Culturally Adapted Consensus Definition and Action Guideline: Japan's Advance Care Planning.

CONTEXT: A conceptual framework for advance care planning is lacking in societies like Japan's valuing family-centered decision-making. OBJECTIVES: A consensus definition of advance care planning with action guideline adapted to Japanese society. METHODS: We conducted a multidisciplinary modified Delphi study 2020-2022. Thirty physicians, 10 healthcare and bioethics researchers, six nurses, three patient care managers, three medical social workers, three law experts, and a chaplain evaluated, in 7 rounds (including two web-based surveys where the consensus level was defined as ratings by ≥70% of panelists of 7-9 on a nine-point Likert scale), brief sentences delineating the definition, scope, subjects, and action guideline for advance care planning in Japan. RESULTS: The resulting 29-item set attained the target consensus level, with 72%-96% of item ratings 7-9. Advance care planning was defined as "an individual's thinking about and discussing with their family and other people close to them, with the support as necessary of healthcare providers who have established a trusting relationship with them, preparations for the future, including the way of life and medical treatment and care that they wish to have in the future." This definition/action guideline specifically included support for individuals hesitant to express opinions to develop and express preparations for the future. CONCLUSION: Adaptation of advance care planning to Japanese culture by consciously enhancing and supporting individuals' autonomous decision-making may facilitate its spread and establishment in Japan and other societies with family-centered decision-making cultures.

Olfactory function and discrimination ability in the elderly: a pilot study.

We recently reported that subjects with a higher olfactory identification threshold for rose odor declined more in attentional ability in the elderly. This study focuses on discrimination ability and olfactory identification threshold in twelve elderly subjects living in a community (age: 80.9 ± 1.6). Olfactory function was assessed by the rose odor identification threshold. We assessed the discrimination ability by distinguishing 5 similar odor pairs. Our results showed that the subjects with a higher olfactory identification threshold (≥ 5) declined more in discrimination ability (14% ± 14%, p = 0.03) compared to those with a lower threshold (≤ 4) (averaged value set at 100%). As discrimination ability is related to the basal forebrain cholinergic system, our results suggest that olfactory impairment links to the decline in cognitive function relating the cholinergic system.

Association between Experience of Pet Ownership and Psychological Health among Socially Isolated and Non-Isolated Older Adults.

The psychological health effects of pet ownership have been widely studied, but only a few studies investigated its impact among socially isolated older adults. The present study aims to investigate the psychological health of older adults with or without the experience of pet (i.e., dog or cat) ownership who are socially isolated or not socially isolated. This study used cross-sectional data from 9856 community-dwelling older adults in a metropolitan area of Japan. Social and non-social isolation and type of pet ownership (i.e., dog or cat) were stratified to examine the psychological health. Logistic regression models indicated that, after adjusting for demographic and potential confounders, socially isolated older adults who never owned a dog were 1.22 times more likely to report lower psychological health in comparison to socially isolated current or past dog owners. No such difference was observed among cat owners. The results suggest that the experience of dog ownership may be effective to improve the psychological health among socially isolated older adult.

The relationship between olfaction and cognitive function in the elderly.

This study investigated the relationship between olfaction and cognitive function in 12 elderly people (age: 80.9 ± 1.6) living in the community. Olfactory function was assessed by the identification threshold for rose odor. Four cognitive measures consisting general cognitive ability assessed by Mini-Mental State Examination (MMSE), its sub-domains, and attentional ability assessed by drawing a line to connect the numbers consecutively (trail-making test part A; TMT-A), were assessed. Subjects with a higher olfactory threshold (≥ 5) declined more in the performance speed of TMT-A (73% ± 7%, p = 0.05) compared with those subjects with a lower threshold (≤ 4) (averaged value was set at 100%). Other cognitive statuses assessed by MMSE tended to decline in subjects with higher thresholds. Because attentional function relates to the basal forebrain cholinergic system, our results suggest that olfactory impairment links to the decline in cognitive function, particularly of attention-relating cholinergic function.

[The impact of support from medical professionals on families' decision-making during end-of-life care].

