社会医学研究．第 30 巻 1 号．Bulletin of Social Medicine, Vol.30（1）2012

原著

Factors associated with the survival of community-dwelling elderly
people whose demented status is overlooked: six-year follow-up in an
urban city in Japan
都市在宅高齢者における認知症見逃し群の生存関連要因
6 年間の追跡調査より
Chisako Yamamoto1）, Tanji Hoshi2）
山本 千紗子 1），星 旦二 2）
1）Faculty of Nursing, Chukyogakuin University2）Department of Urban Environment, Tokyo Metropolitan University

1）中京学院大学

看護学部

2）首都大学東京

都市環境学部

Abstract
The purpose of this study was to search for factors associated with the six-year survival of elderly people
in an urban city in Japan whose demented status was overlooked. From the September 2001 baseline data of
the complete survey of community-dwelling elderly people aged 65 years and older (the elderly), the number ofanalysis subjects was 13,058, and 12,147 survivors were followed up for 6 years. We used the Tokyo Metropolitan
Institute of Gerontology (TMIG) Index of Competence to measure the functional capacity of elderly people basedon five activities of daily living that included instrumental and intellectual activities: making bank deposits and/or
withdrawals, filling out forms/documents such as pensions forms, reading books/newspapers, shopping, and foodpreparation.
Among these five activities, we defined the first three, which involve language and cognition, as intellectual
activities and used them to derive cognitive scores. We divided the elderly into the family-recognized demented(FRD) and the non-demented (ND), and we further divided the latter into higher and lower scoring-cohorts (NDHSC and ND-LSC). Our previous study1) showed that people in the ND-LSC were equivalent to those whose
demented status is overlooked. We performed Cox proportional hazards regression analysis (Cox regression
analysis) to calculate hazard ratios (HRs) for death (or risk of death) in the ND-LSC. The results showed genderdifferences in the factors associated with six-year survival: in men, these were inabilities in making bankdeposits/withdrawals, reading books/newspapers, shopping and food preparation, and in women, these were
shopping and food preparation only. The results suggested that the declining status of these activities could be
useful guides for family caregivers in early detection of demented status and prognosis for survival, and thatthey could provide significant information for family-support programs.  
抄録
2001 年 9 月実施の 65 歳以上都市在宅高齢者調査の分析対象者 13,058 人のうち、6 年間の生存状況を追跡できた
12,147 人について、老研式活動能力指標を活用し、日常生活の手段的自立と知的能動性を含む 5 活動「預貯金出入・― 59 ―

社会医学研究．第 30 巻 1 号．Bulletin of Social Medicine, Vol.30（1）2012

年金等書類記入・新聞書物を読む・買い物・食事の用意」を中心に、ベースラインの 3 年後および 6 年後の追跡調査結果から、生存関連要因を探索した。文字を用いる必要のある「預貯金出入・年金等書類記入・新聞書物を読む」
を知的 3 活動として得点化し、家族が同居高齢者を認知症と認識している群（家族認識認知症群）以外の、いわゆる健常と見なされている群（非認知症群）を、知的活動高得点群と低得点群に分けた。非認知症群の知的活動低得
点群は、認知症を見逃されている群に等しいことが、先行研究で明らかにされている 1）。非認知症・低得点群について、Cox 回帰分析にて死亡ハザード比 (HR) を求めた。結果は、非認知症・低得点群に共通の生存関連要因には性差が見られた。男性特有の要因は「預貯金の出入ができない・新聞書物を読まない・買い物ができない・食事の用意ができない」であったが、女性では「買い物ができない・食事の用意ができない」のみであった。性差が見られるこれらの活動能力の低下状態は、認知症の早期発見と生存予後に関する家族用指標となり、地域家族支援プロ
グラムの有用な情報となりうることが示された。
Key words：Japanese elderly in an urban city, lower scoring-cohort in the non-demented, factors associatedwith six-year survival, gender differences, guide for family caregivers in early detection ofdemented status and prognosis for survival.
キーワード：都市在宅高齢者、知的活動低得点群、6 年生存関連要因、性差、家族用認知症・生存予後判断指標
Ⅰ．INTRODUCTION

were taken by local governments, synchronizing withAccording to the census of October 1, 2010, thenational government policies. For example, Tama

total population of Japan was 128.06 million2), and theCity, Tokyo, has been sending lecturers even toaging rate of 23.1％ was estimated to rise to 40.5％

small groups of five participants or more7）. Wards inby 2055. Thus, the size of the elderly population

Yokohama City have been offering lectures such asin Japan as a whole is expected to increase. The

How to Prevent Dementia, Understanding Dementia

population aged 75 years and older (late elderly) is

and Assisting the Elderly with Dementia, Key to

expected to exceed the population of the elderly

Slowing Brain-aging 8）. They attained the goal ofpeople between 65 and 74 years (early elderly) in

one million dementia supporters in late May 20099）.

