Patterns of long-term care service use and multimorbidity in older Japanese adults: A cross-sectional study of claim data.

AIM: The long-term care (LTC) insurance system provides a combination of several services in Japan; therefore, it is important to clarify service utilization. Furthermore, it is important to consider multimorbidity among older adults, who frequently present several diseases. This study aimed to clarify LTC service utilization patterns, including those for newly added multifunctional services, and to describe the basic characteristics, including multimorbidity, of these patterns. METHODS: We included 37 419 older adults in care need levels 1-5, living at home, who used LTC services in October 2017. We used LTC and medical claims data that were linked using unique identifiers from the National Health Insurance, Advanced Elderly Medical Insurance, and LTC Insurance of Shizuoka Prefecture in Japan. LTC service utilization patterns were identified using cluster analysis based on service fees. Multimorbidity was analyzed using the Charlson Comorbidity Index (CCI) and compared characteristics in these patterns. RESULTS: Six LTC service utilization patterns were identified: light use (51.0%), intensive use of day care (33.7%), intensive use of short stay (6.3%), intensive use of home help (5.1%), multifunctional LTC in small-group homes (MLS) use (3.7%), and MLS and home-visiting nurses (MLSH) use (0.2%). MLSH use had the highest CCI (3.6 ± 2.3). Intensive use of day care and short stay had the lowest CCI (2.6 ± 1.9). CONCLUSIONS: The characteristics of multimorbidity differed by LTC service utilization patterns. Our findings are useful for considering service utilization that takes into account the characteristics of older adults. Geriatr Gerontol Int 2024; 24: 283-289.

Physical function decline predictors in nursing home residents using new national quality indicators.

AIM: To determine the predictors of physical function (PF) decline among nursing home residents using items from the Long-term care Information system For Evidence (LIFE), a system launched in 2021 to ensure the quality of long-term care. METHODS: The LIFE data of 1648 residents from 45 nursing homes in Japan were retrospectively collected in July 2021 (T0) and January 2022 (T1), including demographics, PF assessed by the Barthel index (BI), nutrition and oral health, and cognitive function. The Dementia Behavior Disturbance scale was used to assess the frequency of certain behaviors, such as "waking at midnight." The predictors of PF decline, defined as a decrease ≥5 in the BI score at T1 compared with that at T0, were determined using mixed-effects logistic regression analyses. PF at T0 was classified into high (>60 BI) and low (≤60 BI) groups. RESULTS: The participants' mean age was 87.2 ± 7.1 years, and 45.3% experienced PF decline. The significant predictors of PF decline were age ≥ 90 years, body mass index <18.5 kg/m2 , dementia diagnosis, moderate and severe cognitive impairments, not vocalizing reciprocal exchanges at will, always "waking at midnight," and high PF at T0. CONCLUSIONS: The LIFE items predicted PF decline among nursing home residents, suggesting that LIFE data can be used to ensure the quality of long-term care. Geriatr Gerontol Int 2024; 24: 123-132.

Impact of home-visit nursing service use on costs in the last 3 months of life among older adults: A retrospective cohort study.

INTRODUCTION: Considering Japan's aging society, the number of older individuals who die at home is expected to increase. In Japan, there are challenges in utilizing and promoting home-visit nursing services at the end of life for community-dwelling older adults. We examined the use of home-visit nursing services at the end of patients' lives and the recommended use patterns of this service (utilization, timing of initiation, and continuity) that contribute to reducing the medical care and long-term care costs (total costs) in the last 3 months of life. DESIGN: This was a retrospective cohort study. METHODS: We examined 33 municipalities in Japan, including depopulated areas. The analysis included 22,927 people aged 75 or older who died between September 2016 and September 2018. We used monthly medical care and long-term care insurance claims data. Participants were classified into five groups based on their history of home-visit nursing service use: (1) early initiation/continuous use, (2) early initiation/discontinued or fragment use, (3) not-early initiation/continuous use, (4) not-early initiation/fragment use, and (5) no use. Univariate and multivariate linear regression analyses were performed to examine the association between total costs in the last 3 months of life and patterns of home-visit nursing service use. RESULTS: Overall, the median age was 85, and 12,217 participants were men (53.3%). In the last half year before death, 5424 (23.7%) older adults used home-visit nursing services. Multivariable linear regression analysis of the log10-transformed value of total costs revealed that compared with the no use group, the early initiation/continuous use group was estimated to have 0.88 times (95% confidence interval: 0.84, 0.93) the total costs in the last 3 months of life (p < 0.001). CONCLUSION: Early initiation use of home-visit nursing services may contribute to reducing total costs in the last 3 months of life for Japanese people aged 75 years or older living at home as they approach the end of life. CLINICAL RELEVANCE: When approaching the end of life, many older adults require daily life care and palliative care. Policymakers are strengthening end-of-life care for community-dwelling older adults in Japan. Although the current results do not demonstrate the effectiveness of home-visit nursing services, they provide a perspective from which to assess the use of home-visit nursing services and its impact on older adults. The findings can be helpful in considering how to provide nursing care in home-care settings for older adults who prefer to spend their final days at home.

