Case report: An N-of-1 study using amplitude modulated transcranial alternating current stimulation between Broca's area and the right homotopic area to improve post-stroke aphasia with increased inter-regional synchrony.

Over one-third of stroke survivors develop aphasia, and language dysfunction persists for the remainder of their lives. Brain language network changes in patients with aphasia. Recently, it has been reported that phase synchrony within a low beta-band (14-19 Hz) frequency between Broca's area and the homotopic region of the right hemisphere is positively correlated with language function in patients with subacute post-stroke aphasia, suggesting that synchrony is important for language recovery. Here, we employed amplitude-modulated transcranial alternating current stimulation (AM-tACS) to enhance synchrony within the low beta band frequency between Broca's area and the right homotopic area, and to improve language function in a case of chronic post-stroke aphasia. According to an N-of-1 study design, the patient underwent short-term intervention with a one-time intervention of 15 Hz-AM-tACS with Broca's and the right homotopic areas (real condition), sham stimulation (sham condition), and 15 Hz-AM-tACS with Broca's and the left parietal areas (control condition) and long-term intervention with sham and real conditions (10 sessions in total, each). In the short-term intervention, the reaction time and accuracy rate of the naming task improved after real condition, not after sham and control conditions. The synchrony between the stimulated areas evaluated by coherence largely increased after the real condition. In the long-term intervention, naming ability, verbal fluency and overall language function improved, with the increase in the synchrony, and those improvements were sustained for more than a month after real condition. This suggests that AM-tACS on Broca's area and the right homotopic areas may be a promising therapeutic approach for patients with poststroke aphasia.

Isolation of Shiga Toxin-Producing Escherichia coli from the Surfaces of Beef Carcasses in Slaughterhouses in Japan.

Shiga toxin-producing E. coli (STEC) is an important foodborne pathogen worldwide. It is necessary to control and prevent STEC contamination on beef carcasses in slaughterhouses because STEC infection is associated with beef consumption. However, the frequencies of STEC contamination of beef carcasses in various slaughterhouses in Japan are not well known. Herein, we investigated the contamination of beef carcasses with STEC in slaughterhouses to assess the potential risks of STEC. In total, 524 gauze samples were collected from the surfaces of beef carcasses at 12 domestic slaughterhouses from November 2020 to February 2023. The samples were measured for aerobic plate counts and tested for pathogenic genes (stx and eae) and major O-serogroups (O26, O45, O103, O111, O121, O145, and O157) by real-time PCR screening. Subsequently, immunomagnetic separation (IMS) was performed on samples positive for stx, eae, and at least one of the seven O-serogroups of STEC. Isolation process without IMS was performed on samples positive for stx, including those subjected to IMS. STEC O157:H7 and stx-positive E. coli other than serotype O157:H7 were isolated from 0.6% and 4.6% of beef carcass surfaces, respectively. Although the STEC O157:H7 isolation rate was low and stx-positive E. coli other than serotype O157:H7 belonged to minor O-serogroups, the results mean a risk of foodborne illness. Furthermore, a moderate correlation was observed between aerobic plate counts and detection rates of stx-positive samples by real-time PCR screening. The STEC O157:H7 isolated facilities showed higher values on aerobic plate counts and detection rates of stx-positive samples than the mean values of total samples. Therefore, these results suggest that it is important to evaluate hygiene treatments against beef carcasses for the reduction of STEC contamination risk, particularly in facilities with high aerobic plate counts.

Factors Related to Oral Problems in Patients with Prolonged Disorders of Consciousness in Long-Term Care: A Cross-Sectional Study.

Factors influencing oral problems, such as malocclusion and oral motor dysfunction, in patients with prolonged disorders of consciousness (DOC) remain unclear. This study aimed to clarify the relationship between oral problems and physical function, communication, respiration, and oral intake status, as well as related factors in patients with DOC receiving long-term care at home. A cross-sectional study was conducted in October 2018; 127 patients who developed DOC > 5 years ago were analyzed. The differences between patients with and without oral problems were examined, and a binomial logistic regression analysis was performed to examine factors associated with oral problems, with the presence of oral problems as the dependent variable, and age, the number of years since onset, drooling, oral intake status, and the presence of a family dentist as explanatory variables. A post hoc power analysis of the binomial logistic regression analysis for oral problems (odds ratio: 2.05, alpha value: 0.05, incidence of oral problems: 0.80, and total sample size: 127) demonstrated an observed power of 93.09%. Oral intake status (p = 0.010) and the number of years since onset (p = 0.046) were significantly related to oral problems. Preventive oral management and rehabilitation from the early stage after onset may be effective for oral problems in patients with DOC.