2017 and will continue to increase thereafter3）. Since

They projected to increase this number to 4 million

age is a risk factor for dementia, the prevalenceby 2014 10）. Under an Urgent Project to Improveof dementia will increase among the late elderly4）.

Quality of Life and Medical Service for People with

Based on the 2002 data of the primary insured

Dementia, they have been promoting dementia

elderly who were approved for long-term care, theeducation in primary and secondary schools to

Ministry of Health, Labour and Welfare estimatedincrease understanding and supportive action for

the number of people with dementia to be 1.49

people with dementia and their family caregivers10）.

million in 2002, 2.5 million in 2015, 3.23 million in 2025,

Knowledge and findings on dementia based on

and 3.76 million in 2035, with a peak at 3.85 million invertical and longitudinal studies are significant in

2040 and then a decrease to 3.78 million in 20455）.

dementia education programs. It is essential forWith a rapidly increasing aging rate, valuing

analytical studies to focus on gender differences to“creation of a society where people continue living  

provide useful knowledge, since statistical figures

comfortably even after suffering from dementia”,

differ by gender, the best example of which is

the Japanese government implemented a program

average life expectancy. A previous study showed

entitled Nationwide Caravan to Train One Million

a great gender difference in the prognosis of elderly

as part of the Ten-people with dementia11）. Since female gender is aYear Strategy to Provide People Knowledge on

risk factor of dementia12）, the prevalence of dementia

Dementia and to Create a Healthy Community. A

in elderly women aged 85 years and older isnumber of preventive measures against dementia

approximately twice as high as that in elderly men,

Dementia Supporters in 2005

6）

― 60 ―

社会医学研究．第 30 巻 1 号．Bulletin of Social Medicine, Vol.30（1）2012

both in Japan (11.3％ in men and 22.9％ in women4）)

Ⅱ．METHODS
1．Baseline and follow-up surveys

and in the United States (12.1％ in men and 20.3％ in
13）Baseline data were derived from the Complete

women ).
In a three-year follow-up from the 2001 baseline,

Survey of the Community-dwelling Elderly of 65

Yamamoto 14） clarified that the hazard ratio (HR)Years and Older compiled in September 2001 in City

for death in the family-recognized demented (FRD),

A in the Metropolis. Self-administered questionnaires

as a whole, among the community-dwelling elderly

were mailed to all elderly subjects. Responses werewas 1.401 (p=0.016, 95％ confidential interval [CI]returned by mail by the addressees themselves or by=1.066-1.858). When analyzed by gender, it was

proxies when the addressees were unable to respondsignificant only in men, whose HR for death was 2.051

for reasons such as absence, hospitalization, cognitive(p=0.004, 95％ CI=1.251-3.364) and in women was

impairment or demented status. Questionnaires

1.092 (p=0.617, 95％ CI=0.774-1.540). Yamamoto andconsisted of 44 items, including fundamental

15）

Hoshi

showed that family caregivers observed theattributes, respondents (addressee himself or herself,elderly to be demented when they perceived theiror proxy), family members, self-perceived health,inability to make bank deposits and/or withdrawals,

activities of daily living, instrumental activities,

to fill out forms/documents such as pensions forms

socio-economic status, long-term care insurance,

and to read books/newspapers. The results wereand others. This study was not based on definite

common both in men and women and also in the two

diagnoses but on respondent data compiled in 2001.

sets of data taken in an urban city (data collection in

The respondents in the 2001 survey were followed

2001, 13,067 analysis subjects) and in ten rural towns

up for six years and their survival was investigatedand villages from Northern Hokkaido to Southernin September 2004 and October 2007. During the six-

Kyushu (data collection from 1998 to 1999, 12,757

year follow-up period, 915 people moved to otheranalysis subjects). Inability in food preparation was

cities and 1,899 died. In both 2004 and 2007, total ofcharacteristic in women and common in the two

