Effect of home-based training using a slant board with dorsiflexed ankles on walking function in post-stroke hemiparetic patients.

[Purpose] To investigate the effects of a 30-day rehabilitation program using a slant board on walking function in post-stroke hemiparetic patients. [Subjects and Methods] Six hemiparetic patients with gait disturbance were studied. The patients were instructed to perform a home-based rehabilitation program using a slant board, thrice daily for 30 days, the exercise included standing on the slant board for 3 minutes, with both ankles dorsiflexed without backrest. For all patients, the Brunnstrom Recovery Stage, Barthel Index, range of motion of the ankle joint, modified Ashworth scale scole for calf muscle, sensory impairments with Numeral Rating Scale, maximum walking speed, number of steps, and Timed "Up and Go" test were serially evaluated at the beginning and end of the 30-day program. [Results] The program significantly increased walking velocity, decreased the number of steps in the 10-m walking test, and decreased Timed "Up and Go" test performance time. [Conclusion] This rehabilitation program using the slant board was safe and improved walking function in patients. The improvement in walking function could be due to a forward shift of the center of gravity, which can be an important part of motor learning for gait improvement.

Interview- and questionnaire-based surveys on elderly patients' wishes about artificial nutrition and hydration during end-of-life care.

AIM: To promote advance directives, it is crucial to understand how many older persons have wishes related to end-of-life care. Additionally, it is important to understand how cognitive function or mood affect these wishes. METHODS: For the interview-based survey, 99 inpatients aged 75 years or older were enrolled after excluding patients with a Mini-Mental State Examination score of 20 or less. For the questionnaire-based survey, 99 outpatients aged 75 years or older without dementia were enrolled. Both surveys comprised the same items on older patients' wishes related to artificial nutrition and hydration (ANH) during end-of-life care. RESULTS: Of the total enrolled patients, 76.8% participated in the interviews. Of these, 50.0% were against ANH during their end-of-life care, including the patients who were definitely against ANH (26.3%). In contrast, just 5.3% wished to receive ANH. In the questionnaire survey, 65.6% of the respondents were against ANH, and 4.9% wished to receive ANH. Aging and Mini-Mental State Examination scores of less than 24 were significantly associated with a higher tendency to decline from participating in the interview. However, the distribution of the interview answers was not associated with age, Mini-Mental State Examination or Geriatric Depression Scale scores. Of the interviewed patients, 84.2% agreed to their responses being preserved in their medical records. CONCLUSIONS: Although the majority of the elderly patients were against ANH during end-of-life care, many patients did not have definite wishes in Japan. The percentage of those who were against ANH was not associated with cognitive function or depressive state. Geriatr Gerontol Int 2016; 16: 1204-1210.

[Survey of members of the Japan Geriatric Society regarding the revised version of their Position Statement on terminal medicine and care for elderly patients].

AIM: To clarify the opinions of members of the Japan Geriatric Society regarding the revised version of their Position Statement on terminal medicine and care in elderly patients. METHODS: A self-report questionnaire was sent to special honorary members, emeritus academic staff, and officers and delegates of the Japan Geriatrics Society (789 people). The questions were: 1) Do you agree with the Position Statement as revised by the Ethics Committee of the Japan Geriatric Society or not? 2) Do you have any ideas about any specific item and its' content or necessary revisions and if so, what are they? 3) Are there any headings or items that should be added to the Q&A section and if so, what are they? RESULTS: The response rate was 28.5% (225/789). Of these, 91.6% agreed with the revised version of the Position Statement. More than 80% of respondents had no suggested revisions. Suggested items that should be added to the Q&A were: advanced directives or advanced care plans, legal interpretation on the withholding of life-support treatments including hemodialysis, the establishment of a guardian system, and legal interpretation of the decisions made by the Ethics Committee. CONCLUSION: Although most respondents agreed with the revised version of the Position Statement, some issues remain to be discussed, including the relationship of patient autonomy with the optimal benefits for those in terminal-stage disease, the decision-making systems regarding the introduction and withholding of life-support treatments such as artificial nutrition, artificial ventilation, and hemodialysis.

[Problems impeding the introduction of care services under the long-term care insurance system].

