TheKOM"SemleDementiaGradingSystemand

StandardCarePlanmngGuide

HitoeKanai

JournalofSocialPOlicyand

SocialWOrkN0．7

JapanCollegeofSocialWork

March2003

TheKOMISenileDementiaGradingSystemandStandardCarePlanningGuide

HitoeKanai

【Abstract】

InordertoestabliShacaresysrmfbrseniledementiasufferers,itisindispensabletofirstobserve

suchsuHも配rsandsysCmaticallyunderstandtheirsymptomsandbehaviorfiFomaG@caring''viewpoint,

ratherthansimplyananalyticalviewpoint.However,itisalsoimportanttopresentobjectiveand

scientificguidelinesfOrcaneinorderthatthecarerscansharethesameunderstandingaboutthe

sufferers'needsandthusprovideconsistentcare.

'I11issmdyattemptstoseektheanalyticcriteriafbrseniledementiasufferersfiFomsuChacare-

orientedviewpoint・Wehavedevelopedachartcalledthe｡GKOA皿Chart''andutilizedittoobserve

andcollectdataaboutthesufferers'symptomsandbehavioralpattems.FOrexample,themaximum

scorefbrthecognitivecheckpointsinthisChartissetat77;achievingthisscol℃wouldsuggestthat

theindividualhassoundcognitivefmctions・Accordingtothedegreeofcognitivemalfilnctioning,

thesuffererscanbecategorizedintosixgroupings:GroupsAtoF,dependinguponthescores

achieved,Inthemalsthatweconducted,wecategorizedthesufferersintothesesixgroupsusing

theKOMIchart.Next,wefbcusedonboththeirlostabilitiesandremainingabilities,whichcan

alsobedeCrminedbytheuseofKOⅣⅡChart,andfinallystrucmredaStandardCarePlanfbreach

ofthesixgroups・EIYleeffectivenessoftheseStandardCarePlansisnowbeingverified,andweare

hopingtoutilizetheChartandPlansetfbrallseniledementiasufferersincaIE．

【KeyWords】

Dementia,KOhmchart,Gradingsystem,StandardCarePlan

Preface

PurposeoftheKOMISenileDementiaGradingSysFm

SenileDementiaisatypicalillnessofgeriatricregression・IntheculTentsituationwhel℃theelderly

populationisrapidlymcreasing,amongthevariousgeriatricillnessesseniledementiamparticularrequil巳s

urgentmvestigationconcemmgitsdevelopment.Nospecifictreatmenthasbeendevelopedfbrthisillness,

norhasanyspecializedcareappmachbeenclearlypI℃posed,despitehighsocialexpectations・Atpresent,

carefbrdementiasuffererswhollyreliesupontheindividualcarer'sskillsandapproach.

Thecriteriacun･entlyusedtodetennmethedegreeofdementiahaveallbeendevelopedbydoctors.

Althoughthesecriteriaareusefilltotheoreticallydiagnosethelevelofdementia,theycannotprovidea

greatdealofhelptocarersinplanningtheeverydayschedulesfbrdementiasufferersandtheirfamily

l5

ｌ

ｌ

ｌ

Ｉ

■

Ｉ

members.

AnationalinsurancesystemfbreldedycarehasnowbeenlaunchedmJapan,andanofficialdesignation

systemfbrpubliccarerequirementshasbeenintroduced・However,thecoverageofsuchadesignation

systemisnotsufficientfOrpracticalcarerequirements・Seniledementiadoesnothavesuchasignificant

effectonthesuffel℃r'sphysicalfi℃edom,unlesstheillnessisatanadvancedstage・Thus,sufferersoften

appeartobehealthierandmol巳selfcontrolledthantheyacmallyare.Becausethecun'entcaredesignation

systemfbcusesonsupportfbrthecarerecipient'sphysicaldifficulties,itcannotadequatelybeusedtomakecareplansfbrseniledementiasufferers.

Thisiswhyspecializedcriteriafbrcareplanningfbrseniledementiasufferersisessential.

TYlispublicationoffersagradmgsystemfbrseniledementiasufferersthatmakesuseoftheconventional

KOⅣⅡChart・ThisKOMISenileDementiaGradingSystemenablesustodetennine6gradesofdementia

byreferringtothenumberofmarksintheCognitiveConditionintheKOMIChart・Detailsarealso

providedaboutthegradingsystem,andtheprocessofestablishingthestandardcareplansfbreachgmde

ofsennedementiasuHererd皿DughutilizmgthemfbmationprDvidedbythegradmgsystem,theassociated

StandardCarePlanningGuide,andtheconventionalKOMIRadarChart.

Byworkingthroughthisprocess,appropriatecareplansbasedoncommonolliectivecriteriacanbe

createdbyanyoneinvolvedinthecal℃ofdementiasuffel℃rs．

’1

DirectionandExpectationsconcemingResear℃hintotheCaFSystemfOrSenileDementia

Sufbrers

Iamconfidentthatourleseal℃honthedevelopmentofagradingsystemfOrseniledementiaandthe

standardizationofcareplanningintroducedinthispublicationwillmakeasiglificantcontributiontothe

careenvironmentinJapan.Thedirectionandexpectationsofourreseal℃hcanbesummarizedasfbllows:

1)InJapan,seniledementiahasbeengenerallycategorizedintothreelevels:"","todeJWe,and

SeVere・TheKOMISenileDementiaGradingSystemintroduces61evelsorgrades,fromAtoF,

thusenablingmol℃individually-tailoredcareseIvices.

