Keywords

1 Introduction

Last November in Tokyo an international conference was held as a follow-up to the G8 Dementia Summit. This year Prime Minister Shinzo Abe declared a “national strategy on dementia.” Countermeasures against dementia require the attention of the entire nation. It is estimated that in Japan, by 2025 one out of every five elderly persons above age 65, or roughly seven million people, will have dementia.

The basic principle of the “Plan for Promotion of Measures against Dementia,” also known as the New Orange Plan, is “to respect the wills of those who have dementia, and to realize a society where they can live in a familiar, good environment and continue living life in their own way.” This principle overlaps with our principle, which is “With the collaboration of medical treatment and nursing care, to make it our goal to have everyone smile every day and live life in accordance with their true selves.”

The group home “Nursing Care for Communal Living for Dementia Patients” is a nursing insurance service for those with dementia to receive care and live communally. It is specialized to offer care of those with dementia to support respect for the individual and decrease BPSD (Behavioral Psychological Symptoms of Dementia) including depression, paranoia, irritation, excitement, violence, wandering, etc.

At the group home, non-drug treatment is the main way of dealing with dementia. Specifically, the treatments include reminiscence therapy, music therapy, physical therapy, occupational therapy, recreational therapy, and horticultural therapy. In this paper we would like to introduce environmental maintenance and psychotherapy as methods. This is the concrete practice of Person Centered Care [1]. In one of the forms of reminiscence therapy which focuses on memory dysfunction, media therapy, the person reminisced with their family and staff about their life, and it was attempted to raise the quality of care and as a result there was a decrease in BPSD.

At the group home “Terado” records of conversations (process records) of patients with dementia were read before and after the practice of tea ceremony, which has been continued at the group home since its opening. The practice of tea ceremony at the group home has an effect towards unexpected emotional reactions, mood, and emotions, and not only does it allow patients to enjoy the activity at the moment, but was seen to be effective in the improvement of everyday living, feeling purpose in life, and creating a sense of belonging. For those with dementia whose ability to communicate verbally has deteriorated by their condition, the practice of tea ceremony provides the security of following a set pattern and also allows better relations with others through spending time together at the same place with the same purpose. Also it provides an occasion for family members and staff to understand the person with dementia, who they are and how their spirits are. This leads to greater respect for the individual with dementia and a consequent reduction of BPSD.

2 Practicing Tea Ceremony at “Terado”: Tea Ceremony

The group home must provide time and space where people can smile from their heart and make full use of their survival ability. The care staff must respect those with dementia as “whole persons” and at all times acknowledge their personhood [1]. However, the amount of time is in fact limited in which each person with dementia is listened to and acknowledged as a whole person and their suffering is understood. Therefore, it is important to devise strategies for daily recreation.

Types of recreation rooted in traditional Japanese culture such as “Ikebana” (Japanese flower arrangement) and tea ceremony are more easily accepted by those with dementia and are popular among family members and care staff. As a practical matter, without the approval of family members continuation is difficult, and if the recreation is not interesting for the care staff then it does not last long.

Tea ceremony, along with “Ikebana”, was first among arts young ladies were expected to master, and “Kaiseki” cuisine, served as part of the tea ceremony, has now been designated a world heritage. Honeymoon meals served at ryokan (Japanese style hotels) are probably a luxurious version of “Chakaiseki” (meals served during tea ceremony), and “Wagashi” (Japanese sweets) using bean-paste skillfully are beautiful to the eye and certainly delicious. Few people may have the morning habit of boiling water in a pot and enjoying a little powdered tea, but most Japanese people have had the experience of healing their fatigue with a little powdered tea and tea ceremony sweets at a temple in Kyoto or a tea store in Kamakura. Whether or not they were formally taught, most Japanese also know that it is proper to hold the tea ceremony bowl with both hands, not one; to raise it reverently over the head; and to slowly turn it before drinking.

