Health Promotion for Older Population in Japan: Importance of Preventive Care and Successful Assisted Living

    

    

    Figure 3: The concept of preventive care in Japan [5].
    

Secondary Prevention for Long-Term Care

An increase in long-term care expenses due to an increase in the aging population can affect the insurance premiums of both old and actively working generations [10]. With comprehensive reform of social security and the tax system, establishing an integrated community care system and ensuring the sustainability of the Japanese LTCI system are essential [11] (Figure 1). LTCI in Japan was introduced in 2000 to cover social care for 2 million people aged 65 years or older; and the number of insured people under LTCI doubled by 2006 [12,13]. Since 2006, LTCI has been revised to focus on preventive care by detecting people aged 65 years or older who are at high risk of needing future care or support. The preventive care project provides community-based exercise programs and programs to improve the cognitive function and malnutrition status. Many local governments are trying to detect community dwelling older people who are at high risk, using the basic health checklist called “Kihon Checklist” [14]. The basic health checklist consists of 25 items and seven categories (daily life, physical ability, nutrition, oral condition, seclusion, forgetfulness, and mind) for the screening of older people who have functionally or cognitively declined [14]. A subject is identified as having “Low physical strength” if they show three or more negative responses to questions 6-10. “Low nutritional status” is assessed by answers to both questions 11 and 12, with a negative answer indicating a lower status, and “Low oral function” is defined as two or more negative responses to questions 13-15. A subject is identified as showing frailty if they give at least 10 or more negative responses to questions 1-20 (interpreted as “Overall low score for questions 1-20”). The target people for the secondary preventive care project, who are at high risk of needing future care or support, are defined by the criteria of the Japan Ministry of Health, Labor and Welfare as those who show lower function in at least physical strength, nutritional status, oral function, and overall low score for questions 1-20. When we approach them to start preventive intervention, we should also reference the categories of: “Houseboundness”, “Low cognitive function,” and “Depression risk” to provide effective interventions. “Houseboundness” refers to people who answered “no” to question 16. “Low cognitive function” referred to participants who had at least one or more negative conditions in questions 18-20, and “Depression risk” referred to elderly people who had two or more negative responses (questions 21-25). We clarified the usefulness of Kihon Checklist for the prediction of future disability of community dwelling older peoples using future LTCI certification [15,16]. “Low physical strength”, “Low nutritional status”, “Low cognitive function” and “Depression risk” in Kihon Checklist were strongly associated with 3 years later certification of LTCI. Thus, Kihon Checklist could be useful for prediction of future disability status of older peoples and high risk of needing future care or support in LTCI [17]. Interventions and preventions for physical strength, nutritional status, cognitive decline and depression are supposed to be very important. Actually, various preventive intervention programs were provided in the community by the local government, and they have proven to be effective for preventing functional or cognitive decline of older people.

Just recently, Japan Ministry of Health, Labor and Welfare started using the new questionnaire for the elderly in elderly health check-ups [18]. This new questionnaire for the elderly focuses on identification of the frailty status [19,20] compared with the Kihon Checklist as described above. It is desirable that this questionnaire is utilized for preventive care and hospital care for older people.

Of course, there is the big difference in the preventive care approach between urban and rural town. The preventive care programs in each town should be based on the properties of the town such as number of population, rate of old peoples, main industries, local facilities and so on.

Tertiary Preventive Care and Importance of Successful Assisted Living

Japan is now facing a super-aged society, in which the average life expectancy is over 81 years for men and over 87 years for women. Physiological aging essentially progresses, leading to organ dysfunction and decline of physical and cognitive functions. In most old people, pathological aging, that is “disease”, will develop. Human aging is accelerated via these processes in all of us. About 50% of those aged 85 or older had the certification of LTCI, as shown in Figure 4 [21]. One third of people with the certification of LTCI above moderate levels (above Level 3 out of 5) have severe disabilities or require assisted living.

    

    

    Figure 4: Certification of Long Term Care Insurance in Japan.