Objective: The aim of the present study was to clarify the signs and symptoms of impending death in end-of-life senile dementia from the point of view of formal caregivers in rural areas.
Patient/Materials and Methods: We used qualitative data based on retrospective analyses. The data was gathered following a workshop on end-of-life care of the elderly with dementia attended by formal caregivers that was held in Iga City, Mie Prefecture, Japan, in September 2011. There was a total of 29 workshop participants. The workshop products were created in the first session of the workshop entitled “Signs of death.” During the session, we used the brainstorming method, and participants took turns stating at least two signs, symptoms or premonitions of death. In the end, there were 93 cards in total displaying signs of impending death observed in the end stage of dementia. These 93 entries were then classified into clear categories.
Results: The categories defined were breathing disorder, consciousness decline, vital power decline, reduced oral intake, feces disorder, calm and peaceful character, blood pressure decline, change in skin color, patient odor, edema, preagonal vital power, body temperature decline, bedsore/wound deterioration, body weight reduction, cyanosis, and oliguria. The most frequently cited symptoms fell in the breathing disorder category (12 cards), followed by consciousness decline (9 cards), vital power decline (9 cards), reduced oral intake (6 cards), and feces disorder (6 cards). Also frequently mentioned were symptoms falling in the calm and peaceful character, patient odor and preagonal vital power categories.
Conclusion: The results show that formal caregivers in rural areas identified breathing disorder as a top indicator of impending death in end-of-life senile dementia cases. The results also highlight some other characteristic signs of impending death, such as preagonal vital power and calm and peaceful character. This research could help develop formal caregivers’ observational skills in the end-of-life care settings.

Objective: Japan introduced a new metabolic syndrome (MetS) screening and intervention program. However, the specific benefits of the program have not yet been identified. The aim of our study was to highlight the role of the program in reducing risks related to MetS in a Japanese rural area.
Methods: We used data from a prospective observational cohort study of all users who underwent an annual health checkup at a public clinic in a rural area. The subjects of the present study were all users aged 40-74 years who participated in the MetS program between January and September 2010. We ultimately analyzed a total of 413 subjects followed up 12 months after enrolment. The subjects were divided into two groups based on the need for educational support: support and non-support. In each group, we compared the subjects’ MetS conditions at baseline and 12 months later.
Results: Thus, 88 subjects out of 413 were assigned to the support group. Among the support group subjects, there were no significant changes in glycemic metabolism, lipid metabolism, blood pressure and accumulation of visceral fat between the baseline and follow-up checkups. Among the non-support group subjects, there were no significant changes in glycemic metabolism, lipid metabolism and blood pressure between the baseline and follow-up checkups, but there were significant changes for the worse in accumulation of visceral fat with time.
Conclusion: Unfortunately, the metabolic conditions of the rural subjects who participated in a new MetS screening and intervention program did not improve with time. Our findings underscore the importance of developing educational intervention programs to encourage the general population to modify their lifestyle and acquire healthier habits.

We conducted a survey of syllabuses of Japanese medical and nursing schools to develop a comprehensive educational program to teach undergraduates of Japanese medical and nursing schools about end-of-life care for the elderly.In addition to the program we developed with the present survey, teaching about ageism and the definition of the end of life of the elderly is necessary.The present survey suggested the importance of teaching about the quality of life of the elderly, including the items of comprehensive geriatric assessment.

1) We performed a pilot study using surveys before and after the completion of an education program we developed. The subjects of this study were the staff of a geriatric health services facility in Nagoya City.2) Although the degree of confidence in providing end-of-life care and attitudes towards death did not change significantly, the attitudes of staff towards providing end-of-life care did change significantly.3) This pilot study demonstrates that an educational program on end-of-life care at long-term care facilities can improve the attitudes of staff toward end-of-life care. This study constitutes an important step toward improving education in end-of-life care for the staff long-term care facilities.

