Protecting the health of the elderly: a review of WHO activities

World Health Organization a,r, ~ Regional Office for Europe ~ ~ Copenhagen 'SI ii ~ Public Health in Europe 18 Protecting the health of the elderl A review of WHO activities IIIIIII IIIII IIIII IIIII IIIIIIIIII IIIII IIIII IIIII II * 000?8S½J .. Muriel Skeet ,, ISBN 92 890 1154 8 © World Health Organization 1983 Publications of the World Health Organization enjoy copyright protection in ac- cordance with the provisions of Protocol 2 of the Universal Copyright Convention. For rights of reproduction or translation , in part or in toto, of publications issued by the WHO Regional Office for Europe application should be made to the Regional Office for Europe, Scherfigsvej 8, D K-2100 Copenhagen 0 , Denmark. The Regional Office welcomes such applications . The designations employed and the presentation of the material in this publica- tion do not imply the expression of any opinion whatsoever on the part of the Secretariat of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. The mention of specific companies or of certa in manufacturers' products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned . Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. The views expressed in this publication are those of the author and do not necessarily represent the decisions or the stated policy of the World Health Organization. PRINTED IN DEN MARK ISSN 0300-4880 CONTENTS Preface ........ . I. The process of aging . . . . The aging process. Assessing old age . Future research .. 2. Establishing priorities in research ... .. . Aging of the nervous system . . Aging of cardiac muscle . Aging and endocrine function . The humoral immune response in aging Biological prospects for the extension of life . 3. Aging societies. . . . .... . ..... . Aging of populations . . . . . . . . . . . . Some effects of the multi-generation family . Health of elderly populations . 4. Clinical studies .. .... . Aging in relation to disease . Nutritional studies .. Physiological performance studies . Studies of cardiovascular diseases . Pharmacotherapy studies. Studies of mental disorders 5. Research programmes . Preventing premature aging and disease Promoting health . .. ... . . . • Health and social function assessments . Prevention and control of disease . Identification of risk groups . 6. Planning and providing services . Paye VII 2 4 8 11 12 14 15 16 17 19 19 33 37 41 41 42 45 49 50 57 63 63 69 71 72 74 77 General concepts and principles of geriatric services. . . . . . . . 78 Steps in planning and organizing health care services for the elderly . 79 Strategic planning . . . . . . . . . . . . . 80 V Some economic aspects of health care The primary level of care. Secondary and tertiary levels of care Continui ty of care Care of the dying . Division of responsibility . Some pointers to research 7. Education and training. Education and trai ning of professiona ls. Ed uca tional issues by profession . Educa tion and training of non-professionals . References. . . . . . .... . ... . .... . Annex. WHO meetings related to the care of the elderly . VJ 80 83 94 97 99 100 102 105 105 111 118 121 124 Preface During 1982, the year in which the United Nations held its World Assembly on Aging in Vienna , the European Region of WHO experienced an upsurge of interest in the health care of the elderly. This was due not only to the increasing numbers of elderly people in the Region , but also to their needs and demands/ or an actil'e old age on the one hand and health and social care on the other. requirements that have not been and are still not being adequately met. By the time of the World Assembly, WHO had been continuously inrnlred in the health care of the elderly f or almost a quarter of a century. But up to now no attempt has been made to reriew the contribution to this f ield of WHO, and the Regional Office f or Europe in particular.for the benefit of those directly inl'Olred or prof essionally interested in the subject. The most striking change during that period has been the shiji away from the gerontological approach. the purely scientific and academic study of aging carried out in a fe w centres inl'Olred in basic and beharioural research. The scient ific study of aging continues unabated, but the approach has broadened to in l'O fre many disciplines and to express a concern with the • ·greying of nations· ·. in the words of Dr R. Butler. Director of the National Institute on Aging in the United States. This l'Olume is based entirely on reports of WHO meetings related to the care of the elderly held since 1958: the author has introduced no ne1r material nor any of her own ideas. For this reason some of the facts presented may no longer be rnlid , and some of the approaches may hare been orertaken by more recent developments. Some of the terminology, too. may no longer be consisten t with current usage . The book has been written fo r those who are interested in derelopments in health care of the elderly f rom an interdisciplinary and international point of riew , and who may hare fo und it difficult to find their way around the multitude of WHO reports and publications on the subject. For this reason the tex t has been arranged in sel'en chapters corering the principal issues with u·hich WHO has been concerned. A common criticism of recommendations made in WHO reports, and thus of the many recorded in this l'Olume, is that they are too general. This criticism is partly justified. But the care of the elderly is so closely bound up with the traditions. socioeconomic development , health serl'ice structure and political system in each indil'idual country that it is manifestly impossible for WHO to make recommendations that are universally applicable. Each country must find VII ways of providing care for the elderly that correspond to its specific circum- stances. What WHO seeks to do is to bring together international experience and disseminate the knowledge available. so that countries are helped to find a solution more quickly. more economically and more effectively . The WHO Regional Office for Europe now has its own programme on the health care of the elderly, an important component in the Organization 's strategy for achieving "health/or all by the year 2000". By then , it is hoped, the elderly will be leading healthy and socially and economically satisfactory lives. For them the goal can be achieved step by step through close cooperation between scientists. the caring professions and the general public. If this volume contributes to a beu er understanding of the problems of the elderly, and greater mutual cooperation among the interests involved , it will have served its purpose. VIII Leo A. Kaprio WHO Regional Director for Europe 1 The process of aging Today we are witnessing a new phenomenon in the history of mankind: the extraordinary increase in the proportion of older people in the population. Fundamentally it is a triumph. Almost universally it is regarded as a problem. Until recently scientists and medical practitioners were very largely concerned with childhood and maturity, life expectancy being relatively short and the small proportion of the population that survived beyond middle age being scarcely noticeable and therefore posing few, if any, social problems in general. Furthermore, earlier periods in history traditionally provided roles and care for the older generation, and the