International Common Denominators in Geriatric Rehabilitation and Long‐Term Care

The topics are by now painfully familiar and appear with nagging regularity in the newspaper and medical journals: the population of older persons is growing at an exponential rate (especially the “old old”). The hospital system is strained and costs are rising, leading to draconian mechanisms to reduce length of stay. Long-term care facilities are similarly strained, and caregivers are “burned out” and no longer able to care for aging relatives because of lower income or dual-career couples living a great distance from aging parents. New and innovative mechanisms, such as flexible respite programs, day care, and home care are growing in use to fill the caregiver gap. Geriatric evaluation and rehabilitation, as well as case management, tries to prevent long-term care and hospital utilization while preserving function and independence of the older adult. But the newspaper with these headlines is the Tokyo Sun (Asahi Shinbun), and the medical journals are the Japanese Journal of Geriatrics (Nihon Ronen Igakukai Zasshi) and Gerontology (Ronen Shakai Kagaku). The articles read just like the articles we have all read in our American counterparts. But in Japan, the themes have perhaps a greater urgency, a more nervous tone, and perhaps a detectably sadder, guiltier edge. In geriatrics, the common priorities of clinical care and health services research abound between our countries (no doubt pertinent to most developed nations); yet important differences are there, differences that may or may not effect the proper policy response. In this issue of the Journal of the American Geriatrics Society, Dr. Ishizaki and colleagues sought correlates of discharge disposition from a Geriatric Intermediate Care Facility (GICF) in the Saku area of the Nagano Prefecture.1 These facilities, also known as IMCFAs (Intermediate Care Facilities for the Aged), were instituted under a national mandate in 1987 to establish subacute medical and rehabilitative care to frail older individuals and their caregivers. As of 1991, there were 522 such units in Japan, with a total of 42,000 beds.2 The GICF or IMCFA described in the Ishizaki study1 is perhaps not unlike a geriatric evaluation unit (GEU) or geriatric evaluation and management (GEM) unit in a midwestern US city of moderate size with surrounding farming industry, perhaps a city like Memphis, Tennessee.3 The results are not unexpected: that functional impairment, gender, previous institutionalization, and socioeconomic factors (such as living alone) increased the likelihood that older GICF users would be discharged to hospitals or nursing homes versus home.1 Interestingly, increased age (i.e., the old-old) and cognitive impairment did not achieve significance in the multivariate logistic regression analysis. Thus, some things are the same, and some are different, when comparing similar analyses done in the US3-5 and Japan.1 These results may appear “ho-hum” to aficionados of the GEU/GEM literature.6 But is there special pertinence to these results in Japan? Is there more than meets the eye? First, the authors are to be commended for undertaking this study. Clearly, things are changing very rapidly in Japan, and the nation is grappling with an “elderly imperative” much like ours in the US—but with some very important differences, particularly in regard to rate of change. The Japanese people as a group attain unrivaled longevity. There have been exponentially fewer wage earners per retired person over the last 2 decades, during which younger Japanese have become a highly mobile, international workforce (hence are less often near their older relatives in the mother country and unable to provide “hands on” care). Care of the older parent has historically fallen to the oldest son (read wife of the oldest son), but now the oldest son is often in New York, or Berlin, or London, and his dual-career spouse is there with him. And a very strong current of thought among Japanese older people is the wish to avoid being a burden on the younger generation. The age-old ways of Japanese society have changed with the times, just as they have here in the US, and they have changed rapidly. But the Japanese, and the Americans, are resourceful people, and elaborate, innovative programs have quickly come into being in both countries, including the rehabilitation unit outlined in the article in this issue,1 day care, home care, and attendant care. Nursing homes certainly exist in Japan (over 2400 facilities in 1991 with 171,000 beds7), but they are not used as much as they are in the US (housing only 3% of Japan's ≥ 65 year-old population, vs 5% in the US8), nor are they as equipped to handle medical illness.2 Hospitals in Japan have for many years used what we might refer to in the US as the “swing bed” mechanism, in which areas of the hospital deliver a lower level of care, somewhere in between what one might see in a nursing home and on a medicine or surgery unit of an acute care hospital. Some readers of these pages may heave a nostalgic sigh when reading about lengths of stay of up to 6 months. It makes one harken back to the good old days before DRGs, when patients actually stayed in the hospital until they got better! But this has become less and less tenable in Japanese hospitals as they face some of the same fiscal constraints as US acute care facilities. The GICF initiative in Japan is clearly, and overtly, a mechanism to decompress hospitals by shortening length of stay and avoiding subsequent (“bounce back”) admissions. Of interest, the predictors of outcomes found in the present study, specifically for nursing home placement, are similar to those of most cited US and European studies.5 For example, living location and functional impairment are common predictors in virtually all studies. Impaired cognition fell out of the logistic regression in the Ishizaki study,1 suggesting that it was a less important factor than living location, physical debility, gender, and social supports. This leads one to wonder whether cognitive impairment and dementing illness have different connotations in Japan, or is there less of it? The latter seems unlikely; 50% of subjects in this study had cognitive impairment,1 in keeping with the findings of the Japanese Ministry of Public Health and Welfare study in which 60% of residents of standard nursing homes and GICF/IMCFAs were cognitively impaired.2 Or, perhaps dementia is more often coupled with physical debility in Japan — it has been long said that multi-infarct dementia is relatively more important as a cause of dementing illness in Japan than Alzheimer's disease, in contrast to the US where the converse appears to be the case. Japanese investigators are encouraged to take the next step in carrying out randomized controlled trials of GICF/IMCFA versus regular care, as has been done here and elsewhere.3,4,6 It would be well to do such trials soon in the rapidly changing environment of Japan — indeed, one wonders if there was a trend in placement and determinants of the same, even during the time of the Ishizaki study (1987–1991). Among the more important results of the GEU research in the US have been the concepts of targeting GEU services to those most likely to benefit and the importance of continuing geriatric follow-up. These would be important research topics in Japan as well. It would also be interesting to carry out GICF research in the more urban areas of Tokyo, Hiroshima, or Osaka to see if determinants of nursing home placement are different there. GICFs may take on more and more characteristics of subacute care, just as nursing homes in the US have, particularly in urban areas, as national and local governments put pressure on hospitals to shorten length of stay. In concert with these evolving trends, more and more case management has come into use by Japanese older people, and this will likely continue, and increase, as the social care infrastructure of the older Japanese population changes. Expansion of home care services will undoubtedly ensue as has occurred in the US. Therefore, while we have very much in common with our contemporaries in Japan, there are differences. Perhaps we can learn from each other how to deal better with the growing long-term care challenges in care of our older population.