Advocating for Older Adults with Dementia in Acute Care Hospitals
Japan Academy of Gerontological Nursing 2016 Position Paper (Short version)
Today, due to increased life expectancy, dementia is becoming a part of life that everyone, including one’s own parents,
grandparents, or even oneself, is likely to experience. For the people of Japan, dementia is no longer simply a difficulty faced by“other people.”
Older adults with dementia admitted to acute care hospitals are confused and become easily agitated in these unfamiliar
environments. Family members providing support during this period also experience difficulty when dealing with the exigencies of
hospitalization. In this context, nurses in acute care hospitals are confronted with difficult issues when caring for older adults withdementia. One such problem is that current training methods are often unable to dispel the stigma associated with dementia
among nurses, ultimately impacting the quality of care they provide. Another challenge is that despite the challenges faced bythese patients, including the hospital environment detached from the rhythms of daily life, and a nursing system that does notencourage the acquisition of practical knowledge to address the individuality of older adults with dementia, the required level ofcare should be the same as that provided in the context of long-term care facilities. Furthermore, because nurses have not acquired
the communication skills required to decipher the intentions of older adults with dementia, it is difficult for them to envision theirpatients’ lifestyle or life after recovery, hence the tendency to distance themselves from their patients and the patients’ families.
Moreover, underlying these challenges is the major premise of “medical treatment that prioritizes speed and efficiency.”
Family-related factors also exist in tandem with the abovementioned medical care-related factors. Specifically, older patients withdementia may experience unreasonable treatment yet family members under the pressure and responsibility of making life anddeath decisions on the patient’s behalf, may keep silent in the face of such treatment by those providing therapy or medical
treatment, because they feel that the recovery of their loved one is most important. Thus, these patients are placed in vulnerable
situations.
The major challenge is that this results in situations where patients in acute care hospitals are advocated for by neither theirfamilies nor those responsible for their medical treatment, and that older adults with dementia are often left in isolation.
The Japan Academy of Gerontological Nursing considers these factors as the most pressing challenge facing nurses caring for
older adults with dementia, and in providing practice guidelines for nurses and allied professionals in acute care hospitals, states
the following eight “positions” for facilitating collaboration between medical treatment and care teams, and for promoting nursing
practice that guarantees a sense of security and peace of mind for older adults with dementia receiving acute medical treatment aswell as for their family members.

Position 1 Eliminating negative attitudes and stigma toward older adults with dementia.
Position 2 Protecting older adults with dementia within an environment that prioritizes medical treatment.
Position 3 Promoting safe and early discharge fostered by sharing a lifestyle vision based on prospects ofpost-treatment recovery with patients’ families and caregivers.
Position 4 Presenting an overview of means that promote patient-centered medical treatment and carewhile taking into consideration the constraints faced by acute care hospitals:① Medical treatment and care that discourages the use of physical restraints② Medical treatment and care that identifies practices that worsen the confusion of elderly patientsand strain the patience of family members③ Medical treatment and care that has a lifestyle vision for older adults with dementia.
④ Medical treatment and care that promotes team-based personal care based on patients’ prognosis
and lifestyle.
⑤ Improving aspects of the medical treatment and care environment and customs that are ill-suited
to older adults with dementia.
Position 5 Understanding the endurance and burden faced by families of older adults with dementia.
Position 6 Updating our knowledge of dementia and dementia care regularly and consistently.
Position 7 Gathering and presenting evidence as a basis for formulating guidelines and revising medical
payments for medical care.
Position 8 Systematizing dementia nursing by concerted efforts to amass academic knowledge.
To realize these propositions, in addition to supporting and educating nurses, the Japan Academy of Gerontological Nursing also
will provide guidance to entire acute care hospitals through interdisciplinary collaboration and cooperation with families,
caregivers, and the public. We will also undertake regular reviews of this position paper to remain current with the situation inacute care hospitals and to respond to future changes in the medical system and requests from the public.

*This position paper can be accessed at the website of the Japan Academy of Gerontological Nursing
http://www.rounenkango.com/

Advocating for Older Adults with Dementia in Acute Care Hospitals
Japan Academy of Gerontological Nursing 2016 Position Paper
Purpose of Issuing a Position Paper

Members Involved in this Study

People have the right to receive the best acute medical treatment
according to their wishes. The Japan Academy of Gerontological Nursing
hereby states its position on acute care nursing for older adults withdementia, in light of the principles of dementia care and in upholding thisright, seeking to promote a nursing practice that guarantees a sense of
security and peace of mind for older adults with dementia as well as theirfamilies, and to facilitate collaboration with medical treatment teams, inaddition to providing practice guidelines for nurses and allied
professionals in acute care hospitals.

