It's time to think about a new deal for the old DAVID WOODS
"Having learned to consider old age akin to disease (the North American elderly) develop unlimited economic needs paying for interminable therapies that are usually ineffective and frequently demeaning and painful, which most often call for recovery in a special milieu." So says philosopher Ivan Illich in his provocative and stimulating little red book, "Medical Nemesis". Illich goes on to point out that 10% of the US population is over 65, that 28% of health care is spent on this minority and that medicine cannot do much for illness associated with ageing - and even less about the process of ageing itself. Small wonder that the rapidly growing numbers of people over 65 - that arbitrary age at which most of them are put out to pasture - are viewed as an affront to medical science, as collections of variously declining organs and faculties and as subjects for inventive euphemism. The aged are "senior citizens" who are offered "golden age" tickets at movie theatres, and are usually herded together. in "twilight homes" because the rest of us know instinctively that that's what's best for them. Physicians, like anyone else, don't like to be reminded of their own mortality, yet they, faced with an aged patient for whom they can do little or nothing, must also confront the limitations of their science. Perhaps this is why, among the 60odd varieties of medical specialists, there are to my knowledge no geriatricians as such. This may be all to the good, since such a specialty would not be like collecting inanimate antiques that might be restored to their original condition; moreover, it would fly in the face of conventional medical school teaching which tends to show that science has a ready solution for practically everything.
Geriatrics doesn't lend itself to easy black-and-white answers. The old person's feelings of loneliness or uselessness, for instance, may give rise to a host of psychosomatic problems which require reassurance, time, knowledge, compassion - not just a quickie prescription for another chemical. For this reason, the family physician may be ideally suited to take a particular interest in old people. First, because the needs of the aged are based more on care than on cure; second, because continuity of awareness and attention provides this type of care - at the very least linking episodic in'tervention by other specialists. But whoever does the caring, a great deal of immediate discussion is going to have to take place if we, in Canada, are to avoid a geriatric crisis. As Dr. Cope Schwenger put it to
60 CMA JOURNAL/JULY 3, 1976/VOL. 115
Hastings: a community matter
the inaugural symposium on community health in Toronto last October, there are now 1.7 million Canadians over 65. By 1986 that figure will increase by 50%; it will have increased by 100% in the year 2001 and by 250% in 2031. And that's not merely some fanciful prediction: all those people are living now. Dr. Schwenger pointed out that there will also be tremendous increases in the over-75 and over-85 populations, with an attendant higher demand for institutional care. Unless we ensure that such care is used only for the severely disabled, said Schwenger, "we're going to break the bank." Recognizing the need for new answers if a geriatric crisis is to be averted, Dr. John Evans, University of Toronto president, has initiated a task force on gerontology. The task force will be chaired by Dr. John Hastings, associate dean of the faculty of medicine's community health division, who believes that the problem and its solution are community matters involving what he calls an ecumenical, multidisciplinary approach. One would hope that such a holistic view of geriatrics will be able to embrace old people themselves, for surely it is they who - perhaps more than anyone else - can provide the sharpest focus on health care for the aged. For example, a research project conducted last year in Ottawa to find out what old people believe they need in the way of health and social services showed that lack of transportation and limited awareness of financial assistance programs are two barriers to seeking out health resources in the community. Often, as a delegate to a 1974 CMA symposium on geriatric care observed, old people cannot travel, or pay for travel, to doctors' offices; those who do manage to find their way there may simply not have the funds to fill the resulting prescription.
Another speaker at the same symposium felt that a return to the housecall would benefit older patients, although it was agreed that physicians' fee schedules would have to be adjusted so that MDs weren't financially penalized for providing geriatric care in the home. But since it is mainly ongoing care that's needed, since mobility and lack of awareness of community resources are major problems for the aged and because, both from economic and humanitarian standpoints, the familiar home environment is preferable to the institutional one, the community is the key to effective geriatric care. In this context, the obvious back-up to continuous care from the family physician is the community volunteer, who can provide information and companionship, support and direction, transportation... Dr. Andrew Russell, honorary treasurer of the College of Family Physicians of Canada, says that getting this community support is not easy. And that's a shame, he believes, because often all the old people need is someone to talk with. Dr. Russell, a Beamsville, ON general practitioner who has a particular interest in geriatric care, says that his "specialty" is one that some family doctors simply drift into. Younger GPs, he says, tend to shy away from it because of what they see as limited rewards - you can't see quick improvements - and possibly because of inadequate medical school training in geriatrics. In his case, he was more or less coralled into it when the United Church built a home for the aged in Beamsville - Albright Manor - with 230 residents and a staff of 100 fulltime and 40 part-time workers. The town, with a population of 4000 and five physicians, including Dr. Russell, who practise in one group, had an instant and urgent need for a geriatrician. Russell, a soft-spoken but forthright fellow in his SOs, is clearly a people doctor whose adjustment to the new role would not have been a major one. More of the same Older people, he says, get more of the same afflictions - and more severely - than younger ones; you can't prescribe the same dosages because the aged often don't tolerate drugs well. But mostly, he believes, their needs are for someone to give them reassurance and a sense of worth. Apart from the inevitable degenerative problems, says Dr. Russell, the old suffer from loneliness, from a feeling of worthlessness and from a sense that they're merely putting in time.
