INTRODUCTION

There is a very vaguely defined word "Boke" in Japanese. When Boke is interpreted broadly, it includes normal mental aging, depression, mere illusion and delusion.
This paper discusses practical care offered at Usa Nursing Home TAISEIEN with an emphasis on dementia as defined in "Manual for Diagnosis and Statistical Processing of Psychiatric Diseases" published by American Association of Psychiatry, and more particularly on Alzheimer type senile dementia.

1. BASIC POLICY POR CARE

(1) Specialized care supported by related academic studies
As generally referred, dementia includes various conditions and diseases, and to discuss them collectively is not scientific nor specific. We should first distinguish dementia from those conditions that are similar to but not true dementia, and then identify the causes for dementia.
For instance, fever is seen in various diseases, and its treatment and care differs depending on the causative disease. The difference in underlying diseases calls for different treatments and care. The same is true of dementia. Depending on the underlying diseases, its mode of manifestation and psychological mechanism differ. The primary step in the specialized treatment and care is to respond to such differences. We therefore need support of related sciences such as medicine and psychology.
Alzheimer type senile dementia and cerebrovascular type dementia should at least be distinguished in care giving. For the cerebrovascular type dementia, we recommend caring them with patients of other diseases, while we recommend an exclusive care for Alzheimer type dementia. TAISEIEN is a facility exclusively for those with Alzheimer type dementia.

(2) Care for demented people regarding them as with disorders in daily activities
The secondary basic rule is to consider various behaviors of the demented elderly not as pathological problems but as mere difficulties in daily life.
For example. I should like to consider urinary incontinence. In a normal person, the signal from his bladder reaches his brain via the spinal cord when a prescribed amount of urine is accumulated and he feels an urge to urinate. The brain then judges whether or not he is in a condition to urinate. If he is attending a conference, he controls himself. If the brain judges it appropriate. he mentally locates the toilet, walks there, opens the door, enters it, locks from inside, loosens his belt, unfastens buttons or a fastener, assumes a correct posture for urination, relieves the restraint not to urinate, loosens the sphincter of the urinary tract. which m turn contracts the muscle of the bladder wall and begins urinating. After he is finished, he uses toilet paper, tidies himself, flushes the toilet, washes hands, unlocks the door, and goes out, thus completing the activity of urination.
A demented elderly may commit errors in various stages of these activities. For instance, a person reels an urge to urinate normally, but cannot rind the toilet because he has lost the sense of orientation, and fails in urination. If his action is interpreted as urinary continence, the countermeasure is the use of diapers. When it is considered as a difficulty in daily life in locating the toilet, then various countermeasures are conceivable. The toilet can be marked with a bold sign so that it can be located easily. The staff watches the client and astute]y senses that he wishes to urinate from his countenance and motions, and guides him to the toilet. By recording the time of urination and learning the interval, he is guided to the toilet at appropriate times. We expect that a sensor which is activated when a prescribed amount of urine accumulates in the bladder will be developed in a near future.
For those who find it difficult to undress and tidy himself afterward, a rubber band may be used instead of a belt or a string, or a Velcro tape may be used instead of buttons or a fastener to help him cope with his difficulties. For those who cannot flush the toilet properly, a sensor can be provided for automatic flush. For those who fail to feel micturition or those who cannot tell this because of a language disorder and have to rely on diapers, a sensor to tell wetting of the diapers is used. Reference will be made later to this device.
One of the basic policies is not to regard the behaviors of the demented elderlies as something to be restrained as a pathological problem, but as difficulties in daily life. In this context, we expect development of products with Japan's high technology to be really helpful for caring the demented elderlies to cope with their daily problems.
Conversely, such problems in daily life are useful for improving care. For instance, a demented elderly may have the difficulty in performing more than two ,things for one object concurrently or orderly. In order to protect them from exposure to risks, we use a lever type door knob for the rooms that we do not want them to enter. One must perform three operations of lifting the lever, rotating it by 90 degrees, and pulling the door forward in order to open this door. Thus, only one or two of our clients can actually open this door.
We are currently using various methods of assessing dementia including the Hasegawa Method. These methods can determine and evaluate to a degree the presence/absence of dementia, but not U]e content of their difficulties in daily life. We are looking forward to the development of an assessment method that would look into such matters in order to use it for our care.
A case for whom a sensor is used to detect wetted diapers is discussed.
Our system uses RX-NM made by NKK connected to NEC PC-9801.
An 81 year old woman with Alzheimer type dementia has various symptoms such as insomnia, hyperkinesis, speaking in loud voices, wandering, binge eating, pica ingestion, and playing with her feces. She was admitted to TAISEIEN because caring for her at home became difficult. Upon admission, she did not know where the toilet was located and wandered around. If guided properly to the toilet, she could discharge herself without difficulties. In the early morning of November 27, 1989 which was two months after her admission, she fell and suffered a fracture of the right femoral neck which required a surgical operation. After about two months, she was discharged from the hospital on January 23, 1990 with an indwelling catheter. She pulled the catheter out several days afterward, and was placed on diapers. From February 6th of the same year, a sensor to detect wetting was used. Figure I shows her urinary discharges during February, and Figure 2 urinary Frequencies measured at 30 minutes interval. The graph tells that peaks of discharge frequencies are at 10:00, 14:00, 16:00, 20:00 and 4:00. In March, we let her sit on the toilet seat at 6:00, 9:00, 13:00, 15:00, 18:00 and 2:00 but kept her on diapers and a sensor at other times. Figure 3 shows the result, indicating a radical decrease of diaper wetting. After March 17, we stopped using the sensor, and began periodically guiding her to toilet for discharge. The encircled parts in Figures 1 and 3 show that she had two to three urinary discharges with short intervals. This means that she cuts urination short because it is uncomfortable to urinate into diapers. If she was taken to the toilet to empty her bladder completely, the interval before the next urination is extended.

