Long-term Care Insurance System Research Articles

Association Between Adverse Childhood Experiences and Dementia in Older Japanese Adults

The prevalence of dementia in Japan has been increasing. Childhood poverty has been associated with increased risk of cognitive impairment, possibly mediated by individuals' educational paths. However, the associations between dementia and adverse childhood experiences other than poverty and education have not been well documented. To examine the association between adverse childhood experiences and dementia onset among Japanese individuals born before 1948 who grew up during and after World War II. A 3-year (2013-2016) follow-up was performed of 17 412 participants in the Japan Gerontological Evaluation Study, a population-based cohort study of adults aged 65 years or older. Data were analyzed in December 2019. Dementia onset was assessed through the public long-term care insurance system. Adverse childhood experiences before the age of 18 years were assessed by survey at baseline. Seven adverse childhood experiences were assessed: parental death, parental divorce, parental mental illness, family violence, physical abuse, psychological neglect, and psychological abuse. Participants were classified according to whether they had 0, 1, 2, or 3 or more adverse childhood experiences. Cox regression models were used to estimate hazard ratios for the risk of dementia. Among 17 412 participants (9281 women [53.3%]; mean [SD] age, 73.5 [6.0] years), dementia occurred in 703 participants (312 men and 391 women) during a mean follow-up of 3.2 years (range, 2.4-3.3 years). Among all participants, 6804 (39.1%) were older than 75 years; 10 968 (63.0%) reported 0 adverse childhood experiences, 5129 (29.5%) reported 1 adverse childhood experience, 964 (5.5%) reported 2 adverse childhood experiences, and 351 (2.0%) reported 3 or more adverse childhood experiences. Participants who experienced 3 or more adverse childhood experiences had a greater risk of developing dementia compared with those who grew up without adverse childhood experiences, after adjustment for age, sex, childhood economic hardship, nutritional environment, and education (hazard ratio, 2.18; 95% CI, 1.42-3.35). After successive adjustment for adult sociodemographic characteristics, social relationships, health behavior, and health status, this hazard ratio was attenuated but remained statistically significant (1.78; 95% CI, 1.15-2.75; P = .009). This study found that having 3 or more adverse childhood experiences was associated with increased dementia risk among older Japanese adults.

Association between frailty in community-dwelling older adults certified as requiring support in the long-term care insurance system and social capital among local neighborhood volunteers

Association between frailty in community-dwelling older adults certified as requiring support in the long-term care insurance system and social capital among local neighborhood volunteers

Association between skeletal muscle mass index and lung function/respiratory muscle strength in older adults requiring long-term care or support.

[Purpose] We focused on skeletal muscle mass index, one of the biomarkers of sarcopenia, and investigated the association between skeletal muscle mass index and the parameters of lung function and respiratory muscle strength. [Participants and Methods] After applying the exclusion criteria, we included, in this cross-sectional study, 120 community-dwelling older adults aged ≥65 years who required long-term care/support and underwent ambulatory rehabilitation under the long-term care insurance system in Japan. We measured the skeletal muscle mass index, forced vital capacity, forced expiratory volume in 1 second, peak expiratory flow rate, maximum expiratory pressure, and maximum inspiratory pressure. The data were analyzed using Pearson correlation coefficient and multiple regression analysis. [Results] The skeletal muscle mass index was positively correlated with only maximum expiratory pressure for both male and female participants by Pearson’s correlation coefficient. With the skeletal muscle mass index as a dependent variable, only the maximum expiratory pressure was significant for both male and female participants by the multiple regression analysis. [Conclusion] Therefore, the findings of this study suggested that compared with lung function tests, maximum expiratory pressure, which is an indicator of respiratory muscle strength, is related to muscle mass. Maximum expiratory pressure might be the most useful indicator for sarcopenia.