Objective: Multiple studies worldwide have supported the predictive validity of self-rated health (SRH) with regard to disability and mortality among elderly people. Although SRH is an important study topic providing clues to enhance a person’s quality of life, there is currently insufficient data on age- and gender-specific differences among factors associated with SRH in Japan, particularly in rural areas. The present study examined the factors associated with SRH of a segment of Japan’s rural population by age- and gender-specific analysis.
Methods: We used data from a cohort study of all users who underwent an annual health checkup at a public clinic in a rural area. The study subjects were 155 male and 169 female users from June 2009 to August 2010 who agreed to participate in this study. We divided the study subjects into 4 categories as follows: men aged less than 65, women aged less than 65, men aged 65 and over, and women aged 65 and over. The subjects who responded positively to the SRH-related questions were defined as the high SRH group, and those who responded negatively were defined as the low SRH group. We then compared the data between the high and the low groups in each category.
Results: In all four categories, there were statistically significant differences in regular hospital or clinic attendance between the high and low SRH groups. In all four categories, there were no significant differences in eating or exercise habits between the two SRH groups.
Conclusion: Because regular hospital or clinic attendance by a subject is indicative of the presence of chronic health problems, it is natural for the subject’s perception of their own health to be negative. However, rural physicians should provide patients with emotional and psychological support to deal with any health-related concerns positively.

AIM: gradual shift, from hospitals to long-term care facilities, in where elderly people spend their last years is expected in Japan.Therefore, we performed a questionnaire survey to assess the opinions of directors of long-term care facilities about end-of-life care and director education.
METHODS: In December 2006, data were collected through mailed, anonymous, and self-administered questionnaires. The subjects of this study were managing directors of 214 long-term care facilities in Nagoya City. Our questionnaire survey focused on the directors' attitudes about the following end-of-life issues: 1) requirements for implementing progressive policies for end-of-life care, and 2) educational training for end-of-life care. For data analysis, we divided the facilities into three groups: geriatric hospitals, geriatric health services facilities, and nursing homes.
RESULTS: Directors of 82 facilities returned completed questionnaires (response rate, 38.3%). They regarded staff education concerning end-of-life care, outside medical support, private rooms for end-of-life care, and 24-hour availability of physicians or nurse as requirements for quality end-of-life care at long-term care facilities. Nursing-home directors felt more strongly about the need for 24-hour medical services for end-of-life care than did directors of other types of facilities.Also, most directors wanted to receive additional training about clients' decision-making processes, communi-cation skills, and legal issues related to end-of-life care.
CONCLUSIONS: Our results suggest that staff education concerning end-of-life care and 24-hour medical services are required for quality end-of-life care at long-term care facilities for the elderly.

  Teaching hospitals play an increasingly important role in clinical training, and improvement of the education system is required. To effectively utilize limited human and material resources for clinical education and to enhance clinical education and medicine treatment throughout a region, cooperation between hospitals is essential. However, cooperation for clinical education training beyond prefectures or training hospitals cannot be said to be sufficient. The Kisogawa Medical Conference, a collaborative system of 5 training hospitals located around the Kiso River estuary, held medical lectures, hands–on seminars, and joint–hospital case conferences. Cooperation in medical education training and exchanges beyond prefectures and training hospitals is expected to lead to substantial improvements, not only in medical education training, but also in medical care throughout a region.

  To respond to the physician shortage, the capacity of medical schools has been increased through selective admission of student to practice in medically underserved areas; however, neither a system nor a curriculum for such students has been established. At Nagoya University, selected students have been admitted, and the division of Education for Community–Oriented Medicine was established in fiscal year 2009. We have introduced special curricula for these students, such as a seminar for community–oriented medicine, training for medical research, local hospital tours, and a special interprofessional education course. In fiscal year 2013, community medicine is expected to be implemented as a compulsory subject in the 4th year curriculum. For the education of students selected to practice in medically underserved areas, we believe that older students serving as role models and cooperation with other organizations and community are important.

　In the coming ″Super-aging society″ , collaboration between medical professionals and health workers in home-care will be critical. Thus, undergraduate interprofessional education is important for the improvement of a collaborative attitude. We ran a 2-day IPE program for a medical and a rehabilitation student focused on collaboration for patients who have chronic diseases and problems in Activities of Daily Life (ADL) . As a result, one showed marked improvement in ADL while the other did not. Students learned not only roles and perceptions of other professionals but also a sense of worth and an appreciation of the difficulty of patient-centered home-care.