Fig. 1 Urination Frequency in a Month (Feb., '90)

Pig. 2 Urination frequency at 30 minutes interval (Feb., '90)

Fig. 3 Urination per month (March, 1990)


(3) To find the object hidden behind a seemingly meaningless behavior of an elderly
Specialists, particularly physicians, describe the conditions and activities of the demented elderly using medical jargons such as disorientation, wanderings, coprophilia, insomnia, excitement, etc. These alone are not useful for care. Wanderings alone can be attributed to various reasons such as for looking for own's home, looking for a toilet, looking for an imaginary client as a sales person, and looking for one's children. Behind seemingly meaningless behaviors of a demented elderly lie true objects and needs. In order to loam them, it is important not to restrain them but to observe the situation calmly with a scientific mind. In this context, we recommend against bodily restraints.

(4) Care without restraining physical or behavioral activities
Coprophilia or playing with own diaper is intended by the person to remove the discomfort after discharge. Letting the elderly wear one-piece dress to bodily restrain and prevent him from doing such an act is a physical restraint and violation of human rights. We do not resort to such a measure in our institution.
Placing the patient in an single room and locking the room is strictly prohibited even to prevent aimless wanderings. According to a survey. more than half of Japan's special nursing homes for the elderly lock the rooms constantly or as the need arises. One should be fully aware that locking the room, isolation or physical restraint of a patient in welfare facilities are illegal and criminal acts under the Law for Mental Health. I doubt advisability of public subsidies for providing individual rooms with sound roof walls and doors at special nursing homes for the aged.
I am a psychiatrist and I believe psychotropic medicines or sleeping pills are contraindicated for the patients suffering from insomnia, hyperkinesis, speaking in loud voice or wandering. I believe that psychotropics are indicated for pathological episodes of illusions or delusions and excessive fatigue because of intense uneasiness or excitement, and that leaving patients unattended with such conditions is contrary to their welfare. I therefore occasionally use small doses of psychotropics with care and observation. I also believe that we should be extremely careful in restraining patients socially, mentally or psychologically in addition to using physical or pharmaceutical restraints.