OBJECTIVE: To identify problems currently impeding the introduction of care services to seniors who are not yet taking advantage of such services despite the need for some kind of in-home care, and to examine effective solutions by creating a model that clarifies relationships among these problems based on covariance structural analysis. METHODS: An anecdotal self-completion questionnaire was sent by mail to public health nurses who provide consultations to seniors in 657 locations throughout the mainland Japan, Honshu. The cases targeted in this survey were seniors for whom the introduction of care services was perceived to be difficult. Respondents were asked to relate one particularly memorable case encountered since April 2000 in which intervention assistance was provided through home visits. The survey consisted of 43 questions, including demographic information, basic case data, the outcome of intervention assistance in the case cited, and obstacles to introducing nursing services. We analyzed the 311 valid responses received (valid response rate: 47.3%). After performing factor analysis on the problems that were considered to impede the introduction of care services, we examined the relationships among these problems using covariance structural analysis and selected the model that best fit the data. RESULTS: 1) Problems that were considered to impede the introduction of care services were extracted from the results of an item analysis and factor analysis as follows. Factor 1: "Resistance to changing lifestyle." Factor 2: "Relative's lack of understanding or cooperation." Factor 3: "Lack of ability to handle procedures and contracts." Factor 4: "Lack of informal support." Factor 5: "Resistance to undergoing medical exams." 2) We performed a covariance structural analysis using the five factors derived from the factor analysis as the latent variables, and selected the best-fitting model, in which GFI = 0.929, AGFI = 0.901, and CFI = 0.950. The model showed that factors 3, 4, and 5 overlapped with factors 1 and 2 in impeding the introduction of nursing services, thus impeding the introduction of care services. CONCLUSION: The relationships among the problems impeding the introduction of care services were clarified using an anecdotal survey administered to public health nurses. To provide adequate support to these seniors, efforts must be made to examine community-based methods of providing intervention assistance tailored to the needs of individuals, as well as to examine systems of identifying and accommodating seniors who require assistance because they lack the ability to handle bureaucratic procedures themselves and also lack other sources of support.

Incidence of falls and fear of falling in Japanese patients with rheumatoid arthritis.

The objective of this study is to determine the incidence of falls and fear of falling by gender and age in Japanese patients with rheumatoid arthritis (RA). Among the Japanese patients who participated in a single-institute-based prospective observational cohort study of patients with RA, namely the Institute of Rheumatology Rheumatoid Arthritis, 765 men (median age 63 years) and 4,231 women (median age 60 years) with RA responded to questions related to falls. Eight percent of men and 11% of women reported one or more falls during the previous 6 months. At least one fall and multiple falls were significantly more frequent in men (p < 0.05) and in women (p < 0.001) with RA over age 65 and age 75 years, respectively, although there was no significant linear increase in risk with age. Sixteen percent of men and 22% of women reported fear of falling. More men over age 65 tended to report fear of falling than those under age 65 (p < 0.001), although the incidence of women with fear of falling increased with advancing age. Japanese patients with RA over age 65 and age 75 appeared to have a high risk of at least one fall and multiple falls, respectively.

[End-of-life care in a special elderly nursing home characteristics of patients who died in nursing home facilities and current status of end-of-life decision-making].

AIM: We investigated the characteristics of people who died in a special elderly nursing home and the current status of end-of-life decision-making. METHODS: Subjects comprised 168 residents who were discharged from a special elderly nurshing home in Yokohama between April 1998 and June 2008. A total of 3 patients were excluded from this study due to insufficient inclusion criteria. We collected and retrospectively examined the basic descriptive information regarding the terminal phase of care from medical records, death certificates, and the notes of nurses, caregivers and counseling staff. RESULT: Of a total of 165 subjects comprising 38 men (23%) and 127 women (77%), 30 (18%) died in a nursing home facility (facility mortality group), 101 (61%) died in hospitals (hospital mortality group) and 34 (21%) were discharged from special elderly nursing homes for transfer to long-term hospitalization (hospitalization group). To clarify the factors which led to death within the facilities, we analyzed: 1) age at discharge, 2) sex, 3) residency period, 4) number of hospitalizations, 5) length of hospital stay, 6) number of children, 7) number of conferences regarding end-of-life care in 2 groups: the facility mortality group and all others as the second group, as explanatory variables on multiple discriminant analysis. This revealed a higher number of conferences, a higher age at discharge, and a smaller number of hospitalizations in the facility mortality group. Only 12 (7%) people were able to convey by themselves how they wanted to spend the remainder of their lives, and 61 (37%) people conveyed this information via family members. However, 100 (61%) people were unable to confirm it by either self-report or family members. CONCLUSION: The people who died in special elderly nursing homes had a higher age, fewer hospitalizations, and had been involved in more conferences regarding terminal care. However, it was very hard to confirm individual intentions regarding terminal care periods. Further studies will be necessary to determine what kind of terminal care is needed in special elderly nursing homes when it is difficult to confirm individual or family intention regarding the terminal period.

