Evaluation of an advance care planning training program for practice professionals in Japan incorporating shared decision making skills training: a prospective study of a curricular intervention.

BACKGROUND: We developed a novel training program for health care professionals that incorporated shared decision making (SDM) skills training into an advance care planning (ACP) training course, the first in Japan. This study aimed to assess the training program's impact on health care professionals' knowledge, skill, attitudes, and confidence to initiate ACP. METHODS: Using the novel Japanese educational program, we evaluated the effect of 8-month programs conducted eight community training sites of professionals who can practice ACP in a local area in Aichi Prefecture (the Aichi ACP Project). SDM skills training was provided during the workshops conducted in the ACP training course, and the participants' satisfaction and understanding of the training were assessed. After the completion of two workshops, information on SDM skill results from the training and submitted assignments were collected anonymously from the training sites. RESULT: A total of 404 participants completed all education programs. After the first workshop, at least 95% of trainees stated that they were satisfied with the training and that it was useful for ACP practice. The evaluation of the results between the first and second workshops indicated improvement in SDM skills on some items of the SDM measures. In the second workshop, at least 90% of participants submitted implementation reports, and after the second workshop, a survey of confidence in ACP practice was administered, with responses indicating improvement. There were high levels of interest in education related to the ACP practices of oneself and others. CONCLUSIONS: This educational program can be an effective for developing professionals who can practice ACP with SDM skills.

Adapting the patient and physician versions of the 9-item shared decision making questionnaire for other healthcare providers in Japan.

BACKGROUND: In Japan, the number of older people with various health problems and difficulties in living is increasing. In order to practice patient-centered care for them, not only medical professionals but also multidisciplinary teams including care professionals and patients need to practice shared decision making (SDM) in the context of long-term care. For this reason, a measure of SDM in consultations with healthcare professionals (HCPs) other than physicians is needed. Therefore, this study aimed at adapting the patient and physician versions of the 9-item Shared Decision Making Questionnaire (SDM-Q-9, SDM-Q-Doc) for consultations with HCPs other than physicians in Japan. METHODS: A pair of SDM measures that can be used by HCPs other than physicians, "Care SDM-Questionnaire for care receivers (SDM-C-patient)" and "Care SDM-Questionnaire for care providers (SDM-C-provider)" were prepared based on the Japanese versions of the SDM-Q-9 and SDM-Q-Doc. The internal consistency and conceptual structure of these measures were tested by secondary analysis of data from 496 participants from a workshop on SDM for different HCPs. Measurement invariance were tested by multigroup confirmatory factor analysis (CFA) for the patient (SDM-C-patient and SDM-Q-9) and provider (SDM-C-provider vs. SDM-Q-Doc) versions. RESULTS: Both the Japanese SDM-C-patient and SDM-C-provider demonstrated high internal consistencies (Cronbach's α coefficient was 0.90 and McDonald's ω coefficient was 0.90 for both measures). CFA showed one-factor structures for both measures and original measures for physicians. Moreover, multigroup CFA showed configural and metric invariance between the novel care measures and original physician's measures. CONCLUSIONS: Thus, the novel SDM measures for care providers in Japan as well as the original physician's measures could be used in training setting. As these measures were tested only in a training setting, their reliability and validity as new measures for care should be tested in a clinical setting in future.

Job satisfaction among physicians providing health care to the elderly in Japan: a qualitative study.

BACKGROUND: Physicians' job satisfaction plays an important role in service delivery. Japan is a country with a higher number of elderly people and their medical care is a crucial issue. To date, no study has been conducted on the job satisfaction of geriatricians serving the elderly in Japan. This study aims to explore the job satisfaction and motivation of physicians providing health care to the elderly working at different hospitals in Japan. METHODS: In-depth interview of 23 geriatric physicians was conducted and data were coded and analysed. Qualitative content analysis was conducted to identify the response themes. RESULTS: Three major themes emerged from the analysis and they are: satisfaction as a primary care provider, career development, and suitable communication with patients. Geriatric physicians enjoy their work with inter-professional collaboration and are satisfied to provide primary health care to elderly people. Geriatrics is a very promising career to them and they enjoy the communication and empathetic doctor-patient relationship in their service. CONCLUSIONS: Japanese physicians providing health care to the elderly are enjoying their work due to a suitable environment, multi-professional collaboration, work-life balance, and patient-doctor relationship.

