Table 2 Challenges in managing multimorbidity for patients with dementia in Japan and Michigan

Environment

-Needs for community resources, family support

-Stigma to dementia

-Gap in available informal care resources in rural and urban areas

-Distance and transportation (to access health care services)

System

(Medical, Insurance)

-Lack of robust management guidelines for multimorbidity patients with dementia

-Short consultation time (10–15 min.) for managing multimorbidity with dementia

-System change of long-term care insurance causing a disadvantage for patients in the use of care service

-Free access medical system (barrier for patient-centered, holistic management)

-Medicare covers very little

Team

(Health care and

service provider)

 < Primary care physicians > 

-Complexity of adjusting medications

-Concerns for polypharmacy, adverse effects

-When to start, stop, or change dementia medications

-Identifying different types of dementia or psychosis-associated symptoms

-Managing behavioral issues

 < Primary care physicians > 

-Approaches to the patient's living environment and local community

 < Primary care physicians > 

-Preventing falls

-The use of anticoagulant medication

 < Other professionals > 

-Needs for care-coordinating professionals (social workers, care managers, case managers) knowledgeable in helping patients with dementia and behavioral issues

 < Other professionals > 

-Varied skill levels of care managers and visiting nurses

-Lack of professional care resources in rural areas

-Complex care management with crowded professionals in urban areas

-Hospitals or facilities might not accept patients with behavioral and psychological symptoms

 < Other professionals > 

-Need more access to specialists (Psychiatrists, Neurologists, etc.)

-Need for telemedicine (Consultation with specialists)

-Difficult to find a multidisciplinary team for old frail patients

-Lack of information or access to home care resources (situation varies by primary care physicians' setting)

Individual

(Patients and family)

-Decline of patients' self-management ability (life in general, clinical visits, medication)

-Patients living alone or only with an old spouse

-Patients having children or proxy in the distance (communication difficulty)

-Behavioral and psychological symptoms of dementia

-Patients/family not accepting or understanding dementia diagnosis

-Patients or family refusing care support (stigma)

-High burden on family caregivers

-Difficulty understanding the patients' will (decision-making for end-of-life care)

-Dependent attitudes to doctors in decision-making

-Financial limitation of patients/family, many cannot afford good care (move into a facility, acquiring home care)

-Caregivers not attending clinical visits (hard to understand patients' condition at home)

-Family members not agreeing to a DNR

-Cultural diversity (Language barriers, different ways of dealing with dementia)