【桑葛石原研翻译系列】日本养老经验：追求最佳健康与文化交融

作者：MICHAEL J. ANNEAR,JUNKO OTANI,JOANNA SUN

塔斯马尼亚大学-威克痴呆症研究和教育中心，霍巴特，塔斯马尼亚，澳大利亚

大阪大学-人文科学研究生院，日本关西大阪

澳大利亚新南威尔士州卧龙岗市卧龙岗大学医学与健康科学学院

桑葛石（译）

摘要

日本是一个超级老龄化的社会，老年人口在一直不断增长，这给老年护理体系面带来了巨大压力。本研究在日本中部和北部的八个养老机构进行自然观察，探索日本老年护理是如何配置的。在生活质量和健康方面，确定了四个方面的潜在获益。日本政府规定，养老机构必须雇用一名合格的营养专家来指导老年人的膳食。生活康复的概念可以给老年人寻求最大限度地提高身体和认知能力，并有可能延长寿命。日本政府还规定了更低的员工与老年人的比例，以便为老年人提供更高水平的护理。最后，日本的设施优先考虑季节性和文化实践，将老年人与墙外的世界连接起来。

关键词：老年人，日本，护理提供，人口老龄化，养老机构

日本是一个超老龄社会，其65岁（含65）以上[1]的人口占20%以上。出生率和死亡率的下降促使日本老年护理发生了一场革命，公共和私人服务提供者为日益增长的需求[2]提供服务。在东北亚，对年老亲属的家庭照顾有着悠久的历史，符合儒家孝道[3]的要求，但是有组织的公共或私人供应[3]水平很低。在日本，根据1898年《明治民法典》的规定，养老照顾历来是家庭的责任，该法典规定长子负责[4]照顾年迈的父母。直到1963年日本通过了《老年人福利法》，正规的养老机构才成为主流[4]。目前，超过6%的65岁以上（含65）的日本人生活在养老机构（特殊的老年之家、老年医院和老年人保健设施）中，尽管超过人口老龄化的速度[5]，老年护理入院的原因包括家庭缺乏护理人员、健康状况下降或姑息护理要求[6]。与类似的发达国家（澳大利亚和美国的抚养比为22)相比，日本是全球抚养比最高的国家之一(42）[7]这意味着仅通过对工作人口征税来资助老年的护理可能是不足的。因此，日本通过一项长期护理保险计划提供资金，成年人从40岁开始缴纳，在获得服务时需要10%的个人分摊费用[6]。医生对65岁的老年人进行的需求评估，以确定护理要求。

在2016年，研究人员调查了日本关西和东北地区的8个养老机构，研究老年护理是如何在这个超龄社会中配置的。研究人员的观察是自然的、不参与的，并在研究日记和影像中记录。研究人员通过对比日记，来确保观察的客观性，并反映他们在“自然主义概括”[8]过程中的印象和经验。日本的一些要素可以为其他地区的老年人护理提供参考。重点的护理内容包括营养支持、生活康复、规定的人员配比、文化习俗。

营养支持日本政府要求所有公共养老机构必须雇用一名合格的营养师，以确保老年人的营养需求得到满足[9]。尽管有营养不良和饮食结构不合理的报道[10,11]，但在欧洲、北美和亚太区域的发达国家，养老机构聘请营养学家并不常见。例如，日本老年男性的饮食平均总能量（2,280千卡) 低于美国可比老年人(2,609千卡)，原因是脂肪摄入量平均降低10%(总蛋白质消耗没有明显差异）[12]。在这种情况下，积极管理体重不足是一个值得特别关注的饮食干预，而膳食替代配方则很少使用。为老年人提供广泛的季节性菜单也是很有必要的。日本的老年护理融合了现代营养学和传统的主要以植物为基础的饮食，主食主要是米汤、大米、发酵 食品、鱼、豆腐和蔬菜。空间是养老机构为老年人提供的重要环境，家属可以烹饪食物，老年人也可以从市场或志愿者经营的现场咖啡馆购买额外的食物。有研究表明日本养老机构创造的饮食环境，健康的食物选择和合理的饮食环境增加了老年人实现饮食目标和提高生活质量的可能性[13]。

