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Keywords:

  • behavioral and psychological symptoms of dementia;
  • concurrent medical conditions;
  • dementia;
  • medical resources;
  • national health program

Abstract

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. RECENT HISTORY OF THE NATIONAL PROVISIONS AGAINST DEMENTIA IN JAPAN
  5. FUNCTIONS ACTUALLY EXPECTED FROM DCE
  6. ACTUAL STATUS OF MEDICAL RESOURCES FOR DEMENTIA
  7. MEDICAL CENTER FOR DEMENTIA
  8. CONCLUSIONS
  9. REFERENCES

Herein, the Medical Center for Dementia, which was introduced in 2008 as a new national health program in Japan, is reviewed from the perspective of the recent history of the national provision against dementia and the findings of a series of studies on the current status of medical care for dementia. The Medical Center for Dementia was developed to provide special medical services for dementia and connect with other community resources in order to contribute to building a comprehensive support network for demented patients. Specifically, the Medical Center for Dementia provides the following: (i) special medical consultation; (ii) differential diagnosis and early intervention; (iii) medical treatment for the acute stage of behavioral and psychological symptoms of dementia and concurrent medical conditions; (iv) education for general practitioners and other community professionals; (v) network meetings for the establishment of medical–medical and medical–care connection; and (vi) provision of information regarding dementia to the public. Special Medical Consultation Rooms would play an important role in the efficient functioning of the Medical Center for Dementia. In cooperation with municipal governments, the Medical Center for Dementia is also expected to play an important role in policy making and to improve the local status of medical care for people with dementia.


INTRODUCTION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. RECENT HISTORY OF THE NATIONAL PROVISIONS AGAINST DEMENTIA IN JAPAN
  5. FUNCTIONS ACTUALLY EXPECTED FROM DCE
  6. ACTUAL STATUS OF MEDICAL RESOURCES FOR DEMENTIA
  7. MEDICAL CENTER FOR DEMENTIA
  8. CONCLUSIONS
  9. REFERENCES

According to the Population Statistics of Japan 2006 published by the National Institute of Population and Social Security Research,1 the number of elderly people aged 65 years and over will reach 30 000 000 by 2012 and peak at 38 600 000 in 2042. Although a subsequent decrease in this number will be seen, the proportion of elderly people in the population will continue to increase, reaching 40% by 2052. It is also noteworthy that the main source of this increase in the proportion of the elderly in the population is found in the old-old, those aged 75 years and over, the proportion of which is expected to exceed that of the young-old, those aged 65–74 years, in 2017 (Fig. 1).

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Figure 1. Projected population of Japan and the proportion of the population that is young-old (65–74 years) and old-old (75 years and over).

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The increase in the size of the old-old population is strongly associated with an increase in the number of elderly individuals with dementia, because the prevalence of dementia exponentially increases with age, doubling with every 5-year increase in age. When using the national prevalence of dementia by sex and age group estimated by Otsuka,2 the projected population by age (Population Statistics of Japan 2006) indicates that the population of demented elderly individuals aged 65 years and over will be 2 500 000 in 2010, increasing to 3 000 000 in 2015, and reaching to 4 000 000 in 2030 (Fig. 2). The estimated population and increasing prevalence of dementia will largely differ by municipality3 (Figs 3 and 4). Therefore, in addition to the national provision against dementia, concrete measures should be established by each municipality.

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Figure 2. Projected population of elderly individuals with dementia in Japan.

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Figure 3. Estimated population of elderly individuals with dementia by prefecture. In 2035, the largest number of elderly individuals with dementia will be found in Tokyo (425 000), whereas the lowest will be in Tottori prefecture (21 000).

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Figure 4. Increasing proportion of elderly individuals with dementia by prefecture. From 2005 to 2035, the largest increase in the proportion of elderly individuals with dementia will be found in Saitama prefecture (3.1-fold), whereas the lowest will be in Shimane prefecture (1.5-fold).

