Change in the post-discharge destinations from a senile dementia therapy ward in Japan: the second report

Background: The new long‐term care insurance (LTCI) system, known as Kaigo‐Hoken, was implemented in April 2000. We previously reported a change in the type of destination after discharge from a senile dementia therapy ward (named the Midori ward) following implementation of the LTCI system at Fukuoka Prefectural Onga Hospital during the period from 1 April 1999 to 31 March 2001 in Psychogeriatrics (2003; 3 : 104–108). We subsequently investigated the type of destination after discharge from the Midori ward at Fukuoka Prefectural Onga Hospital during the period from 1 April 2001 to 31 March 2002. Methods: We used data from a total of 320 discharged inpatients with dementia who fulfilled the criteria according to the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM‐IV) for dementia of the Alzheimer's type, vascular dementia and other types of dementia. We compared the period from 1 April 1999 to 31 March 2000 before the LTCI implementation and the periods from 1 April 2000 to 31 March 2001 and 1 April 2001 to 31 March 2002 after the LTCI implementation. The type of destination after discharge and the place of origin of the inpatients before admission were classified into one of the following groups: (i) nursing home or geriatric care facility group; (ii) hospitalization group; (iii) home group; and (iv) death group. Results: No significant change was evident when the subjects’ post‐discharge destinations were compared or when the subjects’ pre‐admission residences and post‐discharge destinations were compared. These results were similar to our previous report which appeared in Psychogeriatrics (2003; 3 : 104–108). Conclusion: While the LTCI system has become more widely used, it is still necessary to analyze each case and provide the care that encourages people with dementia in senile dementia therapy wards to return to their homes under the LTCI system.     

Problems of integration of medical care and welfare service: medical treatment under long-term insurance system

The advent of the long‐term care insurance system has brought substantial structural change not only in the social welfare field but also to the medical care system. Long‐term care insurance has also been introduced into the geriatric hospital system to reduce medical care insurance expenditure. As a result, in cases of emergency involving people under long‐term care, adequate medical care can not be expected because of a shortage of medical treatment wards for the aged. At a sanatorium‐type hospital, the upper limit of the insurance payment is decided by the care degree required by the patient. So from the standpoint of the hospital management, it is necessary to admit patients requiring more severe degrees of care to a sanatorium‐type hospital. It has become difficult to hospitalize dementia patients requiring care degrees 1 or 2. Under the long‐term care insurance system, the problem of medical treatment for the aged becomes all the more serious.     

Decline in quality of life for patients with severe dementia following a ward merger

The effect of a ward merger on the quality of life of patients with severe dementia in a mental hospital was investigated by means of the observational method of dementia care mapping (DCM). Nineteen patients in two long-stay wards were included in the study prior to the merger. Fourteen of these were observed in the merged ward, together with five newly admitted patients. Key DCM indicators showed that the quality of life of patients included in both phases of the study had declined significantly. This may be explained, in part at least, in terms of a cycle of demoralization and depersonalization' in the interaction of staff and patients. Further research is required into the dynamics of this cycle.     

Long-term evaluation of animal-assisted therapy for institutionalized elderly people: a preliminary result

Background: Many researchers theorize that animal‐assisted therapy (AAT) will have an effect on people suffering from the symptoms of dementia by evaluating short‐term‐effects. The purpose of this research was to evaluate the psychological and behavioral effects of AAT on elderly residents of a nursing home on a long‐term basis. Methods: The subjects consisted of 10 residents of a residential nursing home. Researchers first created each participant’s goal in an agreement with the nursing home staff. Visits were made twice a month, and on each occasion three or four dogs were taken. The residents were able to freely feed, hold and play with the dogs, with each dog placed on a separate table. Data collection methods included GBS Scale Japanese Version (GBSS‐J) and Mental Function Impairment Scale (MENFIS). Data was collected four times during the period 2003–05. The scores were analyzed using SPSS11.5J. Results: According to GBSS‐J, the scores for intellectual function, spontaneity, emotional function and other mental functions decreased during the first 6 months of the study and then increased until the twelfth month. The score for Motor function increased over the 12 months. When comparisons were made item by item, there were significant decreases in impaired orientation in space, and emotional liability during the first 6 months. According to MENFIS, the overall score tended to decrease during the first 6‐month period but increased from 6 months to 12 months. There was a tendency for scores to decrease in impaired emotional function, especially impaired suitability of emotional expression and impaired stability of emotional expression over the 12‐month period. Conclusions: After 6 months of participation in AAT, there were improvements in mental functions, though physical functions decreased. It is suggested that after a 6 month period each subject’s needs and goals should be re‐examined.     

