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Geriatr Gerontol Int 2014; 14: 138–145

ORIGINAL ARTICLE: EPIDEMIOLOGY,

CLINICAL PRACTICE AND HEALTH

Longitudinal study of the cognitive, behavioral and physical

status of day care service users with dementia: Factors
associated with long-term day care use
Toshiyuki Ono,1 Akira Tamai,1 Daisuke Takeuchi,1 Yuzuru Tamai2 and Yuka Hasegawa3

Departments of 1Psychiatry, 2Internal Medicine, 3Division of Rehabilitation, Tsuruga Onsen Hospital, Tsuruga, Japan

Aim: The aim of the present retrospective study was to investigate the time-courses of the cognitive, behavioral and
physical status of day care service users with dementia, and to determine the factors associated with the long-term use
of day care in order to aid the development of better interventions.
Methods: We analyzed the data of 162 consecutive patients who attended our day care clinic for 1 year or more
between 1 April 2000 and 31 March 2010. The patients were divided into three groups according to the length of their
day care attendance (the 1-year, 3-year and 5-year groups). Then, we investigated the time-courses of their cognitive,
behavioral and physical status. Logistic regression analysis was used to detect the factors that affect the duration of
day care service attendance in dementia patients.
Results: The Hasegawa Dementia Scale-Revised (HDS-R), Assessment Scale for Symptoms of Dementia (ASSD)
and Nishimura’s Activities of Daily Living (N-ADL) scores of the three groups all significantly deteriorated during the
study period except for the HDS-R score of the 3-year group. Higher age and a high ASSD score were associated with
a short period of day care service attendance, whereas the patients’ daughters-in-law acting as a caregiver was related
to the long-term use of day care services in model 1.
Conclusions: It is better to control behavioral and psychological symptoms in order to improve the utilities of day
care for dementia patients. The caregiving environment of dementia patients might be associated with the length of
day care attendance. Geriatr Gerontol Int 2014; 14: 138–145.

Keywords: behavioral and psychological symptoms, caregiver, day care, dementia, longitudinal study.

Introduction strongly associated with the long-term use of day care

Many studies have found that day care services for
dementia patients are useful.1–4 For example, Zank and
Schacke reported that visiting a day care center had
significant positive effects on the well-being and demen-
tia symptoms of dementia patients.3 In addition, we
found that the behavioral and psychological symptoms
of dementia (BPSD) were often responsible for the insti-
tutionalization and hospitalization of day care users
(Ono et al., unpublished data).
It is important to understand the prognosis of the
cognitive, behavioral and physical status of day
care users, and to understand which factors are most
Accepted for publication 28 February 2013.
Correspondence: Dr Toshiyuki Ono MD, PhD, Department of
Psychiatry, Tsuruga Onsen Hospital, 41-1-5 Yoshiko, Tsuruga,
Fukui, 914-0024, Japan. Email: turugaoh@poem.ocn.ne.jp
services in order to aid the development of better inter-
ventions for this patient population. In the present
study, we investigated the time-courses of the cognitive,
behavioral and physical status of day care users, and
evaluated the factors associated with the long-term use
of day care services.
Methods
Participants and procedures
We retrospectively analyzed the data of 162 consecutive
dementia patients who started to attend our day care
clinic, “Sunday” at Tsuruga, Fukui, Japan, between 1
April 2000 and 31 March 2010. The patients who
attended the day care center for 5 years or more were
followed up until 31 March 2012. Both patients with
intermittence for less than 12 months and those without
it were included, because our preliminary examination
showed that 92.7% of the patients who reused the day