Impact of family involvement and an advance directive to not hospitalize on hospital transfers of residents in long-term care facilities.

OBJECTIVE: With the rapidly aging population, the number of residents transferred to hospitals from long-term care facilities (LTCFs) is increasing globally. The objective of this study was to investigate the association between family involvement and an advance directive (AD) for not hospitalizing and hospital transfers among LTCF residents with dementia. METHOD: Using the InterRAI assessment database from September 2014 to June 2019, we included 874 residents from 16 LTCFs in Japan. RESULTS: Of the 874 participants, 19.0% had an AD for not hospitalizing, and 20.5% were transferred to hospitals. An AD for not hospitalizing decreased the likelihood of hospital transfers (p = 0.005). Multilevel logistic regression analysis showed that family involvement was not associated with hospital transfers (odds ratio [OR]: 1.18; 95% confidence interval [CI]: 0.77-1.80), while an AD for not hospitalizing was significantly associated with decreased hospital transfers (OR: 0.50; 95% CI: 0.28-0.89) among the LTCF residents. CONCLUSIONS: Although ADs are not legally defined in Japan, we found that an AD for not hospitalizing decreased hospital transfers. Given that many older people tend to hesitate to express their wishes in clinical decision-making situations in Japan, regular discussions are necessary to help them express their care preferences while also documenting the discussions to ensure the residents receive high-quality care.

Unplanned Hospital Visits and Poor Oral Health With Undernutrition in Nursing Home Residents.

OBJECTIVES: In 2021, the Japanese government began operating a long-term care (LTC) database called the Long-Term Care Information System for Evidence (LIFE). However, its utility has not been verified. Regarding unplanned hospital visits of nursing home residents, one of the challenges in LTC is that poor oral health with undernutrition could indicate high-risk residents. Therefore, this study examined the association between poor oral health with undernutrition assessed using the LIFE data and unplanned hospital visits of nursing home residents. DESIGN: Retrospective cohort study. SETTING AND PARTICIPANTS: The participants were 237 residents aged ≥65 years in 4 nursing homes in Japan. The analyses included 1041 LIFE data entries repeatedly measured for the participants every month and unplanned hospital visit data during the observation period. METHODS: The participants' LIFE and unplanned hospital visit data were obtained from the nursing home providers. Poor oral health was defined using oral items included in the LIFE data and body mass index. Using the LIFE data, the association between poor oral health and unplanned hospital visits within 1 month after LIFE assessment entries was analyzed. The odds ratios (ORs) and 95% CIs were calculated using a generalized linear mixed model. RESULTS: In total, 59 of 1041 LIFE data (5.7%) entries were unplanned hospital visits within 1 month after LIFE assessment. Among patient characteristics, significant differences were noted in dementia diagnosis [OR (95% CI): 2.66 (1.26-5.63)], although no significant differences were observed in other characteristics. Multivariate analysis using participant identification as a random effect confirmed that poor oral health was associated with unplanned hospital visits within 1 month [adjusted OR (95% CI): 2.63 (1.05-6.61)]. CONCLUSIONS AND IMPLICATIONS: Poor oral health assessed using the LIFE data could be used as an indicator to identify nursing home residents at high risk for unplanned hospital visits.

Patterns of visiting nurse services for older adults in Japanese residential facilities: A latent class analysis.