“Hare and ke”: From ancient times the Japanese called ordinary days “ke” and non-ordinary days, those celebrating festivities and annual events, “hare,” thus differentiating the ordinary and the extraordinary. Japan, with its four seasons, has cherished annual events which give color to everyday living, and the Japanese people have enjoyed a lifestyle of variety with clear lines drawn. “Hatsugama” (the first tea ceremony of the year) at New Year’s as shown in Fig. 1 and the practicing of tea ceremony with seasons in mind allows those with dementia to have rhythm in their lifestyle and encourages rehabilitation of the brain’s ability to awaken and recover memory.

Fig. 1.
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“Hatsugama” in our group home

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3 Method

3.1 Planning the Practicing of Tea Ceremony

Practicing tea ceremony with those with dementia requires different considerations from practicing it with healthy people. To determine what specific considerations were necessary, discussions were held among the staff in charge, the teacher, nurses, care workers, and care managers, and an appropriate environment was set in place.

  1. 1.

    “Hatsugama” was set as an occasion for the participation of all residents, nursing care workers, and members of the community.

  2. 2.

    To enable residents, nursing care staff, and members of the community to wear kimono (Japanese traditional clothing) when participating in “Hatsugama”, a yearlong kimono-wearing class will be held, thus building enthusiasm.

  3. 3.

    To gain their support, family members will be informed that tea ceremony is part of the care of dementia.

  4. 4.

    To heighten expectation, tea ceremony practice will be brought up in ordinary conversation.

  5. 5.

    Residents’ general health will be improved. Leaving the main room and going to the tea room of the guest house creates a sense of being on an expedition, but if general health conditions are not good, this can become burdensome.

3.2 Method of Application of Practice of Tea Ceremony

Place, time, and frequency of tea ceremony practice are as follows.

  • Place: tea room of group home “Terado”

  • Time: from 2 pm until about 4:30 pm. People will be entering on their own so everyone can participate at their own pace

  • Frequency: once a month

Regarding the actual practice, the following stipulations were observed (Fig. 2).

Fig. 2.
figure 2

A photograph taken during practice

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  1. 1.

    The purpose is not to have participants master the procedures for making tea but to allow them, as experts in life, to offer advice to younger nursing staff members practicing tea ceremony.

  2. 2.

    Equipment such as “Fukusa” (silk wrapping cloth), folding fans, and “Kaishi” (paper folded and tucked inside the front of the kimono) are to be made ready to be quickly used.

  3. 3.

    “Mochi” (glutinous rice cake) should not be the main snack as it can stick in the throat.

  4. 4.

    The temperature of the powdered tea must be monitored. Never say “Please be careful because it is hot.”

  5. 5.

    The “Fukusa” is not to be handled by those with disability of the hand. Share information with the doctor beforehand.

  6. 6.

    Take existing friendships into consideration so that members of each table can enjoy their time together. Make sure that those who do not get along are not seated at the same Table 

  7. 7.

    Pay careful attention to whether participants are tired or not, or if they are pushing too hard.

  8. 8.

    Make sure that residents are not getting bored with nothing to do. Try to talk to those who do not usually strike up conversations themselves when there are many people around.

  9. 9.

    On the day of tea ceremony practice, make announcements to the residents in the morning and repeat over and over that today is the day for tea ceremony practice. Prepare the tea room together for making sure no one is forced to participate.

  10. 10.

    When the delivery of “Wagashi” comes from the local store, receive it together with the residents, and ask about the origin of the name of the “Wagashi” and its ingredients.

  11. 11.

    The staff receives training in preparation of the tea. Participants will refine their manners as guests, and enjoy talking about the season and the sweets as well as the arrangement of the room, the hanging scroll, the teacher’s comments, and the tea equipment.

  12. 12.

    The staff, as they practice preparing the tea, will maintain close coordination and adjust the entering of people from the main room.

3.3 Participants in the Tea Ceremony Practice

The average age of the group home residents is 85, and depending on the day they may or may not be able to participate. Also, it is difficult to maintain the same mood so the participants are not the same people each time. Besides residents, neighboring elderly people and local volunteers are also invited. At times a variety of guests may also participate, including local elementary school students, family members, kimono-wearing teachers, and staff of other offices.