138 兩 doi: 10.1111/ggi.12071 © 2013 Japan Geriatrics Society

 Longitudinal study of day care users
care clinic restarted to attend within 12 months. The
patients with intermittence over 1 year were excluded.
For the univariate and multivariate analyses, the
patients were divided into three groups according to
the length of their day care service attendance: (i)
patients who attended the day care service for ⱖ1 year
and <3 years (1-year group); (ii) those who attended for
3–5 years (3-year group); and (c) those who attended
for 5 years or more (5-year group). Median lengths of
day care attendance were 23, 44 and 73 months in the
1-, 3- and 5-year groups. A total of 89 patients in the
1-year group stopped attending the day care clinic due
to hospitalization because of physical problems (27)
and psychological problems (17), for institutionaliza-
tion (25), intention (10), and other reasons (10). A total
of 31 patients in the 3-year group stopped attend-
ing the day care clinic for hospitalization because of
physical problems (13) and psychological problems
(5), for institutionalization (6), intention (5), and other
reasons (2).
All of the patients fulfilled the criteria outlined in the
text version of the fourth edition of the Diagnostic and
Statistical Manual of Mental Disorders (DSM-IVTR)
for dementia of the Alzheimer’s type (DAT), vascular
dementia (VaD) or other types of dementia (OTD). A
total of 101 patients with DAT, 53 with VaD and eight
with other types of dementia attended our day care
clinic. Their age, sex, diagnosis, physical comorbidity,
complications during day care attendance (complica-
tion), primary caregiver and the number of cohabitants
were recorded. Cognitive status was assessed using
the Hasegawa Dementia Scale-Revised (HDS-R),5 and
the BPSD were evaluated using the Assessment Scale
for Symptoms of Dementia (ASSD).6 The ASSD con-
sists of 45 items including psychosis, affective symp-
toms, hyperactivity, apathy, aberrant motor behavior,
appetite/eating disturbance and sleep disturbance. A
high score on the ASSD indicates that the patient has
severe behavioral and psychological symptoms. The
patients’ functional status was assessed using Nish-
imura’s Activities of Daily Living scale (N-ADL).7 We
aimed to carry out these assessments every 3 months. If
it was not possible to obtain a patient’s HDS-R, ASSD
and/or N-ADL score at the scheduled time, we used
the score obtained before or after the scheduled time as
a substitute.
First, we investigated the differences in the character-
istics of each group. Next, we evaluated the difference in
the number of people cohabiting with the patient
among patients with different types of primary care-
givers. Then, we examined the time-courses of the
patients’ HDS-R, ASSD and N-ADL scores. We also
evaluated the differences between the patients’ initial
HDS-R, ASSD and N-ADL scores, and the scores at the
end of terms of 12, 36 and 60 months in each group, as
well as the annual changes in these scores. The annual
© 2013 Japan Geriatrics Society
changes were calculated using initial scores and those at
the end of terms.
Finally, binominal logistic regression analyses were
used to elucidate which factors affect the length of day
care service attendance by dementia patients.
Informed consent was obtained from all patients
and/or their caregivers. The experimental procedure
was carried out in accordance with the Declaration of
Helsinki.
Statistical analyses
The differences between each group’s characteristics
(age; sex; diagnosis; HDS-R, ASSD and N-ADL
scores; comorbidity; complication; primary caregiver;
and number of cohabitants) were assessed using the
Kruskal–Wallis test for continuous variables and the
c2-test for categorical data. The Steel–Dwass test and
c2-test were used for comparing the characteristics
of two groups. The Kruskal–Wallis test was used
to assess the differences in the number of cohabi-
tants among patients with different types of primary
caregivers.
The time-courses of each group’s HDS-R, ASSD and
N-ADL scores were analyzed using the Friedman test.
The Wilcoxon test was used to evaluate the differences
among the three groups in the change between the
participants’ initial HDS-R, ASSD and N-ADL scores,
and those at the end of terms of 12, 36 and 60 months,
whereas the Kruskal–Wallis test was used to evaluate the
differences in the annual changes in the participants’
HDS-R, ASSD and N-ADL scores among the three
groups. The Steel–Dwass test was used to assess the
differences in the annual changes in these scores in
comparisons between two groups.
Binomial logistic regression with a stepwise method
was used to analyze the associations between various
patient characteristics and the 1-year and 5-year groups.
In these analyses, we analyzed the effects of age, sex,
diagnosis, comorbidity, primary caregiver and the
number of cohabitants, as well as the initial HDS-R,
ASSD and N-ADL scores as measures of cognitive,
behavioral and functional status in model 1. In model 2,
we used characteristics including age at the final
attendance, sex, diagnosis, comorbidity, complication,
primary caregiver and the number of cohabitants, and
the final HDS-R, ASSD and N-ADL scores, respec-
tively. Caregivers were divided into five categories
(spouse, son, daughter, daughter-in-law and others).
“Others” included other relatives and caregiving staff.
The Hosmer–Lemeshow test was used to assess the
goodness-of-fit of these models. There were a few
pieces of missing data; however, there were no signifi-
cant differences in any variable between the whole
sample and the sample used in the binomial logistic