minimum of intervention was required from agencies outside the elderly person's own family . The significant increase in life expectancy has opened up new and relatively uninvestigated periods of life during which profound changes take place. Middle age and old age, like the earlier phases oflife, have unique features that need to be studied and understood for themselves. The increased proportion of middle-aged and older persons has brought about new social pressures and needs that require imaginative thinking. Research, service, and training programmes must take into account: (a) differences in biophysical charac- teristics between older and younger people; (b) alterations in physiological capacity and function; (c) changes in the later stages of life; and (d) the special influences of the socioeconomic organization of society on older people and the special adaptations required to meet their needs. Although the field of gerontology is relatively new, broad divisions of subject matter have already appeared and, within them, various specialties related to particular aspects and problems of aging. Gerontology began with the study of the biological and psychological processes of aging in the individual and now includes the study of time-related changes and their interactions and their biological, physiological, and sociological aspects . Geriatric medicine is that branch of medicine concerned with signs and symptoms, treatment, rehabilitation, and prevention in aging patients. Social gerontology, a recent term, covers the growing body of theory and knowledge concerning the aging individual as he is influenced by, and influences. society. and society itself as it acts upon aging individuals and adapts itself to their presence and needs. Research on the phenomenon of senescence, as a complex of morpholo- gical, functional, psychological, clinical , and social changes, has made considerable progress over the past two decades. Many people, foundations, organizations, and governments have contributed to the progress, promoting understanding of the aging process and improvement of the quality of life in the later years. But much more needs to be done. THE AGING PROCESS Perhaps the most basic study in understanding the nature of the aging process is that of biological changes occurring with time. Time leaves its mark at all the levels of the living organism, molecules, cells, intercellular substance, organs, and the organism itself. In man and the higher vertebrates aging takes the form of a morphological and functional involution as progressive as it is silent. For most of the organs whose full development is not reached until about the twentieth year or whose cells have the power of renewing themselves, the decline in performance is not detectable until after growth is complete. Insidious and progressive changes are reflected in the organism by a steady decline in the adaptability of the individual and a parallel increase in his susceptibility to environmental stresses. Studies have provided many examples of this progressive reduction in function . Another fundamental characteristic of the aging process is variation . Not only do functions and activities decline in different ways in the individual, but a particular function or ability may also age at a different rate in different individuals. In other words, in a given poi:;ulation certain persons are " fast '' and others " slow" in relation to average aging for any one function . The most marked variations in rates of aging are seen among populations living in widely different ecological conditions, for example in certain African and Asian populations who still practise their traditional ways of life and in European and American city dwellers . Within countries, too, there are marked differences between city and country dwellers and between individuals differing in lifestyle. type of occupation , and socioeconomic level. Morphological aging Since the first observations made by Quetetet in 1835, many authors have described the modifications produced by age in the external morphology of the individual. From some of the most thorough studiesa undertaken, it is known that the body features that vary most with age are stature, sitting height, breadth of shoulder (biacromial diameter), and depth of chest (anteropos- terior diameter of the thorax). The considerable and progressive diminution of the standing height in the aged observed in cross-sectional studies of practically all contemporary human populations has two causes: the long-term trend towards an increase in the stature of younger generations and the shortening of the spinal column in a Hannesson ( 1976). Icelanders; Herskovits ( 1927). American Negroes; Takahashi & Atsumi (1955) Japanese; Marquer & Chamla (1961). French; and Khosla & Lowe (1968) British . 2 older subjects. Only the latter phenomenon is attributable to the aging process and it is caused by the progressive modification of the protein matrix of the skeleton and the steady decline in the density of the long bones and the vertebrae (Broman et al., 1958). The second category of morphological criteria of aging relates to the amount and disposition of fat deposits, measured by: weight; humeral (triceps) skinfold combined with measurement of the maximum upper arm circum- ference and diameter with the triceps contracted which, in conjunction with the measurements of the humeral skinfold, serves as a criterion of muscular development (Brozek, I 956); subscapular skinfold; para umbilical (abdo- minal) skinfold; iliac (cristal ) skinfold; and dorsal skinfold of the hand (Ryckewaert et al., 1967). Physiological aging A distinction must be made between aging as a long-term biological process and old age as a natural and inevitable stage of individual development. The term physiological aging signifies the natural onset and gradual development of the age changes characteristic of the species. In the individual, aging has been defined as a progressive loss of vigour which eventually leads to death . In the past its chief characteristic was considered to be a diminished ability to adapt to the environment. This concept of failing homoeostasis has been challenged however in recent years by one of homoeorrhesis, the theory being that aging in itself is a process of adaptation in which the internal environment is modified to meet the stresses of degeneration as well as of external change. Because there is a great variation in individual aging, a person may reach an advanced chronological age and yet show few of the accepted signs of age. Equally, individuals in early middle age may have a biological age greatly in excess of their chronological age. Although in these cases the premature signs are said to be pathological, it is not easy to say when physiological changes become pathological. For example, a theromatous changes in the inti ma of the coronary arteries are considered to be pathological , yet it is the exception not to find such changes in persons over the age of 60. Biological and chronological age The importance of the assessmen t of biological age in man has been recognized by WHO for many years. As early as 1963 a seminar held in Kiev on health protection of the elderly and the aged and the prevention of premature aging stressed the need for a method to be developed fo r the determination of biological age. At that time, because no criteria for assessing biological age had been standardized. older persons were graded chronologi- cally as fo ll ows: - the middle-aged (45 - 59 years) - the elderly (60 - 74 years) - the aged (75 yea rs and over). Persons of 90 years or over were class ified as " the very old ". 