AIM: To examine the patterns of the visiting nurse services provided to older adults in a type of residential facility in Japan and to identify associated factors. METHODS: This secondary analysis used past survey data from visiting nurse service agencies providing services to older adults in residential facilities with few nurses, known as non-specified facilities in Japan. Approximately 515 cases were used to determine the patterns of visiting nurse services using latent class analysis. Multinomial logistic regression analysis examined the relationships between identified classes, residents' characteristics, facilities, and services provided by visiting nurses. RESULTS: Three service patterns were identified as follows: Class 1, observational and follow-up care (37.1%); Class 2, chronic disease care (35.7%); and Class 3, end-of-life care (27.2%). Class 1 comprised fewer nursing services than the other classes and primarily involved the observation of medical conditions, whereas Classes 2 and 3 involved higher care-need levels and provided diverse nursing care support. Specifically, Class 3 was associated with the inclusion of family (odds ratio: 2.42) and a visiting nurse at the attached facility (odds ratio: 4.88). CONCLUSIONS: The three identified classes describe the older residents' healthcare needs. Additionally, the factors associated with the end-of-life care class suggest that older residents with these factors may have difficulty accessing end-of-life care by visiting nurses. Geriatr Gerontol Int 2023; 23: 326-333.

Gradient boosting decision tree becomes more reliable than logistic regression in predicting probability for diabetes with big data.

We sought to verify the reliability of machine learning (ML) in developing diabetes prediction models by utilizing big data. To this end, we compared the reliability of gradient boosting decision tree (GBDT) and logistic regression (LR) models using data obtained from the Kokuho-database of the Osaka prefecture, Japan. To develop the models, we focused on 16 predictors from health checkup data from April 2013 to December 2014. A total of 277,651 eligible participants were studied. The prediction models were developed using a light gradient boosting machine (LightGBM), which is an effective GBDT implementation algorithm, and LR. Their reliabilities were measured based on expected calibration error (ECE), negative log-likelihood (Logloss), and reliability diagrams. Similarly, their classification accuracies were measured in the area under the curve (AUC). We further analyzed their reliabilities while changing the sample size for training. Among the 277,651 participants, 15,900 (7978 males and 7922 females) were newly diagnosed with diabetes within 3 years. LightGBM (LR) achieved an ECE of 0.0018 ± 0.00033 (0.0048 ± 0.00058), a Logloss of 0.167 ± 0.00062 (0.172 ± 0.00090), and an AUC of 0.844 ± 0.0025 (0.826 ± 0.0035). From sample size analysis, the reliability of LightGBM became higher than LR when the sample size increased more than [Formula: see text]. Thus, we confirmed that GBDT provides a more reliable model than that of LR in the development of diabetes prediction models using big data. ML could potentially produce a highly reliable diabetes prediction model, a helpful tool for improving lifestyle and preventing diabetes.

Factors related to a sense of security with medical and long-term care services among community-dwelling middle-aged and older adults in Japan.

AIM: The aim of this study was to identify factors related to a sense of security with regard to medical and long-term care services among middle-aged and older adults. These are for consideration of strategies for the establishment of a community-based integrated care system. METHODS: A cross-sectional survey was conducted in 2400 men and women aged ≥40 years in two cities. Survey items included a scale for sense of security for medical and long-term care, experience of medical and long-term care services, and social and demographic factors. Data were analyzed using univariate and multiple regression analyses. RESULTS: In total, 945 respondents were included in the analysis. In multiple regression analysis, sense of security was significantly higher with ability to consult with medical professionals on medical and long-term care, availability of emotional and instrumental support, norm of reciprocity in the community, community attachment, economic comfort, higher age and male gender, and significantly lower with experience of bereavement at a hospital and depression. CONCLUSIONS: These findings stress the importance of facilitating consultation with medical professionals, support for caregivers of terminally ill patients, and mutual support in the community in a community-based integrated care system. Geriatr Gerontol Int 2022; 22: 568-574.

Care needs level in long-term care insurance system and family caregivers' self-perceived time-dependent burden in patients with home palliative care for cancer: a cross-sectional study.

