1. Alzheimer’s Association Japan
Noriyo Washizu
Case Management
in Dementia
Alzheimer’s Association Japan

2. conflicts of interest to report.
Conflict of Interest Disclosure Noriyo Washizu, Master of Social Welfare
Has no real or apparent
conflicts of interest to report.

3. Alzheimer’s Association Japan
Hello everyone.
★ I’m Noriyo Washizu from Alzheimer’s Association Japan.
★ It’s a great honor to be here to speak to such distinguished people from around
the world in this beautiful city San Juan.
Today I will talk about the case management in dementia through our experience in Japan.
As many of you know, Japan has the highest ratio of elderly population and the longest life expectancy in the world.
Currently in many countries the number of elderly and people with dementia is increasing rapidly.
I would like to share our experience to build a dementia-friendly world.
I hope my presentation will help you understand how important case management is for living well with dementia.
Alzheimer’s Association Japan

4. Outline Fundamental issues in case management
Part 1:
Fundamental issues in case management
Definition
Key issues 　
Part 2:
Case management of dementia in Japan
The history of the elderly/dementia care and case management
Introduction of recent approaches for case management in dementia
J-DECS (Health care decision making support for people with dementia)
Kyoto integrated dementia care plan 2013 to2017
・ This is a brief outline of my presentation.
I would like to divide my presentation into two parts.
The First, fundamental issues in case management.
The second, case management in dementia in Japan.
The second part includes the history of the elderly and dementia care in Japan and current approaches related to case management in dementia and a real story.

5. 1. Definition 2. Key issues in general /dementia
Fundamental issues in case management
1. Definition
2. Key issues
in general /dementia
Let me start with part 1, fundamental issues of case management.

6. Definition By The Case Management Society of America By Japan MHLW
“Case management is a collaborative process of assessment, planning, facilitation, and advocacy for options to meet an individual’s health needs through communication and available resources to promote quality cost – effective outcomes.”
By Japan MHLW
“Case management（Care management ) is the effective, ongoing, and collaborative process and system to fulfill the client’s well-being life in the community by application and improvement of services and developing the social resources.”
First, the definition.
Many health and social care organizations have their own definition of case management.
They are worded differently in some degrees, but they have common factors.
Here I would like to show two examples of them.
★ The first one is a definition by the Case Management Society of America which is quoted in 　
　　ADI Alzheimer’s Report 2013.
★The second one is by the Ministry of Health, Labor and Welfare Japan.
Let me point out that in Japan we mostly use the term “care management” for “case management”
Here I use the term “case management” for care management in Japan to make my presentation simple. ・　
By 厚生労働省
「利用者が地域社会による見守りや支援を受けながら、地域での望ましい生活の維持継続を阻害するさまざまな複合的な生活課題（ニーズ）に対して、生活の目標を明らかにし、課題解決に至る道筋と方向を明らかにして、地域社会にある資源の活用・改善・開発をとおして、総合的かつ効率的に継続して利用者のニーズに基づく課題解決を図っていくプロセスと、それを支えるシステム」

7. Keywords of Case Management
Social resources
Sｋｉｌｌｓ
Assessment
& planning
Advocacy
Through these definitions, the　common key words in case management are ★Social resources, ★Skills( assessment・planning) ★Advocacy, ★collaboration,★ and Effectiveness.
Collaboration
Effectiveness

8. Five key issues in case management in dementia
Ethics
Continuity
Social
resources
Case management
Dementia
When we think of case management in dementia specifically, we have to keep in mind five key issues.
They are 1.Ethics 2.Social resources 3 Family 4.integration 5.Continuity.
I will talk about each.
Integration
Family