Assessment and Prediction of the Demand for Long-term Care for the Elderly in China

Objective: To explore the demand of long-term care in China. Methods: First, based on the data collected from multiple channels, the number of disabled elderly in China and the long-term care demand were predicted by the macro simulation demand model and markovdo state transition model. The second is to compare and analyze the implementation plan of the long-term care insurance system in China’s pilot areas, discuss the existing problems, and put forward Suggestions. Results: From 2020 to 2050, the number of disabled elders in China will rise from 33813 700 to 60 535 700, and the total long-term care costs will rise from 6.73 billion yuan to 29.12 billion yuan. Conclusion: In the future, China should build a multi-level long-term care guarantee system, actively explore the long-term care insurance system, and improve the long-term care service supply system.

Sustainability of Public Long-term Care Insurance System and Difference between Municipalities

Sustainability of Public Long-term Care Insurance System and Difference between Municipalities

THE STRUCTURE OF CARE MANAGERS’ PRACTICE RESPECTING THE AUTONOMY OF THE FRAIL ELDERLY IN JAPAN

The objectives of current study are to clarify the structure of practice respecting the autonomy of the frail elderly under the Long-Term Care Insurance system in Japan and to discuss the related factors to the practice. The mailed self-administered questionnaire survey was conducted on 1398 care managers who working in In-Home Long-Term Care Support Providers in A City in Osaka with the condition that “office with multiple care managers engaged and one care manager with more than 5 years’ experience”. The response rate was 51.0% (713persons) and no missing data 615 (44.0%) was analyzed. Analysis was carried out using Mplus.ver8. The structure of practice respecting the autonomy of the frail elderly and the rerated factors were examined as a causal model using structural equation modeling. As the result, it was confirmed the goodness of fit to the data (RMSEA=0.049, CFI=0.927). By the confirmatory factor analysis, the care manager’s practice respecting the autonomy of the elderly was confirmed associating with three-factors structure; (1)data collection and assessment, (2) strength perspective and (3) professional relationship. Furthermore the practice was significantly affected by self-esteem of care-managers performance (β=0.494) and self-reflection to own work (β=0.269). In conclusion, the current study supported the hypothetical consideration in which self-esteem and self-reflection in care manager’s practice significantly affected the practice respecting the autonomy of the frail elderly.

STAFFING AND CARE QUALITY OF NURSING HOMES IN KOREA

Staffing has been regarded as the most important factor for the quality of care service in nursing homes. Korea introduced Long-Term Care Insurance (LTCI) in 2008. The payment system of LTCI has incentivized LTC facilities based on the staffing level of LTC facilities. This study aims to investigate whether staffing is associated with quality of care. The effect of staffing on care quality was assessed using ordered logit analysis. Staffing data in 2015 were retrieved from claim data in the National Health Insurance Service. The publicly reported care service quality grade in 2015 was used as a proxy for care quality. Staffing of registered nurses (RN) and social workers were strongly associated with the care quality. As the number of RNs per residents additionally increased, the LTC facilities were more likely to receive better grades (OR=16851.54, p<0.000). The effect of social workers’ staffing was significant for the care service quality, even though the effect size of smaller than that of RNs (OR=345.87, p<0.000). However, staffing in other professions such as nurse assistants (NA) and personal care workers (PCW) was insignificantly associated with care quality. The effect of staffing on service quality might not be profession-neutral. RN staffing affects most in care quality in Korea. Still, the possibility remains that PCWs or NAs could serve for indirect care services such as cooking or cleaning because of short staffing in indirect care services. This finding could be considered when designing financial incentives for nursing homes in Korea as well as other countries.

DO THE PRESENCE OF ADULT CHILDREN AND THEIR MARITAL STATUS MATTER FOR ACCESS TO THE PUBLIC LONG-TERM CARE SYSTEM?

Knowing how the presence of family affects access to the public long-term care system is important for evaluating the adequacy of the system. This study examined the relationship between the presence of adult children and their marital status, and access to a public system by examining the gap between self-reported care needs and the official certification as needing care under the Japanese public long-term care insurance system. Data from Japan’s 2016 Comprehensive Survey of Living Conditions were used. A total of 23,466 older adult claimants, aged 65 years and older were analyzed. Outcomes were whether or not claimants were officially certified as needing care under the system, and the relationship of the presence of both live-in and live-out children and their marital status were examined controlling for claimants’ age, gender, education, financial status, and physical and cognitive conditions. Females comprised 64.8% of the sample, and the average age was 83 years (SD=7.8). The percentage of claimants living with a single or married child were 25.2% and 26.9%, respectively, and 60.1% were parents of children who lived independently. The percentage who were officially certified as needing care was 68.5%. Logistic regression analysis revealed that claimants with a live-in child were less likely to be officially certified as needing care, and claimants with live-in a single child were less likely to be officially certified compared with those with a married child. Live-in single children may provide long-term care by themselves, and the excess burden on them needs to be further investigated.