regression analysis.
兩 139
 T Ono et al.
All statistical analyses were carried out using SPSS
version 17.0 (SPSS, Chicago, IL, USA) and Statcel3
(OMS Shuppan, Tokorozawa Saitama, Japan).8 P-values
of <0.05 were considered significant.
Results
First, we evaluated the differences in the patients’ initial
HDS-R, ASSD, N-ADL and final N-ADL scores, and
also differences in the type of primary caregiver among
the three groups. The initial HDS-R, ASSD, N-ADL,
the final N-ADL scores, and the primary caregiver dis-
tributions of the 1-year and 5-year groups were signifi-
cantly different, and many of the patients in the 5-year
group were cared for by their daughters-in-law. The
initial HDS-R and N-ADL scores of the 1-year group
were significantly lower than those of the 5-year
group. In contrast, the initial ASSD score of the 1-year
group was significantly higher than that of the
5-year group; and also, the final N-ADL score in the
5-year group was significantly lower than that of
the 1-year group. There were no significant differences
in age, sex, diagnosis, comorbidity, complication or
the number of cohabitants among the three groups
(Table 1).
We also detected a significant difference (P ⱕ 0.001)
in the number of cohabitants among the patients with
different types of primary caregiver (mean number of
cohabitants: spouse: 1.85, SD 1.41, median 1; son: 1.86,
SD 1.58, median 2; daughter: 1.88, SD 1.68, median 2;
daughter-in-law: 2.49, SD 1.65, median 2; other rela-
tives: 1.08, SD 1.44, median 0.5; staff: 0, median 0). The
patients who were cared for by their daughters-in-law
lived with significantly more cohabitants than the
patients in the other primary caregiver groups.
The HDS-R (mean 15.8, median 16 to mean 13.7,
median 14; n = 73; P < 0.001), ASSD (mean 33.5,
median 31 to mean 43.2, median 41.5; n = 78; P <
0.001) and N-ADL (mean 43.4, median 47 to mean
40.8, median 42; n = 80; P < 0.001) scores of the 1-year
group gradually deteriorated during the study period, as
did those of the 5-year group (mean 20.8, median 22 to
mean 17.1, median 16, n = 31, P = 0.032; mean 22.8,
median 22 to mean 46.5, median 34, n = 29, P < 0.001;
and mean 45.8, median 49 to mean 37.1, median 42,
n = 34, P < 0.001, respectively). In the 3-year group, the
patients’ ASSD (mean 24.4, median 18 to mean 51.1,
median 46; n = 17; P < 0.001) and N-ADL (mean 45.7,
median 46 to mean 34.8, median 41; n = 19; P < 0.001)
scores gradually deteriorated during the study period,
whereas their HDS-R scores remained relatively stable
(mean 19.0, median 20 to mean 15.7, median 15.5;
n = 16; P = 0.082; Fig. 1).
There were significant differences between the initial
HDS-R, ASSD and N-ADL scores, and those at the end
of terms of all groups except for the HDS-R score of
140 兩
the 3-year group (Table 2). The annual change in the
HDS-R and N-ADL score differed significantly among
the three groups. There were no differences in the
annual changes in the ASSD scores between any of the
groups. The Steel–Dwass test detected significant dif-
ferences in the annual changes in the HDS-R score
between the 1-year group and 3-year, and in those
between the 1-year group and 5-year group (Table 3).
Binominal logistic regression analysis showed that
older age (B –0.077; Wald 5.306; P = 0.021; odds ratio
[OR] 0.926) and a high ASSD score (B –0.027; Wald
4.781; P = 0.029; OR 0.974) were associated with a short
period of day care attendance. Being cared for by your
daughter-in-law (B 1.684; Wald 6.660; P = 0.010; OR
5.385) was associated with the long-term use of day care
services in model 1. Model 2 showed that low N-ADL
score (B –0.058; Wald 10.647; P = 0.001; OR 0.943)
were associated with a long period of day care atten-
dance. The patients who were cared for by their
sons (B 1.429; Wald 3.928; P = 0.047; OR 4.176) or
daughters-in-law (B 2.006; Wald 9.950; P = 0.002; OR
7.436) were related to the long-term use of day care
services (Table 4).
Discussion
In the present study, we found that during their atten-
dance at day care services, the cognitive and physical
functions of dementia patients generally declined
regardless of the length of their day care use. The
mean annual changes in the patients’ HDS-R and
N-ADL scores were -1.71 and -2.43 points, respec-
tively. Panella et al. reported that after using the day
care program service for 3 months the dementia
patients showed non-significant improvements in their
cognitive and physical functions; however, after this
period their scores for these functions continuously
declined.1 Cox found that although the patients’ physi-
cal and cognitive functions continued to decline
throughout the 6-month respite program on Alzhe-
imer’s disease, their caregivers reported significant
improvements in their behavior.9
In contrast, in a study of elderly patients that had been
sent home from hospital emergency rooms, Caplan et al.
reported that the patients in their intervention group did
not show any reduction in cognitive function until the
18-month follow-up examination, whereas the control
group showed significant decreases in their cognitive
function at 6 and 12 months.10 In addition, Viola et al.
reported that a multimodal rehabilitation program
was associated with cognitive stability and significant
improvements in quality of life in Alzheimer’s disease
patients.11 These reports show the usefulness of respite
programs for preserving cognitive function in elderly
patients. However, the programs examined in these
studies only lasted for relatively short periods.
© 2013 Japan Geriatrics Society
 Longitudinal study of day care users