2. PSYCHOLOGICAL CHARACTERISTICS OP ALZHEIMER TYPE DEMENTIA

(1) Living in a fictitious world
As pointed out by Dr. Murobuse of Kikuchi Hospital, Kumamoto, elderly people suffering from Alzheimer type dementia, particularly Korsakoff type, appear to be living in a fictitious world of their own. This world transcends the logical cause-result relationship, time-space or gain/loss, and sensitivity is the determinant factor for activities. Thus, it is important to recognize this fictitious world and to secure a sensitive life in caring such people.
As I mentioned in the beginning. I believe the care for Alzheimer type dementia is best given in a facility which cares such people exclusively. The rationale is that it is easier to construct the world of fiction in such an environment.

(2) Living with an intense sense of uneasiness
People with Alzheimer type dementia are living with an intense sense of uneasiness as their past and present are cut apart because they forget what happened minutes ago. This sense of uneasiness is intensified if he is alone. Thus. Alzheimer type demented elderlies constantly seek their peers, excessively adapt themselves to others, and prefer a lively environment. When this characteristic is applied to their care, leading them in plural numbers to the toilet or bathroom achieves a better result than leading them singly. Group recreations are preferred than individual ones.

3. ROLE-PLAYING IS THE ATTITUDE TO TAKE IN CARING ALZHEIMER TYPE SENILE DEMENTIA

A fictitious world is a world of drama and theatrical art, a world of children playing house, make-believe-shopping, and playing school. Caring for the Alzheimer type dementia thus requires role-playing.

(1) Providing a proper stage
A drama requires a stage. Stage sets, props, costume, lighting and backdrops are required even for imaginary dramas. The institution is a theater, and facilities, equipments and furniture are props and stage sets. It is important to create an environment where demented old persons can live in a fictitious world of their own in a relaxed and safe way despite difficulties in daily life.
Our institution is described as a theater. Corridors are connected together in a loop, and clients can walk the corridors as much as they like. Benches are placed along the corridor to sit down and take rest, and a court yard is planted with flowering plants to please the eyes. On the walls are placed flower arrangements, photographs, pictures, and handicraft works made by clients during the work therapy. People who silently wandered the ground shortly after admission to the institution begin to appreciate flowers and works on the walls, talk to each other holding hands, and begin to walk more leisurely. At the center of the loop is located the staff's office. The staff constantly watch clients, speak to them as they pass the corridor, and try to let them relax. As there are many who hide slippers and walk barefoot, the floor is heated by the hot water pipes installed beneath (Figure 4).

