the discontinuation of care, such as death or illness of caregiver, emotional stress and economic burden of caregiver.
　Many family members first visit general practitioner (GP) in the community, when they notice some signs of dementia in their elderly and find some difficulty in caring them. In those situations, GPs should give great assistance in sustaining the family member caring the demented elderly staying at home. I discussed the medical management and services by the GPs delivering primary care for the demented elderly, and their problems which GPs are forced to confront. Under the present situations where the effective method of treating dementia has not been established, I think it is our important task to strive for stability of the family life of the demented elderly. To achieve this, it is quite urgently required to establish the network of delivery system which definitely needs the cooperation with the health and welfare services in the community.

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Many patients with senile dementia are being taken care by their family. Family’s attitude and responses to the patient influence upon symptoms and the course of dementia. Most patients with dementia are actually taken care of by their family, who are experiencing various difficulties in dealing with the patient. Assisting the family to ameliorate burdens of caregiving introducing relaxed attitude and to improve quality of care are important tasks of nurses.
　The assistance by nurses include the following: understanding problems of the family, sorting their problems from their standpoint, giving information that would be useful in reducing difficulties, helping them understand nature of the disease and the patient’s behaviors, supplying knowledge and skills of nursing so that the family can take care of the patient properly.
　Counseling should be individualized by adjusting to lifestyles of the patient and family members and to the clinical stage of dementia. Objective assessment of their problems and finding practical ways of improvement in care, with due consideration on their wish and competence are necessary and assistance should be directed to not only physical but psychological aspects as well.

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　Since there is at present no effectical medical treatment for dementia, the theme“How is the demented elderly managed？”could mean the theme“How are caregivers of the demented elderly managed？”． Although family caregivers caring for their demented relatives experience serious burden and stress, many of them wish to care for their relatives at home. Thus, developing interventions for caregivers and their family members that alleviate caregiver’s burden would be valuable.
　The author and the colleagues have assumed a theoretical psychological stress model concerning the relationships among the components of stress process that caregivers experience (possible stressors, caregiver’s burden as cognitive appraisal, stress symptoms, and coping), and the factors that modurate/moderate the relationships and the components. In this paper, significance and benefit of examining factors that elicit or alleviate caregiver’s burden in the light of our psychological stress model is to be discussed.
　　　　　　　　　　　

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　The Kosai Care Center was established in May 1984, and it is a welfare facility for physically and mentally disabled aged persons staying at homes. This center functions as a Home Care Support Center, Day Service Center and provides services such as day care for the elderly with senile dementia, functional rehabilitation and short-stay service.
　In this article, the following items on day care for elderly with senile dementia are mentioned: details of execution, purpose, supporting process, operational method (who the services are aimed at, frequency of usage, usage fee, pick-up service), activity programs, family support programs and staff. Furthermore, the effect of day care, based on the research conducted by us, are mentioned.
　The day care service for the elderly with senile dementia is being helpful in terms of extending the time of home care; besides that, there are great merits for the family also. It is important to positively support families so that they will be able to continue nursing care without losing their desire to do so.
　　　　　　　　　　　　　

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　This is a report on the current activities of public health nurses to assist caring for the demented aged and their families in the community at one of the centers, Hirakata city in Osaka prefecture.
　There are 22 public health centers in Osaka prefecture and 6 of those centers opened the consultation services for the aged. The number of dementia aged per one center was 33.3 cases in 1987 and increased to 44.5 cases in 1989.
　In order to assist care-givers of dementia aged, it is imparative to establish a meeting place for them. As to human resources, authors attempt to get care-givers of dementia suffers as well as volunteer helper from the community. In Matsubara city, there has been currently three meeting places which serve as a satellite function to center. This program has been developed by the group for occupational therapy. In addition, the author emphasize the importance of education the general public about the care of the dementia.
　　　　　　　　　　　　　　　　

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　The number of the demented elderly as estimated by the Ministry of Health & Welfare is 993, 801 as of 1990; 738, 910 are living in their homes and 254, 891 are staying in hospitals and institutions. As long as the elderly population continues increasing, the number of the demented elderly is expected also to increase.
　The measures taken by the government and the municipal bodies for such persons are not at all satisfactory, and it is only in recent years that efforts to improve them have become evident.
　The primary problem today is the limited availability of services. When the demented elderly are being cared for at home, the support services are badly needed but not readily available. When dementia advances requiring admission to a hospital or an institution, the bed for such a person is not timely available either. Needs for day services (night cares), short stays and home helper dispatches are particularly acute, requiring improvements. For institutions, increasing the number of beds, clearly defining the roles of hospitals vs. institutions, and closer cooperation between them are urgently needed.
　The second problem is that communities do not have the proper care system for the demented elderly. It is necessary to establish a care system under which an integrated service from the care at home to the care at institution is supplied by the coordinated efforts of the responsible organs and persons in the community. A place to render medical diagnosis and overall judgment including recommendation of treatment should be opened to offer an integral service by selecting the optimum health, medical and welfare services to answer the specific needs of the elderly.
　The third problem is the shortage of absolute number of human resources to respond to the caring needs for the demented elderly. Further efforts are needed to secure the human resources and to give training to health and welfare personnel for acquiring the knowledge on dementia and mastering the techniques for care of the demented.
　　　　　　　　　　　　　　　　　　　　　　　　　　　