12,147 individuals (5,665 men and 6,482 women) weresets of data. It was also clarified that among thefollowed up.  

non-demented (ND) elderly, which were defined as

2．Study populationelderly people who were not FRD, there were people

1）Subjects

whose demented status was overlooked: 6.3％ in men

Questionnaires were mailed to all elderly people1）

and 9.3％ in women , and their cognitive scores wereaged 65 years and older living with a spouse and/or

low. These findings showed that detailed studies

child’s family (n=16,462), and 13,195 people responded

on dementia should be done, focusing not only on

by mail (response rate 80.2％). After inappropriate

the known demented status of the elderly but also

responses were excluded, the number of analysis

on the levels of intellectual activities in the ND.

subjects was 13,058 (6,010 men and 7,048 women),

Knowledge and information based on findings would

among which 11,529 addressees (5,450 men andbe significant when the elderly themselves and their

6,079 women) responded for themselves, and 1,529

family caregivers could apply it to practical use forresponses were by proxies (560 men and 969 women,

early detection of demented status in everyday life.

who were all family members) (see Table 1). We

The purpose of this study was to search for

defined those whose family caregivers responded asfactors associated with the six-year survival of urban

proxies due to the addressee’s demented status orcommunity-dwelling elderly people whose demented

cognitive impairment as the FRD, and the others as

status is overlooked, from among five activities of

the ND. The number of FRD was 239 (67 men anddaily living including instrumental and intellectual

172 women), and their average age (and standard

activities.

deviation [SD]) was 80.6 ± 9.2 years in men and 84.7

     ± 7.7 years in women. The number of ND was 12,819― 61 ―

社会医学研究．第 30 巻 1 号．Bulletin of Social Medicine, Vol.30（1）2012(5,943 men and 6,876 women) and their average age

was probably because approximately 60％ of the(and SD) was 72.0 ± 6.1 years and 73.1 ± 6.7 years in

population lived in the so-called New Town, in which

men and women, respectively (see Table 2).

the population aged 45 to 54 years occupied the2）Outlines of the study fieldlargest proportion16）. The aging rate rose to 19.2％

The study field, City A, is located in the suburbs

as of January 2, 2009; however, it was still lowerof metropolitan Tokyo. According to the 2005 census,

than the national average of 22.8％ in 2009. City A is

which reflects the background of this study frompossibly a younger city in Tokyo metropolitan areas.

2001 to 2007, it had a population of 146,587, and3．Analytical methods

consisted of 62.9 thousand households, among which

To search for factors associated with survival, we

59.5％ was nuclear families which include households

used the Tokyo Metropolitan Institute of Gerontology

of a couple only, households of a couple with their(TMIG) Index of Competence. Having partly modified

child(ren) and households of one parent with his orit, we applied five activities of daily living, including

her child(ren), 35.7％ was one-person households

instrumental and intellectual activities. We measured

and 4.8％ other households. The largest proportion,functional capacity by activities including making

80.0％, worked in tertiary industry, the service

bank deposits and/or withdrawals, filling out forms/

industry, in which 58.4％ worked in information

documents such as pensions forms, reading books/

technology, medicine, care and welfare service,newspapers, shopping, and food preparation, andeducation including supplementary private schools,

cognitive scores by the first three activities, whichgovernment and local offices, and other professions

require language and cognition. We allocated onethat were difficult to classify.

point to a positive answer. Scores ranged from 0

The aging rate in 2005 was 15.8％, which was

to 3 points. In association of the status of the FRD

lower than the national average of 20.2％. Thisand cognitive scores, we calculated areas under the

Table 1. Respondents at Baseline

Table 2. Family-recognized Demented(FRD) and the others (the Non-demented (ND)) at Baseline― 62 ―

社会医学研究．第 30 巻 1 号．Bulletin of Social Medicine, Vol.30（1）2012

receiver operator characteristic curves (AUC) andIn men HRs from highest to lowest in three-year

determined the highest AUC, i.e., the cut-off point

survival were inabilities in shopping (HR=2.368,

of 0-1/2-3. We defined the 0-1 scoring cohort as the

p＜0.001, 95％ CI=1.650-3.399), reading books/

lower-scoring cohort (LSC) and the 2-3 scoring cohort

newspapers (HR=1.894, p＜0.001, 95％ CI=1.334-2.688),

as the higher-scoring cohort (HSC). We further

making bank deposits/withdrawals (HR=1.636,

divided the ND into an LSC (ND-LSC) and an HSC

p=0.014, 95％ CI=1.106-2.419) and food preparation(ND-HSC).  