9. derived from Hyper cognitive culture
Ethics
Autonomy
Beneficence
Non-
Maleficence
Justice
Difficulty in
indication of
intension
Person with dementia
First, the Ethics.
A person with dementia has difficulty in indicating intension and decision making.
So in the case management in dementia we have to pay keen attention to four principles of ethics: autonomy, beneficence, justice and non-maleficence.
In addition there is stigma derived from hyper cognitive culture.
Dr. Stephen G. Post says in his thoughtful book The Moral Change of Alzheimer Disease
“I -think –therefore -I am –culture” that is to say Hyper cognitive culture, emphasizes rationalism and economic productivity.
We should change the world view of <I think therefore I am>to the view of <I will feel and relate, while disconnected by forgetfulness from my former
myself, but still I am.>
Stigma
derived from Hyper cognitive culture
Difficulty in
decision
making

10. Utilization & Innovation of Social resources
Initial Impact
Utilization &
Innovation of
Social resources
Broad range Care Needs
The next is social resources.
To think of the social resources for dementia, there are three issues.
First is The initial Impact
The challenge of dementia emerged over the last 30 years and has been rapidly growing.
We have not developed enough social resources for dementia care.
Second is Broad range of care needs.
People with dementia need care in all areas of life, such as medical, nursing, social, personal and spiritual.
Third , the process of the disease is apt to be prolonged and fluctuating.
We have to utilize effectively and also innovate the resources to meet the special needs of people with dementia.
Prolongation
&
Fluctuation

11. Physical/Mental/Financial
Family
Care Practioner
Spokesperson
Advocator
Family matters
Social life
Job
Physical/Mental/Financial
Impact
Family is also a crucial issue.
Dementia care is long-term and given mainly by families. For example, In Japan, more than half of people with dementia beyond the middle stage are cared for at home.
★Families need to take central roles as< an actual care practitioner> as <a 　　
　　spokesperson> as <an advocator>.
★Also, the family caregivers are apt to be 　　
　　sandwiched between jobs and family responsibility.
Alzheimer’s report in 2013 noted the impact of caregiving in dementia is 　
　　physically, mentaly,　and financially higher than care giving in non-dementia.
Burn out

12. Integration Client at home Home helper Dental hygienist Bathing Meal
Delivery
Client at home
Rehabilitation
Next is integration
People with dementia need care in all areas of life and receive various types of services daily.
For example, the chart is the case of my home visiting nursing patient with dementia and living alone.
Six service providers and a clinic are involved in his care and 6 staff or more visit him each day.
If the services are fragmented the clients are confused and subsequently worsen.
Doctor
Nurse
Day care center

13. Continuity Awareness Moderate Mild End of life
Next is Continuity of care
★Generally the course of dementia involves a long process .
★The types and amounts of care should be changed according to the condition.
★However, people with dementia are vulnerable to changes in the environment.
To avoid the exacerbation by rapid change, it is important to anticipate the next stage for　smooth passage.
Awareness
Moderate
Mild
End of life

14. Five key issues in case management in dementia
Ethics
Continuity
Social
resources
Case management
Dementia
To conduct case management in dementia, these five key areas should be kept.
Integration
Family

15. Symphony of living well with dementia
This is the image of case management.
I think case management can be compared to the performance of a symphony.
A solo player is a client and member players are the people surrounding , such as family and various professionals. And the conductor is the case manager. The conductor should coordinate each part to create a beautiful harmony.
Up to here , I have talked in general terms about case management in dementia.
Let me move on to part 2.

16. Case management in Dementia in Japan
Here I will introduce the up-to date case management in Japan.
But before let me talk about the history of elderly &dementia care in Japan.
The history helps to understand the current condition.
Past and Present

17. The History of Elderly Care and Case Management in Japan
2010 ~
Integrated community care system
Case management
focused on the whole community
2000 ~2010
Start and Development of Long Term care Insurance
Case management
within
Long term Care Insurance
1980~2000
Preparation for the aging society No
Case management
The history of elderly care in Japan can be divided into four periods.
★The first is from 1960 to 1980, family care or institutionalization by law.
There was no social resources for the elderly care and no case management.
★The second is from 1980 to 2000, preparation for the aging society to promote qualitative 　　　
　　and quantitative expansion with trials and errors.
★The third is from 2000 to 2010, the start and development of long-term care insurance and
　　case management.
★The fourth is after 2010, when the case management is required to focus on the whole 　
　　community.
1960~1980
Family care/
Institutionalization/Hospitalization No
Case management