PREDICTION OF THE NUMBER OF AND CARE COSTS FOR DISABLED OLDER ADULTS FROM 2020 TO 2050 IN URBAN AND RURAL AREAS IN CHINA

Disability for the elderly has become a crucial policy concerns in rapidly aging Asia counties, especially in China. This study aimed to predict the trend of the number of and care costs for disabled older adults from 2020 to 2050 in urban and rural areas in China. Population Administration Decision Information System was used to predict the population of China by urban and rural areas and age group from 2020 to 2050. Monte Carlo simulation and Policy Simulation Model were used to estimate the number and care costs of disabled elderly between urban and rural areas, based on the Chinese latest census data, statistical yearbook, and national survey database. The total disabled population rises rapidly from 43.75 million in 2020 to 91.4 million in 2050, of which 69.7% were urban adults. Compared with the values in 2020, the growth rates of the adults with mild, moderate and severe disabilities were 108%, 104% and 120% in 2050, respectively. The value were 167% and 39% in urban and rural areas, respectively. By 2050, the total care costs increase from 538.0 billion yuan in 2020 to 8530.8 billion yuan, of which 80.2% occurs in urban areas. The predicted results indicate that the numbers and care costs for disabled older adults increase sharply from 2020 to 2050, especially in urban areas of China. It provided a series of evidence for the establishment of the long-term care insurance system in China.

Factors associated with changes of care needs level in disabled older adults receiving home medical care: Prospective observational study by Osaka Home Care Registry (OHCARE).

To clarify factors associated with changes in care needs level and mortality among disabled older people receiving home medical care over a period of 2.5 years. The study included 179 participants, aged ≥65 years, receiving home medical care, who consented to join the Osaka Home Care Registry study. The main outcome was changes in the care needs level of participants eligible for the long-term care insurance system. We investigated the association of changes in care needs level with basic characteristics and care-receiving status. At the 2.5-year follow up, 20.0% of participants showed deteriorated levels, and 41.8% of participants died. In multiple logistic regression, age (odds ratio [OR] 1.10, 95% confidence interval [CI] 1.00-1.21; P = 0.051) and bone joint diseases (OR 0.34, CI 0.09-1.22; P = 0.098) were possible risks associated with deterioration of the care needs level. Male sex (OR 3.28, CI 0.91-11.74; P = 0.068) was a possible risk factor for mortality, and lower serum albumin (OR 0.22, CI 0.07-0.73) was a significant risk factor for mortality. We clarified the different factors associated with deterioration of the care needs level and mortality among disabled older people. Old age and bone joint diseases might be predictive factors for the further deterioration of independence of physical activity, and a low serum albumin level is considered to be strongly associated with increased mortality. Geriatr Gerontol Int 2019; 19: 1198-1205.

Effects of Copayment in Long-Term Care Insurance on Long-Term Care and Medical Care Expenditure

ObjectiveThis study aimed to clarify the difference in (1) long-term care (LTC) usage and expenditure and (2) medical care service usage and expenditure before and after the change in the copayment limit for qualifying individuals from 10% to 20%. Setting and ParticipantsThis quasi-experimental longitudinal design used the database from 1 prefecture of Japan that included 570,434 person-month records of 23,879 insured individuals (in August 2014) who used LTC services between August 2014 and July 2015 and were aged 65 years and older on August 1, 2014. MethodsWe conducted difference-in-difference estimations to compare “before” and “after” outcome differences between insured individuals whose LTC copayment increased to 20% and those whose copayment remained at 10%. Sex, age, Care Needs Level, subsidy, and public assistance were adjusted in the models, along with robustness checks. ResultsDifferences in both insurer's payment and insured's copayment indicated statistical significance between those whose copayment increased and those whose copayment did not increase. We found no significant difference in the number of minutes of home care service use, days of facility care service use, and LTC expenditures among those with copayment increases as well as those with no increase in copayment following the insured's copayment increase policy implementation. In contrast, the policy implementation caused significant differences in the number of days of hospitalization, medical care expenditures, and total expenditures. Conclusions and ImplicationsThe increase in insured individuals' copayment decreased LTC insurer's payment. However, total LTC expenditure increased over time although the increase trend slowed down in the treatment group after the copayment increase policy implemented. Besides, medical care expenditure increased consistently among insured individuals whose copayment increased. As there appears to be a “balloon effect” between LTC and medical care services, it is important to discuss the medical care system while considering the LTC insurance system comprehensively.