2)AlthoughtheKOMISenileDementiaGradingSystemisdesignedtoindicatethelevelofdementia,

itdoesnotmeanthateachmdividual'sdementiaconditionalwaysfbllowsacourseofdeclinefrom

AtoF・EachgradesimplyindicatestheculTentstateoftheindividual・IfapprOpriatecareisgiven,

thegradeshouldimprove・TheKOMISenileDementiaGradingSystemprovidesavisualscale

thatpresentsthepositivecorrelationbetweenappropriatecareandthesufferer'scondition,and,

accordmgly,theimportanceofsuchcare.

3)TheKOMISenileDementiaGradingSystemcanbeappliedtoanyonewhohasbeendiagnosed

withseniledementia・Italsocanbeusedmanysituation-itdoesnotmatterwhethertheindividual

isathome,inhospital,orinacarehome・ItthelBmlBprovidesacommonstandardthatcanbeused

inavarietyofsituations.

4)Afterdetenniningthegradeofdementia,astandardcareplancanbeeasilycreatedusingthe

StandardCarePlanningGuide,whichisprovidedaspartoftheKOMISenileDementiaGrading

System.

’

’

’

’’

16

5)Thissystemdoesnotrequireanyspecializedknowledge,nordoesitinsistuponacertaintypeofprofessionaltodefinethecareplan.

6)MarkingtheCognitiveConditionintheKOMIChartisanimportantprerequisiteoftheKOMISenileDementiaGradmgSystem・AIso,thegeneraluseoftheKOMIRadarChartfbrpracticalcare

planningfbrsufferersisessential.

TheKOMISenileDementiaGradmgSystemonlyrequiresthatitsusershaveacertainsystematic

understandingofKOBntheoryandtheKOMIChartSystem.

7)ToprovidecarefOraseniledementiasufferer,itisessentialtohaveanoverallawarenessofthe

lifestyleofthesuffererandhisorherfamilymembers.Inadditiontosuchobservations,asufficiently

specializedknowledgeofseniledementiaisimportantinordertomakeappropriateuseoftheKOMISenileDementiaGradmgSystem｡TherightcaIefbrseniledementiasuffererscanbeachieved

onlywiththisthoroughbackground.

Webelievethatthefindingsobtainedthroughourrese虹charealreadyatthestagewheretheycanbe

appliedinpractice.WesincelelyhopethatourKOMISenileDementiaGradingSystemanditsassociatedStandardCarePlanningGuidewillbeutilizedanditseffectivenessverifiedbycarersthemselves.

1．Methodofinvestigation

ThefbllowingmethodwasusedfOrourinvestigations:

(1)DividetheseniledementiasuffelBrsmtogroupsaccoldingtotheirscoreintheCognitiveConditionchartandthecharacteristicsoftheirmentalbehavior.Smdyeachgroupindetailtodetermme

whetherthereisanysignificantcolrelationbetweenthescoreandtheirsymptoms.

(2)Throughthesmdy,attempttounderstandhowthemarkedCognitiveConditionintheKOMIChartcandefinethestateofdementiasufferers,andestablishthepathwaytoutilizethisinfbrmationto

createcareplansfOrindividualsufferers.

(3)EstablishaStandardCarePlanningGuidethatenablesthecreationofcareplansthataresuitable

toeachgroupofsufferers.

2.Subjects

S呵ectswereselectedbyopportunitysamplingthroughoutJapan・Allselectedsuhiectswerepatients

whoweremedicallydiagnosedassuffering

fromdementia;however, thecauseoftheir

dementiawasignored.

RatioofMaleandFemale

Male

Sex

3.Results

(1)DetailsofSubjects

-Validnumberofsuhjects:200

-Ratioofmaleandfemale:

71males:129females

129FEmale

15050 100

NumberofSuhiects

0

17

-AgeRange

Under50:4

60s:27

70s:66

80s:80

Over90:23

AgeConstimtionof200DementiaSubiects

Under50s

60s

Age 70s

80s

Over90

Ｌ争日唖晒到日．

80一一一

卜 ・≦一国23 ’

ＩＩ |｜ ’

0 20 40 60 80 100

NumberofSuhiects-ResidentialStatus

OwnHomes:25

ResidentialCareHomes:74

Hospital: 101

ResidentialStatus

(Residentialcarehomesincludehealthfacilities

fbrtheeldelly,nursingandwelfalBfacilitiesfOrthe

OwnHomes

CareHomes

Hospital

25

74

eldedy,andshelteredaccommodation)101

0 20 40 60 80 100 120

1NumberofSuhiects

-TypeofDementia

Alzheimer'sdisease:50

DuetoCerebralVascular

Malfimctions: 137

Unknown:13

TypeofDementia

-PeriodofAffliction

Lessthanlyear:31

1-3years:79

4-6years:32

Morethan7years:4f7

Unknown:11

AIzheimer'sdisease

DuetoCerebralVascularMalhlnctions 13 7

Unknown

1 ． ｡' ・ ろ.． ：･名ず1

0 50 100 150

NumberofSuhiects

Periodofaffliction

跡即| ’31Lessthenlyear

l～3years

4～6years

MoIcthan7years

Unknown

騨輝蕊鐵鯉鶴音:意憲弓癖奮酌人一 ｡ . レユ 79

灘繍識

47

0 20 40 60 80 100

NumberofSubiects

18

ｆ

脅噸幾息“

鱗羅認溌

牛遜良娼詑昌

鴬霧鍵

．:自, ,､；:;" ．. .､ゞ .､ ‘ ：

圏職息

§“ 蕊

灘 騒騒蕊醤

騨溌

灘園型～

鼻蕊

-J’上

ツ蓉畠昇り0丸

②CategorizationofDementiaSufねrem

Inordertocategorizethesuhjectsintogroupsaccordingtotheircurrentcognitiveability,wefirst

fbcusedontheamountofblankmarksintheCognitiveConditionchartincludedintheKOMIChart.