18. Major policies & elderly population ratio
*Integrated community care
policy
*5year plan for dementia care
*LTC insurance
*Future plan for
Elderly care
*Dementia supporter
national campaign
31.6%
*Health care
act for elderly
*Gold Plan
*new Gold plan
*Gold plan 21
23.0%
Universal health insurance & pension system
Social welfare service act for Elderly
17.4%
This graph shows major policies for the elderly and the aging population ratio over time.
In early ‘60, Japan achieved universal health insurance, a universal pension system and enacted the elderly Social Welfare Service Act.
These three form infrastructure for the aged society but just at the beginning.
From 1960 to1980 was the period of family care and limited Institutionalization by the government.
Aged care was assumed to be the family’s duty.
There were no social resources and case management for elderly care and the shattered families sent their parents to elderly hospitals as a last resort.
There elderly were forced to be bedridden to the end of their lives in horrible circumstances.
It was during this period that Alzheimer’s Association Japan started as a family caregiver, peer support group. (in 1980)
AAJ
12.1%
9.1%
7.1%
5.7%
Family care & institutionalization preparation& trials case management super care management

19. As you can see, this is a patient restrained in his bed.
These pictures between the 1970’s~1980’s are taken from the book “ The elderly hospital” written by Kazuo Okuma, a famous journalist in1988.
The book raised an alert over the elderly issues.
Restrained patient in his bed – From the book “The elderly hospital” By Kazuo Okuma, 1988

20. Lunch time at a hospital for the elderly
The lunch time of the elderly hospital From “The elderly hospital” By Kazuo Okuma, 1988

21. From the book “The elderly hospital” By Kazuo Okuma, 1988
Another example of Restraint
From the book “The elderly hospital” By Kazuo Okuma, 1988

22. The history of aged care & elderly population ratio
*Integrated community care
policy
*5year plan for dementia care
*LTC insurance
*Future plan for
Elderly care
*Dementia supporter
national campaign
31.6%
*Health care
act for elderly
*Gold Plan
*new Gold plan
*Gold plan 21
23.0%
Universal health insurance & pension system
Social welfare service act for Elderly
17.4%
★From 1980 to 2000 was the period of preparation towards the coming aging society.
The impact of the increasing elderly population and the soaring medical costs, caused by hospitalization of the elderly, drove the development of systems and infrastructure, supported by the economic growth.
The development was facilitated by three national plans.
But aged care was still managed mostly by families and in a few cases provided by the government in a uniform way.
Institutional care was focused on efficiency and rationality.
Meanwhile in the middle of the 90’s new attempts, such as group homes and assisted living were started by the influence from the North Europe.
12.1%
9.1%
7.1%
5.7%
Family care & institutionalization preparation& trials case management super care management

23. Increasing of Aged Care Services
The graph shows the increasing number of home helpers and residential facility beds promoted by three national plans.
Gold Plan New Gold Plan Gold Plan 21

24. The picture is from a text book published by the Japan broadcasting Corporation. The scene is from the first hospital for dementia patients established in1984 by Dr. Ken Sasaki, one of the pioneers of the dementia care.
People were just walking around the special corridor for wandering.
It was a safe way to wander, but at that time we did not comprehend why they were wandering.

25. The same hair style and uniform. It was easy to keep clean
The same hair style and uniform. It was easy to keep clean. There were no furniture in the bed rooms to avoid the risk of injury.