The differentiation of depression from senile dementia in the elderly

Two studies were carried out to validate the St Thomas' Questionnaire (SQSD) for use by health professionals to distinguish between cases of depression in the elderly without underlying organic involvement, and thus potentially reversible, from those of a progressive and irreversible senile dementing state. In the first study 50 patients with a diagnosis of senile dementia, 50 with functional disorders known to include an affective component and a control group of 50 coping elderly people within the district were psychologically tested. Independent assessments by a psychiatrist were also provided for the two experimental groups. After taking age and IQ differences into account using multiple regression, performance scores on the SQSD were compared between groups. Significant differences were found (p<0.01) between controls and dementing patients and between depressed patients and dementing patients, but not between depressed patients and controls. When individual subtests of the SQSD were examined, certain items were found to be of greater discriminatory value than others, and in the second study the less discriminatory items were eliminated and a shorter version of the test was administered to a further sample of 50 patients diagnosed as depressed and / or dementing. Again significant differences were found (p<0.01) between the groups, demonstrating the SQSD to be of diagnostic value in discriminating a primarily depressed state from a dementing process.     

Promoting value in dementia care: Staff,resident and family experience of the capabilities model of dementia care

Objectives: This Australian study examined individual experiences of the implementation of the Capabilities Model of Dementia Care (CMDC) and subsequent outcomes for the care of residents with dementia living in long-term care. Furthermore, this study aimed to explore those factors that facilitated and inhibited the implementation of the new model of care.

Methods: The CMDC was developed and then tested in a non-randomised clinical trial. Staff, residents and family experiences of their involvement and perceptions of the model were captured at the end of 12 months. Semi-structured interviews and focus groups were conducted with the 25 participants (12 nursing staff, 6 residents with dementia, 7 family members). Questions varied depending on the participant group but were designed to assess experiences of and changes to care during the intervention. Inductive thematic analysis was used to identify the experiences of the implementation of the CMDC.

Results: Five themes included: general reflections on nursing care, implementation of the CMDC intervention, positive outcomes of the CMDC intervention, challenges in the implementation of the CMDC, difficulty sustaining care and tensions between participants’ perspectives of care.

Conclusion: Positive change resulted from implementation of the CMDC, however, staff mentorship was identified as a key to sustaining changes in practice.     

Quality of in-home care,long-term care placement,and the survival of persons with dementia

Purpose of the study: Caregivers of persons with dementia living at home adopt a variety of caregiving styles that vary in quality. Three styles of high-quality care and poor-quality care have been identified. The outcomes, however, of varying styles of caregiving are unknown. Our purpose was to investigate the linkage of quality of care to long-term care placement and survival.

Design and methods: We used a sample of 148 primary caregivers of a relative living at home and needing assistance due to memory or thinking problems. We used items from four existing scales and five new items to construct measures of high-quality and poor-quality care. Long-term care and survival were determined from two follow-ups. Cox proportional hazards regression was used to estimate the relationship of quality of care to long-term care placement and survival.

Results: Poor quality of care increased the risk of long-term care placement, as expected, but high-quality care was not related to placement. Surprisingly, high-quality care increased the risk of death while poor-quality care decreased the risk. Secondary results were: wishful/intrapsychic coping (a dysfunctional type of emotion-focused coping) and long-term care placement shortened the survival; and caregiver personality traits of neuroticism and agreeableness lengthened the survival.

