Four issues are discussed in relation to the government measures for welfare of the elderly as viewed by an administrative official in charge: l) aging of the Japanese society and the demented elderly; 2) the history and evaluation of the government measures for welfare of the demented elderly; 3) the framework for welfare of the aged as proposed by the Ministry of Health & Welfare (MHW); and 4) the current status of and challenges for the care of the demented elderly.

1. AGING OF JAPANESE SOCIETY AND PROBLEMS INVOLVING DEMENTED ELDERLY
The ratio of people aged 65 and older as against the total population of Japan in 1990 was 12.1 % and may be called small compared to some of the European countries where aging of the society is far advanced. Aging will advance rapidly also in Japan in the next 30 years and the ratio will be 16.9% in the year 2000 or 10 years from now, and 25.2% in 2020 with about 32,000,000 people who are aged 65 or older. Thus, Japan will become one of the super aging societies of the world and will be challenged to cope with welfare for the aged.
The phenomenon of "rapid aging" uniquely characterizes the Japanese society and presents difficulties for the administration and the society. This means that resources should be quickly improved to meet the needs for social or medical services.
The ratio of 25.2% after the aging process is completed in 30 years will be higher than in any other countries, indicating the magnitude of the aging society in Japan.
Japanese people enjoy the longest life expectancy in the world even today. The aging society will consequently be one where the majority will be in the late senescence period. For instance, in the year 2000 which is less than 10 years from now, the population aged 75 and over will increase by 45%.
It is known that the longer the people live, the higher the incidence of dementia will become. The number of demented elderly in Japan to-day is estimated as 900,000, 740,000 of whom are living in their homes, 100.000 in social welfare facilities or health institutions for the aged, and 150,000 in hospitals. These figures describe the background of Japan's demented elderly in Japan.
In contemplating measures for the elderly. the increased number of elderly persons requiring care is considered as the problem of dementia. As for the social resources available for care, old people in Japan mostly have lived with families and their care has been traditionally supported by family members.
It is true that 80% of those aged 65 and older lived with their child(ren) up to 1970. This figure declined to 59% in 1900. Compared to European countries or the United States, the percentage is still very high. And yet it shows a steady declining tendency. Because of the increased number of working women, care available for the elderly within household is certainly decreasing.
In a situation such as this, one inevitably relies on services from out-side sources. This is one of the serious problems faced by Japan today.
Difficulties in caring the demented elderly have long been pointed out by various statistics and family members who are looking after such persons.
There is a survey which compared difficulties of care for the demented elderly and the non-demented elderly in a special nursing home for the aged (special nursing home). The survey evaluated the difficulties in care rendered for assisting with meals, toilet, or baths by a 5-point score: "very difficult" ," considerably difficult"," ordinary", "not so difficult" and "not at all difficult". More than 50% of the care for the demented elderly for all items were evaluated as either "considerably difficult" or "very difficult".
Compared to this, only 10 to 30% of the care for other old persons were evaluated as "considerably difficult" or "very difficult". Even in a special nursing home staffed by professional caregivers the care for the demented elderly is evaluated more than two times "difficult". When the number of such persons increases from 990,000 to 1,500,000, the situation at home or in institution is expected to become extremely difficult.

Table Estimated number of demented elderlies living in institutions and hospitals