Fig. 4

Verandas are provided outside the rooms to expand the psychological space and to secure the escape routes for emergencies such as fire. Veranda can be reached directly from the rooms and are provided with guide rails. If one walks alongside the guide rail. one is led into the room naturally. There are provided infrared sensors above the guide rails to alert the staff if a patient tried to climb over the rail and go outside. TV cameras are provided outside the building to monitor the verandas and garden. Any stray persons can thus be detected easily and the staff alerted b the buzzer in the office.
Since demented elderly persons commit errors because of their inability to spot the toilet in time, we placed conspicuous signs. Our toilet is a flush type, but many people no longer know how to flush a toilet. The urinal is mounted with a sensor for automatic flushing, and a shower is provided inside the toilet to wash soils that may attach to the body. The toilet seat is heated to let the clients sit comfortably even during the winter time. The biggest problem is the toilet paper. Clients tend to take toilet rolls with them, hide them inside their cloth or wrap around the body to play. The staff always carry extra rolls to hand them out whenever the see somebody enter the toilet.
The next point concerns colors. The overall color scheme was planned to create a cheerful and comfortable atmosphere, but I wonder if the scheme was appropriate. With aging, the cornea becomes tinted with yellow. Thus, old people are looking at things as if through yellow colored glasses. According to a recent study using a camera mounted with a yellow filter, some colors are very hard to see. For instance, yellow becomes indistinguishable from white if seen through a yellow filter. I used bright yellow for the toilet door, but this may have been a mistake. I have found out that red, bright pink and blue are well perceived by the elderly. At our institution, the residents and staff wear any clothes that they like, not uniforms. When a young staff wears a colorful dress of red or blue, the old people invariably admire the dress, saying "You look pretty. Where did you buy it? Was it expensive?" They always take watermelon and strawberries first from a variety of fruits served.
I tried to alleviate disorientation by using colors, although the design plan did not allow the use of different colors for all individual rooms. I therefore had the doors painted in different colors. In the looped corridor, the northern part and the southern part are painted with different shades of green. The floor in front of the emergency exit is painted red and the outer walls of the staff office are painted pink to make them conspicuous.
The building is one-storied, faces the south and has no steps in order to provide a wide, open space. Common spaces such as a multi-purpose hall for group activities, work therapies, recreation, etc. and a dining room are also important.
The hall is spacious and has a well for lighting and ventilation.
Most rooms accommodate four persons, and a few are for two-person or single-person occupancy. Although I agree in principle with the theory of providing individual rooms for single-person occupancy, I think that mid-stage Alzheimer type senile dementia people appear to relax more if they share a room with several people. This is not so for those in the initial and the terminal stages. This is because of their intense anxiety which is aggravated by being alone. There are both Japanese style tatami rooms and Western style rooms with beds. Our clients seem to prefer tatami rooms. As for the beds, we use low beds in order to prevent falls and fractures.
We pay special attention to the shape and position of the receptacles and switches for lights, faucets, door knobs, etc. based on our philosophy of helping the demented elderlies to cope and overcome the difficulties in daily life.

(2) Scenario adapted to individuals
A drama requires a scenario. Those with Alzheimer type dementia are described as going back to their childhood. However, I feel that no matter how advanced dementia is, the elderlies have had experiences of long and fruitful years and they arc not children. To treat them as children is to defy their self-respect and unstabilize them mentally. An old person may be angered and refuse to change if he is told to change because he has wetted his clothing and his act of urination was not property done. But he would listen if the staff blamed himself instead. We should adopt an individualized scenario depending on the client.
It is important to familiarize oneself with the life history, academic background, professional background, personal traits, etc. of clients in order to write butter scenarios. It is also important to learn about the society and life of the past ages when they grew up and had been active in society and manners and habits of those ages by conducting historical researches. Dialogues should be spoken with the accent of the area where they grew up. Speaking with a dialect of the southern Japan to a person born in the northern Japan is not preferable. The staff should learn slangs and professional jargons, but naturally avoid foreign words that have crept into Japanese language recently.
There are differences depending on the degree of dementia. As the dementia proceeds, the person appears to grow mentally younger. An 80-year-old person claims that she is 18 and unmarried, and a scenario adapted to the situation should be written.
Thus, the most important thing is to be fully aware of individual traits of all the clients, to write scenarios for each of them, and be fully aware of such scenario.

(3) Training actors endowed with sensibility and sense of humor (human resources)
Every old person is a veteran actor with experience in life extending longer than any of the staff. Even though he may forget things, his sensibility is not impaired and his perception astute. No matter how well the scenario is written, the staff should be prepared to cope with more. The staff should support old persons so that they can play the leading roles in a relaxed and pleasant way, and should be prepared even to speak ad lib lines in response to unexpected acts and lines of the elderly. It is important to be fully equipped with intelligence, culture, and sensibility in addition to expertise knowledge. Improving the quality of human power is essential. At our institution, the number of staff exceeds the government standard by seven. One of d]em is the occupational therapist, although the current national standard does not require one. We believe he is an essential person for the care of demented elderly. I urge the government to review the standard and increase the quorum of staff to include an occupational therapist.