3 Senility, according to the seminar, implied a strongly pronounced age change and constituted a new qualitative condition calling for constant care of the individual, while premature aging implied any partial or general acceleration of the rate of aging resulting in the individual being ahead of the average aging time scale for the population to which he belonged . Seven years later WHO sponsored a detailed report on the assessment of biological age in man (Bourliere, 1970). This summarized much of the available data relating to age and changes in physiological function , and made recommendations on possible approaches to the development of an index of biological age . Once more the identification of such an index was seen to be not only theoretically important but also of great practical value. If. for administrative decisions relating to retirement, employment, or current health status, functional or biological age is substituted for chronolo- gical age, it is clear that a simple index number is required for each individual. At a multidisciplinary world conference on aging organized by L'lnstitut de la Vie in 1977, the published proceedings of which were supported by WHO (Danon et al., 1981), it was observed that this approach makes the implicit assumption that functional age is a single characteristic that can be quantified . Conceptually, it may be regarded as similar to mental age, which was first devel- oped by Binet on the basis of performance scores of schoolchildren undergoing a battery of tests involving a variety of mental performances, the results being validated against ratings of intelligence made by teachers who had observed the performance of each child during school classes. This, however, would require the assignment to each individual of some estimate of functional age based on criteria other than chronological age . At present no such criteria are available. It is also doubtful whether ratings of functional age could be obtained, as few observers would be able to follow a number of adult subjects during the performance of a broad spectrum of activities. In view of these difficulties , there is no alternative to the use of chronological age as a basis for judging the validity of any index of functional age . Ideally , functional age and chronolo- gical age would be the same, discrepancies between the two representing deviations in individual performance. In fact, the high degree of variance in physiological and psychological performance among individuals of a given chronological age indicates the applicabilit y of this idea (Brondfonbrener et al. . I 955). ASSESSING OLD AGE Attempts to assess old age have included the measurement of changes in function in the overall performance of an individual: physical capacity, work performance, intellectual ability, and mobility . Tests of physiological aging have been described by Bourliere ( 1963), while Le Gros Clark ( 1956) used the length of working life as a yardstick for measuring the physical changes that characterize old age. Comfort ( 1969) based a battery of tests to measure human aging on the work of Hollingsworth et al. ( 1965), in which the highest correlations were for those characteristics - such as greying of hair and skin changes - which contribute most to the clinical impression of age . 4 Tests and criteria recommended for assessing biological age can be divided into those which can be used in the workplace or in a nearby centre, and therefore are easily applicable to large numbers of people, and those which require a short stay in hospital and therefore are not applicable to the entire population under study, being carried out on a subsample of (say) one in ten or on subjects found to be abnormal at their first regular examination. The WHO seminar in 1963 discussed the various types of test available and agreed that the most valuable were those simple enough to be undertaken at the workplace. Of the two main categories of test - static and dynamic - the latter, measuring the subject 's margin of adaptation to stress, were considered to be of particular interest. Samples of population used in establishing criteria for aging should include all the persons randomly selected from the population under study: healthy persons (the vast majority); those with hitherto unsuspected disease (more numerous than might be expected) detected at the medical check-up that should always accompany such tests; and lastly, the few already known to be ill at the time of examination. All the studies should be accompanied by a nutritional survey and also by a social survey covering household and working conditions, family life, and leisure. The same seminar recommended that in conducting mass surveys, sample surveys, or surveys of specific population groups the subject's state of health should be established by the usual medical methods. The general clinical signs of age change (posture, gait, hearing, greying of hair, etc.) should also be recorded at the same time, following the practice of research institutes such as those at Bucharest, Helsinki, Kiev, Leningrad, and Paris. The qualitative changes affecting the main functions should then be quantitatively assessed. The seminar recommended that in mass surveys tests should be conducted to obtain the following information on individuals: Category I I. Weight 2. Standing height 3. Chest fluorography 4. Pulse 5. Blood pressure 6. Cardiac output 7. Respiratory frequency 8. Vital capacity 9. Maximum time for which breath can be held after forced inspiration and after forced expiration . 10. Blood (haemoglobin rate, red and white corpuscles) 11 . Serum cholesterol 5 12. Sugar content of urine 13. Visual acuity 14. Simple memory test (IO words) . Tests 4, 5, 6, 7, 8, and 9 should be carried out before and after a Master's step test - a test many cardiologists include in routine examinations. Stress testing can only be undertaken when the individual has a sound cardiovas- cular system. An accurate job analysis - including changes in work periods or patterns - should also be made. If the patient has stopped working. his reason for doing so should be noted , together with his capacity for self-care or self-help. A concise comprehensive job analysis can provide a useful picture of the individual's general conditions, working capacity, or impairment and he can then be classified according to an invalidity scale, which culminates in generalized senility, a state requiring constant care. The extent of age changes identified may be recorded as absent ( - ); only slight ( + ); marked ( + + ); or severe ( + + + ). The data on the patient's functional and organic condition may then be compared with his chronological age. In surveying subsamples, additional tests should be carried out to provide more comprehensive data, especially on the cardiovascular and respiratory systems and the energy balance. The following have been recommended for subsample surveys: Category 2 I. Regular grid photography 2. Measurement of skinfold thickness 3. Maximum breathing capacity 4. Cardiac output 5. Electrocardiography 6. Ballistocardiography 7. Speed of spread of pulse waves 8. Plethysmographic and oscillographic investigation of reaction of hands to thermal stimulation 9. Basal metabolic rate 10. X-ray of vertebral column 11. Serum protein fraction 12. Sugar tolerance test 13. 