PURPOSE: Although home care improves patients' quality of life (QOL), several studies have suggested that home care lowers the QOL of family caregivers and decreases their mortality. To alleviate the deleterious impact of home care on caregivers, the major burdens on caregivers and the clinical characteristics of the caregivers vulnerable to the major burden needs to be clarified. METHOD: A survey questionnaire was distributed to 710 family caregivers of patients with cancer in Japan, and 342 valid responses were obtained (valid response rate: 48.2%). The Burden Index of Caregivers was used to identify the major burden on caregivers. To assess the associations of the patients' care needs level and other clinically relevant factors with the major burden, a multivariable-adjusted logistic regression model was used. RESULTS: The time-dependent burden was identified as a major burden. An adjusted model showed a nonlinear association between the care needs level and the time-dependent burden, in which the caregivers of the patients who required moderate care needs level had the highest time-dependent burden [adjusted odds ratio of none, mild, moderate, and severe care needs levels: 0.50 (95% confidence interval 0.07-2.12), 1.08 (0.43-2.57), 1.87 (1.01-3.52), and 1.00 (reference), respectively]. Additionally, older patients and younger caregivers were significantly associated with a time-dependent burden. CONCLUSION: The time-dependent burden was highest in caregivers at the moderate care needs level and younger caregivers. An imbalance between the demand and supply of care services may be improved by considering the clinical characteristics of both patients and caregivers.

Association between respiratory and heart rate fluctuations and death occurrence in dying cancer patients: continuous measurement with a non-wearable monitor.

BACKGROUND: The present study aimed to explore the association between impending death and continual changes in respiratory and heart rates measured using a non-wearable monitor every minute for the final 2 weeks of life in dying cancer patients. METHODS: In this longitudinal study, we enrolled patients in a palliative care unit and continuously measured their respiratory and heart rates via a monitor and additionally captured their other vital signs and clinical status from medical records. RESULT: A dataset was created comprising every 24-h data collected from every-minute raw data, including information from 240 days prior to death from 24 patients (345,600 data); each patient's data were measured for 3-14 days until death. After confirming the associations between the respiratory and heat rate values on the day of death (n = 24) or other days (2-14 days before death, n = 216) and the mean, maximum, minimum, and variance of respiratory and heart rates every 24 h by univariate analyses, we conducted a repeated-measures logistic regression analysis using a generalized estimating equation. Finally, the maximum respiratory rate and mean heart rate were significantly associated with death occurring within the following 3 days (0-24 h, 0-48 h, and 0-72 h), except for the maximum respiratory rate that occurs within 0-24 h. CONCLUSION: The maximum respiratory rate and mean heart rate measured every minute using a monitor can warn family caregivers and care staff, with the support of palliative care professionals, of imminent death among dying patients at home or other facilities.

Environmental factors related to sleep latency among inpatients in rehabilitation wards according to functional independence measure cognitive scores.

BACKGROUND: No study has investigated sleep-related environmental factors in patients according to their functional independence measure (FIM) cognitive scores. AIMS: The aim of this study is to examine the associations between environmental factors such as noise and sleep latency according to the FIM cognitive scores among inpatients in rehabilitation wards. DESIGN: This is a prospective longitudinal study. METHODS: This study measured the sleep state using a bed-based actigraphy, environmental data from Environmental Sensor®, and medical record information of 33 inpatients in the rehabilitation wards during 2018. A linear mixed-effect model was used to analyse the associations between sleep latency and environmental factors. Participants were grouped according to high or low FIM cognitive scores. RESULTS: The average patient age was 77.2 ± 10.9 years, and 48.5% were male. In the high FIM cognitive score group, the loudness and frequency of noise exceeding 40 dB during sleep latency were significantly associated with sleep latency. In the low FIM cognitive score group, only the noise frequency was associated with sleep latency, and intra-individual variance was larger than that of the high group. CONCLUSION: These findings suggest that providing night care with attention to subdued noise is important, particularly for patients with low cognitive functional independence levels measured by the FIM cognitive score.

Factors Related to End-of-Life Care Discussions Among Community-Dwelling People in Japan.