4. CASE STUDY ON CARE OP ALZHEIMER TYPE SENILE DEMENTIA

We shall call an 82-year-old Alzheimer type senile dementia woman as "Mrs. T " Her husband, a government official, died 30 years ago, and all of her four children have independent households, leaving her alone to live. From about 5 years prior to admission, she began to manifest symptoms of dementia. Dementia gradually progressed and reached a stage where she could no longer extinguish the fire, find her own home, and properly urinate, making her solitary living difficult. As a result of consultation, three of the children living in the same city decided to take turns in caring for her at their homes for one month at time. The monthly changes in environment and poor quality of care made her mental state most unstable. At her eldest daughter's home, she thought the son-in-law was a total stranger and even hit him with a club thinking that he was a thief who came into the house to steal from her. The son-in-law could nor take this insult long, and the rift between the wife and the husband aggravated to the point that the divorce was discussed and the marriage was on the verge of collapse. Because of the differences over how to care the parent, children quarreled and did not talk to each other any more.
The eldest daughter became so desperate that she felt that there was no choice but to kill herself and her mother. She chanced to pass TAISEIEN at such a time and asked for an appointment when she saw the announcement offering counselling services concerning the elderly. At the time of counselling, all she did was to cry and we were afraid that she might kill her parent if left unaided. We contacted the municipal government's office where she lived, took the mother to TAISEIEN under a short term urgent care, and then attended to the procedure of letting the mother enter the institution on a long term basis.
The biggest difficulty we had with Mrs. T. was that she refused to eat meals served at TAISEIEN, although she ate meals brought by her daughter. Even when specially prepared meals adapted to her preferences were served, she would not eat. Gradually, the staff learned that Mrs. T. did not eat meals "because she bad no money". Reasonings by the staff that "meals are free" " , meals are paid by the government" or "meals are paid for by her daughter" did not convince her.
Mrs. T. always carried a small purse in which she kept tissues and rubbishes. As most of our clients can no longer control their money, the administrator's office keeps their money on their behalf. Mrs. T. was no exception and thus she had no money in her purse. One day a staff thought of placing a 100 yen coin in her purse and inviting her to buy the meal at the dining room. She ate the meal, and then asked the price of the meal. When told that the meal was \500, she gave \100 and asked for change. After this incident, the staff made copies of \10,000 and \1,000 bills and stuffed her purse with the copied money. Mrs. T. was convinced that she could not take meals without paying for them. She asked prices for any services performed and paid with the paper monies that were provided by the staff. when asked for change, the staff gave her changes with the copied money. She was very generous and gave money to her mates spending as much as \1 million a day. Her friends would keep the money in their pockets, stockings, between mattresses, or even flush them in the toilet. Even though the staff kept collecting, Mrs. T. spent so much that the staff had to work very hard copying and forging notes. After about one year, she became accustomed to TAISEIEN to regard it as her own home, and began complaining that strangers were entering her home without permission. The staff had to pay the rent with the forged money. This state lasted for some time, but gradually she lost interests in money. She then made frequent demands to go home, and the staff coped with such situation in the following manner.
Mrs. T. : "I want to go home. Is this the bus for"'?"
Staff ' : 'Yes. Mr. T."
Mrs. T. : "Please give me a ticket."
Staff : "Yes thank you (And hands Mrs. T the ticket specially prepared for her)."
Mrs. T. : "How much is it?"
Staff : "5 sen, ma'am. (It should not be \50 or \100, because she will be offended and say the price is too high. So it has to be \0.05.)"
Mrs. T. : "(She takes out the copy of \10,000 and gives it to the staff) Here you are."
Staff : "Thank you, ma'am."
Mrs. T. : "Where is my change? (She says indignantly The staff gives her five \1,000 bills.)"
Mrs. T. : "What time is it?"
Staff : "It is ･･･ o'clock."
Mrs. T. : "When is the next bus?"
Staff : "(Shows her the specially prepared timetable)
You have to wait another 30 minutes. Why don't you have tea (and serves her tea)?"
She forgets about going home as she has tea and chats with the staff. But after 30 minutes. she does the same thing.
Another trouble wilt Mrs. T. was that she became agitated when visitors came to TAISEIEN. She began talking in loud voices, wandering around, and taking out and putting back things in the closet aimlessly. We first thought that she did not like being seen by strangers and guided her to a room not visible to the visitors. One day, she found a pillow in the closet and asked the staff to "cook rice". We then realized that Mrs. T. wanted to offer foods to the visitors. On the day when we had other visitors, we asked Mrs. T. to serve tea. She was all smiles and served tea to the visitors, talking with them. Thus, Mrs. T. was always kept busy on the days when visitors came. In the evenings, she would come with the pillow and ask to cook rice. She apparently thought that the pillow contained rice. The staff would answer to her request by asking how many servings she needed or asking her to help with the tea and to wait.
Our next case concerns Mr. Y. who is 75 years old and has Alzheimer type dementia. Mr. Y. graduated from a teachers' college, taught at junior high schools for many years, and was appointed the principal and the chairman of the Committee for Education. Whenever Mr. Y. caught me talking to visitors, he criticized my way of presentation. In gatherings, he would always begin a speech which he never ends and gets angered if anybody tried to stop him. However, if we learned to ask him in advance to "Say a few words, but finish within one minute because we are pressed for time today". He would just say "hello" and bother us no more. He thought that the staff on night duty were the students who were not allowed to go home because of some misconducts, and would ask what they have done. He would not listen to the staff explaining about the night duty. "I forgot to do home work" or "I did not do the cleaning job" was the proper answer for him who would "talk to the class room teacher as a school master, and you may go home now". Then he went to his room to sleep.
Alzheimer type dementia patients are satisfied if we acted to comply with their wishes and demands and to humor them as if they were children playing shop or school. This method, however, is not effective for the cerebrovascular type dementia patients. The latter live in the realistic world, not in the fictitious world, and require explanations supported by reasons. For them, the fiction does not work. This is what I meant by my statement in the beginning that one word is not enough to describe all the dementia, and that care tailored to the specific needs and character of the underlying diseases for the dementia is necessary.

