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Keywords:

  • dementia support doctor;
  • dementia;
  • long-term care insurance;
  • network of medical care providers;
  • outpatient;
  • psychogeriatric services

Abstract

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHODS
  5. RESULTS
  6. DISCUSSION
  7. ACKNOWLEDGMENTS
  8. REFERENCES

Background:  The Wakae Clinic opened its Mental Silver Clinic in May 2002 to provide psychogeriatric services for outpatients with long-term care insurance, and medical services and care for patients with senile mental disorders, mainly dementia.

Methods:  The present report describes a study of 100 patients who received services from the Mental Silver Clinic over 5 years, from January 2003 to December 2007. It compares the age of first diagnosis and age of onset disorder with confirmed diagnosis, results of the initial Mini-Mental State Examination, and Behavioral and Psychological Symptoms of Dementia (BPSD), as well as other parameters.

Results:  Sixty-three of the patients (63%) were diagnosed with dementia. The most problematic behaviors are identified, the most frequent of which was delusion, followed by hallucination, reversed day and night or insomnia, negligence of fire, and delirium.

Conclusions:  The number of VaD patients was smaller than DLB patients at mental clinic.


INTRODUCTION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHODS
  5. RESULTS
  6. DISCUSSION
  7. ACKNOWLEDGMENTS
  8. REFERENCES

Medical services and care for senile mental disorders, especially dementia, are becoming increasingly important.1 The Japanese national care insurance system classifies individuals aged 65 or older as Class 1 insured, while those aged 40–64 are classified as Class 2. In May 2002, Wakae Clinic, a psychiatric clinic without beds located in Chuo-ku, Kobe, Hyogo Prefecture, Japan, opened its Mental Silver Clinic to offer special psychogeriatric services for outpatients with long-term care insurance, which provides medical services and a place for nursing care in cooperation with other local home-, community-, and facility-based services using the national care insurance system.

When the Mental Silver Clinic was opened, treatment and diagnosis were initially offered one day a week, with services provided to 0–1 new patients per day (0–4 new patients per month). To minimize the waiting time for each outpatient, all consultations were by appointment only.

A network of medical services providers is important in these types of outpatient clinics, especially for patients with dementia. Thus, a Memory Loss Outpatient Network model was developed (Fig. 1). The network is composed of affiliated dementia outpatient clinics in Kobe characterized by different levels of care, indicated by heavy lines in Fig. 1, with the Memory Clinic used to provide special outpatient services for a university hospital2 placed at the uppermost level.

image

Figure 1. Silver clinic network in Kobe, Japan.

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Our Mental Silver Clinic is placed at the lowermost level and participates in hospital–clinic cooperation by utilizing the Memory Loss Outpatient Network. Since August 2006, the Wakae Clinic has also provided dementia support in a role specified by the national government in 2004 to promote cooperation for dementia care. To satisfy the support doctor role, an oval model centered on the Mental Silver Clinic was developed, as shown in Fig. 1. This model promotes the sharing of accurate information regarding dementia by exchanging findings and opinions at regional medical association meetings to facilitate regional cooperation centering on early discovery and treatment of dementia at clinics with other specialties, as well as by family doctors. Lectures on dementia are given to doctors belonging to the medical association and to family doctors as delegates of the medical association for care insurance, in order to develop a system to support daily diagnosis and treatment by family doctors in cooperation with local medical association members. As the chairperson of the Collegiate body of the Committee for Certification of Care Needs, the author also determines the degree of support or care needed based on family doctor briefs and certification of care needs investigation slips. In this regard, consultation with local core hospitals, special hospitals for senile dementia disorders, and senile dementia centers in for image testing, such as magnetic resonance imaging (MRI) and inpatient care is conducted. In addition, collaboration to implement mild cognitive impairment examinations at the Institute of Biomedical Research and Innovation (BRI), using mainly PET, has been established, with follow-up examinations conducted at our clinic for additional treatment.

With respect to nursing care, the author gives lectures on dementia to nursing and support specialists, and provides consultations for home-based services (home helper services, day services, day care, and short stay), community-based services (group home, small multifunctional home care) and facility services (healthcare and nursing care facilities for the elderly and special elderly nursing home).

The process of outpatient diagnosis and treatment begins at the first consultation, during which a detailed medical history is obtained by having the patient answer questions on an interview sheet (major complaint, time of onset and health history). Specifically, the family member or caregiver accompanying the patient is asked about the medical history related to the onset and existence of risk factors (e.g. high blood pressure, diabetes, hyperlipidemia, depression, history of head injury, family history of dementia) to determine the time of onset, initial symptoms, and later progress of the disease. Next, a neurological examination (presence of gait disorder, sensory impairment, dysarthria, pathologic reflex and muscle weakness), psychological examination (Mini-Mental State Examination (MMSE)), blood tests, and other examinations are performed. If a differential diagnosis is required, electroencephalography is used and the local core hospital is asked to perform neuroimaging examinations (head computed tomography/MRI and brain single photon emission computed tomography).