Cell Surface and Functional Features of Cortical Bone Stem Cells.

The newly established mouse cortical-bone-derived stem cells (mCBSCs) are unique stem cells compared to mouse mesenchymal stem cells (mMSCs). The mCBSC-treated hearts after myocardial infarction have been reported to have greater improvement in myocardial structure and functions. In this study, we examined the stemness features, cell surface glycan profiles, and paracrine functions of mCBSCs compared with mMSCs. The stemness analysis revealed that the self-renewing capacity of mCBSCs was greater than mMSCs; however, the differentiation capacity of mCBSCs was limited to the chondrogenic lineage among three types of cells (adipocyte, osteoblast, chondrocyte). The cell surface glycan profiles by lectin array analysis revealed that α2-6sialic acid is expressed at very low levels on the cell surface of mCBSCs compared with that on mMSCs. In contrast, the lactosamine (Galß1-4GlcNAc) structure, poly lactosamine- or poly N-acetylglucosamine structure, and α2-3sialic acid on both N- and O-glycans were more highly expressed in mCBSCs. Moreover, we found that mCBSCs secrete a greater amount of TGF-ß1 compared to mMSCs, and that the TGF-ß1 contributed to the self-migration of mCBSCs and activation of fibroblasts. Together, these results suggest that unique characteristics in mCBSCs compared to mMSCs may lead to advanced utility of mCBSCs for cardiac and noncardiac repair.

Swallowing function in advanced tongue cancer patients before and after bilateral neck dissection following superselective intra-arterial chemoradiotherapy for organ preservation: a case-control study.

OBJECTIVE: This study aimed to evaluate swallowing function in advanced tongue cancer patients before and after bilateral neck dissection following superselective intra-arterial chemoradiotherapy (CRT). METHODS: A videofluoroscopic swallowing study (VFSS) was used to evaluate swallowing function in 10 patients with advanced tongue cancer before and after bilateral neck dissection. RESULTS: Laryngeal penetration increased in the postoperative VFSS. Temporal analysis comparing two time points revealed that, after surgery, oral transit time increased significantly, but there was no difference in pharyngeal delay time or pharyngeal transit time. Spatial analysis revealed significant decreases after surgery in the maximum distance of upper esophageal sphincter (UES) opening, the maximum distance of hyoid bone movement in both the anterior and superior direction, and the maximum velocity of hyoid bone movement. CONCLUSIONS: Laryngeal penetration and aspiration increased as a result of limited hyoid movement and diminished UES opening after bilateral neck dissection following superselective intra-arterial CRT for advanced tongue cancer.

An Isoform of Nedd4-2 Plays a Pivotal Role in Electrophysiological Cardiac Abnormalities.

We have previously shown that neural precursor cell-expressed developmentally downregulated gene 4-2 (Nedd4-2) isoforms with a C2 domain are closely related to ubiquitination of epithelial sodium channel (ENaC), resulting in salt-sensitive hypertension by Nedd4-2 C2 targeting in mice. The sodium voltage-gated channel alpha subunit 5 (SCN5A) gene encodes the α subunit of the human cardiac voltage-gated sodium channel (I Na), and the potassium voltage-gated channel subfamily H member 2 (KCNH2) gene encodes rapidly activating delayed rectifier K channels (I Kr). Both ion channels have also been shown to bind to Nedd4-2 via a conserved Proline-Tyrosine (PY) motif in C-terminal with subsequent ubiquitination and degradation by proteasome. Therefore, loss of Nedd4-2 C2 isoform might be involved in electrophysiological impairment under various conditions. We demonstrate here that Nedd4-2 C2 isoform causes cardiac conduction change in resting condition as well as proarrhythmic change after acute myocardial infarction (MI). The Nedd4-2 C2 knockout (KO) mice showed bradycardia, prolonged QRS, QT intervals, and suppressed PR interval in resting condition. In addition, enhancement of T peak/T end interval was found in mice with surgical ligation of the distal left coronary artery. Morphological analyses based on both ultrasonography of the living heart, as well as histopathological findings revealed that Nedd4-2 C2 KO mice show no significant structural changes from wild-type littermates under resting conditions. These results suggested that Nedd4-2 with C2 domain might play an important role in cardio-renal syndrome through post-transcriptional modification of both ENaC and cardiac ion channels, which are critical for kidney and heart functions.