[Malignant lymphoma with IgG4-related disease arising in a very elderly man].

IgG4-related disease (IgG4-RD) which is characterized by an autoimmune abnormality and elevated serum IgG4 level often presents as swelling, nodules, and the thickening of multiple organs. It typically occurs in middle-aged to elderly patients, but its pathogenesis remains unclear. Lymphadenopathy is frequently seen in IgG4-RD, which clinically requires a differential diagnosis from malignant lymphoma. We herein report a case of malignant lymphoma with IgG4-RD arising in a very elderly man.An 85-year old man with a 6-year history of autoimmune pancreatitis was diagnosed as IgG4-related hypophysitis 13 months prior to admission. Hydrocortisone was prescribed for secondary adrenal insufficiency after this presentation. At 9 months before admission, he began to suffer from central diabetes insipidus, and desmopressin was also prescribed at that time. However, 9 months later, he presented with fever, weight loss, and systemic lymphadenopathy while demonstrating elastic hardness, flexibility, and no tenderness. A pathologic specimen obtained from a right axillary lymph node biopsy revealed diffuse large B cell lymphoma. Considering his age and performance status, palliative therapy was chosen, and thus prednisolone was administered. He was transferred to another hospital to receive palliative care on the 55th day after hospitalization.We should consider the clinical course, pathological findings, serum IgG4 level, and other involved organs in order to differentiate malignant lymphoma from IgG4-related lymphadenopathy. To our knowledge, this case is the oldest known patient to have ever been reported. Both IgG4-RD and malignant lymphoma are frequently seen in elderly people, therefore, we should deepen our knowledge of these diseases.

WITHDRAWN: Psychotherapy for depression among incurable cancer patients.

BACKGROUND: The most common psychiatric diagnosis among cancer patients is depression; this diagnosis is even more common among patients with advanced cancer. Psychotherapy is a patient-preferred and promising strategy for treating depression among cancer patients. Several systematic reviews have investigated the effectiveness of psychological treatment for depression among cancer patients. However, the findings are conflicting, and no review has focused on depression among patients with incurable cancer. OBJECTIVES: To investigate the effects of psychotherapy for treating depression among patients with advanced cancer by conducting a systematic review of randomized controlled trials (RCTs). SEARCH METHODS: We searched the Cochrane Pain, Palliative and Supportive Care Group Register, The Cochrane Controlled Trials Register, MEDLINE, EMBASE, CINAHL, and PsycINFO databases in September 2005. SELECTION CRITERIA: All relevant RCTs comparing any kind of psychotherapy with conventional treatment for adult patients with advanced cancer were eligible for inclusion. Two independent review authors identified relevant studies. DATA COLLECTION AND ANALYSIS: Two review authors independently extracted data from the original reports using standardized data extraction forms. Two independent review authors also assessed the methodological quality of the selected studies according to the recommendations of a previous systematic review of psychological therapies for cancer patients that utilized ten internal validity indicators. The primary outcome was the standardized mean difference (SMD) of change between the baseline and immediate post-treatment scores. MAIN RESULTS: We identified a total of ten RCTs (total of 780 participants); data from six studies were used for meta-analyses (292 patients in the psychotherapy arm and 225 patients in the control arm). Among these six studies, four studies used supportive psychotherapy, one adopted cognitive behavioural therapy, and one adopted problem-solving therapy. When compared with treatment as usual, psychotherapy was associated with a significant decrease in depression score (SMD = -0.44, 95% confidence interval [CI] = -0.08 to -0.80). None of the studies focused on patients with clinically diagnosed depression. AUTHORS' CONCLUSIONS: Evidence from RCTs of moderate quality suggest that psychotherapy is useful for treating depressive states in advanced cancer patients. However, no evidence supports the effectiveness of psychotherapy for patients with clinically diagnosed depression.

Study profile on baseline survey of Daiko Study in the Japan Multi-Institutional Collaborative Cohort Study (J-MICC Study).