17-Ketosteroid content in urine (daily excretion) 14. Dynametry 6 15. Fatigue (ergography) 16. Locomotor function recovery test 17 . Range of accommodation 18 . Time of recovery after dazzle 19. Test of vibration sense 20. Electromyography 21. Electroencephalography 22. Reaction time 23 . Wechsler's memory test 24. Clement's coding test 25 . Examination or photography of retina 26. Immunological test (humoral and cellular). To interpret correctly the results of biological tests the gerontologist needs to have at his disposal a set of precise data on the state of health of each individual. From comparison of individual performance and lifestyle with the occurrence of certain diseases, indications will eventually emerge regarding the probable cause of many phenomena of aging. Experimentalists can then determine the validity of the explanatory hypotheses arrived at by epidemiol- ogists and finally discover the mechanisms involved . Criteria for tests Shock ( 1981) has listed certain criteria that should be met by any battery of tests designed to develop an index of functional age. These are as follows: (I) The tests should cover a broad spectrum of performance of a priori significance. Although greying of the hair, for example, is highly correlated with age, it probably has little to do with performance and hence little to contribute to an index of functional age. (2) Each test should yield reliable quantitative results, i.e ., repeated testing of the same individual over short time intervals should yield comparable results. This requirement raises serious doubts about including items that depend on single clinical impressions. On the other hand, ratings made by a number of observers on the same subject might be appropriate. (3) Each test in the battery should be reasonably correlated with age in a linear fashion . Since some characteristics do not show a linear regression with age, adjustments in scores from these tests need to be made. In some cases where age differences do not appear systematically until the age of 40 or 50, subjects below these ages may need to be excluded. 7 (4) Some tests in the battery should evaluate the individual's response to a measurable physiological stress. Examples of such tests include the response to standardized exercise, the rate of removal of excess glucose from the blood, and the introduction of standardized distractions during problem-solving or learning tests. (5) The test must be applicable to subjects of all ages . (6) The tests must be relatively painless, with minimal dependence on the motivation of the subject. (7) Tests should not require long testing periods or elaborate procedures available on ly in hospitals. Although tests such as the measurement of cardiac output and renal clearance might be useful in relatively small samples for purposes of standardization, they are not applicable in general surveys of large populations. Methodological problems There has been general agreement at all WHO meetings, including in recent years those of the directors of national institutes of gerontology, that the combination of a number of tests predicts biological age more accurately than any single test and may serve as an index of biological age, the critical question being which tests should be included. Unfortunately that question cannot as yet be answered, since up to the present time each investigator has drawn up a different battery of tests, administered it under different circumstances, and used different techniques. A major limitation in attempts to develop an index is the relatively restricted range of performances that have been measured. Most stud ies have dealt with anthropometric measurements, sensory and perceptual tests, pulmonary measurements, strength tests, blood pressure, blood cholesterol, reaction time, immediate memory tests, and questionnaires designed to identify personality characteristics. It seems evident that a broader spectrum of functional tests needs to be explored . Another methodological problem is the selection of an adequate sample of subjects for evaluation. The great majority of studies have been conducted on small samples (around IO subjects per decade). In order to validate an index of functional age completely it is necessary to collect repeated observations in subjects until they die. In other words, longitudinal observations are essential. Thus, until a substantial number of the subjects who have been tested early in life actually die, the basic question will remain unanswered . FUTURE RESEARCH Although no single index of functional age is as yet available, analysis of studies already undertaken points the direction for future research. It is clear that, for many tests, a score can be derived that will characterize the 8 deviation of the performance of an individual from the mean value of his age group. It is also clear that, when a number of tests are combined, the functional age calculated from a multiple regression equation will correlate more highly with chronological age than will any of the individual tests; the attempt to derive an overall estimate of functional age is therefore not a futile gesture. Advances in gerontological research over the past decade now make it possible to develop valid indices of functional aging. With adequate resources to support research in this field, the problem can be solved . 9 2 Establishing priorities in research The need for the establishment of priorities in research in the fields of gerontology and geriatric medicine has been a subject of considerable discussion at many WHO meetings. At a meeting of directors of national institutes it was agreed that the subject proposed for research should : - be one in which it is reasonable to expect something can be established - belong to an area in which an adequate number of appropriately trained scientists will be available - represent a burden of illness to individuals - cause personal and family anguish by being a painful disabling condition be such that the result is potentially applicable by the health and other services. Countries and institutes have so far arrived at very different priorities for research. Subjects have ranged from the study of higher forms of neurohor- monal regulation to pedagogical problems, preparation for old age, the identification of risk groups, and the development of quick and reliable methods to assess functional potential. Often there is disparity between the research priorities of governments or politicians and those of institutes, determined on scientific merit. A future aim should be to match political decisions with scientific priorities and to undertake research of benefit to people. Another outstanding cause for concern over the years has been that, although several countries have undertaken similar studies, there has been little attempt to collate or compare results. This has obvious implications for future research methodology. From the various meetings and discussions, however. a number of specific question have emerged, the answers to which could have far-reaching effects. At the level of cell function , why do cell membranes change with age and why do binding sites for hormones diminish? At a still more basic level , why do dividing cells of the body appear to have a limited number of divisions? 