Table 1 Characteristics of the 162 patients

Characteristics Total 1-year 3-year 5-year P-value*

n = 162 n = 89 n = 31 n = 42
mean (SD) mean (SD) mean (SD) mean (SD)
interquartile interquartile interquartile interquartile
Age (years) 79.4 (6.9) 79.6 (7.2) 81.0 (5.8) 78.0 (7.0) 0.374
76, 80, 83.25 76, 80, 84 77, 80, 84 74.75, 79, 82.25
Sex Men 57 36 8 13 0.272
Women 105 53 23 29
Diagnosis DAT 101 55 21 25 0.949
VaD 53 29 9 15
OTD 8 5 1 2
Initial score of (n = 162) 17.3 (7.0) 15.9 (6.9) 17.6 (6.8) 19.9 (6.8) 0.003
HDR-R 13, 18, 22 11, 16, 21 13, 19, 23 17, 22, 24†
Initial score of (n = 162) 30.3 (21.1) 34.7 (22.1) 27.5 (15.2) 23.1 (20.6) 0.002
ASSD 15, 26, 41 19.5, 31, 47.5 17, 23, 34 8.75, 20.5, 28.25†
Initial score of (n = 162) 44.0 (7.6) 42.7 (8.5) 44.7 (5.9) 46.1 (6.2) 0.026
N-ADL 42, 47, 49 38.5, 46, 49 42, 46, 49 45, 49, 50†
Final score of (n = 158) 13.1 (8.9) 12.2 (8.1) 15.1 (8.8) 13.5 (10.3) 0.327
HDR-R 6, 12.5, 19.25 6, 12, 19 9, 15, 22.5 4.75, 13.5, 23.25
Final score of (n = 159) 49.1 (27.2) 48.8 (26.1) 47.4 (26.6) 50.8 (30.4) 0.893
ASSD 28, 42, 69 29.5, 45, 69 28, 39, 65.5 25.5, 40, 75.5
Final score of (n = 162) 35.5 (12.3) 38.1 (10.5) 34.5 (11.8) 30.7 (14.8) 0.018
N-ADL 27, 39.5, 46 31, 41, 47 25, 37, 45 19.75, 33.5, 42†
Comorbidity Yes 113 65 21 27 0.702
No 48 23 10 15
Missing 1 1 0 0
Complication Yes 68 31 15 22 0.281
No 85 53 15 17
Missing 9 5 1 3
Primary caregiver Spouse 47 30 7 10† 0.013
Son 22 10 4 8
Daughter 34 18 8 8
Daughter-in-law 35 10 10 15
Other relatives 12 9 2 1
Staff 10 10 0 0
Missing 2 2 0 0
No. cohabitants (n = 161) 1.86 (1.69) 1.70 (1.79) 2.23 (1.75) 1.95 (1.40) 0.120
1, 1, 3 0, 1, 3 1, 2, 3 1, 2, 3
*The Kruskal–Wallis test was used for comparisons between continuous variables, and the c2-test was used for comparing
categorical data. Significance levels obtained with the Steel–Dwass or c2-test refer to comparisons with the 1-year group;
†
P < 0.05. None of the variables showed significant differences between the 1-year and 3-year groups, or between the 3-year
and 5-year groups. ASSD, Assessment Scale for Symptoms of Dementia; DAT, dementia of Alzheimer’s type; HDS-R, revised
Hasegawa Dementia Scale; N-ADL, Nishimura’s Activities of Daily Living scale; OTD, other types of dementia; VaD, vascular
dementia.

