Let's talk about quality affordable eldercare

The Lien Foundation brought two elderly Singapore women to Japan to see their eldercare facilities, which highlight a simple point that care for the elderly can be delivered in a manner that is humane and cost-effective.

If you have 30 minutes this weekend, you can do worse things than to check out Genki Kaki, a website of the Lien Foundation with articles and videos on ageing in Japan.

The foundation brought two elderly Singapore women to Japan to see their eldercare facilities, including a mall that caters to the elderly, day care centre, assisted living centre and nursing home.

The website uses story-telling and analysis to highlight a simple point: care for the elderly can be delivered in a manner that is humane and cost-effective.

I was bowled over by the rich content on the website. More than that, I was struck by how different the approach is in Japan and Singapore, towards the elderly.

Three takeaways from that series of articles.

1. The elderly can be viewed as an economic minus or plus

The fact that an entire floor of a mall in Tokyo, the Aeon Mall Kasai, is turned over to elders, highlights their potential as consumers.

The department store doesn’t carry baseball bats, but plenty of hiking gear to cater to elderly Japanese folks’ fondness for walking. The supermarket has single portion foods without a singles’ premium. A members’ gym has no treadmills, but many machines for stretching.

Aeon Mall Kasai – a much-loved hangout hotspot for elderly shoppers - conducts mass exercise classes. PHOTO: LIEN FOUNDATION

Much has been said about the potential for the silver economy. We haven’t really tapped that market here. It might be time to, as we near 2030 which is when about one million people cross over into the ages of 65 and beyond.

2. No restraints please, we’re your elders

In Japan, the use of physical restraints in eldercare settings is prohibited.

The Genki Kaki report says nursing homes use sensors to track seniors’ movements, and encourage them to stay active.


In Singapore, not only is it allowed, studies some time ago suggest it is common.

A 2005 paper that has been widely cited, by K. Mamun and J. Lim, reported that out of 390 elderly residents studied, 91 were on physical restraints. Of these 91, 46 or half had “no documented indication for restraints”. The study’s conclusion: “Our study revealed a high rate of restraint use in the nursing homes. A restraint protocol should be available in every nursing home, requiring physician approval for the long-term application of physical restraints and intermittent reviews by physicians to assess the continued need for restraints.”

Restraint use may be useful - for safety reasons, to confine falls, for example. But it’s easy to see how it might become too easy an option for understaffed nursing homes.

To be fair, that was over 10 years ago. A lot of work and resources have gone into the eldercare sector since to boost standards. In 2015, eldercare centres and home-based care providers were given a set of guidelines. The use of restraints is discouraged, but is permitted as a last resort, for a temporary period, when there is an immediate safety risk. It has to be applied under specific protocols and procedures and its use reviewed and documented.

But given that any registered nurse can authorise restraints in a long-term care facility, all those safeguards are of dubious effect unless the institution sets up strict rules against too-easy usage and enforces them.

In the United States, the use of restraints in nursing homes became an issue over 20 years ago. According to one report, “since 1990, physical restraint use in American nursing homes has markedly decreased from 35 per cent in 1991 to 3.3 per cent in 2012”.

In an article published in the Dec 4, 2012, issue of Asian Nursing Research , authors Eun-Hi Kong and Lois K.Evans cited different studies to estimate the prevalence of restraint use in nursing homes: 59 per cent in the Netherlands , 33.7 per cent in Canada, 28 per cent in Finland , 26.2 per cent in Germany and 6 per cent in Switzerland. 

In South Korea, the use of wrist restraints was estimated at 84.6 per cent, based on a study in 2009 of the prevalence of physical restraints in 13 units in seven Korean long-term care facilities. But the introduction of a long-term care insurance plan, which had regulators inspecting homes every two years, sparked a rise in standards in Korea's long-term care sector and created pressure on nursing homes to reduce such use.

This led to a new standard being introduced. Said the authors: "According to the standard, restraint use is allowed only in three situations: life-threatening event, no alternatives to restraint use, and temporary use of restraint to permit care for symptoms of medical conditions. To use restraint, Korean nursing staff is required to provide explanations to and receive written permission from elders and families and also record the reason for and process of restraint use. Therefore, Korean nursing homes are under pressure to reduce restraint use and have started providing restraint reduction education programmes for their staff. Despite these efforts, physical restraints remain in common use in Korean nursing homes.”

Apart from that 2005 study, I couldn’t find any more recent study online on the prevalence of restraint use in nursing homes here. It would be good to have such a study, and have a public discussion on the issue. After all, I am sure that most of us don’t fancy living out our old age in a home where staff resort to physical restraints as a mode of control or for convenience.

3. Good eldercare can be affordable

The Genki Kaki website features a state-funded home in Shibuya in central Tokyo, run by a non-profit organisation, Shoukichi Fukushikai.

In keeping with its no-diaper policy, Japan's state-funded Morinokaze nursing home has ensuite toilets in all rooms, which are equipped with support frames to help residents relieve themselves naturally. PHOTO: LIEN FOUNDATION 

Residents stay in single rooms with attached toilets. There’s a no-restraints policy. There’s also a “no diaper” policy as the home believes it’s good for old people to relieve themselves naturally and that a good diet and exercise help them do so. Half of new residents are on diapers - remarkably, they are successfully weaned off diapers after they arrive.

About once a week, kids from the kindergarten next door come over for joint activities with the elders.

Japan's Morinokaze nursing home is located next to a kindergarten and the children come over at least once a week for tea and joint activities with the seniors. PHOTO: LIEN FOUNDATION

According to the report, “the full costs are between 300,000 and 400,000 yen per person per month (around S$3,700 to S$4,900)”.
“After Government subsidies and insurance, residents pay between 70,000 yen (S$860) and 180,000 yen (S$2,200) per month.”

The Lien Foundation has done a public service in raising awareness of what is possible in good quality and affordable eldercare in Japan. It is left to us Singaporeans to press for higher standards in our own eldercare sector.