Financing Long-term Care: Some Ideas From Switzerland Comment on "Financing Long-term Care: Lessons From Japan".

Ikegami reviews the implementation of mandatory long-term care insurance systems in Germany and Japan, which are organized as pay-as-you-go systems. I propose to go one step further and implement a multi-pillar, mandatory and voluntary long-term care financing system, which combines pay-as-you-go with capital-funded elements. The proposal is based on the observation that Switzerland has implemented a three-pillar system for financing retirement provisions that can be adapted to finance long-term care in a fair and sustainable way.

Community social capital and the onset of functional disability among older adults in Japan: a multilevel longitudinal study using Japan Gerontological Evaluation Study (JAGES) data

ObjectiveThe present study examined the association between community social capital and the onset of functional disability among older Japanese people by using validated indicators of social capital and a prospective...

Disparity in pre-emptive end-of-life conversation experience caused by subjective economic status among general Japanese elderly people: a cross-sectional study with stratified random sampling

ObjectivesPre-emptive conversations (PCs) about end-of-life (EOL) preferences are beneficial for both elderly people and their families to understand and share the preferences. However, the factors which promote/inhibit PCs have yet...

Prevalence of Psychological Frailty in Japan: NCGG-SGS as a Japanese National Cohort Study.

There has been less research conducted on the psychological aspects of frailty than on the physical and cognitive characteristics of frailty. Thus, we aimed to define psychological frailty, clarify its prevalence, and investigate the relationship between psychological frailty and lifestyle activity or disability incidence in older adults in Japan. The participants in our study were 4126 older adults (average age 71.7 years) enrolled in the National Center for Geriatrics and Gerontology-i87uStudy of Geriatric Syndromes (NCGG-SGS). We characterized physical frailty of the following as ≥ 3: slow walking speed, muscle weakness, exhaustion, low physical activity, and weight loss. We used the Geriatric Depression Scale 15 items version (GDS-15) to screen for depressive mood, indicated by 5 points or more on the scale. The co-presence of physical frailty and depressive mood was defined as psychological frailty. The incidence of disability was determined using data from the Japanese long-term care insurance system over 49 months. We found that the prevalence of physical frailty, depressive mood, and psychological frailty were 6.9%, 20.3%, and 3.5%, respectively. Logistic regression indicated that the odds ratios for loss of lifestyle activities were significantly higher in participants with psychological frailty for going outdoors using the bus or train, driving a car, using maps to go to unfamiliar places, reading books or newspapers, cognitive stimulation, culture lessons, giving advice, attending community meetings, engaging in hobbies or sports, house cleaning, fieldwork or gardening, and taking care of grandchildren or pets. During the follow-up period, 385 participants (9.3%) developed a disability. The incidence of disability was associated with both physical and psychological frailty in the fully adjusted model. However, no significant association between disability and depressive mood was found. We conclude that individuals with psychological frailty had the highest risk of disability. Future policies should implement disability prevention strategies among older adults with psychological frailty.

Mass evacuation and increases in long-term care benefits: Lessons from the Fukushima nuclear disaster.