The Japan Multi-Institutional Collaborative Cohort Study (J-MICC Study) is a long-term cohort study to investigate the interactions among genotypes, lifestyles, and lifestyle-related diseases, especially cancer. This article reports the outline of the baseline survey of the Daiko Study, one site of the J-MICC Study. That survey was conducted between June 9, 2008 and May 31, 2010 at the Daiko Medical Center of Nagoya University in Nagoya, Japan. Subjects were registered residents of Nagoya City aged 35 to 69 years who had not participated in other J-MICC sites. Recruitment was mainly announced through leaflets distributed in mailboxes citywide, personal communications, and regional information, such as posters in public or commercial facilities. Participants provided blood plasma, serum, buffy coat, urine, and data on health check-ups. They also completed a self-reported questionnaire on lifestyle, disease history, family history, and for women, reproductive history. As of the end of September 2010, 4 out of 5172 registered participants had withdrawn from the study, leaving data from 5168 participants (1467 males and 3701 females) available for analysis. Mean age +/- standard deviation (SD) was 52.5 +/- 10.3 years. Current smokers accounted for 24.1% (n=354) of males and 6.9% (n=256) of females. Current drinkers included 74.9% (n=1099) of males and 45.9% (n=1699) of females. Lifestyle data and specimens were successfully collected to examine any associations among disease biomarkers, lifestyles, and genotypes.

Chronic Dehydration in Nursing Home Residents.

Chronic dehydration mainly occurs due to insufficient fluid intake over a lengthy period of time, and nursing home residents are thought to be at high risk for chronic dehydration. However, few studies have investigated chronic dehydration, and new diagnostic methods are needed. Therefore, in this study, we aimed to identify risk factors for chronic dehydration by measuring serum osmolality in nursing home residents and also to evaluate whether examining the inferior vena cava (IVC) and determining the IVC collapsibility index (IVC-CI) by ultrasound can be helpful in the diagnosis of chronic dehydration. A total of 108 Japanese nursing home residents aged ≥65 years were recruited. IVC measurement was performed using a portable handheld ultrasound device. Fifteen residents (16.9%) were classified as having chronic dehydration (serum osmolality ≥295 mOsm/kg). Multivariate logistic regression analysis showed that chronic dehydration was associated with dementia (odds ratio (OR), 6.290; 95% confidential interval (CI), 1.270-31.154) and higher BMI (OR, 1.471; 95% CI, 1.105-1.958) but not with IVC or IVC-CI. Cognitive function and body weight of residents should be considered when establishing a strategy for preventing chronic dehydration in nursing homes.

Relationship between blood coagulability and sense of burden among caregivers of patients with dementia.

AIM: This study aimed to examine the relationship between blood coagulability and sense of burden among caregivers of patients with senile dementia of the Alzheimer type. METHODS: A cross-sectional study was carried out involving healthy older caregivers who lived with their patients with senile dementia of the Alzheimer type. We evaluated the Zarit Burden Interview score, levels of von Willebrand factor antigen, D-dimer, thrombin-antithrombin III complex, tissue plasminogen activator/plasminogen activator inhibitor type 1 complex, number of chronic diseases, body mass index and number of medications. A linear regression model was used to estimate adjusted associations. RESULTS: Thrombin-antithrombin III complex levels were higher in female caregivers than in male caregivers (P = 0.07). Headaches were significantly more frequent in female caregivers than in male caregivers, as assessed by a visual analog scale (P < 0.01). The number of chronic diseases and body mass index were positively associated with levels of tissue plasminogen activator/plasminogen activator inhibitor type 1 complex (P < 0.05). Similarly, the number of medications was positively associated with levels of D-dimer (P < 0.05). However, the Zarit Burden Interview score was not associated with blood coagulability (P > 0.05). CONCLUSIONS: The present study found that the number of chronic diseases and body mass index were associated with blood coagulability, and that female caregivers were more prone to headaches and higher blood coagulability than male caregivers. These findings highlight the essential nature of health management during caregiving. The impact of caregiver burden on blood coagulability is likely to differ depending on the long-term or short-term psychological stress associated with caregiving conditions. Geriatr Gerontol Int 2019; 19: 804-808.

Which two questions of Mini-Mental State Examination (MMSE) should we start from?

The MMSE is a simple and commonly used instrument to evaluate cognitive impairment. With the aim of enabling the examiner to skip a large portion of the MMSE when screening subjects with lower possibility of cognitive impairment, we examined the internal distribution of the MMSE scores among 792 older adults visiting a teaching hospital, a long-term care hospital, nursing homes, and a geriatric clinic. The correlation coefficients between the summed scores of any two items of MMSE and the total score were compared. A receiver operating characteristic (ROC) curve was drawn to show the sensitivity and the specificity of predicting cognitive impairment, which was defined by the total MMSE score being less than 24. The mean MMSE score was 20.5 +/- 6.9 (+/-S.D.). A good predictor for cognitive impairment was the summed scores of the time orientation and serial sevens with a sensitivity of 98.2% and a specificity of 69.2% if cut-off was set at 7/7+. This finding appears to help streamline the screening process for cognitive impairment in general elderly population.