生活康复

生活康复是一个深远的日本概念，包括精神的康复和维持正常功能和认知能力。可以说反映了日本医疗保健中出现的一种统领一切的家长式作风[14]，提倡干预。在日本的养老机构中，老年人经常参加力量训练和提供认知刺激的文化活动（如书法）。虽然许多国家的老年人通常在类似年龄（80多岁）[15]进入养老机构，但日本养老机构的老年人寿命更长。日本在老年护理期间的平均寿命是入院之日起49个月[16]，与之相比澳大利亚和美国的类似机构中只有34个月或更少[15,17]。潜在寿命的增长表明，在生命的最后阶段，在适当的支持下有机会维持人体功能并能延长寿命。建议进一步研究日本老年护理中寿命的增加是否与相应的生活质量改善相关，或者是否有其他变量可能混淆。

日本的生活康复与从生理学和营养学文献中了解到的，在晚年生活中积极的功能改变的潜力密切相关，有证据表明，为了改善健康或功能而进行干预永远不会太晚[18]。

规定的人员配置比率

日本养老机构的工作人员与老年人的比例是规定的比例为1：3，公共和私营养老机构都是一样的。一项汇总数据的研究表明，人员配置组合包括大约16%的注册护士、35%的护理人员、4%的物理治疗师、3%的营养师或营养师以及42%的非临床人员[19]。这种临床工作人员的组成结构与包括美国在内的其他发达国家相当[20]。在日本国家长期护理保险计划的帮助下，较低人员配比率才有可能实现，这降低了社会的税收负担。由于日本人口老龄化在本世纪中叶达到高峰，目前的筹资安排是否足够尚不清楚。随着日本人口老龄化和出生率的下降，未来几年日本可能会面临护理人员短缺的问题，尽管日本政府正在努力保持现有的护理水平。需要建立一支专门和可持续的护理队伍，可能需要吸纳更多的移民和新毕业生，以确保维持目前的高护理率。许多其他国家没有规定工作人员比率，例如澳大利亚虽然期望在其老年护理政策内有足够数量的受过适当培训的工作人员，但目前没有支持护理老年人的最低工作人员标准[21]。

季节性和传统文化实践

日本的养老机构通常是多层的，位于人口稠密的城市地区。在这种环境下，老年人很少有机会体验大自然或参与传统的社区生活。健康地理学和环境心理学的实证研究承认定期体验自然的治疗和康复价值[22]，而参与传统文化实践已被证明能提高老年人群的生活质量[23]。日本的老年护理机构注重季节性，强调居民应该在不受身体或认知能力限制的情况下体验季节的变化。观察到的季节性表达机制包括：(a)定期更换艺术品以反映季节；(b)改变菜单包括符合气候条件的传统菜肴；(c)插花和植树活动说明季节的变化；(d)为庆祝传统节日装饰机构。在2016年初春，人们经常看到插花的活动，中心特征是一个萌芽的梅花(图1)。清宫节标志着旧历春天的到来，也在这个时候庆祝，装饰元素随处可见，老年人采取行动(如从门口扔豆子)来驱除一年的霉运。这些活动有助于标记自然周期，并将老年人和外部世界并同他们的文化联系起来。

图表1.日本养老院的季节性艺术品和梅花插花

图片来源：Experiences of Japanese aged care，SGRCR整理

结论

为越来越多的日本老年人提供高质量的老年护理面临挑战，已经出台了一系列旨在优化质量和延长寿命的做法和政策。在世界各地，提供老年护理的生活质量被认为是确保晚年尊严和享受生活的关键。然而，日本的做法包含了实现最佳健康的可能性，其他社会也可能参考日本的做法。一项关于日本老年人护理的代表性研究指出，与其它的发达国家进行比较出现了不同护理结果。未来的研究还应考虑日本以外的不同类型的差异，促进跨文化的比较。

要点

• 日本的人口老龄化非常严峻

• 侧重老年人科学的饮食控制和营养支持

• 生活康复可能与老年人生活质量相关

• 日本政府要求严格的人员配比，以确保护理质量

• 日本老年人护理中，季节性和传统文化实践的沉浸是非常重要的

【原文】

Experiences of Japanese aged care: the pursuit of optimal health and cultural engagement

MICHAEL J. ANNEAR, JUNKO OTANI, JOANNA SUN 

University of Tasmania - Wicking Dementia Research and Education Centre, Hobart, Tasmania, Australia

Osaka University - Graduate School of Human Sciences, Osaka, Kansai, Japan

University of Wollongong Faculty of Science Medicine and Health, Wollongong, New South Wales, Australia