BackgroundThough mass evacuation may increase the need for long-term care (LTC) services, how the need for LTC services increases and how the public LTC system affects it is not well understood. We evaluated changes in public LTC benefits for the people living in the mandatory evacuation areas established after the 2011 Fukushima nuclear disaster and examined the roles of the universal LTC insurance system in Japan.MethodsIn order to evaluate the effect of the mandatory evacuation on LTC benefits, we examined the trends of LTC benefits in the Fukushima evacuation group and the nationwide non-evacuation group. We first decomposed per-elderly-individual benefits at the municipality level into the LTC certification rate and per-certified-individual benefits, and then implemented difference-in-differences analysis using these variables as outcomes.ResultsPer-elderly-individual benefits significantly increased from 2012 onward in the evacuation group, and this was explained by an increase in the certification rate rather than in per-certified-individual benefits. Increases in per-elderly-individual benefits and the certification rate in the post-disaster period were observed in all but the highest care level, and the corresponding outcomes for the highest care level decreased immediately after the disaster. We also found that the increase in the certification rate had been mostly realized by an increase in the number of certified individuals.ConclusionsThe increase in LTC benefits can be associated with the impact of the increase in the number of people newly certified to receive LTC benefits after the mandatory evacuation. In order to cope with the increase in utilization of long-term care and associated costs after disasters in aging societies, both formal long-term care services and social support for informal care for evacuees should be considered important.

소비자의 노후 간병비 관련 인식과 노후 간병비 준비에 관한 연구(Study on the Consumer's Perception and Financial Preparation for Care Costs for the Elderly)

Korean Abstract:본 연구는 소비자의 노후 간병비 관련 인식과 노후 간병비 준비현황을 살펴보고, 노후 간병비 준비에 영향을 미치는 요인을 살펴보고자 하였다. 이를 위하여 30대 이상의 직장인 613명을 대상으로 설문조사를 실시하였으며, 연구결과는 다음과 같다. 첫째, 노후 간병비 관련 인식의 경우, 소비자들은 본인이 노후 간병비의 주된 책임자라고 인식하지만 실제 노후 간병비 지불은 국가의 보조나 지원을 기대하는 것으로 나타났다. 소비자들의 간병비 관련 지식을 분석한 결과 단순 지식 점수는 높았으나 관련 제도나 지원에 관한 지식은 낮았다. 노후 간병비 관련 시간적 거리감과 확률적 거리감을 분석한 결과 시간적 거리감은 비교적 간병비 지출시점을 가까운 미래로 인식하였고, 확률적 거리감은 높게 인식하고 있었다. 마지막으로 소비자들의 간병비에 대한 경제적 부담감 수준은 높게 나타나 간병비가 은퇴자금을 고갈시키는 부담되는 비용으로 인식하고 있는 것으로 나타났다. 더불어 전체 대상자 중 약 21.7%만 노후 간병비를 준비하고 있었고, 한 달에 평균 81만원씩 저축 또는 투자하고 있었다. 둘째, 소비자 특성에 따른 노후 간병비 관련 인식과 간병비 준비를 살펴본 결과, 소비자 특성에 따른 노후 간병비 준비의 차이는 성별, 연령, 총 가계소득, 총 자산에서 통계적으로 유의미한 차이를 보였고 노후 간병비 관련 인식에 따른 노후 간병비 준비의 차이는 지출범위, 책임범위, 시간적 거리감, 확률적 거리감에 따라 유의한 차이가 나타났다. 셋째, 소비자의 노후 간병비 준비에 영향을 미치는 요인에는 지출범위, 책임범위, 시간적 거리감, 성별, 총 가계소득이 통계적으로 유의미한 변수임을 알 수 있었다. 이를 통해 노후 간병비 준비를 증진시키기 위해서 소비자의 간병비 관련 인식, 심리적 거리감, 소비자의 사회․인구학적 특성, 재무적 특성을 종합적으로 고려하는 재무설계 또는 재무상담이 필요함을 알 수 있었다. English Abstract: This study analyzed the consumers’ perception of the care costs for the elderly and their financial preparation, and identify what affects their financial preparations for care costs for the elderly. The data were collected from businessmen over 30 years of age by EMBRAIN, a market research agency. The analysis results and conclusions are as follows. First, with respect to the perception on the care costs for the elderly, the consumers generally did not perceive the fact they should pay for the patient share even if they received the benefit of the senile long-term care insurance system. An analysis of the care costs for the elderly related knowledge revealed a high simple knowledge score but poor scores for the related systems or supports. For the analysis of time and probability distances on the care costs for the elderly in the study subjects, they perceived the higher probability distance than the time distance. Lastly, the level of economic burden on the consumers’ care costs for the elderly was high, demonstrating the expense perceived as a burden. Regarding the financial preparation for care costs for the elderly, only 21.7% of the subjects prepared the care costs for the elderly by saving or investing W810,000 per month on average. Second, regarding the difference of the financial preparation for care costs for the elderly by the consumers’ characteristics, they showed significant differences in terms of gender, age, total household income, and the total asset amount for the difference as to whether to prepare the care costs for the elderly. In addition, an analysis of the financial preparation for care costs for the elderly by the consumer's perception on care costs for the elderly showed significant differences in the recognition of the expenditure scope, responsible scope, and psychological distances. Lastly, the results of the influential elements in the consumers’ financial preparation for care costs for the elderly showed that the elements that influence the preparation of their costs care for the elderly were recognition of the expenditure scope, responsible scope, time distance, gender, and total asset amount.