Suchblankmarksmdicatethatasuhiectcannotunderstandorpe㎡bnnacertainactivitybythemselves.

TheCognitiveConditionchartconsistsofl5checklists,andeachlistcomprisesScheckpoints・We

fOcusedonthesuhjectswhose5checkpomtswereallmarkedasblank,whichindicatesthataseriesof

activitiesareseverelyaffectedbytheirdementia.Next,wedividedthesesuhjectsinto6groupsaccording

tothetotalnumberofsuchtotallyblankchecklists.

Tablelshowsthepercentageofsuhjectswhohaveatleastonefillly-blankchecklistineachgroupand

thenamesofthecheckliststhatmarkedthehighestnumberoffUllblanks.

Tablel

Note:T11efbrmalnamesofthechecklistsandtheircorrespondingnumberinKOMIChartareasfOllows:＊1)12.MakingChangesinDailyLife *2)13DailyTasks*3)14FinancialAdministration *4)15HealthManagement*5)3Excretion *6)4PhysicalMovement*7)5Sleep *8)6PhysicalCleanliness*9)7dothingandLaundry *10)8AtfntiontoAppearance*ll)1Respiration

19

’

Gmups

mumkr㎡Sub陣③

First

Sector

qleckList

Name

S…1d

Sector

CheckList

Name

Third

Sector

qleckList

Name

GroupA(37) 0％ 0% 0％

GroupB(40) 0％ 0％ 48％ Change

Tasks本2

*I

Finance

Health

*3

*4

GmupC(45) 7％ Excretion*5

Movement

Sleep*7

本6

26％ Cleanliness

Clothing*9

*8

Appearance*10

77％ Change

Tasks

Finance

Health

GroupD(41) 15% Respiration

Excretion

Movement

｡11 70％ Cleanliness

Clothing

Appearance

90％ Change

Tasks

Finance

Health

GIoupE(21) 71% Alllists 90％ Alllists 100％ Alllists

GroupF(16) 94％ Alllists 100％ Alllists 100％ Alllists

(3)RawDataconcerningCognitiveConditionandPhysicalConditionScores

Tables2to5showsthelistsofCognitiVeConditionscoresandPhysicalConditionscoresfOreach

subject.Thesearethenumberofshadedmarks,whichmeansthatthepatientscanunderstandandperfonn

thoseparticulartasksorfUnctionsunaided.Table2showsthetotalscoresoftheCognitiveConditionand

thePhysicalConditionfbrallsuhjects.Tables3to5arefbrthosewho1℃sideathome,incarehomes,and

inhospitals,respectively.

nlble2 1able3

CognitiveandPhysicalConditionScores CognitiveandPhysicalConditionScores

fbrAIISuhiects ofHospitalResidelltS

匿覇禧寅r毒I7悪扇面~1雷華一

咽ぶ〕,‐ 画 一■一

I雛巨二二一一三 ■一一 一 =酉ロー~吟f･呂口･ 弘二巾■且一”､画呈4ー…貯望君笛一

‘－－－一宇雪1－窒一＝＝ご印一言一一､..ー－．-一.~‐磯：

鱈三Qwn

I難

騰f銘:曽蝿

冒瞬齢P．b…作句

6卿弗寸0億Ub◆Q自己

｜’

》騨綴綴難癖雛蕊蟻

ニニニーニニ＝二二二二 毒毒毒毒画

’一一一

《ヤ９℃６■虫、戸悲ｒも一●■《唾町ｂ■・●・◆峰山』●つい①抄凸』

轆蝉鍔礁膳犠僻猿辮懸

’一一一一

やマーーーユ

■一

ｔ

f

－

一

ＰＵ

恥も澁

邸”４

籠臺薑ｒｔｔｒ矛ｒＦ・才杏子かヶｒｒＥ・少ｌｒ〆Ｅｏｒ３す＃守許

鱸鰐蕊恥溌識恥耀継溌誌溌騨羅

ｊｌ

１１１１１

１１

三三鬘鬘童

話1織日土影群『蝿鼎も…d鯛

継:gX8鵠:､

職凸岬卑

1識：

鱗l鍵；bq恥凸●b~｡●勺■q函=寸

職■W■F

1緯；!&鍔1眠塑

8

T c U P U

K T 4g 鞭 ．:ｳ 川. 1塁 膿＊ IU0 lぱ 』4

1■幸,､罰,,鰯､瞳同調，●■

脚 誤 蕊 “

ＩＥＪ

ｑ

４

－ｊ

Ｔｇ１

ｆ

罰１．‐郡に

了肌ｆ

ｆｆ

－Ｉ

●Ｉ紅知

り誕壼

一■

一万一

一ｍ』

1〕 釦 1“

｜

’■Tbtal ofCognitive Condition Scores D1Ibtal ofPhysical Condition Scores

20

ThbleSmble4

CognitiveandPhysicalConditionScoresCognitiveandPhysicalConditionScores

of､HomeResidentsofCareHomeResidents

一

ｌ

Ｉ

Ｉ

Ｉ

Ｉ

Ｉ

Ｉ

ｌ

Ｉ

Ｉ

Ⅱ

｜’