26. Permanent admission for reasons of wandering,
The reasons for the hospitalization were wandering, hallucinations and aggression etc.
Permanent admission for reasons of wandering,
hallucination, and aggression, etc

27. The history of aged care &elderly population ratio
*Integrated community care
policy
*5year plan for dementia care
*Dementia supporter
national campaign
31.6%
*LTC insurance
*Future plan for
Elderly care
*Health care
act for elderly
*Gold Plan
*new Gold plan
*Gold plan 21
23.0%
Universal health insurance & pension system
Social welfare service act for Elderly
17.4%
★ I would like to move on to the years from 2000 to In this period, the elderly population ratio was over 17%.
12.1%
9.1%
7.1%
5.7%
Family care & institutionalization preparation& trials case management super care management

28. 2000 The start of long term care insurance Clients decision making
& Case Management
Increase of
elderly population In need of long term care
Decline of family function
・Nuclear family
・Aging of family cares
・Women’s social advancement
Impact of Social hospitalization
・Increasing of the health cost
・Bed blocking X
Long Term Care Insurance
In 2000, the Long term care insurance came into force after the period of 20 years preparation.
There are mainly three background factors.
First, increasing elderly population in need of long term care
Second, declining family function, came from developing of nuclear family system, and women’s social advancement.
Third, the impact of social hospitalization, such as health cost and bed blocking.
★Long term care insurance brought in three matters.
★One, the change from the traditional family care to the social care system
Two, case management for all service users
　 Three, clients decision making in using the services.
Social care resources
Case management
Clients decision making

29. The finance of the long term care insurance
Service Provider
Services
10% of Co-payment
90 % of the cost
Payment for Accommodation & Meals
Tax(50%)
This chart is just a general over view of a very complicated financial system of long term care insurance
All people over 40 are required to pay a mandatory premium.
Users
(Persons certified in need of Long Term Care )
Premium（50％）
Paid by persons over 40

30. How to use the long term care services
<In-facility>
Health care facilities
Special nursing home
Sanatorium medical facilities
<In-home services >
Home visit help
At- home Bathing
home visit nursing
Home visit rehabilitation
Day care service
Short –stay admission service
Provision or subsidy for care equipment
Subsidy for home alternation
Multifunctional care in small homes
Group homes for People with dementia
<Preventive care services>
Application
Investigation
Doctor’s diagnosis
Judgment
Care need Certification
Case (care) Management
This chart indicates how to use the long term care service.
For more information, please visit Ministry of health, labor and welfare website.

31. The number of case managers and work place
(Each case manager works with under 40 clients)
13,567
7,629
Community care
Integrated community
care center
Aged care facilities
87,223
This graph shows the number of case manager and their work place in all over Japan
The credential of case managers is stipulated by Long term care insurance law.
Candidates are required to gain 5 years experience prior to the qualifying exam.

32. The history of aged care & elderly population ratio
*Integrated community care
policy
*5year plan for dementia care
31.6%
*LTC insurance
*Future plan for
Elderly care
*Health care
act for elderly
*Gold Plan
*new Gold plan
*Gold plan 21
23.0%
Universal health insurance & pension system
Social welfare service act for Elderly
17.4%
★Let’s move on to after 2010 to the present and future
It ‘s a period of promotion for integrated community care and specific plan for community dementia care to meet a super aging society.
Case management is required to focus on the whole community.
12.1%
9.1%
7.1%
5.7%
Family care & institutionalization preparation& trials case management super care management

33. Aging situation in Japan
Over 65 population ratio
(2013)
25.0 %
Life expectancy
(2012)
Male 　 79.94
Female
This is the current aging situation in Japan.

34. Increase in the number of the elderly living alone
In over 30% of the elderly were living alone　　　.

35. The number of elderly persons & ratio
with dementia higher than moderate (in millions)
4.62
4.7
4.1
3.5
2.8
This graph shows the number of elderly persons with dementia higher than moderate level.
★The Ministry of Health, Labor and Welfare reported the total number of the elderly with 　
　dementia is 4.62 million and the number of people with Mild cognitive impairment is 4million 　
　in 2013.