CONTEXT: End-of-life discussions regarding healthcare preferences are important to ensure a dignified end of life. OBJECTIVES: This study clarifies the factors associated with such discussions among community-dwelling people in Japan. METHODS: We conducted a cross-sectional survey of 2400 randomly selected community-dwelling adults over the age of 40 in one urban and rural area each, in Japan. The survey investigated whether the respondents had engaged in discussions about their end-of-life care preferences. Logistic regression analyses were conducted to examine the physical, psychological, social, and demographic factors influencing end-of-life care discussions. RESULTS: Of the final sample comprising 1172 respondents, 41.0% had engaged in end-of-life discussions. Of these, 95.2% had engaged in these discussions with family members, 11.0% with friends and acquaintances, and 4.4% with medical or long-term care personnel. Factors associated with end-of-life discussion engagement included requiring outpatient visits, long-term care requirements, availability of emotional support services, experience of the death of a relative within the past five years, living with a spouse, and being unemployed. CONCLUSION: The results showed that roughly 41% of the surveyed community-dwelling respondents had engaged in end-of-life discussions. The findings suggest that providing emotional support to relieve anxiety regarding one's health and the awareness of death, and having the opportunity to interact with others to discuss end-of-life issues, promote the engagement in such discussions in Japan. This study suggests that it is necessary to create an environment that provides social support and engenders awareness of the importance of end-of-life discussions while the community-dwelling people are still healthy.

Nonwearable actigraphy to assess changes in motor activity before and after rescue analgesia in terminally ill patients with cancer: A pilot study.

AIMS: This study aimed to investigate the usefulness of nonwearable actigraphy to assess changes in motor activity before and after rescue analgesic administration in terminally ill cancer patients. BACKGROUND: Evaluating pain in terminally ill cancer patients is difficult; pain assessment tools are needed. METHODS: This was an exploratory descriptive study conducted within a palliative care unit. A nonwearable actigraph was used to measure the activity score and movement index of terminally ill patients with weeks-long prognosis and pain. The actigraph and medical data were integrated, and data were compared 6 h before and after rescue analgesic administration. RESULTS: Among 10 patients (age: 75.8 ± 12.3 years; six men), we evaluated 28 pain episodes (mean activity score: 130.9 ± 180.5 counts per minute; movement index: 68.8%). When pain was relieved at night following rescue analgesic administration, activity score and movement index decreased significantly (6 h before vs. 6 h after analgesics, respectively: 113.1 to 69.7 counts per minute; 64.3% to 41.8%; both p < 0.0001). With no relief after rescue analgesic administration, activity score did not differ significantly 6 h before and after analgesics: 147.3 to 137.7 counts per minute. CONCLUSION: Pain in terminally ill cancer patients could be assessed using a nonwearable actigraph to capture motor activity and improve pain assessment.

The change over time of vital signs with consideration for opioid use in the last 2 weeks of life among cancer patients in a palliative care unit: Continuous measurement of vital signs using a non-wearable monitor.

OBJECTIVES: The aim of this study was to examine the following by using a non-wearable monitor: (ⅰ) the trajectory of vital signs (VS) in the last 2 weeks of life among cancer patients, and (ⅱ) the difference in change over time of VS between cancer patients with and without opioid use. METHODS: We conducted a longitudinal study involving cancer patients in a palliative care unit (PCU) from April 2018 to October 2019. VS were collected continuously using a non-wearable monitor, and we calculated the means of respiratory rate (RR) and heart rate (HR) per hour, and counts of apnea per hour as outcome variables. Explanatory variables were time (subtracting time of death from measurement time of VS, divided by 36) and opioid use. Mean difference (MD) of time represented the slope per hour of VS values. First, we analyzed the associations between VS per hour and time using a linear mixed model (LMM) with random intercepts and slope over time. Second, we analyzed the associations between VS and interaction term between time and opioid use. RESULTS: We analyzed 26 cancer patients. RR (MD: 0.27 beats/min [95% CI: 0.27-0.28]), HR (MD: 1.51 beats/min [95% CI: 1.50-1.52]), and apnea (MD: 0.71 count/hour [95% CI: 0.70-0.72]) significantly increased hourly. In addition, RR was significantly associated with interaction term (MD: -1.59 beats/min [95% CI: -3.11 to -0.07]), which indicates that there is a difference in the slope of RR between opioid users and non-users. CONCLUSIONS: We have successfully described the trajectory of VS in high-resolution under conditions of a natural end of life in PCU.

Measuring well-being in older adults: Identifying an appropriate single-item questionnaire.