Wilson et al. reported that Alzheimer’s disease
patients showed a mean annual reduction in their
Mini-Mental State Examination (MMSE) score of 3.26
points.12 The result of the present study, which showed
that the annual change of HDS-R was -1.71, might
indicate the effect of day care attendance on the cogni-
tive function of dementia patients, because the scores of
HDS-R and MMSE were highly correlated with each
other.13
Caro et al. reported that in patients with mild-to-
moderate Alzheimer’s disease, even relatively small
reductions in cognitive function increased their risk of
losing the ability to live independently.14 Wilson et al.
also reported that changes in cognitive function in old
age primarily reflected person-specific factors rather
than an inevitable developmental process, and that the
rate at which cognitive function declines in Alzheimer’s
disease patients is strongly related to survival.15,16 In the

© 2013 Japan Geriatrics Society 兩 141

 T Ono et al.
present study, the annual changes in HDS-R in the
3-year and 5-year groups were less than that of the
1-year group. It was suggested that sustaining cognitive
function is important for using day care services for a
long period. These reports showed that the mainte-
nance of cognitive functions is necessary for a better
quality of life.
Many reports have shown that the BPSD were
more common in patients with moderate to severe
dementia.17–19 In recent longitudinal studies of the
BPSD, Aalten et al. reported that apathy and aberrant
motor behavior persisted for longer periods, and hallu-
cinations, euphoria and disinhibition were the least per-
sistent symptoms.20 In a study of Alzheimer’s disease
142 兩
Figure 1 Changes in the Hasegawa
Dementia Scale-Revised (HDS-R),
Assessment Scale for Symptoms of
Dementia (ASSD) and Nishimura’s
Activities of Daily Living (N-ADL)
scores of the three groups. The
HDS-R (mean 15.8, median 16 to
mean 13.7, median 14; n = 73;
P < 0.001), ASSD (mean 33.5, median
31 to mean 43.2, median 41.5; n = 78;
P < 0.001) and N-ADL scores (mean
43.4, median 47 to mean 40.8, median
42; n = 80; P < 0.001) of the patients in
the 1-year group gradually
deteriorated, as did those of the
patients in the 5-year group (mean
20.8, median 22 to mean 17.1, median
16, n = 31, P = 0.032; mean 22.8,
median 22 to mean 46.5, median 34,
n = 29, P < 0.001; and mean 45.8,
median 49 to mean 37.1, median 42,
n = 34, P < 0.001, respectively). In the
3-year group, the patients’ ASSD
(mean 24.4, median 18 to mean 51.1,
median 46; n = 17; P < 0.001) and
N-ADL scores (mean 45.7, median
46 to mean 34.8, median 41; n = 19;
P < 0.001) gradually deteriorated;
however, their HDS-R scores remained
relatively stable (mean 19.0, median 20
to mean 15.7, median 15.5; n = 16;
P = 0.082). All P-values were derived
from the Friedman test.
patients, Garre-Olmo et al. showed that their patients’
mean psychotic syndrome score on the Neuropsychiat-
ric Inventory increased by 0.3 points between the base-
line and the 24-month assessment, whereas their mean
affective syndrome score and mean behavior syndrome
score increased by 0 and 1.8 points, respectively.21 Savva
et al. reported that most BPSD were likely to be present
at the 2-year follow-up examination in participants in
whom they were seen at the baseline, although the
strength of this association varied across symptoms.22
Wilson et al. reported that hallucinations, especially
visual hallucinations, were associated with a more
rapid global cognitive decline and increased mortality.23
However, Mossello et al. reported that a 2-month period
© 2013 Japan Geriatrics Society
 Longitudinal study of day care users

Table 2 Differences between the patients’ initial and final Hasegawa Dementia Scale-Revised, Assessment Scale
for Symptoms of Dementia and Nishimura’s Activities of Daily Living scores