11 Many other questions al so await study. Some offer a promise of reducing physical, mental, and social disability, others of minimizing the occurrence of disability in old age. For example, in order to determine which percentile ranking at different ages is significant in terms of predicting future health problems, prospective longitudinal studies are required. A variety of end- points known to be associated with diabetes mellitus need to be examined. Thus, since mortality rates are markedly increased in diabetics, various levels of glucose tolerance performance should be examined for correlation with mortality . It has also been suggested that the development of the known complications of diabetes, such as coronary heart disease and microangio- pathies (eye, peripheral nerves, and kidney) should be analysed. The development of florid diabetes is an essential point to be analysed. Only by imaginative study will the gaps in our knowledge be closed; investment in research can no longer be considered a luxury. AGING OF THE NERVOUS SYSTEM The lengthening of reaction times with increasing age, the slowing up of learning processes, and the decline in memory and mental efficiency have been studied and measured by psychologists over a number of years (Birren, 1959; Bromley, 1966; Jones & Kaplan , 1956; Pacaud, 1955). These studies have brought out two essential points: (I) The rate of decline and the degree of functional impairment vary considerably from one person to another, even in populations that might be thought homogeneous. (2) Different abilities do not decline at the same rate in a given individual. The functions related to experience and the utilization of acquired knowledge resist the assault of time fairly well, whereas those which depend upon capacity for adjustment to new situations show greater deterioration with advancing age (Bourliere, 1970). In the present concept the aging of a complex organism is not the mere result of the aging of separate cells; the organism ages as a complex biological system. For this reason it is necessary to study not only the molecular, cellular, and systematic levels of aging but also the way in which these changes are linked with each other. Changes in physical strength and endurance, sexual capacity, and intellectual ability all follow an inevitable path, although in a unique blend for each individual. Few, however, would deny that the deterioration of mental function with age presents the most difficult challenge to the individual and to those around him . This is also a promising area of research . New drugs are being developed that may be useful in reducing the impairments of memory that plague many older people. Some success has already been achieved in developing drugs to combat depression , and the next decade should show other significant advances in this important field of psychopharmacology. 12 Mental health problems of aging and the aged were discussed at a WHO meeting in 1959 (WHO, I 959). They still remain a challenge to medicine, for they are universal in scope and urgent because of the human suffering they entail. Structural alterations in aging of the brain The complexity of the human nervous system, with its wealth of elements and almost infinitely complex connexions, makes it a particularly difficult system in which to identify changes of causal. as opposed to secondary . significance in the aging process. Gross changes in the brain have been recognized for nearly 150 years (Esquirol. 1938), and the group of microscopic alterations that develop with advancing age has been recognized for over 70 years (Scheibe!. 1975, 1981 ). Age-related changes that occur in the cell bodies themselves and in the extraneuronal surround are pathognomonic of senescence but, with the exception of actual cell loss, their pathophysiological significance remains unclear. Abundant literature already exists documenting the changes known to characterize the aging or seni le brain. They include structural changes of varying kinds in the cell body- lipofuscin pigment granules (Obersteiner, 1903); granulovascular degeneration (Simchowitz, 1911 ); and neurofibrillary tangles (Alzheimer, 1907)- and also in the neuropil surrounding the nerve cells- the appearance of senile plaques (Blog & Marinesco, 1892; Simchowitz, 1911 ). The ultimate change appears when the nerve cell drops out and is replaced by a neuroglial overgrowth (gliosis). All these changes bear a more or less linear relationship to the degree of psychomotor deficit , although their pathophysiological role is not yet clear. Cell loss, of course, represents a final irreversible state and is clear evidence of an absolute decrement in functioning brain elements. Much of the diminution in psychosocial capabilities that accompanies senescence is interpreted as resulting from progressive impoverishment of dendritic neuropil and the resulting loss of enormous numbers of synoptic connexions. This in turn results in a progressive decrease in the computational power of the cerebral cortex and its programme library. Equally characteristic deficits in spatial and temporal orientation are attributed tentatively to the loss of ensembles of hippocampal pyramidal cells. It is important to consider the process of neural aging apart from the more dramatic and catastrophic phenomena of the pre-senile and senile dementing syndromes. It is believed that, while the former represents one aspect of a general protoplasmic reaction , the latter are manifestations of disease processes that affect the nervous system either early (40- 60 years) or later (beyond 65 or 70 years). Nevertheless, the structural changes that develop in and around the neurons are generally the same, differing only in speed of onset and intensity. It is not known what causes the dementing syndrome to develop either precociously or late in life but, whatever the nature of the process, it is likely to bear some relationship to the more gradual changes of age that affect everyone. 13 Neurofibres and aging It is well over a century since microscopic threadlike material was first noted by Purkinje within neurons. but whether they really exist, let alone what their structure and function are, has been widely debated until recently. Today optical birefringence of living cells has proved their existence (Beer et al. , 1937). electron microscopy has revealed their structure, and chemical analysis has demonstrated their nature. Although earlier concepts relating the fibres to transmissions of im- pulses (Bielschowsky, 1905) or to cellular metabolic processes (Parker, I 929) have been discarded, the function of neurofibres is still uncertain . It is widely assumed, however, that they are responsible for axoplasmic transport. Abnormal intraneuronal aggregates of argentophilic fibres are called Alzheimer's neurofibrillary tangles, having first been adequately described by Alzheimer in 1907. In senile dementia of the Alzheimer form the tangles are present in great numbers in neurons of the neocortex and even more in the paleocortex. Large numbers of cortical tangles correlate consistently with dementia (Farmer et al., 1976; Roth et al. , 1966). Matsuyama et al. (1966) found a few such lesions in nearly all human brains beyond the age of 80- regardless of the mental status. This indicates that the causal factor or factors , whether genetic, environmental, or