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RECENT HISTORY OF THE NATIONAL PROVISIONS AGAINST DEMENTIA IN JAPAN

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. RECENT HISTORY OF THE NATIONAL PROVISIONS AGAINST DEMENTIA IN JAPAN
  5. FUNCTIONS ACTUALLY EXPECTED FROM DCE
  6. ACTUAL STATUS OF MEDICAL RESOURCES FOR DEMENTIA
  7. MEDICAL CENTER FOR DEMENTIA
  8. CONCLUSIONS
  9. REFERENCES

Since the latter half of the 1980s, various medical resources and medical fee systems based on the Health Act for Elders introduced in 1983 have been established in order to improve medical care for dementia. Such resources include the Health Institution for Elders established in 1986, the day care fee for severely demented patients introduced in 1988, and the inpatient management fee and the inpatient fee for those admitted to special wards dedicated to dementia treatment or recuperation introduced in 1992 and 1996, respectively. In the context of these national provisions, the Dementia Center for Elders (DCE) project was established in 1989.

The objective of DCE is ‘to improve the quality of local services for health, medicine and the welfare of elders with dementia through providing special medical consultations, differential diagnosis, planning of medical treatment, and emergent services at night and holidays, in connection with other social resources, as well as technical assistance for local professionals involved in health, medicine and the welfare of demented elders (Notification from Director of Health and Medical Bureau in the Ministry of Health and Welfare, 1989). DCE was required to have such functions as: (i) special medical consultations; (ii) differential diagnosis and plans for medical treatment; (iii) emergency services; (iv) coordination of patients’ living situations; (v) technical assistance for local health, medical and welfare professionals; and (vi) improvement of function of DCE itself.

In 2000, the Long-Term Care Insurance (LTCI) Act was enacted for the promotion of the independence of elderly individuals through the provision of benefits according to the extent of disability. Subsequently, local resources regarding long-term care for demented elderly individuals were gradually expanded. In 2005, The Comprehensive Community Support Center (CCSC) was established to actually operate the LTCI system and facilitate the utility of local resources financially supported by the LTCI. Consequently, national provisions for improving medical resources for dementia were reviewed. In line with this policy, the admission fee for those admitted to special wards dedicated to dementia recuperation was repealed in 2006. A subsidy for DCE by the national government was also suspended in 2007. This policy was supported by the findings of a national survey carried out by the National Center of Neurology and Psychiatry in fiscal 2005, which showed that many DCE were not functioning efficiently.

FUNCTIONS ACTUALLY EXPECTED FROM DCE

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. RECENT HISTORY OF THE NATIONAL PROVISIONS AGAINST DEMENTIA IN JAPAN
  5. FUNCTIONS ACTUALLY EXPECTED FROM DCE
  6. ACTUAL STATUS OF MEDICAL RESOURCES FOR DEMENTIA
  7. MEDICAL CENTER FOR DEMENTIA
  8. CONCLUSIONS
  9. REFERENCES

As a result of the disproportionately increasing number of demented elderly individuals, existent medical resources could not be expected to make DCE function efficiently, as both medical and long-term care resources are required in order to provide demented people and their families with comprehensive support.

From 18 DCE, which had been evaluated by the Ministry of Health, Labor and Welfare (MHLW) in fiscal 2006 as being relatively well functioning, eight centers that agreed to participate in the investigation were selected and a questionnaire survey was carried out in fiscal 2007.3 All eight hospitals included a medical emergency center, were equipped with neuroimaging apparatuses including X-ray computed tomography, and employed at least two social workers. The average annual number of new patients who visited the psychiatric division in each hospital in 2006 was 765, with 46% aged 65 years or over. The average annual number of consultations provided in each hospital in 2006 was 401 by telephone and 223 in person. Of the 160 patients with dementia or mild cognitive impairment (MCI) aged 65 years or over who visited one of these eight centers during the period of investigation (November 2007), 37% were referred from general practitioners (GPs) in the community and 11% were referred from other medical divisions within the same hospital. Regarding diagnostic classification, 60% had Alzheimer's type dementia, 8% had vascular type dementia and 23% had MCI. Concerning severity, 36% had mild dementia and 28% had suspected dementia. In 63% of patients, some behavioral and psychological symptoms of dementia (BPSD) were observed, whereas 88% had at least more than one concurrent medical condition. After differential diagnosis and planning of treatment for demented disorders, 54% were followed by the same centers and 28% by GPs in the community. Of the 21 patients who were admitted to one of these DCE during the period of investigation, 57% came from their homes and 14% from long-term care facilities. The main reasons for admission to DCE were difficulty in control of BPSD (95%) and exacerbation of a concurrent medical condition (14%). Emergency admission was requested for 43% of patients and, of these, 89% were admitted on the same day. Most of the admitted patients had a concurrent medical condition (91%).