36. Further Increasing Aging Population The ratio of aged 75 or older
Persons with dementia
Single/Couple households of aged 65 +
Demand of
Integrated community care & Specific strategy for dementia care
With the further development of aging society, over 75 population, the number of people with dementia, and single or couple households of the elderly, are increasing rapidly beyond estimation.
★The long term care insurance has worked well but it is still insufficient for the
super aging society.
Also specific measures for dementia care is required.
★In 2012, the Ministry of Health, Labor, and Welfare announced the five year plan
for dementia .
And the following year the policy of an Integrated community care was announced.
Case management is required to coordinate and innovate the social resources in the community holistically.
・ Also Community development became the urgent issue. National campaign of
Dementia supporter caravan started in 2004, is an example.
It has been conducted successfully and there are more than 4million supporters over Japan in 2013.
　　As of a dementia supporter, everyone who took 90 minutes course about knowledge of dementia
and how to support people with dementia as a citizen can be dementia supporter.
★Integrated community care system policy in 　　　　　　　　　
　 2013
★Five –year plan “measures against dementia
　 2013~2017”
LTC

37. Integrated community care system policy
by the government
GOAL
Integrated management of the services of medical care, social care and welfare
24/7 care setting within a radius of 30 minutes of travel time
Comprehensive Regional Support Center
Cooperation
Small-scale multifunctional care facility
This chart describes the concept of the integrated care policy by the government.
It aims to set up a 24/7 medical, social and welfare care within a radius of 30 minutes of travel time in order to support the elderly to live in their community.
The case management is required to bring in the whole community centering around the client.
Visiting nurse station
Nursing home
Home
Daycare centre
Community activities
Volunteer

38. “Change the flow of dementia care”
Government’s 5-year Plan
“Change the flow of dementia care”
Community care services
Home doctor
Short term treatment in psychiatric hospitalization
Living in the community
Long Term Hospitalization
Integrated community care center
Dementia medical center
Initial Phase intensive care team
Early, proactive, preventive approach
This is the overview of the government 5 year plan “measures against dementia” launched in 2012.
The dementia care has been improved little by little from 1960 with many trials.
But there are still many cases of long term admission in psychiatric hospitals.
The aim of the plan is “change the flow of dementia care”.
First, long term institutionalization should to be changed to living in a comfortable & familiar environment in their community.
Second, post crisis intervention should be changed to an early, proactive, preventive approach.
Post Crisis Intervention

39. The Kyoto Community Dementia Care Model
Government measures
PWD and carers’ perspective
Under two central government policies, many local governments have started their own particular measures.
Among them, I would like to introduce two associated projects of the Kyoto community dementia care model derived from 1350 comments analyzed by the Delphi technique and many discussions.
They are important projects for integrated case management in dementia.

40. People with dementia Explanation Decision Making?
Understand ? Yes is yes?
Decision Making?
Firstly ,J-DECS (Health care decision making support for people with dementia in Japan).
In case management in dementia, health care decision making is one of the most important and difficult issues.
★People with dementia have difficulty in communication ,understanding an decision
making.
It might result in withholding or excessive, or involuntary medical treatment.
J-DECS has started to solve this problem.
Withholding/Excessive/Involuntary
Treatment

41. Target http://j-decs/org Dr. J Narumoto jnaru@koto.kpu-m.ac.jp
Health care decision making support for people with dementia in Japan
Dr. J Narumoto
Target
1.Assessment tools of capacity of decision making for patients with dementia
2.Guidelines and Materials to help the elderly for health care decision making
3.Decision making process model for patients with decision making difficulty
J DECS is a project being studied by the specialists of medicine, welfare, legal experts, and Alzheimer’s Association Japan members.
The target are to develop capacity assessment tools, the dementia and elderly friendly material for explanation, and decision making model.
・ For more information, Please visit the website or mail to Dr. Jin Narumoto on the
slide.