産■-.?,牽画ｬも1 ．卜塞：

七■■毎↑名乃もｂ、、守寺‐４４負ｐ０９期ａｐＦ畦■■グせゃ吟巳唱■

祁癖坪癖澤鵡峠郵坤辨押峰坪坪辨蝦孵誠哩

躯』

涌曲杁靴虹脆別血蝿誕誕郵恥池郷韓叩、批鄭

も■も■■◆０勺■

込むｂｐｑｂ

‐１１！

も？Ｑｐ日■①ＰＯｇｑｑ■〃凸

凸。Ｑ■■■■■句凸 意

“０■ざＰ。。。△端心却９中基

ｑ０則●も一ｄｏｇＰｊＨｄＵ・けＪ

叫叫泌拠叫珈伽小型

》呼酔諜癖泌轆岬押辨砂岬辨蝿岬辨怨》坤蝿州鞭御岬州粋押恥辨州岬岬岬刻鯛呼

’

一一一函 『

正一－｜寺一一 ？

△

０

－叩一一一一1

Q、 輩。 1E

一一一一一一『一一一一一一

層 r町 曲ｳ 弾 :⑨ 11

睡垂F.4g.,b…’ 癖凉茄1■ザ詞分！

’ □■Tbtal ofCognitiveConditionScores Tbtal ofPhysical ConditionScores

21

｜

’’

’(4)CategorizationofDementiaSuffereE

TYlissectionshowsthegroupmgofthedementiasufferersbasedonthenumberofshadedmarksin

theCognitiveConditioninKOMIChart.

｜’’

’Table6KOMISenileDementiaGradingSyStem

’

｜

(5)GroupFeatures

HerewefbcusedonthefbllowingaspectsofthesuhiectsandlistedthefeatulBsofeachgoup:

-Symptomsthataffectthes呵ectgindependenceintheirdailylives.

-Symptomsthataffectthesupportfromcalcrsandfamilymembers.

ｌ

ｌ

ｌ

ｌ

ｌ

Ｉ

22

Group NumberofShadedMarks GradeNames

GroupA 77.0‐50．0 Memory-LossPeriod

GmupB 49.9‐40．0 Toilet-AccidentPeriod

GmupC 39.9‐30．0 ConfUsedkriod

GroupD 29.9‐20．0 DisorientedPeriod

GmupE 19.9-10．0 WithdrawnPeriod

GroupF 9.9‐0 DerangedPeriod

Table7DiSturbingSymptomSandTheirPercentageSinEachGroup

23

Group-a Group-b Group-c Group-d Group-e Group-f

NumberofShadedMarks

inCognitiveCondition75-55 49.9-40 39.9-30 29.9-20 19.9-10 9.9-0

NumberOfSuinects/rotal(200)

40 45 41 21 16

Symptoms

MemoryConfUsion(ShortTもnn) 95％ 85％ 87％ 98％ 90％ 75％

MemoryConfilsion(LongT℃rm) 51% 65％ 67％ 66％ 90% 69％

FalseCognition 51% 65％ 73％ 73％ 67％ 63％

Incontinence(Urine) 19％ 45％ 67％ 63％ 81% 81％

Incontinence(Rces) 5％ 43％ 60％ 56％ 81% 81％

Wandering 3％ 23％ 31% 32％ 24％ 25％

PublicUrination 3％ 10％ 22％ 10% 29％ 0％

ToyingwithFeces 3％ 8％ 20％ 12％ 24％ 0％

IrrationalDemandto.@gohome'' 24％ 13％ 27％ 5％ 10％ 0％

RefilsalofFamilySupport 11% 15% 9％ 27％ 4％ 13%

LackofVoluntary Actions 19％ 15％ 31% 32％ 43％ 50％

LackofSleep 24％ 15% 27％ 24％ 14％ 13%

LackofMotivation 24％ 8％ 22％ 44％ 52％ 25％

UnabletoRespond 0％ 0％ 2％ 2％ 10% 44％

UnabletoRecognizePeople 0％ 10％ 16% 29％ 62％ 75％

Bedridden 0％ 3％ 7％ 15％ 19％ 38％

Bedridden,UnabletoRecognize

People,andUnabletoRespond0％ 0％ 0％ 0％ 0% 25％

｡AvelageScoresintheCognitiveConditionofKOMIChartsCoITespondingtoEachGI℃up

(Figurel)

GroupA Group B

駒“幽回句曇Ｕ⑨毒ｑ鐘

８⑧竃旬“。

星●壁

Group C GroupDⅣ

”。“匿旬舞恥）○三・唾

画

“

嘩

虹

句

幻

。

§

Group FGroup E

24

4.Findings

Throughourstudiestodate,wehaveidentifiedthefOllowingpomts:

1)UsmgthenumberofshadedmarksintheCoglitiveConditionoftheKOMIChart,itispossibleto

gfadetheprogressofseniledementiainto6differentlevels.

2)ThisgadingisbasedonthepeI℃entageofdementiasuffererswhohaveatleastonecompletely

blankchecklistamongthel5differentchecklistsintheCognitiveConditionofKOMIChartin

eachgroup.

3)Wealsofbundthattherewasanorderintheappearanceofcompletelyblankchecklists.Wefbund

thatcompletelyblankliststendtoappearfirstintheThirdSectoroftheCognitiveCondition.