In conclusion, the actual functions expected from DCE were as follows: (i) professional advice regarding medicine and care for dementia; (ii) differential diagnosis and early intervention of dementia disorders; (ii) connection to medical, health, welfare, legal and other social resources in the community; and (iv) emergent intervention for patients with BPSD and concurrent medical conditions. It is noteworthy that in free-descriptive answers to the question regarding current status of medical care for dementia, some participating psychiatrists indicated that it was very difficult to continue providing these services because of financial and personnel shortages.

ACTUAL STATUS OF MEDICAL RESOURCES FOR DEMENTIA

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. RECENT HISTORY OF THE NATIONAL PROVISIONS AGAINST DEMENTIA IN JAPAN
  5. FUNCTIONS ACTUALLY EXPECTED FROM DCE
  6. ACTUAL STATUS OF MEDICAL RESOURCES FOR DEMENTIA
  7. MEDICAL CENTER FOR DEMENTIA
  8. CONCLUSIONS
  9. REFERENCES

What is the actual status regarding medical resources for dementia in each municipality? In 2008, a questionnaire was distributed to CCSC personnel in Sendai City, an urban city with a population of 1 000 000 located in northern Japan. This study aimed to clarify the current situation of medical resources for dementia and the function of CCSC in Sendai City.4

The findings showed that all CCSC accepted consultations from demented people and/or their families. Most CCSC provided various forms of support, including total consultation, connection to medical facilities, coordination of dementia care, intervention for demented people with difficult social problems, protection from an invasion of rights, prevention of abuse, establishment of a community network and education of the public about dementia. However, for connection to medical facilities, only less than half of CCSC ‘usually’ provided such support. Content analyses of free-descriptive answers to the question regarding the current medical situation for dementia showed that both an extreme shortage of special medical resources and insufficient skills for managing demented patients among GPs might lower the function of CCSC to connect with medical resources.

In conclusion, the following are required in order to construct a comprehensive community support system for dementia: (i) special medical facilities providing differential diagnosis, emergency and admission services, management of concurrent medical conditions and intervention for patients with difficult social problems; and (ii) public enterprises to improve the dementia management skills of GPs and strengthen the connection between specialists and GPs.

MEDICAL CENTER FOR DEMENTIA

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. RECENT HISTORY OF THE NATIONAL PROVISIONS AGAINST DEMENTIA IN JAPAN
  5. FUNCTIONS ACTUALLY EXPECTED FROM DCE
  6. ACTUAL STATUS OF MEDICAL RESOURCES FOR DEMENTIA
  7. MEDICAL CENTER FOR DEMENTIA
  8. CONCLUSIONS
  9. REFERENCES

In 2008, the Medical Center for Dementia (MCD) was established by MHLW as a new national health program for improving the local situations of medical care for dementia. The objective is ‘to improve local situations of health and medical care for dementia through establishment of the special facilities providing special medical consultation, differential diagnosis, and medical treatment for acute stage of BPSD and concurrent medical conditions, as well as education for local health, medical, and care professionals, on the basis of the establishment of MCD by municipalities’ (Notification from Director of Department of Health and Welfare for Persons with Disabilities in the MHLW, 2008). Practically appropriate knowledge and information on clinical management of BPSD are required for each symptom or each dementia disease.5–8 MCD is required to provide special medical services for dementia and connect with other community resources in order to contribute to building a comprehensive support network for demented patients. The specific needs are as follows: (i) special medical consultation; (ii) differential diagnosis and early intervention; (iii) medical treatment for the acute stage of BPSD and concurrent medical conditions; (iv) education for GPs and other community professionals; (v) network meetings for the establishment of medical connection; and (vi) the provision of information regarding dementia to the public.