Age-related differences in physiologic and psychosocial outcomes after cardiac rehabilitation.

OBJECTIVE: To examine differences in physiologic and psychosocial outcomes between age groups after an exercise-based supervised-recovery phase II cardiac rehabilitation outpatient program. DESIGN: This is a longitudinal observational study. The study assessed 442 consecutive cardiac patients. Patients were divided into the middle-aged group (<65 yrs, n = 242) and older-age group (> or =65 yrs, n = 200). Peak oxygen uptake, handgrip and knee extensor muscle strength, upper- and lower-body self-efficacy for physical activity, and physical component summary and mental component summary scores as assessed by SF-36 were measured at 1 and 3 mos after the onset of acute myocardial infarction or cardiac surgery and were compared. RESULTS: All physiologic and psychosocial outcomes increased significantly between months 1 and 3 in both groups. However, increases were greater in the middle-aged vs. older-aged group in peak oxygen uptake (+13.1% vs. +8.7%, P < 0.01), knee extensor muscle strength (+17.6% vs. +13.3%, P = 0.01), lower-body self-efficacy for physical activity (+17.3% vs. +12.7%, P = 0.02), and physical component summary score (+5.4% vs. +2.7%, P = 0.02). CONCLUSIONS: Age-related differences in various physiologic and psychosocial measures indicated greater improvement from an exercise-based supervised recovery-phase II cardiac rehabilitation outpatient program in middle-aged vs. older-aged patients. Older adults may derive equal mental or emotional benefit from such a cardiac rehabilitation program but do not experience as much improvement in physiologic outcomes as middle-aged adults.

Predicting recovery of upper-body dressing ability after stroke.

OBJECTIVE: To identify predictors of the recovery of independent dressing ability after stroke. DESIGN: Prospective cohort study. SETTING: Rehabilitation unit at a university hospital. PARTICIPANTS: Sixty-three consecutive stroke patients were enrolled in the study. Twelve patients were not able to complete the study because they were discharged or transferred to another hospital before study completion. INTERVENTION: Fifty-one patients underwent and completed 15 days of dressing training based on the time-delay method, which included the 10 component actions of upper-body dressing and 4 cues given by therapists. MAIN OUTCOME MEASURES: The dressing item of the FIM instrument, Brunnstrom motor recovery stages, presence or absence of deep and tactile sensation, Rey-Osterrieth complex figure test, Kohs block design test, body image test, Weintraub cancellation task, and presence or absence of the visual extinction phenomenon and the motor impersistence phenomenon. RESULTS: The FIM upper-body dressing item score and the cancellation task score at the start of training were significantly better in patients who achieved independence in dressing within 15 training days than in patients who did not (P < .05). The motor impersistence phenomenon was found less frequently among patients who achieved independence in upper-body dressing than among patients who did not (P < .05). However, logistic regression analysis showed that only the FIM score for upper-body dressing on the first day of training was a significant independent predictor of dressing ability at the end of training (odds ratio, 4.33; 95% confidence interval, 1.51-12.37). The receiver operating characteristic curve indicated that a cutoff score of 3 would provide the best balance between sensitivity and specificity for the FIM upper-body dressing item. The positive predictive value of this cutoff score was .90, and the negative predictive value was .70. CONCLUSIONS: Our findings indicate that the FIM upper-body dressing score on the first day of dressing training is an independent predictor of recovery of upper-body dressing ability after stroke.