A comparison of depressive mood of older adults in a community, nursing homes, and a geriatric hospital: factor analysis of Geriatric Depression Scale.

The Geriatric Depression Scale (GDS)-15 was used in 607 adults aged 65+ years living in a community, nursing homes, and a general hospital to explore characteristics of depressive mood in different care settings. Factor analysis of GDS-15 extracted 4 factors labeled unhappiness, apathy and anxiety, loss of hope and morale, and energy loss. The scale scores labeled unhappiness, apathy and anxiety, and loss of hope and morale were negatively correlated with the Barthel Index and the Mini-Mental State Examination scores. The results classified the depressive patterns into 2 types, one fitting the nursing home residents and the other fitting the hospital patients. The dominant factors of the nursing-home type were unhappiness and loss of hope and morale, and the hospital type was highly related with apathy and anxiety. The results indicate an extended utility of the GDS-15 for a deeper understanding of depressive mood in various care settings.

The pleasurable recreational activities among community-dwelling older adults.

This study aimed to clarify what pleasurable recreational activities older adults like to participate in, and to investigate the relationship between those activities and quality of life (QOL). Questionnaires were delivered to older residents (65 years and above) in a Japanese rural area. The residents' background information, the amount of pleasure for various activities, and the QOL were surveyed. The QOL was evaluated by the revised Philadelphia Geriatric Center (PGC) morale scale. The amount of pleasure taken in a majority of the activities, such as conversation with family or neighbors showed a significant association with the happiness score, but only a few activities showed significant association between the revised PGC morale scale and the amount of pleasure. The multiple regression analyses indicated that the amount of pleasure in exercise, the difficulty in managing finances, and amount of pleasure taken in watching TV were significant variables for predicting the happiness score. The results indicated that the amount of pleasure older adults experienced when engaging in activities such as conversation with family or neighbors showed significant association with the older adults' happiness. These results may be helpful in understanding contributions of various activities to the perception of pleasure in older adults.

Influence of behavioral and psychological symptoms of dementia (BPSD) and environment of care on caregivers' burden.

With increasing population of older adults in need of care, caregiver's burden is becoming a major concern. We investigated the relative contributions of BPSD of care recipients, caregiver's background and the care environment to caregiver's burden assessed by using Zarit burden interview (ZBI). Among BPSD, inability of finding the way home, inability of managing money and fecal incontinence were the most difficult symptoms to cope with. A path analysis, by which we constructed a network model to clarify the contributions of the factors examined to the caregiver's burden, indicated that the severity of dementia, the feeling of "would rather die than be in the same condition" and the physical pain of the caregivers showed great direct influences on the score of the ZBI. In conclusion, we clarified kinetic and dynamic interactions of factors affecting caregiver's burden by using a path analysis. The model indicates that the caregiver's burden can be affected not merely by the illness of the care recipients but by the caregiver's background and the care environment.

Impaired autonomic nervous system activity during sleep in family caregivers of ambulatory dementia patients in Japan.

The number of dementia patients requiring care is rapidly increasing in Japan. Consequently, a large percentage of family members, including spouses and children of those with dementia, are assuming the role of primary caregiver. Many caregivers develop health problems including sleep disorders. Some report poor quality of sleep even when sleep duration is normal. In the present study, we used actigraphy and heart rate variability spectral analysis to assess autonomic nervous system activity and quality of sleep in family caregivers of people with ambulatory dementia. The 20 caregivers who participated in our study exhibited significantly higher levels of sympathetic nervous system activity during sleep than noncaregivers. This abnormal activity was most prominent during the first half of the sleep period and was not related to overall sleep duration. We propose that relaxation is inhibited during the first half of the sleep period in this caregiver population. This may be due to increased stress, as caregivers of people with ambulatory dementia may worry about their patients waking and wandering at night, potentially injuring themselves. Our findings indicate a need for increased support for caregivers of people with dementia, including the assessment and treatment of sleep disorders.

The relationship between functional disability and depressive mood in Japanese older adult inpatients.