(HR=1.433, p=0.011, 95％ CI=1.085-1.892); thoseTo explore the relationship between survival andin six-year survival were inabilities in shopping

the five capacities as independent variables, we used

(HR=1.936, p＜0.001, 95％ CI=1.481-2.531), readinga Cox proportional hazards model (Cox regression)

books/newspapers (HR=1.510, p=0.003, 95％

to calculate hazard ratios (HRs) for death (or risk of

CI=1.151-1.982), food preparation (HR=1.460, p＜0.001,

death) by gender three and six years after baseline.

95％ CI=1.209-1.763) and making bank deposits/

Adjustment factors were age, ND-LSC and FRD. The

withdrawals (HR=1.358, p=0.044, 95％ CI=1.008-1.829).

stepwise method was applied to the five capacities.      In women, HRs from highest to lowest in three-year

4．Ethical procedures

survival were inabilities in shopping (HR=2.426, p

The University made an agreement with City A to

＜0.001, 95％ CI=1.576-3.735) and food preparation

protect personal data. The University Committee on(HR=1.889, p=0.003, 95％ CI=1.240-2.879); those in six-

Ethical Issues approved the surveys and the study.

year survival were inabilities in shopping (HR=1.910,

Individuals were all numbered without names, and

p＜0.001, 95％ CI=1.413-2.581), making bank deposits/

an alternative“I don’t want to answer.”option waswithdrawals (HR=1.507, p=0.027, 95％ CI=1.049-2.165)

provided, so that we assumed all respondents toand food preparation (HR=1.383, p=0.058, 95％

have consented to the surveys.

CI=0.989-1.943).
The characteristic factors in men were inabilities

Ⅲ．RESULTS

in making bank deposits/withdrawals and reading

Table 3 shows HRs for death in the ND-LSC, i.e.,books/newspapers both in three- and six-year

those whose demented status is overlooked. The ND-

survival, and those in women were inabilities in

LSC itself was not significant in men or women formaking bank deposits/withdrawals and filling out

three- and six-year survival.

forms/documents such as pensions forms in six-

Table 3. Result of Cox Regression (1):
Lower-scoring cohort in ND (ND-LSC) as an adjustment factor (FRD excluded)― 63 ―

社会医学研究．第 30 巻 1 号．Bulletin of Social Medicine, Vol.30（1）2012

year survival. The common factors both in men and

Ⅳ．DISCUSSION
1．Factors associated with survival in the elderly

women and both in three- and six-year survival werewhose demented status is overlooked (ND-

inabilities in shopping and food preparation.      LSC)For further study, we also performed Cox
regression analysis, in which the FRD were input

1）Characteristic factors in men

as an adjustment factor and the ND-LSC wereThis study showed that inabilities in reading

excluded. Table 4 shows HRs for death in the FRD.

books/newspapers and making bank deposits/

The HR in FRD men and the three-year survival

withdrawals were characteristic factors in men.

was 0.566 (p=0.049, 95％ CI=0.321-0.999). The HR

Yamamoto and Hoshi clarified that family caregivers

in FRD women and the six-year survival was 1.390

regarded the elderly as demented when they(p=0.050, 95％ CI=1.000-1.931). An opposite tendency

perceived inabilities in making bank deposits/of risk of death was shown. A common factor bothwithdrawals and reading books/newspapers, andin men and women and both in three- and six-yearthat the results were the same in rural and urban

survival was inability in shopping. HRs for three-yearareas and in men and women15）. We analyzed thesurvival were 2.680 (p＜0.001, 95％ CI=1.769-4.060)

urban data only in this study, since there were noin men and 2.080 (p=0.004, 95％ CI=1.256-3.446) infollow-up rural data. As described in Outlines of thewomen; those for six-year survival were 2.035 (pstudy field, 80.0％ worked in the tertiary industry,＜0.001, 95％ CI=1.484-2.790) in men and 2.464 (p＜in which 58.4％ worked in information technology,

0.001, 95％ CI=1.862-3.261) in women. HRs for death

medicine, care and welfare service, education,for inability in shopping were more than twice as

government and local offices; most of community-

high both in men and women and also both in three-dwelling elderly people over 65 years retired fromand six-year survival. In the case of inability in foodsuch occupations. Lack of active cognitive activities

preparation, the HR in women for three-year survival

after retirement might possibly accelerate the onset

was 2.070 (p=0.008, 95％ CI=1.214-3.528) and that inof dementia and advance the demented status,

men for six-year survival was 1.399 (p=0.001, 95％

thus worsening survival. This needs further study;

CI=1.150-1.702).   

however, declining capacities of the two activities inmen can possibly be a survival and prognosis guidefor family caregivers to use, since family caregivers
can easily observe them in daily life.  