Families are involved in decision-making regarding end-of-life (EOL) care in Japan. However, how support from medical professionals toward families' decision-making affects families' satisfaction with EOL care has not been adequately studied. We aimed to examine the impact of support from medical professionals considering the care recipients' preferences on families' overall satisfaction with EOL care and the mediating effect of fulfilling care recipients' preferences.We administered self-report questionnaires through home-nursing providers to bereaved families (n=753), who lost loved ones between April 2015 and March 2016. Analyses were conducted with 237 of these bereaved families whose loved ones had been ≥65 years old, and had no missing values in key variables. We asked whether the families had received any support from medical professionals in determining the care recipients' EOL preferences, in discussing how to honor the care recipients' own interests, and in supporting the families' decision-making. We also collected data measuring the overall satisfaction with EOL care, families' perceptions that the care recipients' preferences were honored during EOL care, and demographic characteristics of care recipients and caregivers.Data from 58 male and 179 female family members were analyzed. The average age was 65.8 (standard deviation [SD]=11.9) years. Care recipients were 113 men and 124 women, and their average age was 83.0 (SD=9.1) years old at the time of death. A path analysis revealed that support for families from medical professionals was related to families' satisfaction with EOL care through the mediating factor of fulfilling care recipients' preferences.Support from medical professionals considering care recipients' preferences will help families' involvement in EOL decision-making.

[Factors related to parent-child communication about end-of-life care -A survey of adult children with an elderly parent].

AIM: In Japan, because adult children are expected to perform a key role in decision-making on end-of-life care for older adults, conversing with parents on their wished-for end-of-life care can help these children to become prepared for this filial responsibility. Our aim in this study was to explore how likely Japanese adult children were to discuss end-of-life care with their parents as well as correlates of such discussions. METHODS: We conducted an online survey using a sample of 1,590 adult children with at least one living parent aged 65 or older. We analyzed data from 1,010 children who responded during three consecutive days in October, 2015. RESULTS: A small portion of our participants (22.8%) had discussed end-of-life care with their parents. Logistic regression analysis revealed that such discussions were likely in son-mother (Odds Ratio 〈OR〉 = 3.01) and daughter-mother (OR = 3.15) dyads compared with son-father ones as the reference. Occurrence of such discussions was also associated with having older parents (OR = 1.03), parental experience of severe diseases (OR = 1.47), parent-child coresiding (OR = 2.08), a higher level of perceived necessity for (OR = 1.36) and a lower level of emotional avoidance of (OR = 0.68) end-of-life communication. CONCLUSION: Generally, adult children rarely discuss end-of-life care with their aging parents, suggesting the need to promote such familial communication while considering both children's and parents' circumstances.

Cumulative number of hospital bed days among older adults in the last year of life: A retrospective cohort study.

AIM: To determine whether age, proximity to death and long-term care insurance certification are related to receiving hospital inpatient care; the number of hospital bed days (HBD) among older Japanese adults in the last year of life; and to estimate the total number of HBD. METHODS: Using health insurance claims and death certificate data, the present retrospective cohort study examined the HBD of city residents aged ≥65 years who died between September 2006 and October 2009 in Soma City, Japan. Using a two-part model, factors associated with receiving hospital inpatient care and the total number of HBD in each quarter in the last year of life were examined. RESULTS: The total number of HBD in the last year of life varied widely; 13% had no admission, and 27% stayed ≥90 days. Younger age, approaching death and having long-term care insurance certification were significantly associated with being more likely to receive hospital inpatient care during each quarterly period in the last year of life. In contrast, having long-term care insurance certification and the last 3-month period before death, compared with the first 3-month period, were significantly associated with a fewer number of HBD. CONCLUSIONS: The present study showed that older age was associated with being less likely to receive hospital inpatient care. The findings regarding the risk of inpatient care and total number of HBD in the last year of life help to understand resource use among older dying adults, and to develop evidence-based healthcare policies within aging societies. Geriatr Gerontol Int 2017; 17: 737-743.

Reconsidering long-term care in the end-of-life context in Japan.

In this article, we propose expanding the scope of long-term care such that it involves caring for dying individuals; that is, end-of-life care. In doing so, we identify challenges that families and care/medical professionals face in attempts to design and provide end-of-life care under Japan's societal contexts. Because of the difficulty judging whether an individual is in an end-of-life phase, as well as a growing number of older adults who are unable to communicate their care preferences as a result of cognitive impairment, efforts were almost automatically made to prolong older patients' lives. To respect patients' desires and values, communication among older adults, their families, and care/medical professionals has been increasingly encouraged to make a mutually agreeable end-of-life care decision. At the same time, older adults are expected to indicate their care preferences earlier because their ability to express their ideas should be limited when approaching the end-of-life phase. We thus suggest including advance care planning in the course of long-term care such that older adults, with the help of care/medical professionals, can tell their preferences to their families, who are required to serve as surrogate decision makers in Japan. Our research, however, has shown that Japanese older adults are hesitant to discuss end-of-life issues with their families. On the basis of our findings suggesting older adults' concern that they might make trouble for their families by clarifying their care preferences, we discuss how care/medical professionals should facilitate family discussions on end-of-life care.