  • Group home residents 8–15 people

  • Local elderly people 2–4 people

  • Local volunteers 2–5 people

  • Nursing care staff 3–5 people.

3.4 Evaluation Method

3.4.1 Method of Measuring the Effects of Tea Ceremony Practice

For the evaluation of tea ceremony practice, as regards to the psychological condition of the group home residents, to evaluate A before the practice, B during the practice, and C after the practice, the GBS scale [2], which is the scale used to evaluate the severity of different aspects of symptoms of dementia, was used and selections were made for the evaluation of emotion.

Specifically, the headings were “Emotional blunting”, “Emotional liability”, “Reduced motivation”, “Anxiety”, “Reduced mood” and “Restlessness,” and the person recording evaluated from a level of 0 (normal) to 6 (very bad).

3.4.2 Record of Conversations (Process Record)

A process record, something put forward by Hildegard Peplau (1952), is a written record of interpersonal relationships, especially nurse and patient interactions, in clinical nursing. The format of this record, influenced by the nursing process discipline of Ida Orlando (1972), was refined to a method whereby after an event the nurse notes the patient’s actions (interpersonal interaction), a percept analysis, and action taken based on that analysis, along with the nurse’s introspective observations. When the process record and nurse’s introspective observations were put into practice, Ernestine Wiedenbach (1962) standardized five self-evaluation categories, and clarified the technique of writing the process record so that a series of actions, or sequence, is taken as one undivided unit and each sequence is recorded as a chain of meaningful (i.e. analysis-worthy) actions and perceptions. Table 1 shows the example of the process record sheet.

Table 1. Example of the process record sheet
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3.5 Ethical Considerations

This investigation was carried out after we obtained consent, having explained using written documents that the gathered data will not be used for any purpose other than research, that when the research results are published no information that could identify individuals will be used, that participants’ privacy will be carefully protected, and that if there is any change in the consent data will be deleted, etc. We also explained orally that participation in the study is optional, and based on the response gained we determined that consent was attained.

4 Results

4.1 GBS Scale

Figure 3 shows the average of the GBS scale of all subjects for before the practice, during the practice, and after the practice. For the sake of comparison, the scale for “Ikebana” practice which is done in Terado is shown in Fig. 4. Compared to Fig. 4 of “Ikebana”, in Fig. 3 of tea ceremony the numbers for participants’ condition before practice are low on the whole; in other words, the conditions were good, so no remarkable difference cannot be acknowledged for before, during, and after the practice, but as with the practicing of “Ikebana” there was a tendency of conditions to improve during and after the practice. But for people with relatively bad conditions, as Fig. 5 shows there was a tendency for notable amelioration during the practice. In Figs. 3 and 4 the limit of the vertical axis was at 3.5, but in Fig. 5 it is at 6.

Fig. 3.
figure 3

Average of the GBS scale of all subjects in the tea practice (Color figure online)

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Fig. 4.
figure 4

Average of the GBS scale of all subjects in the “Ikebana” practice (Color figure online)

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Fig. 5.
figure 5

Average of the GBS scale of the people with relatively bad conditions (Color figure online)

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4.2 Records and Analysis of Utterance

As a characteristic of dementia, there is a frequent tendency to “cover up” from a desire that others not know one’s illness-related suffering and anxiety, so it is usually quite difficult to hear the honest feelings of the person. This complicates communication between the one with dementia and the care staff or family members. But this time, the record of utterances during the practice includes mention of the participant’s anxiety and suffering. Below are typical utterances regarding anxiety and suffering about time, relationships, and independence, from the perspective of spiritual pain [3].

  1. 1.

    “Wow, January, when was New Year’s? Did I eat mochi? I don’t know anything anymore.”

Uncertainty of previous memory leads to self-awareness of being forgetful and loss of the past; with the loss of the past, the present becomes uncertain and the future is also lost. There are no plans for the future or goals to shape the present. There is lack of understanding of why the person is where they are. (Spiritual pain with regard to time).

  1. 2.