The diagnosis is confirmed by a comprehensive evaluation of the examination results. Sometimes, especially when diagnosis confirmation is difficult, diagnosis, treatment records and examination data are presented at case study meetings held once a month at the university hospital in order to improve accuracy.

Next, to treat patients with a confirmed diagnosis of dementia, hospital–clinic cooperation with the local core hospital or university hospital is established, based on consultation with the patient and their family.

In these circumstances the detailed progress of the dementia symptoms were recorded for every 6–12 months from the data on regular visits to our Mental Silver Clinic every 2 weeks to 2 months. To understand the trend of patients who visit one silver clinic in Kobe under long-term care insurance, those records were investigated. The prevalence of each dementia disease, severity, and prevalence of Behavioral and Psychological Symptoms of Dementia (BPSD) were analyzed. Prior to the analysis, the author speculated that Alzheimer disease (AD) is the most prevalent, followed by vascular dementia (VaD), dementia with Lewy bodies (DLB), and fronto-temporal dementia (FTD); however, the result was that AD is the most prevalent, followed by DLB, VaD, FTD, and the frequency of DLB is relatively higher than speculated.

METHODS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHODS
  5. RESULTS
  6. DISCUSSION
  7. ACKNOWLEDGMENTS
  8. REFERENCES

The present report summarizes the findings of 100 patients who received diagnosis and treatment at our Mental Silver Clinic between January 2003 and December 2007. It compares the age of first diagnosis and age of onset, disorder with confirmed diagnosis, and results of MMSE and BPSD, as well as other parameters. The study was conducted in accordance with the Ethical Guidelines for Clinical Research (Japan Ministry of Health, Labor and Welfare, 30 July 2003), was approved by a suitably constituted Ethics Committee, and conforms to the provisions of the Declaration of Helsinki 1995 (revised at Edinburgh in 2000).

RESULTS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHODS
  5. RESULTS
  6. DISCUSSION
  7. ACKNOWLEDGMENTS
  8. REFERENCES

The average age of the 100 patients (65 females, 35 males) was 75.6 years. Details regarding the patients and their diagnoses classified by age are shown in Figs 2 and 3.

image

Figure 2. Classification of patient diagnoses (n = 100). ATD, Alzheimer-type dementia; DLB, dementia with Lewy bodies; FTD, fronto-temporal dementia; MCI, mild cognitive impairment; VaD, vascular dementia.

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image

Figure 3. Classification of diagnoses by age group (n = 100). ATD, Alzheimer-type dementia; DLB, dementia with Lewy bodies; FTD, fronto-temporal dementia; MCI, mild cognitive impairment; VaD, vascular dementia.

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Sixty-three of the patients (63%) (38 females, 25 males) were diagnosed with dementia. Of those, 45 (71%) including three with early onset were diagnosed with Alzheimer-type dementia (ATD). Because the average age at first diagnosis for these 63 patients was 78.6 years (no significant difference by gender) and the average age when initial symptoms, such as memory loss were noticed was 75.7 years (no significant difference by gender), the average period from initial symptoms to first diagnosis was 2.9 years.

The average initial MMSE score for the 63 dementia patients was 17.7 points. After classifying these patients by degree of severity, 7 (11%) were classified into the severe dementia group based on a score of 10 points or less, 20 (32%) into the medium dementia group based on a score of 11–17 points, and 36 (57%) into the relatively light dementia group based on a score of 18 points or more (Fig. 4). Table 1 lists the most problematic behaviors, the most frequent of which was delusion (28.5%), followed by hallucination (23.8%), reversed day and night or insomnia (14.3%), negligence of fire (14.3%) and delirium (12.7%).

image

Figure 4. Classification of dementia severity using test scores (n = 63).

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Table 1.  Frequency of Behavioral and Psychological Symptoms of Dementia (BPSD) symptoms in dementia patients (n = 63)
BPSD%
Delusion28.5
Hallucination23.8
Reversed day and night, insomnia14.3
Negligence of fire14.3
Delirium12.7
Resistance to nursing care11.1
Depression7.9
Wandering7.9
Verbal abuse4.8
Physical abuse3.2
Problematic sexual behavior1.6
Stealing1.6
Other1.6

The referral rate from other medical organizations to our Mental Silver Clinic was 55% (55 patients), while eight patients (8%) were referred by nursing care or support specialists. Non-referred patients mostly visited because of subjective or objective symptoms (mainly memory loss) recognized by the patient and/or family.

At 3 months after the initial consultation, 69 patients (69%) were continuing clinic visits, whereas 11 (11%) were referred to other medical facilities, and six (6%) had been admitted to healthcare and nursing care facilities for the elderly or to nursing welfare facilities for the elderly (special elderly nursing homes). One patient died of pneumonia. The remaining 13 patients (13%) stopped clinic visits and their progress is unknown.

DISCUSSION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHODS
  5. RESULTS
  6. DISCUSSION
  7. ACKNOWLEDGMENTS
  8. REFERENCES

The author has written a previous report on the Mental Silver Clinic.3,4

Over the 6 years since our Mental Silver Clinic was established, we have been visited by an increasing number of patients, and have changed the schedule from seeing patients 1 day a week to providing outpatient consultation on any weekday. Because most patients are elderly and often accompanied by family members, caregivers, nursing care, or support specialists, the present diagnosis and treatment system enables consultation better suited to the lifestyle of each patient.