WithmtheThildSectori.G(13)DailyTasks''ismostlikelytobefirstmarkedtotallyblank.Next,

"(14)FinancialAdministration,'' ..(12)MakingChangesinDailyLife,"and"(15)Health

Management''tendtofbllow・Thisolderofappearancewasthesameinbothgroupsthathadahigh

independencefactorintheirlivesandinthegoupwithalowmdependence.Afterthis,completely

blanklistsarelikelytoappearmtheSecondSector・WithmtheSecondSectoritheorderofappearance

is"(6)PhysicalCleanliness,""(7)ClothingandLaundry,"and"(8)AttentiontoAppearance.”

4)ThefbllowingcognitivefUnctionsarerelativelywell-presrvedthroughtheprogressofsenile

dementia.

-Abletofeelcomfbrtableinsunlight

-Abletounderstandaboutfbod

-Abletofeelhunger

-Eagertomoveorwalk

-Abletofelreh巳shedafterhavingbathed.

-Abletofもelpleasurewhenhairstylesorclothesarepraised

-Eagertotalkorexpress.

-Abletounderstandownsex.

-Feelsphysicalcontactcomfbrtable

-Abletounderstandthemselves

-Abletonoticeproblemsmphysicalormentalcondition

5)AsthegradedevelopsfiomAtoF,thenumberofshadedmarksintheCognitiveConditioninthe

KOMIChartdecl巳asesandthenumberofblankmarksincreases.

6)'I11enumberofshadedmarksintheCognitiveConditioninKOMIChartcanbeanindicatorofthe

levelofdementia.

7)Becausethereissomelegularityintheorderofappearanceof曲esymptomsfbreachgroup,the

progressofdementiacanbepredictedbygraspingthecurrentsymptomsandcondition・Inother

words,thesymptomsofdementiaincreasethroughthegmups(grades)AtoF.

8)Attributesofeachgroupscanbedescribedasfbllows:

95%ofsubjectsinGroupAshowedshort-tennmemoryloss,andmorethan50%ofsuhjects

showedlong-tennmemorylossorconfUsion,and/orfalsecognition(memory-lossperiod).

GroupB'smainattributewastoiletproblemsaswellassharingthesameattributesasGroupA.

25

ｌｌｌｌＩｌｌｌ‐卜‐“ｌ，ｌｌｌｌｌｌｌｌｌｌｌｌ１ｌｌｌＪ’－１１‐‐‐‐‐‐Ｉ‐‐‐Ｉ‐‐‐‐‐‐ＩｌＩ‐１１‐ＩＩｌＩＩＩｌｌｌＩＩＩｌＩｌｌｌｌｌＩＩ‐Ｉｌｌｌｌ‐‐ｌ‐‐‐‐ｌＩｌｌｌｌｌ１ｌトーｌ

50%ofsuhiectssufferedfiomincontinenceand23%ofsuhiectssufferedfromwandering(toilet-problemperiod).

GroupCsharedtheattributesofGroupAandB,andthusthefbllowinggroupsincrementallyshal℃dthesameattributesasthepreviousgmups.SuhiectsinGmUpCIevealedavarietyofproblemsthatarecommonlyobselvedintheprogressofdementia,suchasfiFequentwandering,iITational

demandto｡@gohome,''lackofsleep,publicurination,toyingwithfeces,andlackofvoluntaryactions(confilsedperiod).

GroupDwasintheperiodwhenthesuMectsshowedvarioustypesofproblematicbehavior

fi巳quently.TYlemainattributeofthisgmupwasthatthesuhiectscouldnotlecognizetheirfamilymembersandrefUsedsupportfiOmthem・Theirlossofmotivationwasalsoparticularlysignificant.Careathomebecomesdifficultinthisstage(disorientedperiod).

InGroupE,theincreaseofmentalregression,suchaslackofvoluntaIyactionsandmotivation

Wel巳observed,inadditiontotheremainingproblemssuchasmemorylossandphysicaldecline,

includingincontinence, 19%ofGroupEwereinastateinwhichtheycouldnotleavetheirbeds.

25%ofsuhjectsofGroupFshowedthethreesymptomssimultaneously:bedridden,unableto

recognizeothers,andunabletorespond.However,asshowninTable7,GroupFsulliectsshowed

alowerpel℃entagefOrtheappearanceofshort-tennmemoryconfUsioncomparedtoGroupA.

AIso,thepercentagesfOrothersymptoms,suchaslong-termmemoryconfUsion,falsecognition,

andlackofmotivationwelelessthanGroupFandclosertothosefiguresofGroupA・Thisgives

theimpressionthatthes呵ectrsymptomshadimproved;however,thismayonlybeduetoalack

ofattentiontothosesymptomsbytheI巳corders.Itismorelikelythatthesuhjectswhohavethe

symptomsofbeingbedridden,unabletorecognizeothers,andunabletorespond,alsohavebasic

problemssuchasmemoryconfilsionandlackofmotivation(derangedperiod).

9)Distributionofdifferentgroupsofseniledementiasuffel℃rswereapproximatelythesamefOrall

residentialsimations:homes,carehomes,andhospitals.

10)TY'eper℃entagesofsuhiectswhobelongedtothehighlyindependentgrades(GroupsAandB:77

people)ineachresidentialsituationwere32%athome,40%atcarehomes,and42%athospitals.

Thissuggeststhatthedistributionofhighlyindependentdementiasufferersisrelativelyevenfbrallresidentialsituations.

11)Thepercentagesofsubiectswhobelongedtothehighlydependentgrades(GroupsEandF:37

people)ineachresidentialsituationwere20%athome,15%atcal巳homes,andl8%athospitals.