Implications: It is premature to recommend caregiver interventions based on our unexpected findings. Further studies are vital and should include care-recipient impairments and the quality of life of the person with dementia as additional outcomes.     

The use of psychotropic drugs for behavioral and psychological symptoms of dementia among residents in long-term care facilities in Japan

Objective: To examine whether the use of psychotropic drugs (PDs) was related to behavioral and psychological symptoms of dementia (BPSD) focusing on the prevalence, numbers of symptoms, severity, and care burden among the elderly with BPSD living in long-term care facilities in Japan.

Method: We conducted a cross-sectional survey among older people with dementia or similar symptoms (n = 312) using a questionnaire for care staff in 10 selected long-term care facilities. A brief questionnaire form of the Neuropsychiatric Inventory was used to assess BPSD.

Results: PDs were used in 45% among all participants and 47.5% among those exhibiting at least one BPSD. We found that use of PDs was associated with greater numbers, severity, and care burden of BPSD. Also, there was significantly more use of PDs among people who had specific BPSD symptoms, such as delusions, anxiety, and disinhibition, compared with those who did not.

Conclusion: The use of PDs among residents in long-term care facilities with dementia or similar symptoms was relatively low compared with previous reports from other countries. Nonetheless, the greater numbers, severity, and care burden of BPSD were associated with the use of PDs.     

Prolactin responses to thyrotropin-releasing hormone in multi-infarct dementia and senile dementia of the Alzheimer type

The serum prolactin (PRL) responses to stimulation with thyrotropin-releasing hormone (TRH) (500 micrograms Protirelin) were compared in 14 patients with multi-infarct dementia (MID) and 10 patients with senile dementia of the Alzheimer type (SDAT). Between the MID and the SDAT patients, there were no statistically significant differences in the median serum PRL concentrations, median changes in serum PRL concentrations or median proportional changes in serum PRL concentrations. Further, the serum PRL responses did not correlate with the GBS scale scores (degrees of dementia) or the GBS subscale scores (clinical profiles, including motor functioning, emotional functioning and intellectual functioning). In conclusion, the study does not support the hypothesis that serum PRL responses to TRH stimulation are of diagnostic value in differentiating between MID and SDAT.     

Changes in P-300 latency as a result of co-dergocrine mesylate therapy in patients with senile dementia

Most studies of the effects of drugs in senile dementia have used subjective rating scales to measure change in mental and cognitive function. Few have used objective measurement. The purpose of this study was to compare the latency of the P-300 component of the event-related auditory evoked potential before and after drug treatment. Twenty-one patients aged 74–93 with dementia defined by a score of>10 and <25 using the Mini-Mental Status Test of Folstein were treated with Hydergine 13.5 mg or placebo under double-blind randomized conditions for a period of six weeks. The mean P-300 latency in the active group showed a decrease of 60 ms whilst that of the placebo group was prolonged by 25 ms. The difference was statistically significant (p<0.5) in favour of the active drug. These data suggest that this method of assessment is sensitive to drug-induced changes in patients with senile dementia.     

Young-onset dementia and the need for specialist care: a national and international perspective

Objectives: Receiving a timely and accurate diagnosis and gaining access to age-appropriate support for younger people living with dementia (YPD) remains a challenge both in the UK and internationally because the focus of most dementia services is primarily upon the needs of older people. The political case to improve services for YPD depends upon the establishment of an understanding of the clinical symptoms, an unequivocal evidence base about need and an accurate evaluation of the size of the population affected. This short report assesses the evidence base from international studies regarding service design and delivery. The goal is to raise awareness, advance best practice and galvanise the international community to address the serious underfunding and underprovision of care for this marginalised group.