    “Nobody from my family visits me. I feel lonely.”

Impaired orientation leads to a loss of relationships with others. Even family and friends become enemies, resulting in loneliness. (Spiritual pain with regard to relationships).

  1. 3.

    “How long will this hand be functional? I don’t want to live causing trouble to others.”

Functional disorders mean the things the person was once able to do are no longer possible, leading to a loss of independence and productivity. (Spiritual pain with regard to independence).

5 Observations

At Terado, besides the practicing of tea ceremony, they do other recreational activities rooted in traditional Japanese culture like “Ikebana.” But this time, with “Ikebana” and the practicing of tea ceremony, there was a measurable difference in effects. What could cause this difference, when both tea ceremony and “Ikebana” when are traditional forms of Japanese culture? Participants in the practice of tea ceremony included people who were relatively quieter and well-behaved, rather than those whose BPSD are more apparent, so the GBS scale was lower. In the practice of “Ikebana,” attention is given to the flowers in front of one, and if there are scissors and a flower container ready then hands will move by themselves and start arranging flowers naturally. The activity utilizes experiences of the past. In nursing care, attention naturally goes to people who are loud, or to who simply have low ADL and need more intensive nursing care.

A dementia patient, who is paranoid, thinks their daughter-in-law is a thief, and insists someone call the police can focus on something interesting in front of them and enjoy themselves. Another person believes that their grandchild, who is now an adult, is still in elementary school and tries to go pick him/her up at the school. Others mumble meaningless words. Residents with severe symptoms who came in contact with an atmosphere different from the usual, for example the flowers with their various colors and fragrances, the flower teacher, and guests from the larger community, showed amelioration of their symptoms.

It would be incorrect to say that the tea ceremony had no discernible effects. This is because records of conversation during the practice include comments that get to the heart of caring for those with dementia. Usually, those who have a higher need for nursing care and those who speak with a loud voice do not have noticeable BPSD, but those with dementia experience spiritual pain. They feel that living is pointless and experience suffering, feelings of emptiness, purposelessness, vanity, and loneliness. In palliative medicine this is called “spiritual pain.” The thoughts that filter out during the practice of tea ceremony suggest where the staff should direct their awareness and become involved, and are considered true words of the participants.

“Ichigo ichie,” one of the teachings of the tea ceremony, means to value meetings that occur only once in a lifetime, and the non-ordinary place, atmosphere, and environment of the tea ceremony practice allows those words to come true. The shift from the main room to the tea room; the teacher and staff in kimono; the sound of the hot water boiling in the pot; the fragrance of incense; the attention poured on the tea server’s every motion in a charged atmosphere; people giving strict admonishments to the care staff, who become students; people laughing: the space is definitely non-ordinary, and it is a world without barrier between givers and receivers of care. In this environment, whether one is aware of it or not, interpersonal communication is more easily established.

6 Conclusion

People can mind others and move towards independence once they are understood and attain a feeling of mutual understanding. What kind of care does not treat dementia patients as people who no longer know anything but acknowledges their individuality and treats them with according respect? Care eases suffering, makes it lighter, or makes it go away [4]. What is the anxiety and suffering of a person with dementia? Going beyond “cogito ergo sum (I think therefore I am),” there needs to be the mindset of “although I have dementia and I am different from who I once was, I desire, I feel, and I connect to other people; therefore I still exist.” The suffering of those with dementia is the loss of meaning in life, loss of value, loss of purpose, loneliness, alienation, and emptiness which are all “suffering that comes from the loss of the meaning and existence of the self” [5].

Tea ceremony practice in the group home provided a chance to dig deeply into the idea of how and what to do for caregiving. Caregiving is based on relationship, and its purpose is to ease suffering and make it disappear through that relationship. The purpose of the tea ceremony is not to drink delicious tea. As demonstrated in the words “Ichigo Ichie” (once-in-a-lifetime encounter), the tea ceremony provides a setting for people to meet and understand one another. We showed that tea ceremony can be a “shape” that facilitates human relationships and that it can be effectively used in the frontlines of caring for those with dementia.