Table 4. Result of Cox Regression (2):
Family-recognized demented (FRD) as an adjustment factor (ND-LSC excluded)― 64 ―

社会医学研究．第 30 巻 1 号．Bulletin of Social Medicine, Vol.30（1）2012

2）Common factors in men and womenrisk of progression of their demented status. Early

The common factors in men and women were,detection, diagnosis and treatment of dementia are

first, inability in shopping, and, second, inability inessential, not only to enhance and maintain thefood preparation in three- and six-year survival in

quality of life (QOL) of the elderly in late life, but also

ND-LSC men and women. Family caregivers canto decrease the burden of long-term care of family

easily perceive such declines in capacity in everyday

caregivers and increase their QOL. Knowledge that

life, especially in elderly women aged 65 years anddecline of executive functions is a sign of dementia

older whose major role in the households seemed

and associated with survival should be prevalent

to be housekeeping. Capacities of shopping and foodamong family caregivers.

preparation can also be a guide for family caregivers

2．A common factor both in those whose

to use. Thus, there were four gender characteristic

demented status is overlooked (ND-LSC) andin men and two in women.

the family-recognized demented (FRD)

3）Progression of overlooked dementia suggested    In spite of gender differences, follow-up years andShopping and food preparation require executive

two-way Cox regressions analyses, it was inability

functions. They describe a set of cognitive abilities

in shopping that was common in all cases, with anthat are largely carried out by prefrontal areas ofincreased HR for death ranging from 1.813 to 2.680.

the frontal lobe, whose impairment is related to

In other words, the elderly who had become unable

demented status. The components of executive

to shop by themselves had higher risk of death. A

functions are setting a goal, planning, initiating aprevious study clarified that the ND-LSC elderlyplan, and achieving a goal effectively. According togroup was equivalent to those whose demented

the DSM-IV (Diagnostic and Statistical Manual ofstatus was overlooked 1） and this study further

Mental Disorders, the 4th Edition) which provides

showed that the ND-LSC had the same factor and astandards to diagnose Alzheimer’s disease, a patient

rather high HR in inability in shopping as the FRD.

should be diagnosed as demented when he or she

This also suggests that the ND-LSC elderly group

has a memory disorder and impairment of at least

was equivalent to those whose demented status was17）

one executive function . It is said that there is nooverlooked.    

definite standard of diagnosis and that the patient

3．Advanced age of the FRD presumed

should be diagnosed as cognitively impaired while

Mortality statistics in Japan do not include

the patient’s executive functions are obviously moredementia and Alzheimer’s disease, but in US

18）

mortality statistics, Alzheimer’s disease was thedeclined than before .

The result that inabilities in shopping and food

14th leading cause of death among fifteen major

preparation in the ND-LSC increased the HR for

diseases in 1995, and it was the 8th leading cause ofdeath suggested that the ND-LSC was equivalent todeath in elderly people 65 years and older19）. It rose

the cohort whose demented status was overlooked,

to the 8th leading cause of death in 2002 and to theas previously reported by Yamamoto and Hoshi1）.

6th leading cause of death in 200720）. While death by

It is also estimated that the overlooked demented

cerebral stroke and cardiovascular disease decreased

status was already advanced, since impairment inby 20％ and 13％, respectively, Alzheimer’s disease

executive functions is hard to observe in the early

increased by 66％13）. Since elderly people affected bystage of dementia18）.   Regarding declining capacities

severe Alzheimer’s disease have a greater risk ofin shopping and food preparation in the elderly as

pneumonia due to malnutrition and dysphagia, their

symptoms of aging, family caregivers neither thinkcause of death is often classified as pneumonia13）. In

of dementia nor consult a specialist. They overlook

this sense, Alzheimer’s disease as a cause of deathand neglect the demented status of the elderly.

might be higher. Many previous studies reported

Thus, especially the ND-LSC elderly have a greaterthat the average survival after onset of dementia was― 65 ―

社会医学研究．第 30 巻 1 号．Bulletin of Social Medicine, Vol.30（1）2012

approximately five years. Larson et al.21） followed

for prevention and education programs on dementia.    

