[Outcome based quality-improvement methods in visiting nursing services (VNS) in Japan: practical report and feasibility].

For the execution of the nation's public long-term care insurance in the year 2000, and Quality Improvement (QI) of visiting nursing services (VNS) will become extremely important in Japan. Some standard methods to evaluate structure or process in VNS have been published but there is no report of actual QI performance based on outcome measurement in each VNS institution. Modifying the method introduced by JCHO in USA, we performed QI using one negative outcome "unexpected cessation of home care" as a monitoring outcome measurement. In three VNS institutions variously located in Japan, cases of unexpected-cessation in one year were monitored retrospectively, then blindly assessed by nurses. Cases were categorized into "avoidable cessation" or "unavoidable unexpected-cessation", and for the "avoidable" cases the kinds of improvement that would be necessary to avoid this type of unexpected-cessation in the future were discussed. Depending on the situation of the facility, some of the suggested improvements were executed within possible ranges. The numbers of unexpected-cessation of home health care in each institution were 89, 58 and 15 with incidences from all the cases in one year of 46%, 40% and 42% respectively. In these cases, 47, 39 and 15 cases were categorized as "avoidable". Generally, improper nursing assessment in changes of patients' physical condition was the biggest cause of home health care unexpected-cessation. Although some institution were not able to accomplish any part, each institution were able to capture their unique problems and made a detailed specific QI plan to avoid cessation of home care in the future. The two main problems in feasibility were "the analysis took too long (8-9 hours)" and "part-time staff member could not participate". This simple modified QI method provides useful Quality Improvement of Japanese VNS with a limited staff. However, to facilitate execution, a much fairer recognition of the importance of QI, computerization or the partial consignment to a third party, and investigation over a shorter period were considered to be effective.

Predictors of 10-year change in physical, cognitive and social function in Japanese elderly.

Data from the longitudinal Koganei Study, Japan, have been used to predict long-term rate of change in three aspects of quality of life in community living elderly: physical, cognitive and social functioning. Two hundred and forty of the initially 69-71-year-old individuals (75% of the survivors) participated in all three examinations which took place in 1976, 1981 and 1986. Physical function was expressed by mobility and grip strength, cognitive function by visual memory, and social function by six social activities. Rate of change was defined as the regression coefficient of each function on time for each individual. Predictors at baseline of subsequent rate of change were calculated using multiple regression models controlling for initial level of functioning. Several predictors were common to rate of change in more than one function: socio-economic status, activity level, aspects of life style and precursors of chronic disease such as stroke. Rates of change were also affected by specific living arrangements, which suggests culture-specific mechanisms. Despite the variety of patterns of change observed, these results provide some indication that decline in important aspects of quality of life can be prevented.

[Factors affecting death at home in bedridden elderly people].

To examine factors which affect death at home in bedridden elderly people, relatives of bedridden elderly people, in three areas of Japan, who had died, were interviewed, and demographic, medical, social and familial factors were compared between 136 persons who died at home and 132 persons who died in the hospital. 1) In all three geographical areas, significantly more subjects who died at home had physicians who made home visits than in those who died at hospital (p less than 0.01). 2) The mean age at death was significantly higher in the elderly people who died at home than in those who died in the hospital in all three areas (p less than 0.01). 3) The results of multiple logistic regression analysis indicated that physician's home visits and death age were significantly related independently to death at home. This relation was independent of confounding factors such as residential area, disease type, or use of social services.

Memory changes in the Benton Visual Retention Test between ages 70 and 75.

The influences of education and activity on memory of Japanese older adults were investigated. The Benton Visual Retention Test was given to 302 individuals (145 men and 157 women) aged 69 to 71 (average age 70) living in a suburb of Tokyo. Participants were retested 5 years later (average age 75). Memory as evaluated by Benton correct scores declined in both men and women during the 5 years. The influence of the first time Benton score, education, activity, and sex on the second-time Benton score was analyzed by multiple regression analysis. The second Benton score was strongly influenced by the initial score. Level of education and activity contributed to memory after 5 years. No difference in the magnitude of memory changes was found between men and women. The first time Benton score by education term showed a weak but negative contribution.

Falls in the institutionalized elderly in Japan.

Falls can be considered a vital factor in impeding successful aging in the elderly. The purpose of the study is to know rates of falls per year among the elderly, to observe the situations when falls occurred, and to clarify the association of falls with physical deterioration. The survey was carried out in 1406 residents aged 65 and over of the Tokyo Metropolitan Home for the Elderly in 1982. The rate of subjects who fell more than once during a one-year period was 14.5%. Females had a higher rate than males. Sixty per cent of all the falls occurred indoors. As for the cause of the falls, extrinsic factors were accounted three times as much as intrinsic factors. Among injuries sustained by the falls, fracture was more frequent in females than in males. Length of time of standing on one leg was shorter for fallers than for non-fallers in both sexes. However, the differences were not significant when age was controlled. Fall is attributed not only to physical factors but also to environmental factors. Therefore, it should be encouraged to design an environment with devices.