Thesefiguressuggestthatevenhighlydependentsuffererscanremainathomeasfarastheyand

theirfamilymemberscanreceiveappropriatecaresupport.

12)ThepercentagesofsuhjectswhobelongedtoGroupC(45people)ineachresidentialsituation

were22%athome,40%atcarehomes,and55%athospitals.Inthisstage,thesuhiectswere

experiencmgthemostdisorientedperiod,withfiBquentsymptomssuchasfalsecognition,wandering,

andirrationaldemandto66gohome.''Fromthesefigureswecanseethatthisisthemostdifficult

periodinwhichtopmvidesuffererswithcareathome.

Iﾛ

’

’’

‐

ｌ

ｌ26

II

5.EstablishmentofStandardCarePlanningGuidesfOrEachGroup

(1)CharacteristicsofEachGmup'sKOMIRadarChartDismbution(Figme2)

GroupA~8t功■

唾:壼粥てこ工砺二輿_…

Group B

醜色1$坤⑧

…$b副白tDt●

／べ…恂吋

Re…&腕・

務竪｡副割瞬一

“I排t“軸t の丁0■〆“■、 ①函脚”$旬和

⑧『蛇r“ ⑧18･㎡毎の②0口IDg ④~官b8

瀦髪／／

グ

…ham8he 〆…ね←盈些①忠■叫駒畝駆 Z ⑲8p■鱒耐DB閉

3

〆〆

Z Z⑧wBは“

、延①励輝､』M0，℃毎caR

⑧W､皿■8

、ミ①、淀隊釧Mo7…､8緒?率"“ 二／⑪…．

①即牽･OL一

／

①‘．U津『幽軍的

①岬f凹面動

Group…t胸⑭

C Group D~E8Im

.､霊ﾂッｬ-i-⑥塗・､｡■副StDtO

ひ

／ずう…ぬ71

■■…E1頭

秀､｡鰹"‘…．■G“■(I唖

差曳｡……″″

〆つ

シニ勇〆〆~gb8 “l帥t＝ジグ

張の耐率Blr雄一

①疵■旅88陀両〆一

二〆二 〆

⑪ms9蛇 cH0efh8①｡6首“ ④唖8宙I南〆

〆〆

塗一

シ一号〆〆〆

“M■~戯j” “tl■α噸蝉一

.一 ①8冑an●ﾛ1房8

ﾌﾟ‘.…、写?邑垂亨・と全

罰〆〆

鯛:詮、 ::競壼．彦／･聖…堂⑦晩1口･P!今竺 一⑦眺踊､噂

①恥？…

①咋丁以踊的

Group E

~$坤

Group F

“■脱噛

⑬

…ぬ

のU”c『u■■

⑪恥r哩馳

27

(2)MissingCognitionandRemainingAbilities

1)GroupA

(i)MissingCognition

-Manycannotunderstandhowtouseelectricappliances,suchasvacuumcleanersandair

conditionerS.

-Manycannotunderstandwhatisthebestfbodfbrtheirhealth.

-Manycannotmanagethemselveswhentheyhaveexcretoryproblems.

-Manycannotunderstandwhattodoabouttheirsleepingproblems.

-Weakmotivationfbrwashingclothes.

-Conilsedmemories.

-DecreaseinabilityfOrdailytasksandchores.

-Lackoffinancialcompetence.

-Decreaseinabilitytomanagetheirhealth.

1

’’

’

｜

l

l

(ii)Remaininghealthyabilities

-Physicallyingoodcondition.

-Cognitiveabilitiesaresufficienttocarryoutdailyroutines.

-Abletosocializethroughconversationorgoingout.

-Interestedinthehfappearanceandabletoexplessthemselvesthroughtheirappearance.

-Showconsiderationtotheothers.

-Maintaintheirindependenceandhelpthemselves.

-EnjoysmallchangesindailylifeandshowadesilBfbrsuchchanges.

-Abletohandledailymoneyandpurchasewhattheyneed.

-Abletoreporttheirhealthproblemsandhaveadesiretomaintaintheirhealth.

2)GroupB

(i)MissingCognition

-Nointerestinthequalityandquantityoffbodandtendtowardsoveraorundereeating.

-Nounderstandingoftherightplacefbrtheirtoiletrequirementsandtendtohavetoiletaccidents.

-Decreaseindesiretomove,orstartwandering.

-Unconcernedaboutcleanlinessoftheirbodiesoraboutbathing.

-Nointerestinappearance,therefOreunabletoexpressthemselvesthroughtheirlooks.

-ConfUsedmemoriescausingconversationtobeincomprehensible.

-Noabilityconcemingdailyjudgmentsanddailyproblemsolving.

-Noabilitytoperfbnncalculationsandincreaseddifficultyindailyfinancemanagement.

-Lossofhealth-managementability.

１

ｌ

ｌ

ｌ

Ｉ

ｌ

’

１28

(ii)Remaininghealthyabilities

-Justabletomanagedailyroutines.

-Sufficientawarenessofcomfbrtssuchasenioyingthesunlightandfeelmgrefi巳shed.

-Healthyappetite.

-Upperlimbsarefreetomove(althoughthelowerlimbsareweak).

-DesirefOrcommunicationandshowconsiderationtoothers.

-NoauditoryorviSualproblems.

-Abletonoticeproblemsinphysicalormentalcondition.

3)GroupC

(i)MissingCognition

-Eatsonlywhenfed・Novoluntarymtentiontoeat.