Factors related to preference for participation and degree of commitment in community activities among older adults in Japanese depopulated areas

To address the rapid increase in the ageing population, Japan implemented the Long-Term Care Insurance System (LTCS) in 2000. Additionally, a community-based integrated community care system was released in 2012. The purpose of these policies was to help older people who need care or support to continue to live their preferred lifestyles in their own communities. According to this paradigm, older residents are themselves considered members of the community caregiving team and expected to participate in volunteer activities to help the neighbourhood. One such activity is social participation including community activities. Many factors influencing social participation have been found in previous literature. However, knowledge of specific factors about community activities is limited, even though these kinds of activities have attracted policy attention. Our study examined factors related to thoughts about community activities among people aged >40years. We conducted random sampling in two depopulated areas in Japan and used an anonymous mail survey method. Our survey consisted of three parts: social demographics, health and life, and medical/long-term care. A total of 2,466 individuals participated in the study (response rate 52.2%), whose average age was 64.2 (SD=10.3) and 46.5% (n=1,146) were female. Items including talking with neighbours frequently (social demographics), higher self-rated health (health and life), the need for health consultations and the desire to take care of family members when they need help (medical/long-term care) were significantly related to both preference for participation and degree of commitment in community activities. To encourage participation in community activities among older citizens, we recommend interventions related to health literacy and family ties.

Albumin and Hemoglobin Trajectories and Incident Disabling Dementia in Community-Dwelling Older Japanese

Background: Serum albumin and hemoglobin levels are independently associated with subsequent cognitive deterioration in older adults. This prospective study used repeated measures analysis to identify aging trajectories in serum albumin and hemoglobin levels and investigated if these trajectories were associated with incident disabling dementia among community-dwelling older Japanese. Methods: A total of 2,005 adults aged 65–90 years participated in annual geriatric health assessments during the period from June 2002 through July 2017; the total number of observations was 9,330. A review of a municipal database of the Japanese public long-term care insurance system identified 1,999 of 2,005 adults without dementia at baseline, 278 (13.9%) of whom developed disabling dementia during the follow-up period (June 2002 through December 2017). Results: We identified three trajectory patterns (high, moderate, and low) for serum albumin and hemoglobin levels for the age period 65 through 90 years. After controlling for potential confounders, participants with moderate and low trajectories for serum albumin level had hazard ratios of 1.27 (95% confidence interval 0.94–1.72) and 2.07 (1.37–3.11), respectively, for the development of incident disabling dementia, with the high trajectory group as reference. The respective hazard ratios for hemoglobin level were 1.31 (0.93–1.85) and 1.58 (1.04–2.40), respectively. Conclusion: Dementia risk was higher for individuals with low trajectories for serum albumin and hemoglobin levels. This finding highlights the importance of interventions that improve nutritional status and control relevant diseases in middle-aged and older adults with low serum albumin and hemoglobin levels.

장애인활동지원제도와 노인장기요양보험제도의 개선 방안 모색: 고령장애인을 중심으로

장애인활동지원제도와 노인장기요양보험제도의 개선 방안 모색: 고령장애인을 중심으로