42. Kyoto Integrated Dementia care path map
Integrated community care support center/Case Manager
Alzheimer’s Association・ NPO ・ Council of Social Welfare ・ Local government
Assisted Living/ Private Residential Home
LTC Welfare Facility
LTC Health Care Facility
Group Home
Personal Care/Welfare/Housing
Social resources
Initial Phase Intensive Support Team
Memory Café
Welfare Center for Elderly
District Welfare Office
Club of the Aged
Adult　Guardian　ship
Multifunctional in-home care /Short Stay
Day care Center
Home helper/Meals Delivery
Special Daycare Center
People in the community (+Dementia Supporter )
Family members
Person with dementia at home
Medical & Nursing
Dementia Specialist/ Specialized Medical Center /Dementia Support Dr.
General Practitioner /Home visiting
Home visit Nursing/Rehabilitation/Pharmacy
Next is the Kyoto dementia care path map. It was innovated by Dr.Takechi, Department of Geriatrics, Kyoto University Graduate School.
★The center part indicate a person with dementia at home ,family and people in the
　　community .
　　Bottom line is the course of the disease.
★Social resources in the community are tabulated.
★The box on the top is support group, and governmental agency.
★The top half shows personal care and welfare services and housing.
The dark orange boxes indicate residential services.
★The bottom half shows Medical services.
The dark blue boxes indicate admission services.
The map with the names of the social resources in the client’s area gives a visual overview of the flow of the care to a person with dementia, the family and the care team members.
General Hospital, Nursing Home
Medical Center for Dementia
Psychiatric hospital treatment
Awareness Mild　　 Moderate　 Severe End of Life

43. Integrated community care support center/Care Manager
Alzheimer’s Association・ NPO ・ Council of Social Welfare ・ Local government
personal Care/Welfare/Housing
Social resources
Kyoto Integrated Dementia care path Map
Assisted Living/ Private Residential Home
LTC Welfare Facility
LTC Health Care Facility
Group Home
Initial Phase Intensive Support Team
Memory Café
Welfare Center for Elderly
District Welfare Office
Club of the Aged
Adult Guardianship
Multifunctional in- home care /Short Stay
Day care Center
Home helper/Meals Delivery
Special Daycare Center for Dementia
People in the community (+Dementia Supporter )
Family members
Person with dementia at home
Medical & Nursing
Dementia Specialist/ Specialized Medical Center /Dementia Support Doctor
General Practitioner /Home visiting
Home visit Nursing/Rehabilitation/Pharmacy
This is the example of use the Kyoto care path map. It can be used entire process of case management, such as assessment, care planning, a conference, and a case study as well.
★The gray arrows indicate services used.
★The red arrows are services being used.
★The yellow arrow will be service used in the future.
This can be an effective case management tool.
General Hospital, Nursing Home
Medical Center for Dementia
Psychiatric Hospital/Hospital for dementia treatment
Awareenss Mild　　 Moderate　 Severe End-of-Life

44. Kyoto Integrated Dementia Care Path Map
Audit outcome
in 2017
I can expect a cure.
I receive the appropriate services for younger onset dementia.
I have a comfortable place to stay.
I can receive appropriate medical services.
I had early diagnosis and started treatment.
People understand my difficulty in communication and respect my wishes.
Kyoto’s integrated dementia care model achievements will be evaluated in 2017.
The UK’s “National Dementia Strategy final year audit outcome will be used as a reference.
Evaluation will be completed by the feedback from all involved about the points appearing on the picture.
I spend active life with the understanding & support from all people around me.
I have a role as a community member.
I & my family are well supported and feel peace of mind.