Initial score The score at the end of term P-value*

mean (SD) mean (SD)
interquartile interquartile
1-year HDS-R (n = 83) 15.9 (6.8) 13.5 (8.0) <0.001
11, 16, 21 7, 14, 20
ASSD (n = 85) 35.0 (22.3) 44.7 (24.7) <0.001
19.5, 31, 47.5 27.5, 42, 56
N-ADL (n = 85) 42.5 (8.6) 40.0 (9.2) <0.001
38, 46, 49 35, 42, 48
3-year HDS-R (n = 24) 19.0 (5.7) 16.7 (9.6) 0.107
14, 20, 23 8, 19, 25.5
ASSD (n = 24) 24.4 (14.1) 45.5 (29.0) <0.001
15.25, 20.5, 32.75 25.75, 33, 64.5
N-ADL (n = 27) 44.5 (6.2) 35.3 (11.0) <0.001
42, 46, 49 27, 38, 44
5-year HDS-R (n = 39) 20.2 (6.7) 16.1 (9.6) 0.001
17, 22, 24 11, 16, 24
ASSD (n = 38) 23.4 (21.0) 46.7 (31.9) <0.001
8.75, 21, 28.25 24.75, 34.5, 66.75
N-ADL (n = 39) 46.2 (6.4) 37.1 (13.4) <0.001
45, 49, 50 32, 43, 48
*Wilcoxon test. ASSD, Assessment Scale for Symptoms of Dementia; HDS-R, revised Hasegawa Dementia Scale; N-ADL,
Nishimura’s Activities of Daily Living scale.

Table 3 Comparison of the annual changes in the Hasegawa Dementia Scale-Revised, Assessment Scale for
Symptoms of Dementia and Nishimura’s Activities of Daily Living scores among the three groups

Total 1-year 3-year 5-year P-value*

mean (SD) mean (SD) mean (SD) mean (SD)
interquartile interquartile interquartile interquartile
Change in HDS-R score (n = 146) -1.71 (3.89) -2.41 (4.83) -0.78 (2.23) -0.81 (1.39) 0.038
-3.5, -1, 0.23 -5, -2, 0 -2.75, -0.84, 0.59† -1.4, -0.6, 0.2†
Change in ASSD score (n = 147) 7.91 (13.39) 9.61 (16.32) 7.06 (8.60) 4.65 (6.20) 0.499
0, 4.2, 13 0, 7, 14.5 1.84, 3.5, 12.25 1.25, 3.5, 8.7
Change in N-ADL score (n = 151) -2.43 (4.64) -2.47 (5.70) -3.07 (3.41) -1.88 (2.16) 0.036
-4, -1, 0 -4, 0, 0 -5, -1.33, -0.67 -3.2, -1.2, 0
*Kruskal–Wallis test. Significance levels obtained with the Steel–Dwass test refer to comparisons with the 1-year group,
†
P < 0.05. ASSD, Assessment Scale for Symptoms of Dementia; HDS-R, revised Hasegawa Dementia Scale; N-ADL,
Nishimura’s Activities of Daily Living scale.

of day care assistance was effective at reducing the
behavioral and psychological symptoms of dementia
patients.24
In the present study, the patients’ BPSD deteriorated
in all groups and were found to be associated with the
long-term use of day care services. In our previous
study, the BPSD were the main causes of hospitalization
or institutionalization due to dementia (Ono et al.,
unpublished data). These results suggest that BPSD are
important prognostic factors in dementia patients. We
assume that it is necessary to control the BPSD of
dementia patients using adequate interventions in order
to improve their quality of life.
Beeber et al. reported that the following independent
variables affect the likelihood of needing to use an
adult day care service: the size and location (e.g., rural vs
metropolitan) of the county in which a patient lives,
the percentage of county residents living below the
federal poverty line and the number of comorbid condi-
tions suffered by the patient.25 In our previous report,

© 2013 Japan Geriatrics Society 兩 143

 T Ono et al.