Can we do more? With our society's emphasis on youth, with the nuclear family that has shuffled off grandma and grandpa, with medical science's conquest of such killer diseases as pneumonia (once known as the old man's friend) many of the aged have a fear not of dying - but of living too long, of being a burden. A believer in prevention, in understanding the ageing process more fully, Dr. Russell says the old people that cope best are those that have led active lives, physically and mentally. For this reason, he finds that he is urging sports and hobbies on his nongeriatric patients so that they can build early enough the interests that will sustain them in later years. Russell spends about 10 hours a week at Albright Manor. On Mondays and Thursdays he has an office practice there, seeing residents by appointment; on the other days he goes through the one-a-year physical examinations, doing about three a day. He is also on permanent emergency call for the manor, which is about 1.5 km from his home. Inevitably, he finds himself involved in speaking to groups of residents about nutrition, physical activity and other health-related topics - as well as counselling new or potential residents. Acknowledging that this type of medical input fulfils only a part of the geriatric patient's total health needs, Dr. Russell says there must be nothing less than wholehearted community involvement and interest in its older members. For example, he notes the increase in the numbers of patients he sees when the rates are raised at the
Manor. Finances are a source of worry to the old, many of whom are on fixed incomes; perhaps a bank manager or an accountant could provide better therapy when economic troubles arise. Model support system A working model for this type of total community response is the Minneapolis Age and Opportunity Center (MAO), started by executive director Daphne Krause, an 6migr. Englishwoman, 7 years ago. The organization now serves 2000 people a month, providing some 12 500 individual services. Counselling, food and transportation are provided on a 24-hour basis; other services include home-delivered meals, medical care, help with housekeeping, legal advice, financial assistance, telephone reassurance, home visiting and library service for the homebound. MAO, which began on a shoestring budget, went on to attract funding from the US administration on ageing, and from the Minnesota governor's council on ageing, as well as from other agencies - and is now a flourishing medical/social support system offering not only a real alternative to institutionalization but a sunnier life within the community for the aged. In Britain - the Old Country, as it's sometimes called in Canada people suddenly become Old Age Pensioners when they reach 65, which must come as something of a shock to those who not only hadn't thought of themselves as old, but who, biologically, may be rather youthful. Perhaps because Britain has many
CMA JOURNAL/JULY 3, 1976/VOL. 115 61
I
For economic and humanitarian reasons, the home environment is preferable to the InstitutionaL The onus is on the community to back up medical care wholeheartedly so that the home does not become another sort of prison.
more over -65s than Canada does, the healing professions in that country appear to be more involved, more innovative, than their counterparts here when it comes to geriatric care. Canadian input growing
This may be why, as one of their number, Dr. Rory Fisher, puts it "more British geriatricians are being parachuted into Canada" - although he stresses that there's a small but growing group of Canadian physicians who have been doing excellent work in this field. Dr. Fisher, who landed here 4 years
ago, is head of the department of
extended care at Toronto's Sunnybrook
forces, working parties, research programs and the like. At Sunnybrook the extended care department is a 570-bed facility. Overall, it operates on the principal recommendation of the 1974 World Health Organization's "Planning and organization of geriatric services" document, that such services should be provided along preventive lines with emphasis on early diagnosis and on attempts to keep old people in the community as long as possible. To this end, the department has been divided into three units: assessment, to determine the incoming patient's precise needs; rehabilitation, to provide ongoing therapy with the cooperation of the patient's family; and psychogeriatric, where the changing mental function of old age and the depressions that often accompany it are looked after.