Abstract

Japan is a super-ageing society that faces pressures on its aged care system from a growing population of older adults.Naturalistic observations were undertaken at eight aged care facilities in central and northern Japan to explore how aged care is confifigured. Four aspects of contemporary provision were identifified that offer potential gains in quality of life andhealth. The Japanese government mandates that aged care facilities must employ a qualifified nutritionist to oversee mealpreparation, fostering optimal dietary intake. A concept of life rehabilitation seeks to maximise physical and cognitive performance, with possible longevity gains. Low staff to resident ratios are also mandated by the Japanese government toafford residents high levels of interpersonal care. Finally, Japanese facilities prioritise experiences of seasonality and culture,connecting frail older people to the world beyond their walls.

Keywords: older people, Japan, care provision, population ageing, aged care facility

Japan is a super-ageing society with greater than 20% of its population aged 65 years or older [1]. Declining birth and mortality rates have prompted a revolution in Japanese aged care with public and private providers serving a growing demand [2]. In north-east Asia, there is a long history of familial care for ageing relatives aligned to Confucian imperative of filial piety [3], and low levels of organised public or private provision [3]. In Japan, aged care was historically the responsibility of families as mandated in the 1898 Meiji Civil Code, which stipulated that the eldest son was responsible for the care of ageing parents [4]. It was not until 1963 with the passing of Elderly Welfare Act in Japan that formal aged care became commonplace [4].

Presently, over 6% of Japanese aged 65 years or older live in aged care facilities (special homes for the aged, geriatric hospitals, and health facilities for elderly people–herein considered collectively), although admissions are projected to rise significantly with population ageing [5]. Reasons for aged care admissions include a lack of caregivers at home, declining health status, or palliative care requirements [6]. Japan has among the highest global age dependency ratios (42) when compared to similarly developed countries (Australia and the United States have a dependency ratio of 22) [7] suggesting that funding aged care through taxation of the working-age population alone may be insufficient. Accordingly, Japan provides universal access to aged care that is funded through a long-term care insurance scheme, with working-age adults making contributions from age 40 and a 10% individual co-payment at the time of accessing services [6]. Older adults who contact the health system after 65 years of age receive a physician-administered needs assessment to determine care requirements.

In 2016, the authors attended eight aged care facilities in the Japanese regions of Kansai and Thoku to explore how care is configured in this super-ageing society. Aged care visits were conceived as naturalistic, non-participant observations with experiences and impressions recorded in research diaries and photographs. Researchers compared diary notes to identify commonly observed care practices and reflected upon their impressions and experiences in a process of 'naturalistic generalisation’ [8]. There are elements of modern Japanese provision that could inform care practices in other regions. Elements of care provision that stand out include nutritional support, life rehabilitation,mandated staffing ratios, and seasonality and cultural practice.

Nutritional support

The Japanese government mandates that all public institutions that serve food must employ a qualified nutritionist to ensure that the macro- and micro-nutrient needs of residents are met [9]. Oversight by trained nutritionists in aged care facilities is uncommon in developed countries across Europe, North America, and the Asia-Pacific region despite reports of malnutrition and suboptimal diet [10, 11]. The diet of older Japanese males, for example, is lower in mean total energy (2,280 kcal) than comparable residents of the United States (2,609 kcal) due to an average 10% lower intake of fat (with no appreciable difference in total protein consumption) [12]. In this context, active management of underweight is a particular concern with dietary intervention favoured and meal replacement formula seldom employed. Choice and enjoyment are also imperatives with an extensive seasonal menu provided for residents. Japanese aged care melds modern dietetics with a traditional and largely plant based diet characterised by such staples as miso soup, rice, fermented foods, fish, tofu and vegetables. Space is also provided in aged care facilities for family members to reheat home-cooked food for their relatives, and residents can purchase additional sustenance from weekly markets or on-site cafes run by volunteers. The food environment created in Japanese aged care facilities reinforces research that shows proximal access to healthful food choices and an amenable eating context increases the likelihood of achieving recommended dietary targets and quality of life among adults [13].