Fuki HORIUCHI, Harue MASAKI, Kimiko KITAGAWA, Yumiko MOMOSE,
Rituko YAMADA, Michiyo YUASA

Definition of Terms Used in the Position Paper◇Acute care hospitals: General or specialized hospitals that provide
medical treatment for initial stabilization of patients presenting withvarious symptoms for set periods or whose physical health is suddenlycompromised due to accident, illness, or injury.
◇Older adults with dementia: Elderly individuals who have some
capability and strength and attempt to live independently, despite age- or
illness-related cognitive decline causing difficulty in daily life, regardless ofwhether proper diagnosis of dementia has been made, and who maketheir intention known even when unable to express themselves well due
to communication disorders. Note that the term “older adult” does notrefer to a specific chronological age range. This is in line with the view of
the Japan Geriatrics Society as expressed in a position paper on end-of-life
medical treatment and care of elderly patients: “Given that mental andphysical changes that occur with age are highly individualized, it would beinappropriate to define the term according to age.”◇A sense of security and peace of mind for family members:A conditionin which the typical challenges associated with acute care are alleviatedthrough easy and efficient access to acute treatment for older adults withdementia in a way that preserves their dignity, and in which family
members, as the stakeholders who best understand these patients,
receive trust and consideration from medical providers, and are allowed
to participate in caregiving as much as they wish.
◇A sense of security and peace of mind for older adults with dementia:
A condition of being able to receive treatment and lead a tranquil life
without any slight to personal dignity, even in acute care hospitals.

Preparation Process
The following three-stage process was undertaken to prepare a draft position paper;
the final draft was arrived at after soliciting public comments from members of theBoard of Directors, employee representatives, and membership.
(1) Identifying the issues facing nursing practice for older adults with dementia inmedical treatment facilities(2) Clarifying the current state of nursing practice for older adults with dementia inmedical treatment facilities via the following:a. Interviews with nurses with experience in dementia nursing
b. Interview with the family members of older adults with dementia who haveexperienced hospitalization(3) Outlining the fundamental characteristics of nursing practice for older adults withdementia in acute care hospitals(3) Outlining the fundamental characteristics of nursing practice for older adults with dementia in acute care
R3 急性期病院における認知症高齢者の看護の本質は何か
hospitals
Family-related factors associated with patients being exposed and unprotected:
本人が擁護されない家族側の要因：
Tolerating unethicaltreatment based on the notion that a cure is most important,
治るのが一番と考える忍耐と命を委ねらand completely
relying on medical professionals
れる重圧の回避による医療への一任
so as to avoid theburden of being entrusted with life and death decisions.

ひどい扱いを受けることがあっても、治療や医療者の前に我慢や努力をしたり、拘束を容認するのは、人の命を委ねられる重圧から、家族は治るのが一番と考えてしまうからである。

Even if unacceptable treatment is provided to their loved one,family members persevere and choose to exercise restraint
in the face of this unethical treatment.
This is because under pressure of being entrusted with a person’s life,
family members think that “getting better is the most important thing.”

対をなして通底しWorking in conjunction with

しかし狭間で患者が孤立

However

Patients are isolated in the space between

看護師が患者・家族を遠ざけたい思いになる要因：
Factors associatedwith nurses’ desire to keep patients and their families at a distance:
Not having a lifestyle
情報共有に基づく患者の生活像と回復像の欠落
vision or positive recovery vision for their patients based on shared information.

認知症患者はナースを困らせる人として映り、結果的に患者・家族を遠ざけたい思いになるのは、ナースに患者の生活像や家族・他のナースからの情報が、事故・クレームの予防につながるという自覚がなく、治療後の回復像を家族と共有できないからである。

Nurses tend to view patients with dementia as “people who are a nuisance to themselves.”
Hence, they want to keep a distance between themselves and the patients and the patients’ family members.
This is because nurses are unaware of how having a vision of patients’ lifestyles or informationfrom family members or other nurses can help to prevent accidents or reduce complaints,
and so they cannot effectively discuss post-treatment recovery with the patients’ family members.

しかしHowever
ながら認知症という病の実相：
The realityof dementia as a disease:
看護師自身も含め誰もがたどるAn
age-related disease that can affect anyone,
可能性のある老いの道のり
includingthe nurses themselves.

相俟ってIn combination with

しかし
Howeverながら相俟ってIn combination with

認知症を患う老いの過程
は、看護師にとって他人事では終わらず、自分の親や祖父
母、いずれは自らもたどる道にもなりうるものである。

For many nurses, dementia in old age is
no longer a plight that befalls others,
but one likely to befall their own parents
or grandparents, or even themselves as well.