[Future issues for the long-term care insurance system in Japan].

Although the prevention and reduction of requirements for long-term care is one of the main aims of the long-term care insurance system, most of care-recipients have deteriorated in their certified care levels since the implementation of the system in 2000. Demands for services at facilities rather than in-home services are increasing. Waiting lists for public nursing homes are becoming longer and longer. Residential care in for-profit private homes is growing rapidly. Homicides of disabled older persons by their exhausted caregivers are still prevalent. Concerning these serious situations, retaining the human dignity of care-recipients should be the most essential issue of the long-term care insurance system.

Effect of the self-monitoring approach on exercise maintenance during cardiac rehabilitation: a randomized, controlled trial.

OBJECTIVE: To evaluate the effect of the self-monitoring approach (SMA) on self-efficacy for physical activity (SEPA), exercise maintenance, and objective physical activity level over a 6-mo period after a supervised 6-mo cardiac rehabilitation (CR) program. DESIGN: We conducted a randomized, controlled trial with 45 myocardial infarction patients (38 men, seven women; mean age, 64.2 yrs) recruited after completion of an acute-phase, exercise-based CR program. Patients were randomly assigned to an SMA group (n = 24) or control group (n = 21). Along with CR, the subjects in the SMA group self-monitored their weight and physical activity for 6 mos. The SMA used in this study was based on Bandura's self-efficacy theory and was designed to enhance confidence for exercise maintenance. The control group participated in CR only. All patients were evaluated with the SEPA assessment tool. Exercise maintenance, SEPA scores, and objective physical activity (average steps per week) as a caloric expenditure were assessed at baseline and during a 6-mo period after the supervised CR program. RESULTS: Mean period from myocardial infarction onset did not differ significantly between the SMA and control groups (12.1 +/- 1.3 vs. 12.2 +/- 1.2 mos, P = 0.692). All patients maintained their exercise routine in the SMA group. Mean SEPA score (90.5 vs. 72.7 points, P < 0.001) and mean objective physical activity (10,458.7 vs. 6922.5 steps/wk, P < 0.001) at 12 mos after myocardial infarction onset were significantly higher in the SMA than control group. SEPA showed significant positive correlation with objective physical activity (r = 0.642, P < 0.001). CONCLUSIONS: SMA during supervised CR may effectively increase exercise maintenance, SEPA, and objective physical activity at 12 mos after myocardial infarction onset.

[New methods for evaluation of abilities remaining in the elderly with severe dementia].

The elderly with dementia show distinct characteristics and different remaining abilities even in advanced disease. For improvement of the quality of care for the elderly, it is essential to evaluate their remaining abilities. Mini-communication Test, Braiding Test and Vitality Index have been developed to evaluate the abilities remaining in the elderly with severe dementia. The reliability, validity and usefulness of these new methods were discussed.

Health-related quality of life in relation to different levels of disease severity in patients with chronic heart failure.

The purpose of the present study was to compare differences in physiological outcomes and health-related quality of life (HRQOL) in relation to degree of illness in patients with chronic heart failure (CHF) and to compare HRQOL in CHF patients with that of a normal Japanese population. One hundred and twenty-five patients with stable CHF (93 men, 32 women, mean age 63.3 ± 12.4 years) with left ventricular ejection fraction (LVEF) of less than 40% were enrolled in the present study. We used New York Heart Association (NYHA) functional class as an index of degree of illness. In 64 of the 125 patients, physiological outcome measures included peak oxygen uptake (peak O2) and E/CO2 slope. HRQOL was assessed with the medical outcome study short form-36 (SF-36) Japanese version. In addition, SF-36 scores of CHF patients were compared against Japanese standard values. Age and LVEF did not differ according to NYHA functional class. The eight SF-36 subscale scores and peak O2 decreased with increases in the NYHA functional classes, whereas E/CO2 slope increased with increases in NYHA functional class (p<0.05). Of the 8 SF-36 subscales measured in CHF patients, only the bodily pain score attained that of the normal Japanese population. These findings suggest that HRQOL decreases as NYHA functional class increases and other physiological measures worsen. In addition, HRQOL values of CHF patients were low in comparison with standard values of a normal Japanese population.