infectious, are very widespread. It may also reduce to a semantic argument the question of whether this type of tangle is pathological or normal. Abnormality appears to be related to the concentration of lesions. The tangles, made up of bundles of fibres now recognized as pairs of helically wound filaments (PHF), are also present in extraordinary numbers in cases of Guam-parkinsonism dementia (Hirano et al.. 1961). Adults surviving with Down's syndrome to over 35 years of age often have such lesions (Schochet et al. , 1973), and intercountry research in this field was urgently called for by the directors of national institutes of gerontology at their meeting in Bethesda in 1977. Meanwhile much remains unknown: the origin of the PHF in senile dementia is still unclear; and the functional effect of the abnormal fibres on cellular processes is yet to be discovered. Since the PH F is such a distinctive abnormal subcellular organelle, its appeal to most pathobiologists remains irresistib le. Further investigation could shed much needed light on the nature and cause of one of mankind's most distressing disorders. AGING OF CARDIAC MUSCLE Age-associated increases in the stiffness of cardiac muscle are at least theoretica lly advantageous, allowing cardiac muscle with diminished shorten- ing abi lity to develop tension at a rate that remains unchanged. This increase in stiffness, combined with prolongation of the duration of contraction, appears to allow the cardiac muscle on an elderly individual, despite its decreased intrinsic contract ile ability, to develop the same total force during contraction as is developed by the cardiac muscle of a younger person. Thus, 14 in terms of contraction, the age-associated increase in cardiac muscle stiffness appears to be beneficial. Since this increase also characterizes resting cardiac muscle because of decreased diastolic compliance, the aged person is less a ble to adapt to an acute increase in workload . If the pumping ability of the left ventricle is exceeded, acute heart failure or pulmonary oedema will appear more rapidly. Another major finding of recent studies is that myocardium from a senescent rat appears to have diminished inotropic response to agents that require a cell-membrane receptor. In contrast, there appears to be no age- associated decrease in the inotropic response to agents that are believed at present not to require a cell-membrane receptor to exert an inotropic effect. Before such findings can be applied to man , however , the studies must be extended to man . AGING AND ENDOCRINE FUNCTION Normal aging in man is associated with a variety of critical effects on hormone production, secretion, and action, resulting in functional alter- ations that could culminate in age-associated disease (Gregerman & Bierman, 1974). Most hormone secretion is episodic or cyclic, with periodicities ranging from minutes (insulin) to weeks (oestrogens). In age it is the longer endocrine rhythms that show the more obvious changes (e.g., the menopause), but all frequencies of oscillatory endocrine behaviour may be altered. The amplitude of responses to perturbat ion and counter-regulation may be altered in old age without affecting steady-state hormonal levels. Alternatively, larger tissues may become less responsive to hormones with age, leading to a compensatory increase in hormone production and hormone levels to maintain homeostasis. Another possible general type of functional abnormality is an impairment of hormone production, associated with a compensatory decrease in the hormone disposal rate, an increase in tissue sensitivity or, more likely, simply a lower blood hormone level and reduced target tissue effect. The menopause represents the most clear-cut example of endocrine sensescence in which decreased hormone secretion appears to be the primary event. While the ovary ceases completely to secrete oestrogens, increased amounts of adrenal androstenedione are in partial compensation converted to oestrogen in the periphery (Hemsell et al., 1974) and other compensatory mechanisms a lso come into play. Such age-associa ted primary production failure of hormones is not typical of all endocrine systems. The thyroid axis is illustrative of a probable primary decrease with age in the metabolic disposal rate of thyroid hormone, amounting to a loss of about 50 "0 over the entire adult span. This is attributed largely to a progressive slowing of the rate of cellular degradation of thyroxine. A compensatory decrease in secretion rate by the thyroid results in unchanged levels of circulating thyroxine. Despite this decrease in the thyroid secretion of hormone with age, the thyroid gland of the elderly has a good reserve. The anatomical alterations of the gland, often seen with advancing age (multinodular goitre), are 15 apparently compensa tory changes associated with the maintenance of adequate function and reserve capacity. The adrenal cortical axis represents another illustration of a primarily slowed metabolic disposal rate and decreased hormone secretion rates, resulting in unaltered plasma cortisol concentrat ion even at a very advanced age (G herondache et al.. 1967; West et al. , 1961). The crucial problem in interpretation of glucose and glucoregulatory hormone homeostasis during aging relates to the confusing effects of the increase in both absolute and relative adiposity with age (Gregerman & Bierman, 1974). The increase in adipose cell mass is associated with decreased insulin sensitivity (Rabinowitz, 1970), perhaps owing to a reduction in effective insulin receptors (Archer et al. , 1975) or to post-receptor deficits. Thus an aging person, even at constant body weight, would be expected to show a decline in insulin sensitivity. In some individuals relatively normal glucose homeostasis is maintained at the expense of higher rates of insulin secretion; in others glucose homeostasis deteriorates in association with relatively impaired insulin secretory responses. It has been suggested also that insulin secretion might become defective with aging, with a larger proportion of the less biologically active synthetic precursor, pro-insulin , appearing in the circulation (Duckworth & Kitabachi, 1972). Once more many questions remain unanswered. Evaluation of endocrine changes depends on the continued acquisition of knowledge regarding the very wide variation of age-related alterations in hormone function that occur in man. THE HUMORAL IMM UNE RESPONSE IN AGING The association of aging with changes in the immune system has been well documented. Among other researchers, Makinodan et al. ( 1976) have emphasized its decline in function, Walford ( 1969) the regular occurrence of autoantibodies with increase in age . These results are only apparently contradictory, since it is well recognized that the normal immune system should be regarded as a balanced system with positive and negative signals and feedback mechanisms. A defect may disturb the balance and , depending upon its location, lead to different abnormalities, e.g. deficiency and /or product ion of autoantibodies . A third characteristic immunological phenom- enon of the aged is restricted heterogeneity of the immunoglobulins and idiopathic paraproteinaemia. The relationship of the latter to age was the outcome of a population study conducted in Sweden (Axelsson et al., 1966). The etiology and significance of these phenomena are still largely unknown , and it is not possible to predict the development of immune deviations in individual cases. The final situation depends on a number of variables such as special strain, antigen, and sex. It is clear that the enormous flexibility of li ving organisms as well as the complexity of the immune system will need to be taken into account in every theory produced on immunological aging. 