23,000 elderly persons 60 years of age and older

We must offer family caregivers useful knowledge

and reported that 521 persons were diagnosed withbased on the findings of our studies. Although it isAlzheimer’s disease and that the average survival

necessary that the elderly themselves are sensitive

was 4.2 years in men and 4.6 years in women (4.5

to their own decline in such executive functions

22）

followed 13,004 elderly

and consult a specialist early, it is most essential

persons 65 years of age and older for 14 years, fromthat family caregivers can detect the elderly

1992 to 2005, and reported that of 438 demented

demented status at the earliest stage possible.

persons, 356 died , and the average survival after

Family caregivers can easily perceive inabilities indeveloping disease was 4.1 years in men and 4.6

the daily capacities described above in everyday life.

years in women (4.5 years in total). Sugai reported

As a previous study reported, their perception andthat the average survival of people with Alzheimer’s

judgment of the demented status is appropriate24）.

dementia was 6.1 years and that in people with

In addition, they need neither special training nor

years in total). Xie et al.

vascular dementia was 5.5 years, and that dementia

expenses in detection of demented status. Findings

was a factor that increased the HR for death23）.  

of this study can be guides for early detection of

As a reference, we also performed Cox regression

demented status for family caregivers. Offering them

analysis to clarify the common factor in every case.

findings as further information could be a part of a

The HR for death in the FRD was increased only

useful and significant family-support program.

in the case of the ND-LSC excluded and in womenfor six-year survival. In men, for three-year survival

Ⅴ．CONCLUDING REMARKS

it was reduced by 44％. The reason is presumed

Among five activities of daily living, including

to be the advanced age of the analysis subjects. A

instrumental and intellectual activities, the common

previous study

1）reported that the average age atfactor increasing the HR for death for three- anddeath in the ND-HSC was 80.0 years in men and 83.1

six-year survival in ND-LSC was, first, inability inyears in women in 2007, a follow-up year. Since the

shopping for both men and women and, second,

nationwide average age in 2007 was 79.19 years ininability in food preparation. Gender characteristic

men and 85.99 years in women, ND-LSC men lived

factors in men were inability in reading books/

0.8 years longer and women’s lives were 2.9 years

newspapers and making bank deposits/withdrawals.

shorter. The average age of the FRD was 85.6 years

Since knowing the prognoses of dementia is

in men and 90.1 years in women, which was 5.6 years

essential for planning long-term care programs

in men and 7.0 years in women, longer than that in

and implementation of treatment 25）, these findings

the ND-HSC.      should be applied as guides for early detection of

4．Findings as guides for early detection ofdemented statusdemented status for family caregivers to use. Oncethey observe declining capacities in some activities

As it is well known that there are gender

mentioned above, family members must seriously

differences in dementia statistics, we further

accept these declines and promptly and properly

analyzed our data and showed that there were also

take action in treating them.     gender differences in capacities in daily activities

Our results showed that the status of FRD men

associated with prognoses. We also showed that

did not increase the HR for death. One of the reasons

the HRs for death differed greatly, even in the ND,

would be, as described in the above discussion, that

depending on the decline in intellectual activities. We

the average age at death for ND-HSC was younger

must perform studies on dementia focusing not only

than that for FRD; however, it is our future researchon gender differences but also on levels of intellectual

topic to clarify the reason for this in association withactivities. This would provide significant suggestions

causes of death, rank of long-term care insurance,― 66 ―

社会医学研究．第 30 巻 1 号．Bulletin of Social Medicine, Vol.30（1）2012(accessed on May 2, 2010).

annual income, educational background, lifestyle, and

9）Homepage of Nationwide Caravan to Trainother factors to support the findings of this study.

One Million Dementia Supporters: http://www.
Referencescaravanmate.com/news01.html (accessed on

1）Yamamoto C, Hoshi T: Proportion of overlooked

October 10, 2010)

dementia in the community-dwelling elderly: the10）Ministry of Health, Labour and Welfare: An

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