しかし
However
ながらそれ故に看護師が無理難題と感Aspects of care that nurses perceive as unreasonable tasks:

Therefore

Basic Position
The objective of the Japan Academy of Gerontological Nursing is “to contribute toimproving the quality of nursing practice while seeking to advance the field ofgerontological nursing.” The association’s Code of Ethics states, “As experts ingerontological nursing, we will fulfill our duty to contribute to the happiness andwelfare of people through nursing practice, education, research and social
activities.” Specifically, this duty includes “placing the utmost priority on respect forhuman rights, considering individual capabilities, and striving to advocate for therights of elderly patients,” “in our activities, striving not to impose behavioral
restrictions or other undue physical or mental burden on our patients and theirfamilies, nor to cause any pain or discomfort,” “maintaining confidentiality andprotecting the privacy of elderly patients and their families,” and “endeavoring torespect the rights and skills of professionals in other fields and to foster
interdisciplinary collaboration.”
According to the Japanese Guidelines for the Management of Dementia 2010, theprinciples of dementia care are (1) dignity and patient-centered; (2) peace of mind
and a fulfilled life; (3) support to achieve independence and rehabilitation; (4)safety, health, and preventive care; and (5) care in partnership with the family andthe community.
The basic position of the Japan Academy of Gerontological Nursing in this paper is
to contribute to people’s happiness and welfare through adherence to theassociation’s Code of Ethics and to improve nursing practice based on theprinciples of dementia care.

Nurses’ belief
that “patients with dementia are
看護師が患者は“特別な人”
special cases”
does not change:と見方が変わらない要因：
Learningマイナスイメージを払拭でき
methods currently used do not dispel
negative attitudes
toward the disease and its symptoms.
ない病態・症状の学習法“特別な人”という認知症患者に対する見方が変わらないのは、今の病態や症状の学習の仕方をしても、認知症について「恐い」「なりたくない」「治らない病気」「介護負担が大きい」というマイナスのイ
メージを払拭できないからである。

Nurses’ perception of patients with dementia as “special cases”
does not change because even when taught about disease
and symptoms using current teaching methods, they areunable to dispel the negative connotations of dementia
as “scary,” “an undesirable prospect,” “an illness from which
there is no recovery,” and “an illness with a heavy burden of care.”

それ故にじるケア要因：Welfare facility-based nursing care methods requested
病院環境の制約下で求
under the constraints of the hospital environment

められる施設ケア法

相俟って impacts無理難題と感じるだけでケアにつながら
the quality of care they provide. However, within the context

In combination Nurses consider certain tasks as unreasonable, and this negatively
with

ないのは、個別に迫る実践知が蓄積しない看護体制、医学モデルの中にあって、施設ケアの中でできると言われるケ
ア方法や考え方を病院環境という制限の中で求められているからである。

of the constraints imposed by the hospital environment and under
an institutionalized medical model and nursing system that do not
Encourage the acquisition of practical knowledge with which toaddress patients individually, nurses are called on for ideas and nursing
care practices regarded as “possible” in the context of facility-based care.

Therefore
それ故にTherefore

Measures topromote patient-centered medical treatment and care:
本人重視の医療・ケアの推進策：
Nursing guidelinesthat will guarantee certain outcomes,
一定の効果を保証する看護指針とand revisions to
medical fee payments that will motivate organizations
組織を動かす診療報酬の改定

多忙なナースに考えなくても一定の効果を感じられる型や作法を示した関わり方や、エビ
デンスに基づくガイドライン、認知症ケアに真剣に取り組むよう組織を動かす診療報酬改訂は、認知症高齢者本人重視の医療・ケアの推進に効果がある。

Evidence-based guidelines and methods of engagement that present
techniques and methods to nurses who are already very busy, showing
how to achieve certain tangible outcomes without conscious effort,
and revisions to medical fees that will spur organizations
to proactively engage with dementia care will be effective in promoting
a model of medical treatment and care focused on older adults with dementia.

Therefore
それ故にMedical care-related
factors associated with patients remaining unprotected:
本人が擁護されない医療側の要因：
The underlying
premise of medical treatment that prioritizes speed and efficiency.
効率・スピードを求める大命題“治療優先”の医療

本人の意思確認の形骸化、検査・処置の場から家族を排除する慣習、本人擁護のチームもなく、患者の存在や訴えをないものとするような高齢者や家族の人間的な出会いの欠如や拘束が当たり前となっているのは、治療優先の大命題の元、効率・スピードを求め、多忙の中、考える時間も奪われ、疑問を持たせないネーミングによる錯覚の活用があるからである。

In acute care hospitals, the purely rote checking of patient intentions, the practice of
excluding family members from diagnostic and treatment settings,
absence of a patient advocacy team, lack of humane interaction by professionals
with elderly people or their family members which serves to obviate any agency orcomplaint on the part of patients, and the widespread use of physical restraints arecaused by the demand for speed and efficiency, nurses being so busy that they havelittle time to think, and the outcome of paying unquestioning lip service to“giving priority to treatment.”

背後で影
響し

Underlying
influence