45. Story of
Mr. Sakai
Here is the final section of my presentation, A story of Mr.Sakai, a members of Alzheimer’s association Japan.
I think he will explain an example of case management in dementia in Japan now.
He was a capable businessman and also a contributor to the community.
At age 58, Mr. Sakai began to often make mistakes at work.
At age 60, the company required him to have a medical examination.
Then he was diagnosed with Alzheimer’s disease and started medication.

46. When he was 62 he retired because of the Alzheimer’s disease.
Over the following 3 years he attended a painting group and enjoyed tennis with the assistance of club members.
His wife explained his condition to neighbors, friends, and all acquaintances.
Everyone was very supportive.　This slide is his painting.
She also knew of the Alzheimer’s Association Japan monthly caregivers meeting through the newspaper and attended every month with him.
We had fun with him at the meeting and weekend trip. He was a great singer. The problem was once he had a microphone , he never passed it and kept singing.

47. At 64, his condition worsened and he went out frequently day and night.
Sometimes she asked the police to stop him from going out at midnight.
At 65, he started to attend a day care center.
At the day care center he was stable but at home he was often aggressive and agitated.
But he stayed at home using the maximum long term care insurance and welfare services coordinated by his case manager.

48. At 66~67 he got lost and was found afar off by the police .
It was a time for a crisis intervention.
He was admitted to the hospital twice for his treatment and respite care for his wife for one month each.
At 68, after being hospitalized his condition was relatively stable.
But his wife was completely exhausted although she wanted to take care of him at home.
Despite the case manager’s effort it was difficult to find more services because of his physical and mental condition, such as his refusal to be cared for, aggression, and restlessness in an unfamiliar environment.
Ｈis case manager brought in the new system, “nursing home sharing.” Two people use one fixed room every other month in rotation.
He and his wife had a good time both at home and at the familiar nursing home for over one year.
The picture is his pet “Fu.” Fu helped his wife take care of him and comforted both of them.

49. At 69, the disease gradually worsened and his condition deteriorated.
His wife still wanted to look after him at home but it was impossible.　
Through conferences his family decided to have him admitted to the nursing home where he did the home sharing.
She visited him every other day and they enjoyed being together.
One afternoon in June 2013 he enjoyed his favorite ice cream with his wife at the nursing home café as usual.　
Suddenly he became unconscious and fell down.
After two days in the hospital he passed away.
Now she is living alone. She said when I visited her the other day “I just remember his smiling face and thank for all people involved in his care”

50. Conclusion In conclusion
Let’s me summarize the main points of my presentation.
First, to achieve living well with dementia, case management is absolutely essential.
But, it cannot function without social resources.
Case management and social resources are all-in-one.
We should develop them simultaneously
Second ,the social resources and case management are the backbone of dementia care.　
Their principles should be set by a national plan and details should be streamlined by each community to suit each reality.
Third, the keen attention to the ethics to protect the human rights of people with dementia should be kept through a whole process of resource building and case management.
Because they are always at risk of being ignored their existence and dignity
We have learned from our experiences, through trial and errors.
However, we are still in midstream to the goal and facing the many social and economic challenges. We desire to cooperate with people involved in dementia care around the world, just like all of you here,
Finally in closing, I would simply like to say, let’s work together for living well with dementia.
★Thank you very much.
Reference
ADI. Alzheimer’s Report 2013
Dr. Jin Narumoto J-DEC
Dr. Hajime Takechi Aging as a positive phenomenon
Dr. Toshio Mori The guidebook for younger onset dementia care. Kyoto integrated regional care promotion organization
Kazuo Okuma Reportage on the elderly hospital. P19, P99. Asahi Newspaper
Post,S.G,2000.The moral challenge of Alzheimer Disease, P5, The Johns Hopkins University press
Kazuo hasegawa.2012.Dementia care, Vol.1.Japan broadcasting corporation
Kyoto Integrated regional care promotion organization.2013, Kyoto integrated community dementia care policy.
Japan ministry of Health, Labour, and Welfare Annual Health, Labour, and Welfare- social security-