Twice a week, Yukie Ushijima visits a nursing home on the outskirts of Tokyo to meet her 80-year-old mother waiting on the other side of a clear plastic sheet.
Ushijima talks to her through the transparent curtain draped over the facility’s reception desk. Her mother smiles when asked about her day, sometimes with a puzzled expression — the octogenarian has advanced dementia and often can’t recognize her daughter.
“She must think I’m this nice woman who comes by often with gifts,” Ushijima says. “It’s sad, but it’s still an improvement. Until recently she was only allowed to greet me from the second floor landing and I could tell she was becoming increasingly unresponsive.”
The vinyl partition is just one example of the numerous antivirus measures employed by the graying nation’s crowded long-term care facilities. Besides limiting physical contact, many recreational activities and communal gatherings for older people have been canceled or curtailed amid the pandemic. And while such procedures are necessary to reduce infection risks, medical experts say the prolonged state of social isolation is deteriorating the mental and physical health of older adults, especially those with Alzheimer’s and various forms of dementia.
COVID-19 is impacting the most vulnerable in Japan. Tokyo reported last July that the average age of those who died from the pathogen in the capital was 79.3. Meanwhile those aged 65 or older accounted for a record-high 28.7% of the nation’s total population last year, ahead of Italy in second place with 23%. And in 2012, the health ministry estimated that 15% of those over 65, or 4.62 million people, have developed some form of dementia, with the figure forecast to grow to 7.3 million by 2050.
While Japan’s coronavirus death rate remains low compared with those seen in many Western nations, stay at home requests and social distancing measures are taking a toll on the mental health of older people, says Fumihiko Yasuno, chief doctor at the department of psychiatry at the National Center for Geriatrics and Gerontology.
“Although there are individual differences, the pandemic appears to be exacerbating anxiety and depression among older adults,” Yasuno says. Unable to attend karaoke sessions, group exercises and other social activities, many are stuck at home, he says. That has led to an uptick in the number of people visiting his institution for consultations.
“Still, I think there are many others out there who feel ashamed of seeking help” due to the stigma attached to openly discussing mental health issues, he says. For his aging patients, he offers advice centered on two primary methods to reduce stress.
“One is to maintain a healthy daily routine with regular meals, plenty of sleep and exercise, including walks,” he says. “The other is to consciously limit contact with sources of stress.”
Turning off the television and cutting down on the intake of COVID-19-related news is also a starter, he says.
“It’s tempting to keep the television on when you’re hunkered down at home, but receiving a constant stream of negative news only worsens anxiety,” he says.
For those who are clinically depressed, Yasuno says he may prescribe SNRIs and SSRIs, two classes of medication that can be used to treat depression.
“The key to coping with isolation, however, is to feel connected with family and friends who are often the first to recognize when something is wrong with you,” he says. “Depression, for example, is a risk factor for dementia and it is better to treat the symptoms in the early stages.”
Results from a recent survey by a University of Tsukuba research team suggests the pandemic is reducing opportunities to go out, especially among older adults.
As of November, 22%, 28% and 47% of those in their 70s, 80s and 90s, respectively, said they only head out once a week or less. Meanwhile, among those age 60 and older, 27% said they find themselves becoming forgetful or repeating the same things, while 50% said they’ve lost their vigor in life. The survey yielded responses from roughly 8,000 people age 40 or older.
Atsuko Takayama, an 85-year-old resident of Sendai, says she seldom ventures out anymore.
Takayama has difficulty walking, and her 90-year-old husband voluntarily returned his driving license several years ago, meaning they can no longer make shopping excursions unless they hire a taxi. With no large supermarkets close by, she has resorted to having groceries delivered once a week since the onset of the pandemic.
“I stopped seeing my friends as well, since we’ve decided against holding our regular gatherings for fear of contagion,” Takayama says. “We spend most of our time in our house, and I’ve found we are becoming more quarrelsome. But at least we can still take care of ourselves.”
According to a survey conducted by Jiji Press among 52 cities and wards, the number of applications for long-term care insurance soared following Japan’s first state of emergency last spring. It also spiked in September and October, after the nation saw a second wave of infections in August.
Meanwhile, as many as 10 municipalities nationwide saw applications for changing insurance categories, from needing support to requiring care, rise by 30% year on year in October, indicating that older residents’ mobility has deteriorated during stretches of self-isolation.