16 BIOLOGICAL PROSPECTS FOR THE EXTENS ION OF LIFE The foregoing are but a few of the a reas requiring furthe r research sugges ted by the directors of national institutes of geronto logy at their WHO-sponsored meetings over the past five years and by the globa l conference on agi ng organized by L' lnst itut de la Vie. The consensus of scien tific opinion at these gatherings appeared to be tha t the fundamental causes of age changes a re - like developmental changes - programmed in some way within the genetic apparatus bu t their expression can be influenced by extrinsic fac tors. It is in the genetic apparatus that the clock is located. A fruit fly is old in 30 days, a mouse in 3 years, and a man in 90 years. The genetic control of these differences is more or less self-eviden t. The conclusion has been reached that if, by the year 2000, biomedical research triumphed to the extent that deaths caused by vascular disease and cancer were preventa ble, a net increase in life expectancy of approx imate ly 20 years would occur. However, the greatest potential impact on human longevity would be research directed towards reducing the ra te of fundamental biological causes of age changes not related to di sease. The prevention and control of human aging have been a subject of fasc ination to mank ind for centuries but claims made for success in achieving them through a va riety of preventive preparations have been backed by very little objective evidence. A basic tenet of geronto logy and ge riat ric medicine is to discard foolish optimism about the phase of li fe known as old age, to affi rm the value of aged people, and to examine rationally the biomedical, socia l, and behavioural rea lities of aging. Although the mystery of the aging process has not as yet been unravelled, this does not mean that it never will be. Scientific methods can continue to be applied to its stud y as to other stages of the li fe cycle. An essential firs t step is to di stinguish between conditions tha t are a result of agi ng and diseases that may accompa ny old age . To venture beyond the obvious and known physiological aspects of the aging process, a ll avai lable resources, including the humanities and social services, must be mobilized . Careful atten tion needs to be paid to relationships between generations, to lifestyles, and to the socioeconomic status of elderly people in society. Only by do ing so can the quality of old age in genera l and health ca re in particular be improved. And onl y then will the large proportion of old people in the populc}tion cease to be a problem. 17 3 Aging societies Another and very obvious answer to why the high incidence of longevity has become a problem is that it has not been planned for. Forward planning of the 1950s and 1960s rarely gave adequate attention to the demographic forecasts being made at that time. In 1958 a WHO advisory group studied information published by the Organisation for Economic Co-operation and Development on 15 European countries for which population forecasts for the period 1951 to 1971 had been made. It was predicted that there would be an increase of approximately IO % in the total population of those nations and a continuing trend towards a steadily increasing number of older people in each of them. The shift in age structure of the European population was recognized as being more important than the growth of the total population because of its medical, social , and financial implications. While population age structure may exhibit short-lived disturbances owing to such external influences as war, economic crises, and migration, the influence exerted by trends in birth and mortality rates is in the long run more important. At that time fluctuating birth rates and low death rates were the characteristic population trends. AGING OF POPULATIONS By aging of the population is meant the increase in the proportion of people in the higher age groups of the population. An increase in the number of people in this age group may occur without overall aging of the population when other age groups increase in size at a quicker pace. Aging in its demographic sense is not the same as the biological process of aging, which is dynamic and continuous. Chronological age does not measure physiological or psychological age, and the point at which old age begins cannot be specified. For administrative purposes such as determining retirement and pensionable age and in gerontological studies an arbitrary chronological age is used, which often has no relationship to physiological or psychological age or to function or working capacity. Adequate provision for an aging population cannot be made without 19 thorough knowledge of the relevant demographic facts . Since uniformity in collecting and presenting data is a sine qua non for obtaining comparability, which alone can clarify general demographic trends, study of the methods of collecting demographic data is of great importance. From a biological standpoint the method of cohort analysis in demography and vital statistics is especially valuable. Aging of human populations can happen in three ways: (I) If all the people in population A become older than those in population 8, the aging in population A is said to be total. (2) If the population of aged persons increases, it is described as aging at the apex of the population pyramid. (3) If the proportion of young persons decreases, it is described as aging at the base of the population pyramid. Causes of aging populations Whatever the reasons, any important and sustained decrease in fertility produces ipso facto an aging of the population . Such a process may be observed in model as well as in actual populations, even if the latter have been disturbed by major historical events such as wars or migrations; France and Japan provide examples of this trend. Consequently, the populations of developing countries, which nowadays have a young structure, will age if their fertility follows a generalized downward trend . It is likely that aging in these countries will be quicker than it was in the industrialized countries. Some consequences of the aging of a population While the aging of the population is essentially a simple phenomenon, its consequences are multiple and many are not always fully recognized . For instance, too high a proportion of aged people in relation to the workforce of a country represents a heavy economic burden . Above all, it creates great difficulty in providing individualized services - unless inactive people, includ- ing the elderly themselves, can be enlisted to help. The increase in the number of families with few or no children has led to a higher proportion of old people with no children to look after them. This, in addition to the emotional deprivation it brings, often implies the need for community help. Another consequence of the lengthening lifespan is the increase in the number of 4- or even 5-generation families, which means that a couple of working age may have not only dependent children but also