Life rehabilitation

Life rehabilitation is a far-reaching Japanese concept encompassing an ethos of recovery, rehabilitation, and maintenance of functional and cognitive capacity across the lifespan. Life rehabilitation arguably reflects an overarching paternalism that has been reported in Japanese health care [14], which advocates intervention. In Japanese facilities, it is common to see older adults participating in supervised strength training and cultural pursuits that provide cognitive stimulation (calligraphy for example). While older adults in many countries typically enter aged care facilities at a similar age (mid-80s) [15], residents of Japanese aged care facilities live longer. National average lifespan within Japanese aged care is 49 months from date of admission [16] compared to only 34 months or less in comparable facilities in Australia and the United States [15, 17]. Potential longevity gains observed in Japanese aged care facilities suggest that in the final stages of life there are opportunities to support function and increase lifespan when adequate support is in place. Further investigation is recommended to explore whether longevity gains in Japanese aged care are associated with commensurate quality of life improvement, or whether other variables potentially confound measures of longevity. The Japanese ethos of life rehabilitation aligns closely with what we know about the potential for positive functional changes in later life from the physiology and dietetics literature [18] with evidence suggesting that it is never too late to intervene for improved health or function.

Mandated staffifing ratios

Staff to resident ratios are controlled in Japanese aged care facilities with a national government prescription of 1:3 for both public and private providers [16]. Studies of aggregated data from Japanese facilities have shown a staffing mix of approximately 16% registered nurses, 35% care staff, 4% physical and occupational therapists, 3% dietitians or nutritionists, and 42% non-clinical roles [19]. Such clinical staff compositions are comparable to other developed countries, including the United States [20]. Low staff to resident ratios are arguably only possible with the help of Japan s national long-term care insurance scheme, which reduces the tax burden of aged care. It remains unclear whether current funding arrangements will be sufficient as population ageing peaks around mid-century in Japan. With its ageing population and declining birth rate, Japan will arguably face a shortage of care workers in the coming years, although the  government is working to embed a consistent level of care within the sector. A dedicated and sustainable caring workforce, which may include a larger migrant workforce and new graduates, will need to be developed to ensure that the current high rate of care provision can be sustained. Although future need for aged care is likely to create challenges for Japan, many other countries do not have mandated staff ratios. Australia, for example, while expecting adequate numbers of appropriately trained staff within its aged care policy [21], currently has no minimum standard for staffing to support vulnerable residents in care.

Seasonality and traditional cultural practice

Aged care facilities visited in Japan were typically multistorey and located in densely populated urban areas. In such settings, there are few opportunities for residents to experience nature or engage in traditional community life. Empirical research in health geography and environmental psychology recognises the therapeutic and restorative value of regular experiences of nature [22], while engagement in traditional cultural practice has been shown to support quality of life among older cohorts [23]. In Japanese aged care facilities, there is a focus on seasonality, which emphasises that the changing of the seasons should be experienced by residents irrespective of physical or cognitive limitations. Observed mechanisms for expressing seasonality included, (a) changing artwork regularly to reflect the seasons, (b) altering the menu to include traditional dishes that align with the climatic conditions, (c) creating flower arrangements and planting trees to indicate how the seasons are changing and (d) decorating the facility in observance of traditional festivals. During early spring 2016, it was common to see flower arrangements in which the central feature was a budding plum blossom (Umè) branch (Figure 1). The spirit cleansing festival of Setsubun that marks the arrival of spring in the old calendar was also celebrated at this time with decorative elements visible and residents supported to undertake practices (such as throwing beans from their doorway) to ward off bad luck for the year. Such activities help to mark the natural cycles and connect older residents with the outside world and their cultural heritage.

Conclusion

The challenge of providing high-quality aged care for an increasing number of older Japanese has seen a range of practices and policies implemented that aim to optimise quality and length of life. In all parts of the world, providing quality of life in aged care is recognised as vital to ensuring dignity and enjoyment in the final years; however, Japan s approach embeds possibilities for optimal health and inclusion in traditional cultural practices that other societies may consider. A nationally representative study of Japanese aged care and comparison with similarly developed countries is indicated to affirm the outcomes of different approaches to care. Future research should also consider differences between the varied typologies of aged care in Japan and internationally to facilitate domestic and cross-cultural comparisons.

Key points

• Japan leads the world in population ageing. 

• Aged care focuses on nutritional support through scientific and mandated dietary controls. 

• Lifestyle rehabilitation assumes that health related quality of life can be optimised in aged care settings. 

• The Japanese government mandates strict staff to resident ratios to ensure quality of care. 

