Solitary Death: A New Problem of an Aging Society in Japan

To the Editor: Japan, although it has the longest life expectancy in the world,1 has dramatically transformed its living arrangements for older adults in the past few decades. The number of elderly people who live alone has reached epidemic proportions, with more than 4.3 million.2 These individuals are not only slightly older and unhealthier than elderly people living with someone else, but also have less communication with their neighbors; 8.9% of elderly Japanese people living alone do not communicate with their neighbors in their everyday lives.3 The collapse of the conventional local community ties may have caused problems leading to Kodokushi (solitary death) or passing away alone at home, unnoticed by anyone else. Elderly people with no one to care for them are at a risk of dying suddenly in their own homes from an accident or a disease. To make matters worse, their bodies are often left unattended for several days, even over months or years. In Japan, it is estimated that nearly 30,000 people die in Kodokushi every year.4 This letter reports on Kodokushi in a Japanese urban area and discusses the role of social networks in solving the problem. The data for this study were collected in the public housing complex located in Chiba Prefecture in a suburb of Tokyo. Of approximately 8,000 residents, 38% were aged 65 and older. The first Kodokushi victim (a man aged 69) in this complex was found dead in 2001. His body was not found for 3 years after his death at his residence. Sixty-five cases were reviewed from 2000 to 2007, each of which was alerted as a suspicious Kodokushi to the social welfare council, which had jurisdiction over the complex. The most frequent cases (53.9%) were "victimized" (actual Kodokushi), followed by "rescued" (narrow avoidance of death by an alert: 24.6%) and "misreported" (being temporarily away from home: 21.5%). The victims were more likely to be male (60.3%). The mean age of death was 61.3±10.0 (range 32–82) for men and 71.3±12.2 (range 40–90) for women, indicating a significant sex difference (P=.001). Table 1 indicates the consequences of the cases according to three types of informants: family members, neighbors or friends, and officials such as welfare commissioners and caseworkers. Nearly 90% of the alerts from family members were in victimized cases, whereas no rescued cases were reported. In contrast, almost half were rescued cases when the informant was a neighbor or a friend. Although alerts from officials were for a level of victimized cases similar to that from neighbors or friends, misreported cases accounted for one-third of the total number of cases. According to the Fisher exact test, the difference between the informant categories was statistically significant (P=.04). Consistent with a previous study,5 the present study demonstrated that men living alone faced a higher risk of Kodokushi than women. Because men are generally more socially isolated than women,6 living alone would further increase the risk of Kodokushi for them. In addition, men tended to die younger by Kodokushi. Therefore, younger men living alone would require further attention to avoid the hazard of Kodokushi. The most competent informants were neighbors or friends. Living in a neighborhood was important from the perspective of suspecting an emergency of those leading solitary lives and organizing a rescue operation in time. The alerts from officials, although they succeeded in saving some lives, were often misreported. This could be attributed to the fact that officials did not grasp the daily life schedules of those leading solitary lives, as neighbors or friends did. Unfortunately, family members did not play an effective role in preventing Kodokushi. According to a government report, 57.8% of the elderly people living alone did not have any family members within 15 minutes walking distance.7 Kodokushi, therefore, would be a representative problem associated with the weakening of familial bonds in Japan. The results of the study may force a shift in thinking toward adapting to an aging society wherein the saying "Better is a neighbor that is near than a brother far off" is truer than "Blood is thicker than water." Dr. Fukukawa was supported for this study by grants from the Japan Society for the Promotion of Science (19530561). An earlier version of this manuscript was presented at the meeting of the World Mental Health Congress of the World Federation for Mental Health, Athens, Greece, September 2009. Author Contributions: Yasuyuki Fukukawa: study concept, design, acquisition of data, analysis and interpretation of data, and preparation of manuscript. Sponsor's Role: None.