2. PAST DEVELOPMENT OF GOVERNMENT MEASURES FOR CARE OF DEMENTED ELDERLY IN JAPAN
The Japanese Government has addressed the problem of demented elderly from various points of view, particularly since 1986. MHW established the Headquarters for Promoting Measures for Demented Elderly in 1986 for review of the situation in answer to such criticisms as insufficient resource allocation, and lack of integrity and systematization for various measures.
The Headquarters proposed a policy for addressing the problem in 1987 after deliberation for one year. The Headquarters was staffed not only by MHW officials but also by experts of various fields to promote the government measures for demented elderly.
I shall now briefly review the measures for demented elderly prior to 1986. In the field of welfare for the elderly, the Law for Welfare of the Aged was enacted in 1963 under which the official measures for welfare of the aged persons were launched. This law mentioned the concept of the needs for care, i.e. the care of the aged. and in answer to such needs. special nursing homes for the aged were opened.
Such nursing homes are intended naturally for the demented elderly. On retrospect, however, the emphasis has always been attached to people called "bed-ridden" with physical handicaps rather than the demented persons as reflected in MHW's documents and notices. This trend continued into 1970s and it was quite rare for the government to point out the importance of measures for demented elderly in the field of welfare. Symposia were held in many places and I once attended a similar symposium in Niigata. A speaker I met then was a housewife who actually took care of her mother. She said that there was no knowledge or under-standing about the demented elderly among the general public or the ad-ministration in or around 1970. Such situation seems to have been prevailing throughout Japan.
In sum, Japan's systematic measures for the demented elderly were started in 1900s and thereafter advanced bit by bit in areas of welfare, health and medical care or as mental health centers, health centers and medical care centers. It was, however, after 1986 that the issue was ad-dressed seriously when the Headquarters was established within MHW.
I wish to point out the significance of the MHW's Headquarters' report which dictates today's system for measures for the demented elderly. The report began with "definition of the demented elderly", and discussed the incidence and future estimate of the demented elderly. It then discussed the actual status and the challenges, and the measures to be promoted.
Reading the report again today, one realizes the report had performed an excellent role in enlightenment, education or learning as it pointed out that people involved in the health. medical care and welfare including those at MHW should reflect the past history and confirm the lagging status, and also pointed out misunderstandings and prejudices of the general public regarding the demented elderly. It was the fruit of learning and confirmation efforts on the pan of administration and was an expression of their public relations efforts toward the future direction.
Risking the possibility of being misunderstood, social welfare measures up to the present time may be defined as the centralized type in its good and bad meaning. The policy attaching the importance to the measures for the demented elderly proposed by the Headquarters appears to have affected those involved in the municipal administration, health, medical care and welfare.
When we examine admissions to special nursing homes after publication of the Headquarters report, one sees the steady increase of demented elderly. The figure speaks that the report had considerable effects.
The second significance is that the current number and future estimations were clarified for the demented elderly. From 1990, MHW formulated a 10 year plan for health and welfare of the elderly as a link of the 10 Year Strategy for Promoting Health and Welfare of the Aged from 1990. In formulating the long range plan, the estimate for the incidence of demented elderly was considered as meaningful for administration.
Thirdly, a policy for establishing a clear-cut system and promoting it in an integral manner was proposed in regard to the researches/studies/ prevention/support of families in home care, increasing the facilities and human resource training. It is five years since the report was published and I believe that considerable achievements have been made in various fields.
These achievements are briefly discussed. It was decided to build the National Research Center for Longevity in Aichi Prefecture in mid-90s for elucidating the dementia in elderly or its causes.
As for the family support in home care of the aged, the radical increase of resources for welfare of those staying at home was decided under the 10 year plan. Another is the policy for opening 350 centers for dementia in elderly in the second medical zones all over Japan. Currently 79 centers are due for opening or improvement.
It was proposed to establish 10.000 coordinate centers for supporting home care by the year 2000 by annexing them to care resources such as hospitals, health facilities or special nursing homes for the aged.
As for facilities, the increase of beds in the special nursing homes is being proposed. In five years, beds will be increased by 33%, or one new special nursing home opens every three days all over the country.
At the time the Headquarters published the report, special nursing homes for the aged existed only in concept, whereas the current number of such homes is more than 400 including the facilities that are now being improved and the number of beds about 45,000. When these homes are counted as nursing homes, the number of beds will be about 200,000.
Training is being given to physicians, nurses and caregivers at nursing homes in various areas. Three manuals regarding the care of demented elderly were produced last year alone.
"Manual for Diagnosis and Treatment of Dementia in Elderly Patients" is for those involved mainly in diagnosis and treatment. "Manual for Consultation on Demented Elderly" was prepared mainly by the members of the Association of psychiatric Hospitals and published by the Japan Public Health Association. "Care Manual for Demented Elderly" was prepared by the National Conference of Social Welfare for use by old people's homes, health facilities for the aged and day service centers and includes a collection of case studies on care.
Such care manuals are intended to improve the quality of care for the demented elderly and distributed to special nursing homes, health facilities and day centers throughout Japan. I believe that this is one achievement.