Conclusion: The current evidence suggests that there are universal problems, regardless of continent, with delays to diagnosis and poor understanding of optimum models for service provision and long-term care.     

Polymorphism in senile dementia of the Alzheimer type from a viewpoint of senile plaque formation

The present article describes polymorphism in senile dementia of the Alzheimer type (SDAT) from a view point of senile plaque formation. Senile dementia of the Alzheimer type is a disorder in which cerebral β amyloid deposition progresses with age and, finally, causes dementia. Aging, apolipoprotein E (apoE) ε4 gene and head trauma are risk factors for senile plaque formation. Senile plaques begin to appear in some subjects in their 40s, whereas other subjects over the age of 100 years do not have any senile plaques. The apoE gene and other unknown factors may cause this difference in the age onset of plaque formation. Plaque density reaches a plateau before clinical dementia appears. As a result, some non-demented subjects have considerable amounts of senile plaques and it may take 20–30 years from the beginning of senile plaque formation for the clinical manifestations of dementia to appear. In this subclinical period, areas of plaque formation spread throughout the cortex from association areas to the primary cortex. The pattern of this progression is consistent in SDAT subjects and, therefore, the pattern of plaque distribution is an important factor for the pathological diagnosis of SDAT. The predominant plaque type is also different among subjects: whereas diffuse plaques are predominant in some SDAT subjects, typical plaques and amyloid angiopathy are predominant in others. This polymorphism cannot be explained by the apoE genotype. Further studies are required to understand the relationship between plaque formation and both known and yet unidentified risk factors in order to explain the polymorphism of SDAT.     

Behavioral and psychological symptoms of dementia in older residents in long-term care facilities in Japan: a cross-sectional study

Objective: To investigate the prevalence of the behavioral and psychological symptoms of dementia (BPSD) and associated factors in residents in long-term care (LTC) facilities.

Method: We conducted a cross-sectional survey of older residents with dementia or similar symptoms (n = 312) using a questionnaire for care staff in 10 selected LTC facilities in Hokkaido, Japan. The questionnaire included sociodemographic characteristics, health conditions, living environments, and a brief questionnaire form of the Neuropsychiatric Inventory for assessing BPSD.

Results: We revealed that the prevalence of BPSD in LTC facilities (percentage of people exhibiting at least one BPSD) in residents with dementia or similar symptoms was 64%. Having Alzheimer's disease, an imbalance between activities of daily living and cognitive function, poor relationships with other residents, and persistent requests in daily life were significantly associated with having BPSD.

Conclusion: The prevalence of BPSD in LTC facilities was relatively low compared with other countries. The factors found to relate to BPSD may provide useful information for developing care methods to address BPSD in LTC residents.     

Development,reliability, and validity of a self-assessment scale for dementia care management

Background

This study aimed to develop a self-assessment scale for care management of people with dementia and examine its reliability and validity.

Methods

Based on Bloom's Taxonomy, previous research, and experts' opinions on dementia and care management, a scale consisting of 18 items was developed to assess care managers' attitudes, knowledge, and skills in their management of people with dementia. To examine the scale's reliability and validity, data were collected from 638 care managers. Construct validity using exploratory factor analysis, known-group validity, and internal consistency reliability of the scale were evaluated.

Results

Exploratory factor analysis supported the construct validity with a four-factor model and explained 59.1% of the total variance. Following were the four factors: Factor I ‘Person centred care’; Factor II ‘Understanding of disease characteristics, treatment and care’; Factor III ‘Understanding of people with dementia and care management according to their characteristics’; and Factor IV ‘Utilization of local resources surrounding people with dementia’. Regarding the known-group validity, results showed that the group with a qualified chief care manager scored significantly higher than the group without one on Factors I (P = 0.013) and III (P = 0.026). Cronbach's alpha coefficient for the 18 items was 0.928.

Conclusions

The findings prove that the scale has acceptable reliability and validity, and can help care managers reflect on their practice. Future research is desirable to measure the validation of change in the scale.