Growing old in Japan / by Robert L. Anders and Masako Kanai-Pak

Growing old in Japan By the year 1995, Japan's elderly will exceed 25 per cent of the population. Already "the elder is caring for the elderly'' but that is a fact of I ife rather than a long-term solution. Other possibilities need to be considered by Robert L. Anders and Masako Kanai-Pak I n common with many other countries, Japan is experien-cing a significant increase in its ageing population. Some I 0.2 per cent of their 120 million citizens are over the age of 65 and, by 1995, the total will exceed 25 per cent. This ·increase may be even higher because the Japanese's life expectancy is already the longest in the world. A majority of elderly people still 8 live with their children. Over 80 per cent of the population expect their children to care for them when they are elderly, a living arrangement that is very common in East Asian countries. In 1980, the number of elderly who were bedridden was estimated to be 438,000. Out of this number, their children cared for 307,000, and 131 ,000 were confined to hospital beds . About 88,000 older persons were living in nursing homes, and a total of 219,000 were living in other kinds of institution. Even though the elderly express a desire to live at home, it appears that slightly less than 50 per cent are in institutions. Apparently when the level of care required by the elderly increases, the number of families able to provide such care decreases . In Tokyo, where the population is approaching 18 million, one of the WOR LD HEALTH, December 1988 major problems is having a home or apartment large enough to accom- modate both the elderly parents and the other family members. Housing is already a critical issue because of the limited availability of land. With the increase in the ageing popu- lation, it is going to be almost impossible for most families to afford homes large enough for both them and their parents. · As women gain additional edu- cation, the size of their family decreases. Since 1950, the number of children per family has dramatically decreased. The higher education and economic level for both men and women means that, in the long run, the elderly will have to look more and more to the community for their care. In fact, the number of elderly living with their children, particu- larly in the big cities, is already beginning to decrease. This trend is also occurring in the countryside, where a greater percentage (more than 12 per cent) of the population are aged over 65. The children of these elderly people have moved to WORLD HEALTH , December 1988 the cities in order to secure jobs, and this leaves the parents with fewer options available when they become unable to care for themselves . In Japan, as in other developed nations, the tendency towards the "old caring for the older" is also occurring. It is quite common to find the eldest son and/or his wife, who may be in their early seventies, caring for a parent in their late eighties or early nineties. This trend of the elder caring for the elderly seems to have only just begun. Life Care Understandably, therefore, caring for the elderly is becoming a major concern for the citizens of Japan. Since a significant number of the elderly are currently in need of life care (home health, retirement centres, nursing homes), and an even greater number will require these facilities in the future, certain significant changes need to occur. At present, in view of the near absence of longterm care beds, those elderly patients who need what in A majority of Japan's elderly people still live with their children. Nevertheless caring for the elderly is a major concern for all citizens, as fewer people can aHord homes large enough for two generations. Photo WHO/E. Schwab the United States is considered a skilled nursing facility are kept in the acute care hospitals. According to some authorities, 31.2 per cent of the patients in hospital are over the age of 70, and their average length of stay is over 105.1 days. For hospitals in general, the average length of stay is 54.6 days. Japan's current national health insurance programme does not pro- vide coverage for home health care, but the government has a home care demonstration project operating in seven different cities. They are trying to determine if home health care will be effective in reducing the number of hospital days for the elderly. Assuming the programme proves to be successful, the cost of the 9 Growing old in Japan services, or at least some of the cost, could be included under the national health insurance. The use of home health services has the potential to play a vital role in upgrading the care given to the home-bound elderly. Since 1979, Japan has been experimenting with providing day care for selected elderly people. By 1983, they had 81 centres located throughout Japan designed to pro- mote independent living skills for the elderly, and also to provide the family care-taker with a break from providing the daily care. Obviously, the number of these centres will have to increase considerably if this service is to have any positive impact on the care of Japan's senior citizens. The number of nursing home 10 beds will also need to increase in the not-too-distant future. In 1984, it was estimated that there were only 70,000 nursing home beds in the entire nation. More than 100 nurs- ing homes have been opening each year but, because of the increasing number of frail elderly, the shortage has not been significantly reduced . Most facilities still have long waiting lists. The Ministry of Health has included in its goals the develop- ment of intermediate care facilities to look after impaired elderly. These should relieve the hospitals from the task of providing longterm care for elderly patients, most of whom at present have no other option but to remain in hospital. But what options does the Min- istry of Health itself have to ensure that health care for the elderly is comprehensive? The possibilities include: Care homes, individually owned homes which provide the frail elderly with a place to live as well as basic home-maker services. They would also benefit individuals who have no family to support them. Respite care, enabling the family to bring their bedridden elderly into a nursing home setting for a short period of time. The short stay would offer the caregiver a break from providing daily care and support, and enable the caretaker family to take occasional vacations without worrying about the old person's welfare. Day health care programmes to pro- vide skilled nursing care for the WORLD HEALTH, December 1988 A small boy makes music for his grandfather. Sharing the company of children helps to keep old folk "young at heart." Left: The elderly sick could be helped by geriatric assessment centres to function better on return to their homes. Photos WHO/E. Schwab and WHO/T. Takahara elderly in a day-care setting. In the evenings and on weekends, the patient would return home to the family. With this approach, the patient would not need to live in a nursing home but could receive the necessary skilled care. Geriatric assessment centres, prob- ably based in hospitals , would evaluate each patient's problems so as to identify where conditions WORLD HEALTH, December 1988 needed improvement and to make treatment simpler, thus helping the individual to function better at home. Nursing homes, not based on a medical model but designed around a social system model of care. The emphasis would be on social inter- actions, patient well-being and adaptation to the ageing process, with the quality of life as the primary focus. Home health services need to be greatly expanded. Every effort has to be made to keep the patient in the community and out of the hospital or nursing home. With the proper blend of nursing care, medical support and home-maker services, the quality of care in the home should markedly improve. Health care professionals; medical and nursing education will need to include "state of the art" for the elderly in the curriculum. National health insurance would provide incentives for these health care pro- viders to care for the elderly. Again, the entire health insurance package would emphasise keeping the patient out of the hospital system and focus on community-based ambulatory and home health care programmes. The issue of ageing is a pressing one. Tremendous progress will have to be made over the next ten years if Japan is to avoid a crisis in provid- ing for its senior citizens. As one of the strongest economic powers in the world , this nation of 120 million citizens will undoubtedly find means to provide care for its elders . • 11