5. COMPREHENSIVE THEORY BASED ON MEMORIES

A recreational or occupational therapy which uses the effects of role-playing in a more positive way is discussed. Since TAISEIEN was opened, we have taken up various recreations hoping to give our clients more pleasure even in a short period of time. Fortunately, many of our staff have majored in education for small children, are qualified kindergarten teachers, and some have worked in day care centers and kindergartens. We ask them to lead the clients in singing children's songs and to teach them to play castanets and drums. We read popular old Japanese fairy tales and present simple dramas using pictures, dolls, etc. together with old people. As physical exercises, clients play throwing/catching balls, quoits, and simple gymnastics to folk music. Various activities such as calligraphy, flower arrangements, cooking, horticulture, and handicraft were also offered. In 1990, a fine arts major joined us who led clients in such activities as papier-mache making, painting, clay holding an ceramics. This year, a full time occupational therapist joined us to further diversify programs. Flute and guitar players visit us regularly to perform classic music, to which even highly demented people listen intently.
As the programs diversify, we now have monthly themes for activities and a party at the end of month to celebrate birthdays for those who were born in that particular month by presenting the results of activities of the month. For instance, we had the following activities in July this year.
"Summer" and "Mouse's bride" were the themes for July and "The sea" and "By the quiet lake" the songs of the month. The songs were played over [he public address system in the morning, during meals and tea time, and practiced every day. Depending on the songs, they practice and join playing with castanets, tambourines, drums, singing by clapping hands, or the finger moving or rhythm taking motions. Small groups are formed according to the degree of dementia and the level of remaining functions to engage in various activities adapted to the theme of the month. The group with more remaining functions decorate the stage and prepare backdrops, sceneries and props, masks and costumes. They also take parts in the play. Another group talked of their own weddings and marriages as they looked at the picture book of "Mouse's bride". They were also asked to practice songs for the play and vied with each other for muscle force.
The result of a month-long hard work and preparation is presented at the party. It starts with greetings from the president, followed by performance and gift giving. All sing the songs of the month, and watch the drama of the month. In July, a short play entitled "Mouse's bride" was played with everybody wearing masks (Figure 5). The bride and the bridegroom were played by clients wearing handmade gowns. All the residents participated in the play with the support of the staff whenever necessary. Alzheimer type dementia patients love to act in a play and enjoy themselves tremendously.