Depression is commonly found in older adult patients and is often associated with handicaps. The authors administered the Comprehensive Geriatric Assessment (CGA), including basic activities of daily living (BADL), instrumental activities of daily living (IADL), Mini-Mental State Examination (MMSE), Geriatric Depression Scale (GDS)-15, and a socioenvironmental questionnaire to 198 patients who were admitted to Nagoya University Hospital, to examine the relationship between depressive mood and various physical and socioenvironmental outcomes. The overall GDS-15 score was correlated with the BADL and IADL. The factor analysis extracted 4 factors from the GDS-15 subscales. The factors labeled "loss of morale and hope" and "memory loss and reduction of social activity" were highly correlated with both ADLs, social variables, and the MMSE score. The results reveal that factor analysis of GDS-15 will help in understanding the etiology of depressive mood, thereby contributing to better therapeutic approaches.

[Long-term prognosis and satisfaction after percutaneous endoscopic gastrostomy in a general hospital].

Although percutaneous endoscopic gastrotomy (PEG) has been widely acknowledged as a safer method for enteral feeding, its long-term impact on prognosis and quality of life (QOL) in elderly patients is not sufficiently understood. Regarding the indications of PEG, there still exist issues to be studied due to lack of convincing evidence for reduction of expected complications such as aspiration pneumonia or for improvement of prognosis in patients with severe dementia. In this study we investigated the survival rate after PEG placement and family satisfaction retrospectively in 78 elderly inpatients who underwent PEG, by sending questionnaires to the patients or their caregivers. The results of 68 cases (88%) recovered showed that the 1-year survival rate was 64.0%, and the 2-year survival rate was 55.5%. Fifty-three percent of families of patients showed overall satisfaction regarding the induction of PEG. The survival rate was relatively higher than that from previously reported studies. The differences we observed may be attributed to variations in patients' backgrounds (clinical, socio-economic, cultural) in therapeutic interventions. We recognized the importance of clarifying factors which would affect the prognosis and QOL in elderly patients who undergo PEG. The indication for PEG can be made based on comprehensive assessment of the relevant factors in individual cases, taking patient's or caregiver's wishes into consideration.

Physical and functional factors in activities of daily living that predict falls in community-dwelling older women.

AIM: In order to propose rehabilitation strategies for the reduction of falls risk, thereby preventing falls in older women, the present study was designed to explore the physical and functional factors related to actual incidence of falls. METHODS: Fifty-eight female patients aged 65 years and older (mean age ± standard deviation, 80.5 ± 5.7), who were attending a geriatric outpatient clinic participated. All the participants were assessed with their activities of daily living, gait and balance using various scales. Their handgrip strength and muscle strength of lower extremities were also measured using dynamometers. Falls of the participants during the 6 months follow-up period were recorded. RESULTS: Correlation analysis investigating associations between the scores of assessment scales and actual measurement of muscle strength and balance showed that there were significant correlations between handgrip strength and Falls Efficacy Scale, Functional Reach test, Timed Up and Go test, Berg Balance Scale, Motor Fitness Scale, motor Functional Independence Measure in fallers and non-fallers. A binary logistic stepwise regression analysis incorporating all the possible variables into the model revealed that only inability to "being able to go up and down the staircase" in the Motor Fitness Scale remained a significant variable to predict falls during the period of observation. CONCLUSION: The results confirmed that the sub-item in the Motor Fitness Scale has a possibility of being a significant predictor of falls in older women, and therefore might prove useful in considering specific rehabilitation program on falls prevention as well as screening this population at risk of falls.

Influence of regular exercise on subjective sense of burden and physical symptoms in community-dwelling caregivers of dementia patients: a randomized controlled trial.

With an aim to improve quality of life in caregivers of dementia patients, we examined the effect of regular exercise on caregivers' sense of burden and their physical symptoms. Participants were 31 elderly caregivers living with older patients diagnosed with Alzheimer's-type dementia. They were randomly assigned to either the intervention group, who were prescribed regular exercise with moderate-intensity: 3 metabolic equivalents (3METs), 3 times per week for 12 weeks, or the control group, who did not receive any prescription. In the intervention group, significant reductions in the Zarit caregiver burden interview (ZBI) score and in the frequency of feeling fatigued, and an improvement in quality of sleep were observed at follow-up (p < 0.05), while no such changes were observed in the control group. These results suggest that obtaining sustainable habit of moderate exercise may improve quality of life in caregivers of demented patients.