Clinically, the older adults who do not respond to administrative surveys are at high risk for dementia and other diseases in many cases. The aim of this study is 1) to examine this hypothesis, and 2) to establish a support system to reach out to them and help them live well, in the community-based participatory research (CBPR) in Chiyoda-ward, Tokyo, Japan, using a mail survey as a starting point to visit older community-residents who did not respond to the administrative survey.

The participants were residents aged 65+, living in Chiyoda ward, Tokyo, Japan in 2021 (N=4009, mean aged 74.2±6.6, female 54.9%). We conducted the survey by following three steps. First, we distributed self-administered questionnaire to all participants by mail. Second, a survey request letter was mailed to the older adults who did not return the survey (N=675, aged70+). We conducting visit investigation by visiting nurses for old-old people (N=87), and conducting assessment to evaluate risks of dementia and physical health. Third supporting people with high risk of dementia through cooperation among various organizations and various professions, and conducting watching support by visiting nurses as prophylactic care.

For the investigation by mail, 2050 participants sent back the investigation form. Of the 87 people living alone or in aged households who responded to the request for a visit survey, we were able to conduct home-visit surveys for 46 participants (implementation rate: 52.9%). As a result of the comprehensive assessment, 15 participants (mean aged 81.9±5.0, female 53.6%, MMSE: 25.2±2.8), were regarded as participants with high risk of dementia, and 3people of them were started watching support work.

We established a support system for people living with dementia that consist early detection and continuous support by the visiting nurse. There were many cases in which the home-visit nurses investigation led to continuous support. For the further research, it is necessary to review the long-term outcomes of those who received early support concerning whether they could maintain their quality of life.