Many of our diagnosis, treatment, and examination procedures are the same as those reported by Yamamoto et al.5 We are able to achieve similar results as university hospitals by presenting and examining the diagnosis, treatment records, and examination data at case study meetings held at a university hospital, and by implementing cognitive function examinations by serving as a clinical psychiatrist using hospital– clinic cooperation with other hospitals in image examination.

The conditions of our patients cover almost the entire field of mental disorders, with 45 patients (45%) of the present cohort diagnosed with ATD. This figure is lower than the 66.2% reported by Yamada et al.,6 60.2% by Uno et al.,7 and 52% by Yamamoto et al.5 and Uemura et al.,8,9 while it is higher than the 33% reported by Yonemura et al.10 and 27.2% by Tago et al.,11,12 Our results are likely related to the finding that 7% of individuals aged 65 years or more in Japan in 2005 had dementia. Because pre-senile dementia patients aged between 40 and 65 years receive special care insurance, nearly half of our patients were diagnosed with ATD; our clinic offers special psychogeriatric services for outpatients with long-term care insurance diagnoses and treats a wider range of senile mental disorders compared to memory clinics.

Seven of our patients (7%) were diagnosed with dementia with Lewy bodies (DLB), which is mainly diagnosed based on criteria presented by McLeish et al. (2005).13 This ratio was relatively higher than the 4.1% reported by Yamamoto et al.5 DLB patients have a higher frequency of hallucinations and delusions than those with other types of dementia; thus, they tend to seek consultations at psychiatric outpatient services instead of special dementia outpatient services, which would explain the relatively higher number of DLB patients at our clinic. Furthermore, the report by Yamamoto et al. was based on relatively old investigation records from 2004 and the authors commented that the rate of DLB in dementia was lower than more current results. Thus, it is possible that the frequency of DLB will increase as diagnostic precision improves.

Meanwhile, three patients (3%) were diagnosed with vascular dementia (VaD), which is lower than the 44% reported by Yonemura et al.,10 22.8% by Tago et al.11,12 and 16–17% by Uemura et al.,8,9 while it is similar to the 3.3% reported by Yamada6 and 3.1% by Yamamoto et al.5 Perhaps the number of VaD patients was smaller than DLB patients because our clinic provides psychiatric outpatient services, while patients with VaD usually have other vascular disorders, leading them to seek consultations at neurology and neurosurgery departments.

Two patients (2%) were diagnosed with FTD, which is similar to the rate of 2.1% reported by Uno et al.7 The author has had experience with three FTD patients (Pick type, including one early onset case) who were inpatients at a mental hospital. Most FTD patients, especially Pick type cases with prominent behavioral problems and personality changes, seek consultation at a mental hospital with inpatient care rather than a clinic.

Most of the dementia patients seeking consultation at our clinic were diagnosed with light symptoms or were in the relatively early stages of disease after onset, based on the average MMSE score of 17.7 points for all 63 dementia patients, although 57% had an MMSE score of 18 points or more. However, because the first consultation at our clinic occurred at an average of 2 years after the initial onset of symptoms, additional community education about early treatment is necessary.

The most frequent BPSD symptoms were hallucinations and delusions, probably because all seven DLB patients had hallucinations and delusions, and such patients generally seek treatment from outpatient psychiatric services providers. The most difficult symptoms for families and caregivers are verbal and physical abuse, coprophilia, wandering and delirium.14–16 At our clinic, the frequency of wandering is 7.9%, while delirium, verbal abuse, and physical abuse are 5%, 4.8%, and 3.2%, respectively, but we have not experienced any cases of coprophilia. The most common symptoms at our clinic are reversed day and night or insomnia (14.3%), negligence of fire (14.3%) and resistance to nursing care (11.1%). Both medication and innovative nursing care services are needed to reduce the incidence of BPSD symptoms.

It is important to re-examine the methods used for ‘care prevention’ in order to adequately treat patients requiring care or to reduce the degree of needed care. As someone working on the front-line in a memory clinic network, the author believes that the best answer is to tackle senile mental disorders, including dementia, by actively promoting cooperation, such as with diagnosis and treatment, between different fields using facilities like our Mental Silver Clinic. Community education is also important for finding and treating patients with dementia in its early stages.

ACKNOWLEDGMENTS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHODS
  5. RESULTS
  6. DISCUSSION
  7. ACKNOWLEDGMENTS
  8. REFERENCES

I would like to thank Professor Kiyoshi Maeda and Instructor Yasushi Yamamoto from the Department of Psychiatry, Kobe University, Graduate School of Medicine, as well as Dr Takashi Kawachi, from the Image Medicine Research Department, Medical Research and Innovation Center, for their advice at society meetings and assistance with hospital–clinic cooperation.

REFERENCES

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHODS
  5. RESULTS
  6. DISCUSSION
  7. ACKNOWLEDGMENTS
  8. REFERENCES
  • 1
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