Fig. 5

Many researchers reported that remembering the past incidents and telling old tales are very useful for stabilizing the conditions of the demented elderly, particularly their emotional conditions. The programs offered by TAISEIEN are characterized in that various means such as music, drama, painting, cooking, handicrafts, calligraphy, paper culture shows, puppet plays, etc. are combined to enhance the effect of recollections. We call this activity as the comprehensive memory therapy.

6. REALITY ORIENTATION AND RE-MOTIVATION

Such programs may be apprehended as encouraging the elderlies to wander in their fictitious world. We pay special attention to the reality orientation to reinforce the remaining functions and to tell the reality. For instance, we talk of the date, the day of the week, the weather, etc. at the time the clients are awaken, before the meals, and before ceremonies or recreations. In choosing the monthly themes, we pay particular attention to the season and the traditional events of the community in order to remind clients of the season they are currently having. At the birthday party, the dates of those born in that particular month are mentioned, the current news is discussed, and the places of birth and past occupations are mentioned. Even in the short plays, adlib dialogues spoken by the staff are intended to reinforce cognition of the reality. We have monthly events in addition to birthday parties such as the dolls' festival, the cherry blossom viewing, Tanabata Festival of July 7th, the full moon viewing, or rice cake making. We have a day-to-day calendar in the hall to show the date at a glance. Analog clocks appear to be easier than digital ones. We show videos showing old houses and families of the clients, their families, and the famous and historic sites, shrines and temples of their home towns. We have newspapers, magazines and televisions.
One of the activities involves cooking. We are sometimes surprised at the function retained by the demented persons, especially women, in cooking. Young staff members enjoy being scolded and taught cooking skills. The use of a sharp knife presents no problems and electromagnetic cookers protect clients from possible hazard of handling fire. The clients are asked to help with daily chores such as holding towels, aprons and diapers, cleaning, feeding cats, dogs and chicken, and watering flowers. It is our wish that such chores may help them to reconstruct their ties with the real world.

7. SERVICES FOR COMMUNITY CARE

Before opening TAISEIEN. I worked for the Center for Mental Health and was keenly interested in the community mental health. I believe that welfare facilities should have outpatient clinics in addition to inpatient departments as the core for supporting care at home. The community services offered by us during the two years since the opening are discussed.
1) Counselling for the care and mental health of the elderly
2) Class for the care of the elderly
3) Preparing and distributing manuals on the care
4) Short term institutional care
5) Night time care
6) Rehabilitation for outpatients
7) Regular study meetings on difficult-to-care demented elderlies. and publishing and distributing case study reports
8) Preparing and distributing pamphlets for enlightenment and public relations
9) Lectures and education activities for the community
10) Training and receiving volunteers

Based on these activities, we implemented "Project for Promoting Community Care for Demented Elderly" in 1989. The project aimed to develop and organize resources for supporting the care of demented elderly at home, and to structure a care network system with multiple stages.
The project is discussed in more concrete terms.
1) Establishing Council for Promotion of Community Care
2) Fact finding survey on the needs of single and frail elderlies
3) Investigation on the long-term and the short-term inhabitants of Usa Nursing Home TAISEIEN
4) Class for training human resources for caretaking and volunteer training. the preparatory class for the National Examination for caretaker/welfare personnel. and study meetings for cases for whom caretaking is difficult
5) Preparing and distributing manuals for care
6) Implementing day care home business as a service for supporting care at home
7) Education for community people such as lecture meetings
8) Preparing and distributing reports

I would like to discuss the day care home mentioned in (6) above. The day care home service is available currently for one day a week for one person. The hours are generally 5 to 6 hours a day. This may be useful to relieve a caregiver for just one day but not as a substitute for the institutionalized care. For instance, a working couple who care for the old parent while continuing their work cannot benefit from this service. Thus, we offer the day care services every day except Sundays from about 7:00 in the morning until about 7:00 at night. This helps the working couple to continue their work and the farmers families to care for their elderly at home.