• Expressions of seasonality and immersion in cultural practices are valued in Japanese aged care.

References

1. Muramatsu N, Akiyama H. Japan: super-aging society preparing for the future. Gerontologist 2011; 51: 425 32. 

2. Horlacher DE, MacKellar L. Population ageing in Japan: policy lessons for South-East Asia. Asia Pacific Dev J 2003; 10: 97 122. 

3. Feng Z, Zhan H, Feng X et al. An industry in the making: the emergence of institutional elder care in urban China. J Am Geriatr Soc 2011; 59: 738 44. 

4. Hayashi M. The care of older people in Japan: myths and realities of family care . History Policy 2011; 3: 1 7. 

5. Ribbe MW, Ljunggren G, Steel K et al. Nursing homes in 10 nations: a comparison between countries and settings. Age Aging 1997; 26: 3 12.

6. Naomi A et al. Institutional care versus home care for the elderly in a rural area: cost comparison in rural Japan. Rural Remote Health 2012; 12: 1817 1817. 

7. World Bank. Global age dependency ratios. 2016 [cited 2016 8 June]; Available from: http://data.worldbank.org/ indicator/SP.POP.DPND.OL/countries/

8. Creswell JW. Research Design: Qualitative, Quantitative, and Mixed Methods Approaches. Thousand Oaks, California: Sage Publications, 2013. 

9. Ministry of Health Labour and Welfare (Koseirodousho) Nutrition Management System Caculation (Eiyokanritaiseikasan oyobi eiyou manejimento kasan nitsuite). Tokyo, Japan: Japanese Government, 2008.

10. Nieuwenhuizen WF, Weenen H, Rigby P et al. Older adults and patients in need of nutritional support: review of current treatment options and factors influencing nutritional intake.Clin Nutr 2010; 29: 160 9.

11. Suominen M, Muurinen S, Routasalo P et al. Malnutrition and associated factors among aged residents in all nursing homes in Helsinki. Eur J Clin Nutr 2005; 59: 578 83.

12. Zhou BF, Stamler J, Dennis B et al. Nutrient intakes of middle-aged men and women in China, Japan, United Kingdom, and United States in the late 1990s: the INTERMAP study. J Hum Hypertens 2003; 17: 623 30.

13. Morland K, Wing S, Roux AD. The contextual effect of the local food environment on residents diets: the atherosclerosis risk in communities study. Am J Public Health 2002; 92: 1761 8.

14. Morland K, Wing S, Roux AD. The contextual effect of the local food environment on residents diets: the atherosclerosis risk in communities study. Am J Public Health 2002; 92: 1761 8.

15. Australian Institute of Health and Welfare. Residential Aged Care in Australia 2010 11: A Statistical Overview. Canberra, Australia: Australian Government, 2012.

16. Ministry of Health Labour and Welfare (Koseirodousho) Report of Survey on Aged Care Service Facilities (Kaigo sabisu shisetsu jigyosho chosa). Tokyo, Japan: Japanese Government, 2010.

17. Ministry of Health Labour and Welfare (Koseirodousho) Report of Survey on Aged Care Service Facilities (Kaigo sabisu shisetsu jigyosho chosa). Tokyo, Japan: Japanese Government, 2010.

18. Ministry of Health Labour and Welfare (Koseirodousho) Report of Survey on Aged Care Service Facilities (Kaigo sabisu shisetsu jigyosho chosa). Tokyo, Japan: Japanese Government, 2010.

19. Sandoval Garrido FA, Tamiya N, Kashiwagi M et al. Relationship between structural characteristics and outcome quality indicators at health care facilities for the elderly requiring long-term care in Japan from a nationwide survey. Geriatr Gerontol Int 2014; 14: 301 8.

20. Rantz MJ, Hicks L, Grando V et al. Nursing home quality, cost, staffing, and staff mix. Gerontologist 2004; 44: 24 38.

21. The Australian Government, The Aged Care Act. 1997.

22. Detweiler MB, Sharma T, Detweiler JG et al. What is the evidence to support the use of therapeutic gardens for the elderly? Psychiatry Investig 2012; 9: 100 10.

23. Nagaya Y, Dawson A. Community-based care of the elderly in rural Japan: a review of nurse-led interventions and experiences. J Community Health 2014; 39: 1020 8.

Received 24 March 2016; accepted in revised form 4 July201