Medical Centre. Although he regards himself as a geriatrician, he admits that the term hasn't caught on yet in North America where he has become "an internist with a special interest in geriatrics". It's a special interest not shared by many in the medical profession, Fisher Day-hospital suggests, although he says the situation As well as the long-term wards for is changing. He points to the 4-year-old the unavoidably institutionalized stroke Canadian Association of Gerontology, patient, for example, Sunnybrook has which at its Toronto meeting this year focused on a day-hospital concept had a registration of over 300, and to the first in Ontario. the growing number of geriatrics task Patients arrive first thing in the mor64 CMA JOURNAL/JULY 3, 1976/VOL. 115
fling, participate in therapeutic activity, and leave at the end of the day. This, says Dr. Fisher, is less traumatic than bringing them in for an hour or two "and it gives us much more control over the care." Like Dr. Russell, Fisher is a firm believer in preventive medicine and in community care for the aged. Any institution, he says, no matter how well-run, is bound to have some of the attributes of a prison; for reasons both of economics and humanity, our health care system should be better adapted to the needs of the elderly, says Dr. Fisher, and particularly to fulfilling those needs in the familiar environment of the patient's own home. Prevention, he points out, means not only getting rid of such home hazards to the elderly as loose rugs, but encouraging the use of brighter lights for reading and general purposes. It also means actively - and sometimes quite literally - nipping things in the bud; for instance, says Fisher, "I've seen old people confined to bed with ingrown toenails or something that could have been easily dealt with in an ambulatory setting." But he emphasizes that care must be active because many old people are inclined not to report the multiple pathology of old age simply because many of them ascribe their afflictions to age itself. With this in mind, Sunnybrook is planning an outreach program in which all patients over 70 at a nearby group practice will have their health needs checked regularly and automatically. Alternatives For the future, says Fisher, the solution will be to encourage more geriatricians, particularly in the major urban centres, and to develop alternative methods of geriatric care - alternatives that will be markedly different from the existing tendency to bring on more hospital beds and to fill general hospitals with elderly nonacute patients who come to be regarded as placement problems. There are those who work in geriatric care who believe that even to talk about a patient's age is as discriminatory as asking about his religion; that therapy should be based on biological, rather than chronological, age. Perhaps they're thinking of the much-publicized Swedish 60-year olds that are physically the equivalent of North Americans in their 30s. In any event, its clearly time to abandon old ways of thinking about the old. And to develop active, community-based, positive, multidisciplinary approaches to the care of this rapidly growing segment of our population.E
"Having learned to consider old age akin to disease (the North American elderly) develop unlimited economic needs paying for interminable therapies that are usually ineffective and frequently demeaning and painful, which most often call for recovery in a special milieu." So says philosopher Ivan Illich in his provocative and stimulating little red book, "Medical Nemesis". Illich goes on to point out that 10% of the US population is over 65, that 28% of health care is spent on this minority and that medicine cannot do much for illness associated with ageing - and even less about the process of ageing itself. Small wonder that the rapidly growing numbers of people over 65 - that arbitrary age at which most of them are put out to pasture - are viewed as an affront to medical science, as collections of variously declining organs and faculties and as subjects for inventive euphemism. The aged are "senior citizens" who are offered "golden age" tickets at movie theatres, and are usually herded together. in "twilight homes" because the rest of us know instinctively that that's what's best for them. Physicians, like anyone else, don't like to be reminded of their own mortality, yet they, faced with an aged patient for whom they can do little or nothing, must also confront the limitations of their science. Perhaps this is why, among the 60odd varieties of medical specialists, there are to my knowledge no geriatricians as such. This may be all to the good, since such a specialty would not be like collecting inanimate antiques that might be restored to their original condition; moreover, it would fly in the face of conventional medical school teaching which tends to show that science has a ready solution for practically everything.