Table 4 Binominal logistic regression with a stepwise method

B P Odds ratio Cox–Snell R2 Percentage correct

(95% confidence interval) classification
(Model 1)
Age -0.077 0.021 0.926 (0.867–0.989) 0.211 74.4
Primary caregiver
Spouse 0.008 Reference
Son 1.047 0.118 2.849 (0.766–10.597)
Daughter 0.199 0.748 1.220 (0.363–4.106)
Daughter-in-law 1.684 0.010 5.385 (1.499–19.342)
Others -1.784 0.110 0.168 (0.019–1.496)
ASSD score -0.027 0.029 0.974 (0.950–0.997)
Constant 5.685 0.029 294.561
(Model 2)
Primary caregiver 0.231 78.3
Spouse 0.003 Reference
Son 1.429 0.047 4.176 (1.016–17.163)
Daughter 0.774 0.242 2.168 (0.594–7.921)
Daughter-in-law 2.006 0.002 7.436 (2.138–25.870)
Others -1.362 0.229 0.256 (0.028–2.355)
N-ADL score -0.058 0.001 0.943 (0.911–0.977)
Constant 0.513 0.434 1.670
Binominal logistic regression with a stepwise method was used to analyze the relationship between the 1-year and 5-year
groups. The Hosmer–Lemeshow test was used to test the goodness-of-fit of the model 1 (c2 = 9.008, P = 0.342) and model 2
(c2 = 7.316, P = 0.503). ASSD, Assessment Scale for Symptoms of Dementia; N-ADL, Nishimura’s Activities of Daily Living
scale; Others, other relatives and caregiving staff.

reviewing all the users, including the patients using day
care less than 1 year, the length of day care attendance
was not affected by variables related to the caregiving
system (Ono et al. unpublished data). However, in the
present study, the patients who were cared for by their
daughters-in-law were more likely to use day care ser-
vices for a long period and to live with many cohabitants.
Retrospectively, the patients who were cared for by their
sons or daughters-in law attended our day care clinic for
a long time despite their low physical function. In the
other report, we compared the women with dementia
living alone with the ones living with their family mem-
bers.26 In the latter case, most of them were cared for by
their daughters-in-law, which caused them little distress
in caring. Therefore, it is assumed that they have good
relations each other. These results suggest that the
use of day care services is dependent on the caregiving
environment in which a patient’s needs are met.
In conclusion, the cognitive, behavioral and physical
statuses of patients who use day care services generally
deteriorate despite intervention programs. The care-
giving environment seems to affect whether a patient
requires long-term day care. Age and BPSD also play
important roles in the length of day care use. It is better
to confirm the effects of the caregiving environment on
dementia patients and control their BPSD in order to
improve the utilities of day care for these patients.
The present study had several limitations. First, our
conclusions are only based on data from one facility. In
addition, caregiving systems for dementia patients differ
among communities and countries; therefore, our
results cannot be generalized. Further analysis is neces-
sary to investigate the time-courses of the cognitive,
behavioral and physical status of dementia patients,
and evaluate the factors related to the long-term use
of day care in order to aid the development of better
interventions for this patient population.
Acknowledgment
We thank the staff of Tsuruga Onsen Hospital for their
help with this study.
Disclosure statement
The authors declare no conflict of interest.
References
1 Panella JJ, Lilliston BA, Brush D, McDowell FH. Day care
for dementia patients: an analysis of a four-year program.
J Am Geriatr Soc 1984; 32: 883–886.