3. DIRECTION OP CARE POR SUPER OLD
There are three challenges face us today.
One is the radical increase of care services. As mentioned above, Japan must promote countermeasures for the elderly in 30 years as aging in the society advances rapidly. In 1990s which is the first decade, we wish to improve the service supply system as much as possible. The second challenge is building of a system for promoting community care of the elderly. The government measures attach a particular emphasis on home care. The law was revised in 1900 so as to enable integrated community services, along with institutional care that is going ahead albeit slightly, particularly by the municipal governments.
The third challenge is organized promotion of such a system by coordinating the areas of health, medical care and welfare. More concretely, the Health and Welfare Project for the Aged will be launched from 1993 under which coordinated services of health, medical care and welfare will be offered. The preparations are now going on nationally.
In the next chapter, I shall discuss how the fourth challenge of care for the demented elderly will be dealt in the framework just described.

4. CURRENT STATUS AND CHALLENGES FOR CARE OF DEMENTED ELDERLY
I already discussed promotion of home care. There are three kinds of services that are available nationwide in the area of welfare, home helper service, day service and short stay.
There are 100,000 households that benefit from the home helper service, although the service is rendered on an average once a week for two hours only. The majority of beneficiaries are single person households and services rendered are mostly household chores such as preparation of meals and shopping. This picture of the home helper service suggests that only a very small portion of the households caring after demented elderly is benefitting from such service.
According to a survey conducted by a group of family members taking care of demented elderly, only 12% of such families receive the service of home helpers. Considering these facts, one might say that the role of home helpers today is considerably small.
On the other hand, day services and short stays for respite of caregivers appear to be quite useful for the demented elderly. About 2,500 day service centers opened in 1991 indicating the spread of service throughout the country. About 130 people use one day service center, 28% of whom are demented. The use by the above mentioned group is 33%, indicating services rendered by the centers are more accessible to the demented clients compared to the service by home helpers.
Problems encountered in this area include insufficient diffusion of centers and the limited number of uses, once/week/person, because of the limited capacity. Another problem is very few centers offer programs dedicated for the demented elderly.
MHW plans to open small scale day service centers in 1992 to which the demented can go daily if they wanted to and is working on the plan internally. Short stay service is most often utilized today. There are 9,000 beds nationwide exclusively reserved for this service and about 300,000 persons benefit from this service every year. Unfortunately. MHW has no statistics as to the ratio of the demented elderly among these 300.000 persons. According to the Group of Family Members, frequency of utilizing this service is highest among the home care services as 37% of the demented elderly use this service.
Both the day service and the short stay are considered to function as the family support and may be quite useful as the home care for the demented elderly. By the year 2000 MHW aims to achieve such goals as increasing the number of home helpers, particularly the number of their visits to homes with demented or non-demented old people requiring care to three times or six times a week from the current rate of once a week.
Lastly I wish to discuss institutional care. All the statistics indicate the increased percentage of demented elderly in the special nursing homes. According to the National Conference of Social Welfare statistics, 52% of the special nursing homes care the elderly with more than moderate degree of dementia in 1990. According to a questionnaire survey on the degree of dementia of those admitted to special nursing homes in the post 5 years conducted by the Association of Nurses, 87% responded that the dementia aggravated since admission. This suggests the serious nature of the institutional care of the demented elderly.
In a situation such as this, a plethora of studies have been conducted on the care of demented elderly in special nursing homes and their results have been published, for instance in the Care Manuals. I shall therefore not discuss this point further, but would like to emphasize that the strong tie existing between the residents and their family members at special nursing homes appears to help achieve good results.
MHW conducted a survey on residents of special nursing homes for the first time in October, 1990, and observed that 68.3% of residents had visitors in September, 1900; and 24.8% of them had visitors more than three times a month, indicating strong ties between residents and their family members.
At 54 special nursing homes caring after the demented elderly, various programs are being offered. These programs are participated by families at 74% of the facilities and by volunteers at 67% of the facilities. suggesting that activities at special nursing homes are very much open to communities and to families, particularly in the care of demented elderly.
As the health facilities for the elderly, the current objective is to in-crease the number of beds from 45,000 to 280,000 in the next 10 years.
Another challenge is to secure human resources for care in order to increase the service capacity. In order to carry out the 10 year strategy, the required number of nurses is 50,000, home helpers 70,000, and the staff working at day service centers, health facilities for the aged and special nursing homes 110,000.
To secure such human resources is the essential challenge, and the government is promoting the policy measures focused on the improved work environment and conditions and raising the wages by the year 1992.