[Communication with important others regarding their preferences for end-of-life care].

AIM: Our aim in this study was to explore individual factors that make it likely for Japanese older adults to engage in communication with important other persons regarding their preferences for end-of-life care. METHODS: We conducted a questionnaire survey of outpatients at Tokyo Metropolitan Geriatric Hospital in the last six days of March 2012. Nine-hundred and sixty-eight outpatients consented in writing to participate in this survey. Two items on the questionnaire concerned the participants' attempts to communicate their preferences regarding end-of-life care; that is, whether they had discussed this issue with their significant others and whether they had written notes indicating how they want to be cared for in the final days of their lives. RESULTS: The participants who had designated a surrogate decision-maker were more likely to report answers of both than only discussion (OR=2.52) and less likely to reports answers of no communication than only discussion (OR=0.37). In addition, (a) those who did not wish to rely on artificial nutrition or hydration (OR=0.68) and (b) those who often thought about their death were more likely to be in the only discussion group than in the no communication group, although these factors were not significantly associated with whether the participants were likely to be in the both or only discussion groups. CONCLUSIONS: Our findings indicate that individuals often attempt to clarify their preferences in order to make it easier for their significant others to make end-of-life care decision on their behalf, so that they may receive their desired care.

Role of N-methyl-D-aspartate receptors and the nitric oxide pathway in nociception/hyperalgesia elicited by protease-activated receptor-2 activation in mice and rats.

Activation of the peripheral protease-activated receptor-2 (PAR-2) triggers nociceptive behaviour and thermal hyperalgesia in rats. The present study created a novel mouse model for PAR-2-triggered nociception, and then examined the roles of NMDA receptors and the nitric oxide (NO) pathway in nociceptive processing by PAR-2. Intraplantar administration of the PAR-2 agonist SLIGRL-NH(2) elicited nociceptive responses in mice, an effect being more specific in mast cell-depleted mice. This PAR-2-triggered nociception was abolished by the NMDA receptor antagonist MK-801, but not the neuronal NO synthase inhibitor 7-nitro indazole. In contrast, the PAR-2-triggered thermal hyperalgesia in rats was blocked by both agents. Our study thus provides a novel mouse model for PAR-2-mediated nociception, and suggests that NMDA receptors are involved in PAR-2-triggered nociception and hyperalgesia, while NO contributes only to the latter.

Capsazepine inhibits thermal hyperalgesia but not nociception triggered by protease-activated receptor-2 in rats.

Protease-activated receptor-2 (PAR-2), expressed in sensory neurons, triggers thermal hyperalgesia, nociceptive behavior and spinal Fos expression in rats. In the present study, we examined if the nociceptive processing by PAR-2 is mediated by trans-activation of capsaicin receptors. The thermal hyperalgesia following an intraplantar (i.pl.) administration of the PAR-2-activating peptide SLIGRL-NH2 was completely abolished by the capsaicin receptor antagonist capsazepine. In contrast, neither the nociceptive behavior nor spinal Fos expression in response to i.pl. SLIGRL-NH2 were attenuated by capsazepine. Our data imply that trans-activation of capsaicin receptors by PAR-2 might be involved in the PAR-2-triggered thermal hyperalgesia, but not nociception.

The PAR-1-activating peptide attenuates carrageenan-induced hyperalgesia in rats.

We examined if thrombin or a receptor-activating peptide for protease-activated receptor-1 (PAR-1), a thrombin receptor, could modulate nociception at peripheral levels. Intraplantar administration of PAR-1 activators, thrombin or TFLLR-NH(2), but not its inactive control FTLLR-NH(2) or a PAR-2 activator SLIGRL-NH(2), significantly attenuated the hyperalgesia in rats treated with carrageenan, although they had no effect on nociception in naïve rats. The thrombin-PAR-1 system might thus act to attenuate nociception during inflammatory hyperalgesia.