Geriatrics doesn't lend itself to easy black-and-white answers. The old person's feelings of loneliness or uselessness, for instance, may give rise to a host of psychosomatic problems which require reassurance, time, knowledge, compassion - not just a quickie prescription for another chemical. For this reason, the family physician may be ideally suited to take a particular interest in old people. First, because the needs of the aged are based more on care than on cure; second, because continuity of awareness and attention provides this type of care - at the very least linking episodic in'tervention by other specialists. But whoever does the caring, a great deal of immediate discussion is going to have to take place if we, in Canada, are to avoid a geriatric crisis. As Dr. Cope Schwenger put it to
60 CMA JOURNAL/JULY 3, 1976/VOL. 115
Hastings: a community matter
the inaugural symposium on community health in Toronto last October, there are now 1.7 million Canadians over 65. By 1986 that figure will increase by 50%; it will have increased by 100% in the year 2001 and by 250% in 2031. And that's not merely some fanciful prediction: all those people are living now. Dr. Schwenger pointed out that there will also be tremendous increases in the over-75 and over-85 populations, with an attendant higher demand for institutional care. Unless we ensure that such care is used only for the severely disabled, said Schwenger, "we're going to break the bank." Recognizing the need for new answers if a geriatric crisis is to be averted, Dr. John Evans, University of Toronto president, has initiated a task force on gerontology. The task force will be chaired by Dr. John Hastings, associate dean of the faculty of medicine's community health division, who believes that the problem and its solution are community matters involving what he calls an ecumenical, multidisciplinary approach. One would hope that such a holistic view of geriatrics will be able to embrace old people themselves, for surely it is they who - perhaps more than anyone else - can provide the sharpest focus on health care for the aged. For example, a research project conducted last year in Ottawa to find out what old people believe they need in the way of health and social services showed that lack of transportation and limited awareness of financial assistance programs are two barriers to seeking out health resources in the community. Often, as a delegate to a 1974 CMA symposium on geriatric care observed, old people cannot travel, or pay for travel, to doctors' offices; those who do manage to find their way there may simply not have the funds to fill the resulting prescription.
Another speaker at the same symposium felt that a return to the housecall would benefit older patients, although it was agreed that physicians' fee schedules would have to be adjusted so that MDs weren't financially penalized for providing geriatric care in the home. But since it is mainly ongoing care that's needed, since mobility and lack of awareness of community resources are major problems for the aged and because, both from economic and humanitarian standpoints, the familiar home environment is preferable to the institutional one, the community is the key to effective geriatric care. In this context, the obvious back-up to continuous care from the family physician is the community volunteer, who can provide information and companionship, support and direction, transportation... Dr. Andrew Russell, honorary treasurer of the College of Family Physicians of Canada, says that getting this community support is not easy. And that's a shame, he believes, because often all the old people need is someone to talk with. Dr. Russell, a Beamsville, ON general practitioner who has a particular interest in geriatric care, says that his "specialty" is one that some family doctors simply drift into. Younger GPs, he says, tend to shy away from it because of what they see as limited rewards - you can't see quick improvements - and possibly because of inadequate medical school training in geriatrics. In his case, he was more or less coralled into it when the United Church built a home for the aged in Beamsville - Albright Manor - with 230 residents and a staff of 100 fulltime and 40 part-time workers. The town, with a population of 4000 and five physicians, including Dr. Russell, who practise in one group, had an instant and urgent need for a geriatrician. Russell, a soft-spoken but forthright fellow in his SOs, is clearly a people doctor whose adjustment to the new role would not have been a major one. More of the same Older people, he says, get more of the same afflictions - and more severely - than younger ones; you can't prescribe the same dosages because the aged often don't tolerate drugs well. But mostly, he believes, their needs are for someone to give them reassurance and a sense of worth. Apart from the inevitable degenerative problems, says Dr. Russell, the old suffer from loneliness, from a feeling of worthlessness and from a sense that they're merely putting in time.
Can we do more? With our society's emphasis on youth, with the nuclear family that has shuffled off grandma and grandpa, with medical science's conquest of such killer diseases as pneumonia (once known as the old man's friend) many of the aged have a fear not of dying - but of living too long, of being a burden. A believer in prevention, in understanding the ageing process more fully, Dr. Russell says the old people that cope best are those that have led active lives, physically and mentally. For this reason, he finds that he is urging sports and hobbies on his nongeriatric patients so that they can build early enough the interests that will sustain them in later years. Russell spends about 10 hours a week at Albright Manor. On Mondays and Thursdays he has an office practice there, seeing residents by appointment; on the other days he goes through the one-a-year physical examinations, doing about three a day. He is also on permanent emergency call for the manor, which is about 1.5 km from his home. Inevitably, he finds himself involved in speaking to groups of residents about nutrition, physical activity and other health-related topics - as well as counselling new or potential residents. Acknowledging that this type of medical input fulfils only a part of the geriatric patient's total health needs, Dr. Russell says there must be nothing less than wholehearted community involvement and interest in its older members. For example, he notes the increase in the numbers of patients he sees when the rates are raised at the
Manor. Finances are a source of worry to the old, many of whom are on fixed incomes; perhaps a bank manager or an accountant could provide better therapy when economic troubles arise. Model support system A working model for this type of total community response is the Minneapolis Age and Opportunity Center (MAO), started by executive director Daphne Krause, an 6migr. Englishwoman, 7 years ago. The organization now serves 2000 people a month, providing some 12 500 individual services. Counselling, food and transportation are provided on a 24-hour basis; other services include home-delivered meals, medical care, help with housekeeping, legal advice, financial assistance, telephone reassurance, home visiting and library service for the homebound. MAO, which began on a shoestring budget, went on to attract funding from the US administration on ageing, and from the Minnesota governor's council on ageing, as well as from other agencies - and is now a flourishing medical/social support system offering not only a real alternative to institutionalization but a sunnier life within the community for the aged. In Britain - the Old Country, as it's sometimes called in Canada people suddenly become Old Age Pensioners when they reach 65, which must come as something of a shock to those who not only hadn't thought of themselves as old, but who, biologically, may be rather youthful. Perhaps because Britain has many
CMA JOURNAL/JULY 3, 1976/VOL. 115 61
I
For economic and humanitarian reasons, the home environment is preferable to the InstitutionaL The onus is on the community to back up medical care wholeheartedly so that the home does not become another sort of prison.