-Norecognitionofrequirementfbrexcretion.Increaseintoiletaccidentsandotherproblematic

behaviorrelatedtoexcretion.

-IncreaseinwanderingorselfLconfinement.

-Decreaseinthewilltochangeclothesandincreasedmdifferencetoappearance.

-Oftenbecomesdistressedwhenholdingaconversation.Communicationbecomesdifficult.

-Significantdropofinte1Bstmkeepingroomtidy,financialmanagement,andhealthmanagement.

(ii)Remaininghealthyabilities

-Cognitiveabilityenoughtomaintainabilityofdailylife(ADL).

-Abletoswallow.

-Abletodistinguishdayfiomnightandhavethewilltogetup.

-Desiretobathandabletofeelreheshedaherabath.

-Despitelackofinterestinappearance,stillfeelshappywhentheirappearanceispraised.

-Nonnalinterestinsexuality.

-ClearselfLrecognition.

-AbletofeelboredomordiscomfbItinuneventfUlperiodsandhasadesirefbrchanges.

-Abletounderstandconceptofmoneyandretainaninterestinshopping.

4)GroupD

(i)MissingCognition

-Cognitiveabilityhasdeclinedtoaboutone-thirdofanonnaladult'scognitiveability.

-ProblemsareObservedinawiderangeofareasindailylife.

-Individualityiscompletelylost.

-UncontrollablewanderingorselfLconfinement.

-Novoluntaryabilitytocommunicateorsocialize.

29

Ｉ

Ｉ

ｌ

Ｉ

Ｉ

ｌ

’

(ii)Remaininghealthyabilities

-One-thirdofhealthyabilitiesisleft.

-Abletounderstandfbodandfeelhunger.

-Abletoswallow.

-Manystillfeelembanassmenttoreceivesupportfbrcleaningbodyorexcretion.

-Abletofeelrefreshedafterhavmgbathed.

-Abletofeelhappywhenpraised.

-Conversationishardtohold,butstillhavearelativelystrongdesiretocommunicate.

-Manystillunderstandtheconceptofmoney.

5)GroupE

(i)MissingCognition

-Excl巳tionisnotselfsupported・NotabletofeeltheneedfOrexcletion,northeendofexcretion.

Donotunderstandthetoiletandmaybetotallyincontinent.

-However,theradarchartusuallyshowsthattheconditionofdefecationisbetterthanurination.

-Willtomovehasdeclmedandtendencyistoconfinethemselves.

-Lackofdesil℃tobath.

-Nointerestinappearanceorcleanliness.

-Decreaseindesiretocommunicate.

-LossofselfLrecognition.

(ii)Remaininghealthyabilities

-Basiclifemechanismssuchasrespiration,bloodpI℃ssure,andtemperature.

-Abletofeelcomfbrtableinsunlightandfieshair.

-Abletounderstandmod.

-Slightdesirefbrmovementandgettingup.

-Conversationisdifficult,butstilll巳sponsive.

-Abletounderstandtheirsexandenjoyphysicalcontact.

-Slightabilitytonoticeproblemsinphysicalormentalcondition.

6)GroupF

(i)MissingCognition

-95%ofabilitieshavebeenlost.

-BedriddenorselfLconfined.

-NoselfLexpression.

-NoconverSation.

-Allthedecisionsnecessalytomaintaintheirliferelyuponothers.１１トーｌｌｌｌｌＩｌｌｌｌＩ０ＩｌＩｌｌＩｊ１Ｉｌｌｌｌ１ＩｂＩｌｌ１ＩＩｌｌｌｌｌ０ＩｌｌｈＩＩｌ

30

(ii)Remaininghealthyabilities

-Nonnalbreathing,bloodpressureandtemperature・Lifeisselfsupporting.

-Abletounderstandfbod.

-Barelyabletofeelrefreshedafterhavmgcleaned.

-Abletohearvoicesandsounds.

-Occasionallyabletorecoglizethemselvesandothers.

6.EstablishmentofStandardCarePlanningGuide

TmclnPqnf，畑ndzTd 、3rel

1)DonothcusonlyonthemSSingabilities

2)MakethebestuseofremaininghealthyabintieS

3)Supportcnents'humandigmty

4)Providecommrtablestimuli

5)Maintainammnarenvironmentandlitstyle

IZL旦里旦幽型_旦延_E迦皿型g旦旦i…且

1)GroupA

-TYleyareabletomaintamtheirlifeaslongasitiswithinafamiliarenvironmentandlifestyle.

Supporttheirvoluntarywillfbranindependentlife.

-Encouragementisimportanttomaintaintheirconfidence.(Donotblameorscold.)

-Identifyconcretetasksfbrwhichtheclientneedssupport,andprovidehelponlyfbrthosetasks

andmacasualmanner

2)GIoupB

-CI℃ateadailyprogramthatwillenhancetheclient'sremainingabilitiestothemaximumwithin

therangeoftheclient'sfamiliarenvironmentandlimstyle.

-Createoccasionswhentheycancommunicatewithpeopleinafriendlyatmosphere.

-Createoccasionswhentheycanenjoynamreortouchmganimals.

-Listencarefilllytotheircomplaintsabouthealthissues.

3)GrOupC

-Createadailyprogramthatenablestheclienttoperfonnthetasksthattheystillcanmanagein

ordertoencouragetheirindependence.

-PIcvidesupportinsuchamannerthattheclientcanappreciatetheirparticipationandimportance

tosociety.