Feasibility and clinical utility of the Japanese version of the Abbey pain scale in Japanese aged care.

Active usage of observational pain scales in Japanese aged-care facilities has not been previously described. Therefore, to examine the feasibility and clinical utility of the Abbey Pain Scale-Japanese version (APS-J), this study examined the interrater reliability of the APS-J among a researcher, nurses, and care workers in aged-care facilities in Japan. This study also aimed to obtain nurses' and care workers' opinions on use of the scale. The following data were collected from 88 residents of two aged-care facilities: demographics, Barthel Index, Folstein Mini-Mental Examination (MMSE), 15-item Geriatric Depression Scale (GDS-15), and APS-J for pain. The researchers, nurses, and care workers independently assessed the residents' pain by using the APS-J, and intraclass correlation coefficients (ICC) for interrater reliability and Cronbach alpha for internal consistency were examined. The ICC between researchers and nurses, researchers and care workers, and nurses and care workers were 0.68, 0.74, and 0.76, respectively. Nurses and care workers were invited for focus group interviews to obtain their opinions regarding APS-J use. During these interviews, nurses and care workers stated that the observational points of APS-J subscales were the criteria they normally used to evaluate residents' pain. Several nurses and care workers reported a gap between the estimated pain intensity and APS-J score. Unclear APS-J criteria, difficulties in observing residents, and insufficient practice guidelines were also reported. Our findings indicate that the APS-J has moderate reliability and clinically utility. To facilitate APS-J usage, education and clinical guidelines for pain management may be required for nurses and care workers.

Nursing ward managers' perceptions of pain prevalence at the aged-care facilities in Japan: a nationwide survey.

This study aimed to examine nursing ward managers' perceptions of pain prevalence among older residents and the strategies of pain management at the Health Service Facilities for the Elderly Requiring Care (HSFERC) in Japan and to investigate the factors related to the prevalence. Nursing ward managers in 3,644 HSFERC were asked to participate in this study. Questionnaires were sent to them regarding pain prevalence among the older residents in their wards, their provisions for pain care, and other pain management strategies. The perceived pain prevalence factors were examined statistically. The final sample comprised 439 participants (12.0%). A total of 5,219 residents (22.3%) were recognized as suffering from pain on the investigation day. Only 8 wards (1.8%) used pain management guidelines or care manuals, and 14 (3.2%) used a standardized pain scale. The ward managers' age (p = .008) and nursing experience (p = .006) showed a significant negative association with pain prevalence estimation. Moreover, there was a significant association between the groups' pain prevalence estimation and the nursing managers' beliefs that older adults were less sensitive to pain (p = .01), that pain was common among older people (p = .007), and that the time to treat residents' pain was insufficient (p = .001). The ward managers' perceptions regarding pain prevalence varied; the perceived pain rates were possibly lower than the actual percentages. Insufficient pain management strategies at the HSFERC were also suggested. An appropriate pain management strategy for Japanese aged care and its dissemination are urgently required.

Bone-derived stem cells repair the heart after myocardial infarction through transdifferentiation and paracrine signaling mechanisms.

RATIONALE: Autologous bone marrow-derived or cardiac-derived stem cell therapy for heart disease has demonstrated safety and efficacy in clinical trials, but functional improvements have been limited. Finding the optimal stem cell type best suited for cardiac regeneration is the key toward improving clinical outcomes. OBJECTIVE: To determine the mechanism by which novel bone-derived stem cells support the injured heart. METHODS AND RESULTS: Cortical bone-derived stem cells (CBSCs) and cardiac-derived stem cells were isolated from enhanced green fluorescent protein (EGFP+) transgenic mice and were shown to express c-kit and Sca-1 as well as 8 paracrine factors involved in cardioprotection, angiogenesis, and stem cell function. Wild-type C57BL/6 mice underwent sham operation (n=21) or myocardial infarction with injection of CBSCs (n=67), cardiac-derived stem cells (n=36), or saline (n=60). Cardiac function was monitored using echocardiography. Only 2/8 paracrine factors were detected in EGFP+ CBSCs in vivo (basic fibroblast growth factor and vascular endothelial growth factor), and this expression was associated with increased neovascularization of the infarct border zone. CBSC therapy improved survival, cardiac function, regional strain, attenuated remodeling, and decreased infarct size relative to cardiac-derived stem cells- or saline-treated myocardial infarction controls. By 6 weeks, EGFP+ cardiomyocytes, vascular smooth muscle, and endothelial cells could be identified in CBSC-treated, but not in cardiac-derived stem cells-treated, animals. EGFP+ CBSC-derived isolated myocytes were smaller and more frequently mononucleated, but were functionally indistinguishable from EGFP- myocytes. CONCLUSIONS: CBSCs improve survival, cardiac function, and attenuate remodeling through the following 2 mechanisms: (1) secretion of proangiogenic factors that stimulate endogenous neovascularization, and (2) differentiation into functional adult myocytes and vascular cells.