AIM: As the older adult population increases globally, it is important for local governments to measure their health and well-being consistently to effectively support this group. Because definitions of subjective well-being - such as happiness, life satisfaction and subjective health - overlap, it is worth considering which single-item indicator local governments can rely on to measure individual well-being. This study, therefore, explored the correlation between three single-item questionnaires on happiness, life satisfaction and subjective health used in government surveys, and established psychometric scales of happiness, life satisfaction and quality of life, and analyzed which of the three single-item indicators most effectively captured the target well-being. METHODS: Randomly selected people aged ≥65 years in urban and rural areas (n = 1440) answered the questions on the Happiness Scale, the Satisfaction with Life Scale and the Quality of Life scale, and the three single-item questionnaires (happiness, life satisfaction and subjective health). We analyzed the data using correlation and multiple regression analyses. RESULTS: The results showed a high positive correlation between the scales and the single-item questionnaires. The single-item life satisfaction and subjective health questionnaires were significantly correlated with all the three scales. Although there was not much difference in the adjusted R2 values between putting three items jointly and separately, the value of single-item life satisfaction was the best and the subjective health was the second best. CONCLUSION: The results showed that the single-item life satisfaction and subjective health effectively captured the target well-being; these could be the appropriate indicators for a potential optimal index. Geriatr Gerontol Int 2021; 21: 1131-1137.

Provision and related factors of end-of-life care in elderly housing with care services in collaboration with home-visiting nurse agencies: a nationwide survey.

BACKGROUND: Japan has the largest population of older adults in the world; it is only growing as life expectancy increases worldwide. As such, solutions to potential obstacles must be studied to maintain healthy, productive lives for older adults. In 2011, the Japanese government has started a policy to increase "Elderly Housing with Care Services (EHCS)", which is one of a private rental housing, as a place where safe and secure end-of-life care can be provided. The government expect for them to provide end-of-life care by collaborating with the Home-Visit Nursing Agencies (HVNA). The purpose of this study is to clarify the situation of the end-of-life care provision in EHCS in collaboration with HVNA and to examine the factors that associate with the provision of the end-of-life care in EHCS. METHODS: A two-stage nationwide survey (fax and mail surveys) were conducted. Of the 5,172 HVNA of the National Association for Visiting Nurse Services members, members from 359 agencies visited EHCS. Logistic regression analysis was conducted with the provision of end-of-life care to EHCS in 2017 as the dependent variable, and the following as independent variables: characteristics of HVNA and EHCS; characteristics of residents; collaborations between HVNA and EHCS; and the reasons for starting home-visit nursing. RESULTS: Of the 342 HVNA who responded to the collaborations with EHCS, 21.6% provided end-of-life care. The following factors were significantly associated with the provision of end-of-life care to inmates in elderly care facilities: being affiliated with a HVNA, admitting many residents using long-term care insurance, collaborating with each other for more than three years, and started visiting-nurse services after being requested by a resident's physician. CONCLUSIONS: This study clarified the situation of the provision of end-of-life care in EHCS in collaboration with HVNA and the related factors that help in providing end-of-life care in EHCS.

Feasibility and Clinical Usefulness of a Novel Nonwearable Sheet-Type Monitor (Nemuri SCAN): Prognostic Value of Increased Respiratory Rate in Actively Dying Patients.

Objective: The objective of this study was to explore the feasibility of monitoring actively dying patients hospitalized in a palliative care unit using a nonwearable sheet-type monitor that measured the state of sleep and vital signs per minute. In addition, we aimed to clarify the incidence of increased respiratory rate and its relationship with survival time. Design and Measurement: This study was conducted at a 51-bed palliative care unit in Japan from April 2018 through October 2019. Actively dying patients hospitalized in the palliative care unit were eligible to participate. Increased respiratory rate was measured by Nemuri SCAN, and patient's information was extracted from their medical records. Results: In this study, 23 patients were monitored until death; 19 patients with an observational period of 7 days or longer (163 patient days in total) were included in this analysis. There were no adverse events due to use of the nonwearable device. The cumulative incidence of increased respiratory rate (defined as more than 30 respiratory rate per minute) was 63.16% during the observational period, and the mean time between appearance of increased respiratory rate and death was 4.17 ± 4.04 days. Conclusion: This study clearly shows that hospitalized actively dying patients can be monitored using a nonwearable sheet-type monitor that measures sleeping state and vital signs per minute. Further studies are needed to utilize these noninvasive continuous monitoring devices in daily clinical practice.