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　The purpose of this study is to clarify the architectural and planning conditions for nursing homes for the senile elderly. A nationwide survey was conducted through questionnaires given to 2,260 institutions of which 927 institutions answered giving a response rate of 41%. The major results are as follows.
1．According to degrees of separation of senile elderly people from other residents. Categorization into four types was developed, 52% were“integration-type”，28%“semi-integration-type with private rooms”，17%“zone-separation-type”and 2%“segregation respectively.”
2．The ratio of the senile elderly, represented as“severe”and“moderate”as defined by the Hasegawa scale, to accommodation capacity of nursing homes was 53.1% by average and did not vary with the degrees of separation. However, average rations of ambulatory senile elderly people were largely related to them; they extended from 12% in“integration-type”to 41% in“segregation-type.”
3．Looking into the ratio of ambulatory senile elderly people, some linear differences in architectural conditions could be observed between“integration-type”and“segregation-type”homes.
4．In“segregation-type”homes and“zone-separation-type”homes with a large accommodation capacity, a large-scale dayroom or multiple dayroom were frequently installed, gardens and roof-gardens were often utilized, and people working there felt the need for locking up. On the other hand, utilization rate of private room to accommodation capacity in all facilities was 4.8% by average. However, the required level of private room was found to be as high as 14.3%.
　　　　　　　　　　　　　　　　　　

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　We conducted a survey on factors affecting“Home care for the aged with dementia”and presented a report at the 32nd Meeting of the Japanese Geriatrics Society. In the present study, we made a comparative investigation dealing with the characteristics of awareness and the actual situation especially among male-caregivers of the demented elderly.
Methods
The subjects were 50 male-caregivers of the demented elderly in our medical care. The survey was conducted in interview-form and the results were compared with the survey results of a year ago.
Results
1．The family relationships of the male-caregivers are as follows; 60% are husbands and 20% are sons; 28% were in their sixties, 24% in their seventies, and 16% over 80 years of age, at the time of the survey.
As with female-caregivers of the kind, advanced age was marked.
2．Male-caregivers felt great difficulty with work around the house, care for oneself, especially regarding the need for help in eating or taking care of urinary incontinence, psychotic symptom and confused behavior were rare.
3．Male-caregivers in middle age appeared to have more physical and mental vigor compared to female-caregivers, but frequently were less so with aging compared to females.
4．Male-caregivers appeared much more in need of a person to provide assistance than females.
　　　　　　　　　　　　　　　　　　　　　　　　

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　Hasegawa et al. developed and standardized a brief dementia screening scale, called the“Hasegawa’s dementia scale (HDS)”in 1974 which is the most widely used screening instrument for age-associated dementia.
　The HDS was revised with an aim to develop more cultural fair than the original scale. The purpose of the present study is to clarify the clinical utility of HDS revised for screening age-associated dementia.
　The subjects consisted of 117 patients with dementia (mean age: 75.0) and 83 non-demented control (mean age: 76.6). Non-demented subjects were matched to the demented subjects in age and educational background. The severity of dementia were assessed by the Global deterioration scale (GDS).
　The mean score of HDS-R of the demented patients was 10.6 (SD: 6.0) and that of the non-demented subjects was 24.5 (SD: 3.6). The average score of HDS-R of mild dementia was 17.9 (SD: 4.0), moderate 14.1 (SD: 2.8), moderately severe 9.2 (SD: 4.5), severe 4.8 (SD: 3.0). There was significant difference between each groups. The full score of HDS-R was 30 points. There was significant difference in the mean score of HDS-R between the demented and non-demented subjects. When cut-off point was set up at 20／21 point (20 and below; 21 and above), the sensitivity was 0.93, and the specificity 0.86. Thus HDS-R revealed as useful instrument for screening age-associated dementia.
　　　　　　　　　　　　　　　　　　　　　　　

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　The present situation of demented elderly who had taken part in our day care service was investigated by means of a follow up questionnaire. The questions to be answered were:
(1) the patients’ situation: institutionalized or home care.
(2) the patients’ behavioral disturbances and psychiatric symptoms.
(3) the degree of Activity of Daily Living (ADL).
(4) the utilization of welfare services by caregivers.
　The questionnaire was sent 119 caregivers who had taken care of the demented elderly at home. Seventy caregivers replied to the questionnaire.
　The resulted were showed that 38 caregivers continued caring for the demented elderly at home. Fecal incontinence was shown to be one of the risk factors of institutionalization of the demented elderly staying at home. Furthermore, institutionalized patients, had a greater decline in ADL than those who stayed at home. In addition, 31 caregivers who continued taking care of the elderly at home, had a few co-caregivers, and 34 of them used community welfare services.
　These results suggested that the increasing severity of ADL was the one of the risk factors for institutionalization of the demented elderly. It was considered that the important factors of continuing care for the demented elderly at home were the caregivers’ health and minimization of the burden of caregivers.