Prevalence of pain among residents in Japanese nursing homes: a descriptive study.

It is often observed that pain causes substantial problems for nursing home residents. However, there has been little research about the prevalence of pain for nursing home residents in Japan. This study aimed to examine the prevalence of pain in older adults living in nursing homes in Japan by using self-reporting and the Abbey Pain Scale-Japanese version (APS-J) and to explore factors related to pain. This is a descriptive study. Residents in two Special Nursing Homes for the Elderly in Tokyo, Japan, were asked to participate in this study, with the exclusion of short-term temporary residents. Data collected from participating residents included their demographics and the results from the Barthel Index, the Folstein Mini-Mental State Examination, the APS-J, and the Verbal Descriptor Scale for pain. The residents were divided into two groups: residents able to report their pain (self-report group) and residents not able to report their pain. The second group was assessed by using the APS-J (APS-J group). The Mann-Whitney U test, the χ2 test, and logistic analyses were performed to derive factors related to pain prevalence. Data were obtained from 171 residents. The prevalence of pain in the self-report group (n = 96) was 41.7%. For the 75 residents unable to report their pain, 52.0% were assessed by the APS-J to have pain. The overall pain prevalence of all residents was 46.2%. Age, Barthel Index score, and length of time of institutionalization were significantly associated with residents' pain in the APS-J group. Logistic regression analysis showed that contracture (odds ratio 3.8) and previous injury (odds ratio 3.4) were associated with residents' pain in the self-report group, whereas only the length of nursing home stay (odds ratio 1.03) was a predictor for pain in the APS-J group. Nearly one-half of residents had pain when they moved or were moved. Pain assessment and management is needed for residents.

[Comparative study of eating behavior in elderly patients with Alzheimer's disease and vascular dementia: a first report. - Comparison of disturbed eating behavior - ].

AIM: In elderly patients with dementia, it is known that a loss of independence in eating can cause malnutrition, dehydration, a decrease in food consumption and the immune function and further worsening of the cognitive function, with an increased risk of pneumonia and a shortened life expectancy. The purpose of this study was to investigate the occurrence of a disturbed eating behavior in elderly patients with Alzheimer's disease (AD) and vascular dementia (VaD), who together comprise the majority of elderly patients with dementia. METHODS: A total of 233 patients (150 AD patients and 83 VaD patients) who were residents of institutions or group homes were enrolled. The patients underwent an assessment of eating behavior, a cognitive assessment, a neurological examination and measurement of the vital signs. Additionally, statistical analyses were performed to compare eating behavior between the patients with AD and those with VaD at varying severity of dementia. RESULTS: A disturbed eating behavior was observed significantly more frequently as the severity of dementia increased. The prevalence of difficulty in rinsing/gargling and dysphagia increased with the severity of dementia. There were differences in the frequency of disturbed eating behavior between the AD and VaD patients. Among the patients with mild dementia, the VaD patients exhibited a higher incidence of a disturbed eating behavior than the AD patients. On the other hand, some behaviors prominent in the patients with severe dementia were related to various types of cognitive impairment in the AD patients, namely difficulty in beginning a meal, difficulty in maintaining attention while eating and difficulty in performing the specific motor skills necessary to open food packages. Marked individual differences were observed in the mild VaD patients, with a high frequency of disturbed eating behavior and dysphagia related to symptoms of neurological deficits. No correlations were found with the severity of dementia. CONCLUSIONS: Both AD and VaD are types of dementia; however, the frequency of a disturbed eating behavior differs greatly between these populations. It is necessary to focus on differences in these parameters and also the causes of dementia in order to develop effective care techniques for patients with dementia.