Maki Misawa has been operating a home-care service out of Kanagawa Prefecture since the long-term care insurance system was introduced in 2000. She and 12 other care workers make routine visits to the households of around 90 residents, most of them frail and unable to look after themselves. She says many have been holed up in their dwellings amid the pandemic.
“They know they could die if they become infected, so naturally they don’t want to go out and want to restrict who visits them,” she says.
The situation, however, is taxing for Misawa and her colleagues as well.
“We’re getting more work since many of our clients have decided against going to day-care centers,” she says.
Regular meetings at which employees would exchange information have also been suspended to reduce contagion risks.
“Since some of our workers are older and digitally unsure, we’ve been unable to host video chat sessions instead. I’m sure many are also worried about catching the virus themselves and being sources of infections,” she says.
Misawa says she notices how some of her clients’ mobility functions seem to be declining.
“Their legs are getting weaker since routine dance and exercise lessons for older people have all been canceled,” she says. “And for those with dementia, I sense the symptoms are advancing due to lack of contact and communication.”
Sompo Care Inc., one of the nation’s largest nursing care providers, has been experimenting with technology to reduce stress among residents of the long-term care facilities it operates. According to government data, around 6.6 million people require care and approximately 1 million of them are in care homes.
“Prior to the pandemic, our nursing homes have been working with their respective municipalities and local volunteer groups to host recreational activities for residents. But most of those events have been put on hold,” says Kenta Nakahama, senior leader at Sompo Care’s community-based comprehensive care promotion department. “During this time of the year both residents and our care workers look forward to going out to enjoy the cherry blossoms, but, unfortunately, that’s not possible this year.”
Family visits have also been restricted and replaced by video chats and short meetings between acrylic panels, he says. With activity options limited, Sompo Care decided to hire experts to host daily events streamed live on large television screens installed in its nursing facilities.
In April, for example, there are online concerts, exercise sessions, interactive quiz shows and memory games as well as guided virtual trips to the Edo-Tokyo Museum and Odawara Castle scheduled. Of the 277 long-term care facilities Sompo Care operates in Japan, around 250 are participating in the program, Nakahama says.
“Typically we have residents gather in the cafeteria or lounge to take part in the activities. We limit attendance to around 30 to 40 facilities for a single program so there is space for hosts to interact with residents,” he says. “If there’s one takeaway from this pandemic, it may be how we learned how to replace some manual tasks with digital solutions. We deal with older people, and so we weren’t very tech-savvy. However, I think that is changing these days.”
The various limitations, however, are burdening the staff as well, Nakahama says. Japan already suffers from a chronic shortage of care workers. According to a 2018 government estimate, there will be a shortage of 430,000 nursing care staff by 2025, when the youngest of the nation’s postwar baby boomer generation will have turned 75 and the need for care services will significantly increase.
Besides taking multiple precautions against infections, care workers have to be in close contact with local health centers in the event that residents test positive for COVID-19, Nakahama says.
Still, despite its aging population and high population density, Japan has largely avoided the massive clusters that have ravaged nursing homes in the United States and in Europe.
And with hospitals and other facilities restricting visitations to stem the spread of infection, more older patients are opting for home care over hospitalization, according to Jun Sasaki, a doctor and the head of Yushokai Medical Corp., a home medical care provider.
“For terminally ill patients, hospitalization could rob them of their chance to be with their family when it’s their time to go,” he says. “That concern has seen demand for home care rise over the past year.”
Yushokai currently looks after 5,500 patients in Tokyo and three of its surrounding prefectures. Sixty-five doctors are on call around the clock, Sasaki says. To date, four patients have contracted COVID-19. One of them who suffered severe symptoms decided against being taken to a hospital, choosing to spend the final moments at home with family.
Last August, the Japan Geriatrics Society advised people to participate in advance care planning at an early stage. Promoted by the health ministry, advance care planning lets individuals make plans for their future health care wishes, including end-of-life care, in accordance with their personal values.
“As some COVID-19 cases show a rapid deterioration of clinical symptoms and, accordingly, the medical and long-term care staff cannot always confirm the patient’s values and wishes in time, we are very concerned as to whether older patients are receiving the medical and long-term care services that they wish for,” the society said. “It is vital to implement advance care planning as early as possible before suffering from COVID-19.”
Sasaki says the pandemic has forced many to reevaluate how to accept death.
“Death is inevitable,” he says. “What’s important is that those whose final moments are approaching receive the proper physical and psychological care so they can feel content with their lives.”
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