Hospice

When talking about gerontology—the study of older people—most people assume that it is a new study as they have not heard of it. The same goes for hospice. If you bring it up in a conversation most people will know of someone who went through hospice, but again they think that this is a current trend, something new. So, it comes as a bit of a shock when people learn that gerontology is as old as writing itself. The first known record of writing is the Sumerian Saga of Gilgamesh about 4,000 years ago. The most famous of the five poems is "Gilgamesh, Enkidu, and the Netherworld." a poem that describes the love that King Gilgamesh has for Enkidu, a half-god when he tragically dies. An event that sets Gilgamesh on a search to find a cure for aging and to death in order to bring his friend back from the dead. The story has spawned many others, and there are traces of this story everywhere, including in the bible. It is important to understand that the first evidence we have of literature dealt with getting old and dying. 

Even the term “gerontology” was used in 1903 by Ilya Mechnikov, an immunologist who with Paul Ehrlich was jointly awarded the 1908 Nobel Prize in Physiology or Medicine. Gerontology even fathered the discipline of endocrinology (the study of hormones) and transplantation (transplanting organs). A hundred and twenty years later, people still think that gerontology is new because they do not want to think about aging and about dying. This is very much true in Japan as well. In 2016 Mitsunori Miyashita with the University of Tokyo asked Japanese people about a ‘good death’ and showed that they tended to avoid thinking about it. The study also found that they gave their family a large say in how they should die. We do not want to think about death. 

Hospice provides care for people who are dying. Such care was first established during the Crusades in the years after 1000 and became widespread in the Middle Ages. It formally became a branch of medicine when Cicely Saunders founded St. Christopher’s Hospice in London in 1967. This first hospice set the stage for other hospices throughout the world. In Japan, the first systematic palliative care service was launched at Yodogawa Christian Hospital, Osaka, in 1973, and then in 1981, the first palliative care unit (PCU) was opened at Seirei Mikatahara General Hospital, Shizuoka. After 1990 when insurance started covering PCU treatment, hospice grew into a national service that covered all of Japan. By 2017,  there were 394 PCUs with 8,068 beds. All of the designated cancer hospitals have PCUs. 

In Japan, like in every other country, most people want to die at home and a third want to die at PCUs. However, the reality is that most die in hospitals. Masanori Mori and Tatsuya Morita have identified the need for more training and better specialization in Japan to promote better and more accessible care for the dying. And there have been great advances. By 2015 there were more than 50,000 physicians trained in palliative care. While a study that started in 2008 to monitor palliative care in Japan called the Outreach Palliative Care Trial of Integrated Regional Model (OPTIM) has recently found that Nurses' palliative care knowledge, and practice improved with more training. 

The fundamental problem with hospice relates to what we discussed earlier in the introduction, people do not want to talk about it, and that includes physicians and nurses. Health care workers do not want to go into hospice. If you are part of a profession of saving people’s lives then helping them to die seems contradictory. Most people leave hospice till the very end. Others shy away from contacting hospice, even though most hospice services can be delivered to your home. The only way to change this is to accept death as part of the cycle of life. Talking about death does not have to be sad as it can highlight the privilege of being alive. By appreciating that having a good death needs to be planned. We have known this for centuries perhaps now is the time to accept it for ourselves.

Kenkou to Yoi Tomodach 3

References

Mori, M., & Morita, T. (2016). Advances in hospice and palliative care in Japan: A review paper. The Korean Journal of Hospice and Palliative Care, 19(4), 283-291.

Nakazawa, Y., Kato, M., Miyashita, M., Morita, T., & Kizawa, Y. (2018). Changes in nurses' knowledge, difficulties, and self-reported practices toward palliative care for cancer patients in Japan: an analysis of two nationwide representative surveys in 2008 and 2015. Journal of pain and symptom management, 55(2), 402-412.

What are the main challenges facing palliative/end-of-life care today in relation to Japan’s ageing society

Posted on January 31, 2018 by pallcare

Mariko Masujima, Principal Investigator, and Zaiya Takahashi, Core Promoter, the Center of Excellence for End-of-Life Care at Chiba University, describe the present situation, policy and cultures about end-of-life care in Japan.