A national survey of the use of physical restraint in long-term care hospitals in Japan.

AIMS AND OBJECTIVES: To investigate the prevalence of physical restraints in the long-term care hospitals in Japan and to examine the factors of physical restraint use, including the specific skills/techniques that the staff use to minimise the restraints. Background. Despite the national efforts to nullify physical restraint, it is still prevalent in long-term care facilities in and out of Japan. More detailed information regarding what affects physical restraint is needed. DESIGN: Cross-sectional mail survey. METHOD: A questionnaire was sent to a nursing ward manager of the random sample of long-term care facilities in Japan. RESULTS: The average rate of physical restraint was 25·5%. Altogether, 81·0% of the restrained clients were under restraint for more than one month. The most prevalent method of restraint was bilateral bedrails, followed by the use of coveralls and gloves. Factors of restraint were different depending on the type of restraint, suggesting specific approaches are needed for specific type of restraint. CONCLUSIONS: Physical restraint is still prevalent in Japanese long-term care hospitals, and nurses need to develop effective intervention approach to redesigning practice related to physical restraints. Specialised intervention approach seems needed depending on the types of restraint. RELEVANCE TO CLINICAL PRACTICE: Specific approach should be developed to minimise the physical restraint in long-term care hospitals in Japan.

Factors affecting independence in eating among elderly with Alzheimer's disease.

AIM: In elderly patients with dementia, disturbed eating behavior is understood to be a core symptom or a behavioral and psychological symptom of dementia (BPSD). The purpose of the present study was to investigate the factors affecting self-feeding in elderly patients with Alzheimer's disease (AD). METHODS: A total of 150 AD patients who were hospitalized in dementia wards, or were residents of institutions or group homes were enrolled. The patients underwent an eating behavior examination, cognitive assessment, neurological examination and vital function tests. The eating behavior examination consisted of observation of the patients at mealtime. Items assessing eating behavior included the number of feeding cycles, stopping of eating or agitation and dysfunction. RESULTS: Logistic regression analysis carried out to identify factors with a significant effect on decreased independence in eating were difficulty in beginning a meal (OR = 14.498, CI = 2.067-101.690), presence of dysphagia signs (OR = 5.214, CI = 1.031-26.377) and the severity of dementia (OR = 4.538, CI = 1.154-17.843). CONCLUSION: The present study is the first to generate objective data showing that difficulty in beginning a meal is a factor that hinders independence in eating in AD, in addition to the presence of dysphagia signs and the severity of dementia. Assisting AD patients in maintaining eating independence might be effectively achieved by eliminating environmental factors that interfere with beginning a meal, and by providing assistance that will promote beginning a meal. The present results show the necessity of developing effective methods for assisting elderly patients with AD.

Aggression exhibited by older dementia clients toward staff in Japanese long-term care.

This study examined the experiences of staff members from seven Japanese hospitals who had been treated aggressively by older dementia clients. Altogether, 170 questionnaires were analyzed. In the past year, 75.3% and 63.5% of staff members had experienced physical and verbal aggression, respectively. Working numerous night shifts, working shifts other than 3-shifts, and being allotted assignments with clients who had a lower average level of physical capacity were the factors associated with recurrent client aggression. Those staff members who spent adequate time caring for their clients, who gained client consent before providing care, and who tried to build a trusting relationship with their clients were found to have experienced less aggression. Burnout, which is likely to enhance the risk of the staff mistreatment and neglect of older clients, was found to be higher among those who experienced aggression.

Abbey Pain Scale: development and validation of the Japanese version.

AIM: The purpose of this study was to develop and validate the Japanese version of the Abbey Pain Scale (APS-J), to assess pain of older adults who live in nursing homes in Japan. METHODS: In this study, the data were collected from residents in two nursing homes in Japan to include: demographics, the Barthel Index, Folstein Mini-Mental Examination (MMSE), APS-J and Verbal Descriptor Scale (VDS) for pain. Two researchers independently assessed the residents' pain using the APS-J while the residents walked or were transferred from bed to wheelchair. Intraclass correlation coefficients (ICC) for inter-rater and test-retest reliability, Chronbach's alpha-value of the APS-J, and correlation between the APS-J and other variables were examined. RESULTS: Data were obtained from 171 residents. The ICC for inter-rater and test-retest reliability were 0.824 and 0.657, respectively. Internal consistency was 0.645 for the total sample and 0.719 for those with an MMSE score of 0 (n = 58). Multiple regression analysis showed that contractures (P < 0.001), previous injuries (P < 0.001), the MMSE (P = 0.003) and paralysis (P = 0.018) were independently associated with the APS-J. The APS-J and VDS were moderately correlated (r = 0.49; P < 0.01). The APS-J total score and subscales, "change in body language" and "physical changes", were significantly different among subjects with different MMSE score groups. CONCLUSION: Findings show some evidence for the reliability and validity of APS-J.