144 兩 © 2013 Japan Geriatrics Society

 Longitudinal study of day care users
2 Zarit SH, Stephens MAP, Townsend A, Greene R. Stress
reduction for family caregivers: effects of adult day care
use. J Gerontol B Psychol Sci Soc Sci 1998; 53B: S267–S277.
3 Zank S, Schacke C. Evaluation of geriatric day care units:
effects on patients and caregivers. J Gerontol B Psychol Sci Soc
Sci 2002; 57B: P348–P357.
4 Gaugler JE, Jarrott SE, Zarit SH, Stephens MAP,
Townsend A, Greene R. Respite for dementia caregivers:
the effects of adult day service use on caregiving hours and
care demands. Int Psychogeriatr 2003; 15: 37–58.
5 Katoh S, Shimogaki M, Onodera A et al. Development of
the revised version of Hasegawa’s dementia scale (HDS-R).
Jpn J Geriatr Psychiatry 1991; 2: 1339–1347. (In Japanese.)
6 Ono T, Tamai A, Iwata K. Validity and reliability of
the Assessment Scale for Symptoms of Dementia. Jpn J
Geriatr Psychiatry 2002; 13: 191–204. (In Japanese.)
7 Kobayashi T, Hariguchi S, Nishimura T et al. A new clini-
cal scale for rating of mental states and activities of daily
living of the elderly (NM scale and N-ADL). Jpn J Clin
Psychiatry 1988; 17: 1653–1668. (In Japanese.)
8 Yanai H. 4Steps Ekuseru Toukei ver.3. Tokorozawa: OMS
Shuppan, 2011.
9 Cox C. Findings from a statewide program of respite care:
a comparison of service users, stoppers, and nonusers.
Gerontologist 1997; 37: 511–517.
10 Caplan GA, Williams AJ, Daly B, Abraham K. A random-
ized, controlled trial of comprehensive geriatric assessment
and multidisciplinary intervention after discharge of elderly
from the emergency department: the DEED II study. J Am
Geriatr Soc 2004; 52: 1417–1423.
11 Viola LF, Nunes PV, Yassuda MS et al. Effects of a multi-
disciplinary cognitive rehabilitation program for patients
with mild Alzheimer’s disease. Clinics (Sao Paulo) 2011; 66:
1395–1400.
12 Wilson RS, Gilly DW, Bennett DA, Beckett LA, Evans DA.
Person-specific paths of cognitive decline in Alzheimer’s
disease and their relation to age. Psychol Aging 2000; 15:
18–28.
13 Kim KW, Lee DY, Jhoo JH et al. Diagnostic accuracy of
mini-mental status examination and revised hasegawa
dementia scale for Alzheimer’s disease. Dement Geriatr Cogn
Disord 2005; 19: 324–330.
14 Caro J, Ward A, Ishak K et al. To what degree dose
cognitive impairment in Alzheimer’s disease predict
dependence of patients on caregivers? BMC Neurol 2002; 2:
6. [Cited 26 Nov 2012.] Available from URL: http://www.
biomedcentral.com/1471-2377/2/6
© 2013 Japan Geriatrics Society
15 Wilson RS, Beckett LA, Barnes LL et al. Individual differ-
ences in rates of change in cognitive abilities of older
persons. Psychol Aging 2002; 17: 179–193.
16 Wilson RS, Li Y, Aggarwal NT et al. Cognitive decline and
survival in Alzheimer’s disease. Int J Geriatr Psychiatry 2006;
21: 356–362.
17 Reisberg B, Franssen E, Sclan SG, Kluger A, Ferris SH.
Stage specific incidence of potentially remediable behav-
ioral symptoms in aging and Alzheimer disease: a study of
120 patients using the BEHAVE-AD. Bull Clin Neurosci
1989; 54: 95–112.
18 Mega MS, Cummings JL, Fiorello T, Gornbein J. The
spectrum of behavioral changes in Alzheimer’s disease.
Neurology 1996; 46: 130–135.
19 Lyketsos CG, Steinberg M, Tschanz JT, Norton MC,
Steffens DC, Breitner JCS. Mental and behavioral distur-
bances in dementia: findings from the Cache county study
on memory in aging. Am J Psychiatry 2000; 157: 708–
714.
20 Aalten P, de Vugt ME, Jaspers N, Jolles J, Verhey FRJ. The
course of neuropsychiatric symptoms in dementia. Part I:
findings from the two-year longitudinal Maasbed study.
Int J Geriatr Psychiatry 2005; 20: 523–530.
21 Garre-Olmo J, Lopez-Pousa S, Vilalta-Franch J, de Gracia
Blanco M, Vilarrasa AB. Grouping and trajectories of neu-
ropsychiatric symptoms in patients with Alzheimer’s
disease. Part II: two-year patient trajectories. J Alzheimers
Dis 2010; 22: 1169–1180.
22 Savva GM, Zaccai J, Matthews FE, Davidson JE,
McKeith I, Brayne C. Prevalence, correlates and course
of behavioral and psychological symptoms of dementia
in the population. Br J Psychiatry 2009; 194: 212–
219.
23 Wilson RS, Tang Y, Aggarwal NT et al. Hallucinations,
cognitive decline, and death in Alzheimer’s disease.
Neuroepidemiology 2006; 26: 68–75.
24 Mossello E, Caleri V, Razzi E et al. Day care for older
dementia patients: favorable effects on behavioral and
psychological symptoms and caregiver stress. Int J Geriatr
Psychiatry 2008; 23: 1066–1072.
25 Beeber AS, Thorpe JM, Clipp EC. Community-based
service use by elders with dementia and their caregivers: a
latent class analysis. Nurs Res 2008; 57: 312–321.
26 Ono T, Tamai A, Tamai Y et al. The distress of family
members caring for demented elderly and the effect of
gender differences on hospitalization. Jpn J Clin Psychiatry
2008; 37: 305–314. (In Japanese.)
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