Accessed: https://eapcnet.wordpress.com/2018/01/31/what-are-the-main-challenges-facing-palliative-end-of-life-care-today-in-relation-to-japans-ageing-society/

Drugs and Older Adults

America is the country for sex, drugs, and rock and roll….well maybe just drugs and rock & roll.  Americans can be very traditional when it comes to discussing sex, but as for drugs we use medication as much as the Japanese. Most Americans are on some kind of medication or illicit drug. During 2015–2016, almost half of the U.S. population, including children, used one or more prescription drugs.  If you include recreational drugs, alcohol, and tobacco then you can assume that nearly everyone is on some kind of mood-altering drug. In addition, nearly everyone takes caffeine, either from coffee, soft drinks, or tea. Drugs are everywhere and they are differentiated only by whether they are legal or not and whether they are prescribed by a doctor or self-administered.

When discussing the problem of drugs, most people fall into the habit of automatically blaming recreational drugs. There is a long-standing myth that drug abuse is rare among older adults. The belief was that long-term drug addicts either recovered or died, and that addiction and use of illegal drugs by older adults were restricted to a small group of older criminals. But when we look at reality a different picture emerges. It is prescription medication among older people that is a primary concern. It is legal medications that cause more harm--those prescribed by your doctor--or those that you can buy from a pharmacy off-the-shelf. Prescription drugs are more popular with older people, especially older women. Pain relievers remain the most popular drug for the last two decades. Nearly a third of adults over 65 are on prescription medication. Most of these are not addictive, but the most popular medicines are, especially those for pain relievers.

While we see older men being addicted to alcohol and illicit drugs, older women are more likely to be addicted to pain medication like sedatives, hypnotics, and anxiolytics for anxiety. One type of anxiolytics is Benzodiazepines, which treat anxiety, pain, or insomnia, and are highly addictive and common. There are also common medications that older adults should not be taking. These drugs are updated every year under the BEERS criteria. 

Some medications might also be used inappropriately either intentionally or through forgetfulness. Older adults forget what medications they are on, and when and how to take them. Even though the US spends more on medications than any other country—mainly because we pay more for drugs than most countries—Japan leads the world in prescribing medications for older adults. 

When the world saw a decline in life expectancy for the first time this century in 2014, that was not due to wars, in the US this was attributed to the over-prescription of opioid medication. Promoted by big pharma, opioids were sold with the lie that they were not addictive. There was a fivefold increase in prescription opioid overdose deaths from 1996 to 2016 in the US. While newspapers focused on younger adults who misused prescription opioids, it was middle-aged and older adults between 50-64 years and older that use prescription opioids at a higher rate than any other group.

Combined with alcohol, prescription drug abuse among older adults is one of the fastest-growing health problems in the US. Alcohol and prescription drug abuse affect up to one in six older adults. Since older adults have a decreased ability to metabolize chemicals, the drugs stay in the body longer and our brains seem to get more sensitive to these drugs. This makes it dangerous for older adults to use any drug, even if the person is not addicted. On top of this, there is self-abuse. One-tenth of all older adults are also binge drinkers—five or more drinks at a time. Binge drinkers were more likely to be male and more likely to also use tobacco and/or cannabis. In the US cannabis use among older adults increased to one in twenty people, especially among older men younger than 69. Prescription medication combined with other drugs does not mix well.  With increasing access to geriatric doctors, nurses, and gerontologists we see a reduction in prescriptions and an overall improvement in life. In a complex world, having someone help you to navigate around these many drug options will benefit you to get the most from medications.

Kenkou to Yoi Tomodachi 2

References

Han, B. H., Moore, A. A., Ferris, R., & Palamar, J. J. (2019). Binge drinking among older adults in the United States, 2015 to 2017. Journal of the American Geriatrics Society, 67(10), 2139-2144.

Han, B. H., Sherman, S. E., & Palamar, J. J. (2019). Prescription opioid misuse among middle-aged and older adults in the United States, 2015–2016. Preventive medicine, 121, 94-98.

Tsuji‐Hayashi, Y., Fukuhara, S., Green, J., & Kurokawa, K. (1999). Use of prescribed drugs among older people in Japan: association with not having a regular physician. Journal of the American Geriatrics Society, 47(12), 1425-1429.

https://www.addictioncenter.com/addiction/elderly/

https://acpinternist.org/archives/2021/03/cannabis-use-increasing-among-older-adults.htm

https://www.verywellmind.com/us-has-highest-levels-of-illegal-drug-use-67909

https://www.cdc.gov/nchs/products/databriefs/db334.htm#:~:text=During%202015%E2%80%932016%2C%20almost%20one,the%20pattern%20varied%20by%20age.

https://rehabs.com/blog/most-popular-drug-in-us-by-decade/