Recognition and behaviour of caregiver managers related to oral care in the community.

OBJECTIVES: The purposes of this study were to investigate the knowledge, practice and educational background of caregiver managers regarding oral health, how they cope with visiting activities, and to explore related factors to develop an appropriate working strategy for them in the community. METHODS: The subjects were 102 caregiver managers, who voluntarily participated in a seminar organised by the M city government. The collected data were analysed to assess the relationship between the related factors of oral health, career and age, and the correlation amongst items of action process concerning oral health using Spearman's correlation coefficient and Fisher' s exact test with spss 14.0 for Windows. RESULTS: The results were as follows; (i) the mean length of careers of home-care staff and caregiver managers was 3.6 +/- 3.2 and 1.6 +/- 1.6 years respectively, (ii) 90.2% recognised the importance of oral care and 92.2% were interested in oral care, although 32.4% hesitated to provide oral care, (iii) the career of caregiver managers was not significantly related to recognition of concrete objectives of oral care, soft debris and symptoms of periodontal disease, but they recognised the effectiveness of oral care in prevention of aspiration pneumonia, (iv) there was a total of 11 significantly correlated items of knowledge, recognition and practice of oral care and (v) there was a total of 10 significantly correlated items amongst factors of action process. CONCLUSION: Results suggested that knowledge of oral care was related not only to the career but also to age and revealed a basic gap in the range of abilities between the respondent caregiver managers. Some did perform appropriate oral care and carried out the necessary processes.

Relationship of experience and the place of work to the level of competency among public health nurses in Japan.

AIM: To examine the actual competencies of public health nurses (PHNs) working in public organizations in Japan in order to clarify the relationship between the level of competency and the number of years of experience and the place of work. METHODS: The subjects were 1799 full-time PHNs working at 135 prefectural public health centers and 115 municipal health centers, which were randomly selected. Each subject received a questionnaire in the mail, requesting basic personal information and a self-evaluation of six levels of achievement in 11 topics in five categories of competencies. RESULTS: The number of respondents was 1261 (70.1%), with a total of 1184 valid responses (65.8%). In terms of the level of competency, the average score was >3 for all items and the number of PHNs who achieved Ladders 5 and 6 was low, with very few achieving Ladder 6, despite having more years of experience. Furthermore, the level of achievement depended on the workplace, position, and academic background. CONCLUSION: The tasks regarding the education of PHNs in Japan are to establish achievement goals clearly and incrementally and to develop methods and systems that consistently and systematically increase competencies, not only in basic undergraduate education, but also for employed PHNs, through specialized education. In particular, educational methods that lead to high-quality experiences need to be selected in order to develop competencies.

The effect of awareness on the outcome of oral health performed by home care service providers.

OBJECTIVES: The purpose of this study was to investigate the correlations amongst factors, such as knowledge, attitude, practice and oral health behaviour, in caregiver managers so as to improve the oral health of the dependent elderly. METHODS: Data were collected from a sample of 102 caregiver managers from home care service providers using a questionnaire. The respondents were divided into two groups: the group who were aware of effective oral care (A group) and the group who were unaware of effective oral care (U group). The evaluations were frequency distribution tables followed by chi-squared tests of independence and Fisher's exact test. RESULTS: Ninety percent of the respondents thought that dependent elderly needed to be provided with oral care and 77% had been trained in oral care. However, only 44% thought that they could provide appropriate oral care and only 52% had experienced its effect on oral health and general health. There was a significant difference in training by dental hygienists between the A group (36%) and the U group (11%). There was also a significant difference in learning of oral care skills. CONCLUSION: The results suggested a high oral care awareness amongst caregiver managers and an inadequate oral care training system. To improve oral health of the dependent elderly, theoretical teaching alone is not sufficient when providing oral health education and a positive contact with the dental team, especially dental hygienists, is an important factor which supports oral care provided by caregivers.