more over -65s than Canada does, the healing professions in that country appear to be more involved, more innovative, than their counterparts here when it comes to geriatric care. Canadian input growing
This may be why, as one of their number, Dr. Rory Fisher, puts it "more British geriatricians are being parachuted into Canada" - although he stresses that there's a small but growing group of Canadian physicians who have been doing excellent work in this field. Dr. Fisher, who landed here 4 years
ago, is head of the department of
extended care at Toronto's Sunnybrook
forces, working parties, research programs and the like. At Sunnybrook the extended care department is a 570-bed facility. Overall, it operates on the principal recommendation of the 1974 World Health Organization's "Planning and organization of geriatric services" document, that such services should be provided along preventive lines with emphasis on early diagnosis and on attempts to keep old people in the community as long as possible. To this end, the department has been divided into three units: assessment, to determine the incoming patient's precise needs; rehabilitation, to provide ongoing therapy with the cooperation of the patient's family; and psychogeriatric, where the changing mental function of old age and the depressions that often accompany it are looked after.
Medical Centre. Although he regards himself as a geriatrician, he admits that the term hasn't caught on yet in North America where he has become "an internist with a special interest in geriatrics". It's a special interest not shared by many in the medical profession, Fisher Day-hospital suggests, although he says the situation As well as the long-term wards for is changing. He points to the 4-year-old the unavoidably institutionalized stroke Canadian Association of Gerontology, patient, for example, Sunnybrook has which at its Toronto meeting this year focused on a day-hospital concept had a registration of over 300, and to the first in Ontario. the growing number of geriatrics task Patients arrive first thing in the mor64 CMA JOURNAL/JULY 3, 1976/VOL. 115
fling, participate in therapeutic activity, and leave at the end of the day. This, says Dr. Fisher, is less traumatic than bringing them in for an hour or two "and it gives us much more control over the care." Like Dr. Russell, Fisher is a firm believer in preventive medicine and in community care for the aged. Any institution, he says, no matter how well-run, is bound to have some of the attributes of a prison; for reasons both of economics and humanity, our health care system should be better adapted to the needs of the elderly, says Dr. Fisher, and particularly to fulfilling those needs in the familiar environment of the patient's own home. Prevention, he points out, means not only getting rid of such home hazards to the elderly as loose rugs, but encouraging the use of brighter lights for reading and general purposes. It also means actively - and sometimes quite literally - nipping things in the bud; for instance, says Fisher, "I've seen old people confined to bed with ingrown toenails or something that could have been easily dealt with in an ambulatory setting." But he emphasizes that care must be active because many old people are inclined not to report the multiple pathology of old age simply because many of them ascribe their afflictions to age itself. With this in mind, Sunnybrook is planning an outreach program in which all patients over 70 at a nearby group practice will have their health needs checked regularly and automatically. Alternatives For the future, says Fisher, the solution will be to encourage more geriatricians, particularly in the major urban centres, and to develop alternative methods of geriatric care - alternatives that will be markedly different from the existing tendency to bring on more hospital beds and to fill general hospitals with elderly nonacute patients who come to be regarded as placement problems. There are those who work in geriatric care who believe that even to talk about a patient's age is as discriminatory as asking about his religion; that therapy should be based on biological, rather than chronological, age. Perhaps they're thinking of the much-publicized Swedish 60-year olds that are physically the equivalent of North Americans in their 30s. In any event, its clearly time to abandon old ways of thinking about the old. And to develop active, community-based, positive, multidisciplinary approaches to the care of this rapidly growing segment of our population.E