8. SATELLITE SYSTEM

This day care home service is available to those living in certain limited communities, It is impossible to care for more than 10 people at one time because of limitations on hardware and software of the facilities. Therefore, we decided to open satellite stations in smaller communities and to dispatch our staff to offer day care service. The satellites use existing buildings such as public centers, old people's centers, children's day care centers and kindergartens with vacant rooms because of the decreased number of children, primary schools, temples, churches, and private homes. The satellites serve as the base for day care, food services and hot bath services, and offer counselling and training for care. The diaper supplies, purchases and disposal, recycling of care supplies and volunteer services are also offered.
Advantages of the satellite system are discussed below.
1) Services are accessible in the community where people live
2) Access to the day care center is easy.
3) Family members can participate in the activities to receive care training, etc. and form ties with members of similar families.
4) Specific needs are easily identified.
5) Service is available at any time for any length of time.
6) People of the community can participate in the activities, thus enlightening local people and promoting the spirit of mutual help.
7) Healthy elderlies and children can participate as volunteers.
8) Volunteer organization can be organized and community members encouraged to take pan in the welfare activities.
9) Even when some families are reluctant to receive helpers and volunteers at their homes, they are usually willing to receive services at the satellite center.
10) Participation by the physicians, public health nurses, nurses, welfare committee members, welfare case workers, etc, will facilitate mutual cooperation, ties, integration of welfare, health and medical care or private and public administration.

Disadvantages of the satellite system, on the other hand, are that such organization tends to lack the integrity or specificity of care, and fails to appropriately address the need for concentrated and emphatic care. If the parent facility is to support and supervise the staff at the satellites, we can help make up for disadvantages in their training and consultation. We opened the day care service center and the support center for care at home in March, 1991, and the satellites on an experimental basis in July, 1991.

9. SERVICES FOR HEALTH, WELFARE AND CULTURE OP THE COMMUNITY BY THE COMMUNITY POR THE COMMUNITY

The aging rate of Usa City and its vicinity, Oita Prefecture where TAISEIEN is located surpasses that of the national and prefectural averages, and is above 30% in some communities. The exodus of youths to cities leaving old parents behind is excessive. Once the old people become frail in body or in mind, their daily life becomes immediately difficult. Even if they were living together with younger generation, the increase of nuclear families and working women remarkably deteriorates the caring function of a family. It is extremely difficult to look after old parents only by the family members. We are determined therefore to regard every phenomenon of the community as social resources including the deteriorated care functions of households, to incorporate them together, to enhance the spirit of self-help and mutual aid, to improve the care functions as a community, and to create the care system for the community by the community.
Fortunately, local people in Japan have honored the spirit of a commune among families, communities, or of relatives and neighbors. Such spirit should be reinforced in order to encourage building a township, village, humans, welfare and health culture where handicapped or old people may live securely with an institution acting as a core and to build satellites as the base.

10. CONCLUSION

Demented elderlies tend to give the impression that they understand nothing, can make no judgement between good and bad, cause sexual problems, are immoral and malicious, and are a presence without the human dignity. Even though they may have deteriorated memory and are forgetful, their emotions are the same as those of a healthy person and their dignity as human beings should be respected. Alzheimer type demented elderlies, in particular, live their life by being dependent on their sensitivity, not gains or losses or reasons, and their emotions are expressed in a purer form than a healthy person. Therefore, the most important thing in caring them is to pay respect to their sensibilities.
Welfare should not be regarded as a mere technical help for the weak. It should be considered in the light of interpersonal relationship, a person-to-community relationship and as a culture, and is interpreted as the movement for creating new culture, new township, village or humans.