-Donottakeanegativeattimdetotheirproblematicbehavior,orcriticizethemfbrit.

-TYleirvoluntaryparticipationmaybelow,buttheyal巳stillI℃sponsivetoextemalstimuli・Provide

comfbrtaablestimulisuchasconversationthatrecallstheirpast,music,humorouschatandjokes.

31

‐ｌトー‐１１１１０ⅡⅡⅡⅡ，ＩｌｌｌｌｌｌｌｌｌｌｌｌｌｌｌｌｌｌｌＩｌｌｌＩＩｌｌｌｌ－１

-Encoumgesocialinvolvement.

4)GmupD

-CIeateanenvironmentinwhichtheclientcanfeelsecureandstable.

-RemovedangersfromtheirenvirOnment.

-Donotdwellontheeffectsoftheclient'sproblematicbehavior.FOcusontheirhealthyabilities

andprogramdailytaskstosuittheirremainingpowers.

-Donotisolate,Iestrain,orleavetheclientalone.

-Donotovenlsemedicines.

’

5)GmupE

-ProvideasafeandcomfOrtableenvironment,keepingtheclient'slifecycleregularandattheir

ownpace.

-Dementiasuffererslosetheirmotivationinthisstage,butcontinuetoprovidemoderatestimulus

tomaintaintheirattentionandpreventthemfiombecomingisolaed.

-Maintainregularphysicalcontactsothattheycanfeelsecul℃throughhumancontact.

-PlansmallstrollsandoutingssothattheycaneIUoythesunshmeandfteshair.

-Prepalもprocessedfbodssothattheycancontinuetoenjoyeating.

-Iftheclientisfbndofsomeparticularthings,keepmemintheclient'senvironment.

l

6)GroupF

-Createacomfbrtableenvironmentwheretheclientcankeepaclosecontactwiththeclient's

familysothathe/shecanspendapeacefUltimerightuptothelastmoments.

-Paycloseattentiontothequalityofcontactwiththeclient・Donotneglecttheirhumandiglity.

-Appreciateanyremainingabilitiesandsupportthempositively.

7.FindingsfromEstablishingtheStandardCarePIanningGuide

(1)ThesixgroupscategorizedbytheKOMISenileDementiaGradingSystemshowedclear

characteristicsintheCognitiveConditionoftheKOMIChart.Itwasl巳lativelyeasytodescribe

theircharacteristicsinwords.

I

｜’

(2)ItwasfOundthatcontrastingtheKOⅣⅡRadarChartwiththeCognitiveConditionintheKOMI

ChartwashelpfUl,becausethestateofthephysicalconditionshownintheKOMIRadarChart

revealedacorrespondencewiththestateoftheCognitiveConditioninKOMIChartateachstage

ofseniledementia.

ｌ

Ｉ

Ｉ

Ｉ

Ｉ

Ｉ

(3)ThroughthestudyofcontrastingtheKOMIRadarChartwiththeCognitiveConditioninthe

KOMIChart,itwasfbundthattheclients'physicalconditionsstayrelativelyhealthycomparedto

32

’

theircognitivestate・TheclientsggadedasGroupsCandDintheKOMISenileDementiaGrading

SystemexperienceaconfUsedordisorientedperiodintheaspectofcognition,andtherefbrerequilB

asiglificantamountofsupport・However,theirphysicalconditionsaregenerallyhealthyandthis

tendstocreatetheinaccurateimpressionthattheydonotneedmuchsupport・Carehlloverall

observationisessentialtoprovidetherightlevelofsupport.

(4)ThroughdevelopmgtheStandardCarePlanningGuide,fiveprinciplesofcareplannmgemerged.

T11esefiveprinciplescanbeappliedtoeachgroupofclients.

(5)TheStandardCarePlanningGuidewasestablishedbasedonthecharacteristicsofeachgroup,as

identifiedusingtheCognitiveConditionoftheKOMIChartandtheKOMIRadarChart.This

StandardCarePlanningGuidecanbeusedassoonasthegradeoftheclienthasbeendetennined

usingtheKOⅣⅡSenileDementiaGradingSystem.

(6)TheStandardCarePlanningGuideismerelyabasicguidelinefbrcreatingacareplanfOreach

groupofclients・Theacmalcareplanshouldofcoursebetailoredtosuittheindividuall巳quirementsoftheclient'ssituation.

8.Conclusion

Asummaryoftheorderofmakmgcareplansfbrseniledementiasufrerersisshownbelow:

(1)AccuratelymarktheCognitiveConditionintheKOMIChalt.

(2)MarktheKOMIRadarChart.

(3)CountthefUlly-shadedlistsoftheCognitiveConditionoftheKOMIChartandrefertotheKOMI

SenileDementiaGradingSystemtodetennineagradefbrtheclient.

(4)BasedontheStandardCarePlanningGuidethatmatchesthedetenninedgrade,createacareplan

takingintoconsiderationtheclient'sindividualconditions.

ReferenCe

Kanai,H､2001,G.KOMIChartSystem2001-PrinciplesandMethodtoSupportPracticalCaring''.Tokyo:Gendai-

sha

StudyGroupMembers:

KozumiHoshika:TheNightingaleArchives

ShigetsuguAraki:NagaokaSchoolofNursingandWelfal℃

YoshiakiKawakami:HomeCareSupportCenterPearl

KeikoYokoyama:JuniorCollegeDepartment,SaitamaPrefecturalUniversity

KyokoYamazaki:NationalHizenSanatorium

33

’