Sendai City Hospital, a public general medical center established by the municipality in 1930, currently includes 20 clinics and the medical emergency center, has 525 beds in total, and provides care for approximately 1 000 000 citizens. Since 1994, the hospital has also deployed DCE as described earlier. However, the rapid increase in the prevalence of dementia patients resulted in systematic difficulties with DCE and continuing comprehensive medical services for demented patients. These difficulties were primarily as a result of financial and staffing shortages; therefore, waiting times for consultation with the appointed doctor increased by more than 2 months, emergency services could not be provided at night or on holidays, and the various social problems of patients could not be resolved efficiently.

To overcome these difficulties, in 2007, the Special Medical Consultation Room (SMCR) for dementia and mental disorders in elderly individuals was established within DCE on the basis of the municipality budget (Fig. 5). This room is staffed with psychosocial workers, public health nurses and psychologists, and can provide various services including the following: (i) telephone or in person consultations; (ii) preclinical assessment for first-visit patients; (iii) making reservations for clinical consultations with doctors; (iv) mediating to use the long-term care insurance and other social security services; (v) liaison services to connect with other clinics, community social resources and institutions for long-term care; and (vi) case-working to overcome various social problems relating to dementia and mental disorders in the elderly. The Sendai City Hospital was approved as MCD in 2008, when MCD was introduced as a new national program.

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Figure 5. The Special Medical Consultation Room (SMCR) for dementia and mental disorders established in Sendai City Hospital in 2007.

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From 2005 to 2008, the number of services provided per year increased. Specifically, the number of preclinical consultations increased from 603 to 2168, the number of differential diagnoses for first-visit patients increased from 298 to 430, and admissions to psychiatric wards increased from 53 to 72. The average number of days waiting for a clinical consultation with a doctor decreased from 64.7 days in April 2006 to 16.2 days in April 2009. Apparently, SMCR activated liaison services, resulting in the improvement of case-working for patients with difficult social problems. SMCR also contributed to education for hospital staff, city officials, general practitioners and other community professionals, especially those working for the CCSC.4

CONCLUSIONS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. RECENT HISTORY OF THE NATIONAL PROVISIONS AGAINST DEMENTIA IN JAPAN
  5. FUNCTIONS ACTUALLY EXPECTED FROM DCE
  6. ACTUAL STATUS OF MEDICAL RESOURCES FOR DEMENTIA
  7. MEDICAL CENTER FOR DEMENTIA
  8. CONCLUSIONS
  9. REFERENCES

MCD has the potential to improve the local status of medical care for dementia. Based on the published literature, SMCR could play an important role in improving the functioning of MCD.

In 2009, the outline for the practice of MCD was revised and the requirement of a medical consultation room staffed by more than two psychosocial and/or public health professionals was included. The total national budget for this program increased from 190 000 000 JPY in fiscal 2008 to 520 000 000 JPY in fiscal 2009, mainly to address the costs of additional personnel.

However, the extent of the function required for each MCD might differ depending on the size of the population and the actual medical resources available in each municipality. Therefore, it is essential to consider the following questions: How many MCD should be established? How many and what kind of professionals should be staffed? How should effective networks connecting medical–medical resources and medical–care resources be established? How can the number of specialists be increased and how can the skills of GPs be expanded? In cooperation with municipal governments, MCD is also expected to play an important role in local policy making and improve medical resources for people with dementia.

REFERENCES

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. RECENT HISTORY OF THE NATIONAL PROVISIONS AGAINST DEMENTIA IN JAPAN
  5. FUNCTIONS ACTUALLY EXPECTED FROM DCE
  6. ACTUAL STATUS OF MEDICAL RESOURCES FOR DEMENTIA
  7. MEDICAL CENTER FOR DEMENTIA
  8. CONCLUSIONS
  9. REFERENCES