two or three generations of dependent elderly relatives. Statistical measurements of aging It is possible to measure every facet of the phenomenon of aging populations with the help of proper statistical indices chosen according to the theme under 20 investigation . The more common indices are as follows: (I) the proportion of aged people (e .g., those of pensionable age) in the total population (2) the ratio of aged people to the population of working age or to the working population (both being dependency ratios) (3) the ratio of aged people to young people (an indicator of the rate of renewal) (4) the proportion of the very old (chronologically) in the aged population (for instance, individuals aged 80 years and over within the age group 65 years and over) (5) the sex ratio (the number of males compared with the number of females of the same age). Longevity as such may be determined from: (I) the expectation of life at various ages (60, 65, 70, 80 years) by sex (2) the probability of surviving from a given age (say 60 years) to another age (say 65 or 70 years) by sex; or the complement, the probability of dying. Each of these indices can be used to appraise progress and setbacks. Sex ratios There are more women than men over the age of 65 in both developing and developed countries, and the excess is far greater in the more developed countries. For 1975 the sex ratios (i.e., the number of males per I 00 females) were 88 and 64 respectively. In most areas male death rates exceed female death rates at every age and, as a result , the initial surplus of boys is steadily reduced . Female death rates exceed male death rates at some, or all , younger ages in Bangladesh, India, and Pakistan, and extremely low ratios occur where the male population has been depleted because of war. At their meeting in 1977 the directors of national institutes of gerontology considered this aspect of aging populations to be of great importance. They noted that the increased mortality among males from 65 years onwards is frequently the result of a short period of terminal illness, whereas in females increased longevity is often associated with long periods of chronic illness. This observation suggests the importance of the study of chronic invalidism in the later years of life . The differences in mortality and morbidity by sex often create social problems for elderly females . It was agreed that in any survey of the elderly the importance of social demography and of the social psychology of aging should be borne constantly in mind and that it is essential to include persons with non-medical needs as well. Participants in the meeting recognized, in relation to morbidity in the elderly, that there is often a large area that can be classed as " misdiagnosis". 21 N N Table 1. Distribution of elderly population by age and sex Aged 65- 74 years Aged ;;::: 75 years Males Females Males Females No. in Percentage No. in Percentage No. in Percentage No. in Percentage thousands of total thousands of total thousands of total thousands of total Country Year population population population population Albania Algeria Austria 1978 287 8.1 443 11 .2 138 3.9 290 7.3 Belgium 1976 372 7.7 496 9.9 181 3.8 325 6.5 Bulgaria 1977 329 7.5 367 8.3 128 2.9 174 3.9 Czechoslovakia 1975 531 7.4 710 9.4 187 2.6 365 4.8 Denmark 1978 200 7.9 243 9.4 106 4.2 169 6.5 Finland 1976 140 6.1 217 8.9 50 22 109 4.5 France 1976 1 938 7.5 2 537 9.4 972 3.8 1 984 7.4 German Dem. Rep. 1976 680 8.7 1 090 12.1 318 4.1 642 7.1 Germany, Fed. Rep. of 1978 2342 8.0 3698 11 .5 1 089 3.7 2245 7.0 Greece 1978 354 7.7 413 8.7 182 4.0 256 5.4 Hungary 1978 403 7.8 536 9.7 171 3.3 296 5.4 Iceland 1978 6 5.3 7 6.3 4 3.5 5 4.5 Ireland 1976 103 6.5 113 7.2 52 3.3 75 4.8 Italy 1976 2011 7.3 2525 8.8 869 3.2 1 485 5.2 N t.,.> Luxembourg 1978 14 8.0 18 Malta 1977 8 5.4 10 Monaco Morocco 1973 143 1.8 163 Netherlands 1978 420 6.1 544 Norway 1978 160 7.9 194 Poland 1978 987 5.8 1 387 Portugal 1975 281 6.3 396 Romania 1978 687 6.4 859 San Marino 1976 0.581 5.6 0.701 Spain 1976 1 068 6.1 1408 Sweden 1978 378 9.2 437 Switzerland 1978 226 7.4 300 Turkey 1975 613 3.0 667 USSR United Kingdom England & Wales 1977 1 963 8.2 2577 Northern Ireland 1977 48 6.3 65 Scotland 1978 192 7.7 266 Yugoslavia 1977 616 5.7 766 Source: Health Services in Europe. 3rd ed . Copenhagen. WHO Regional Office for Europe. 1981 9.9 6 3.4 11 6.0 6.2 4 2.7 5 3.1 2.0 44 0.5 54 0.7 7.8 231 3.3 370 5.3 9.5 89 4.4 140 6.8 7.7 386 2.3 759 4.2 7.9 104 2.3 191 3.8 7.8 277 2.6 408 3.7 7.0 0.298 2.9 0.447 4.4 7.7 474 2.7 808 4.4 10.5 200 4.9 308 7.4 9.3 115 3.8 208 6.4 3.4 226 1.1 307 1.6 10.2 824 3.4 1 781 7.1 8.4 21 2.8 40 5.2 9.9 78 3.1 176 6.6 6.9 237 22 371 3.4 To identify differences in various cohorts, to review existing techniques, and to develop new methods based on prior definition of problem areas, cross- sectional studies are needed. The directors also recommended that data already existing should be reviewed and possibly re-analysed in order to identify areas where data are either non-existent or limited and, using quantifiable variables, different cultural and behavioural patterns. Population trends in the European Region Of all the regions of the world, it is in Europe that the aging of populations is most significant (Table I) . The proportion of people 60 years of age and over in Europe increased from 12.9 % in I 950 to 16. 7 % in I 970 and is projected to increase to 19.5 '1/0 by the year 2000. The number of people aged 60 and over in Europe as a whole is expected to increase from 81 million in 1980 to IO I million in 2000. The proportion of persons aged 60 and over is the simplest indicator of the aging of populations. Projected percentages of the population in this age group are presented in Table 2 for countries in Europe for 1980 and the year 2000. The projections show that, out of a total of28 countries, the population aged 60 and over in 19 countries will be 18- 22 '10 of the total population by the year 2000. Table 3 presents the projected proportion of the very old, defined as 75 years of age and over. Data indicate that, by the year 2000, 18 countries will have between 55 and 75 inhabitants of this age per IOOO population, while I 0 countries will have 50 or less. Within the elderly age groups the number of women invariably exceeds the number of men in all countries. As projected, by the year 2000 the maximum proportion of men aged 75 and over will be 60 per thousand . For women the figure is 91. The projected number and percentage increase of the population 60 years of age and over by sex for the years 1980 and 2000 are shown in Table 4. Although aging will slow down in the countries that are already greatly affected (Austria, Sweden, and the United Kingdom are good examples) there will be a substantial rise in the number of the aged in Eastern and Southern Europe. When these figures are compared with the number and percentage increase of the total population, it becomes clear that the increase in the aging population in many instances exceeds the increase in the total population. The aging of a population has two dimensions: the relative decrease of children and young persons and the relative increase of the elderly population. Projections show that the proportion below the age of 15 will fall. The decrease in the percentage of children will be balanced partly by the working-age group and partly by the increase in the proportion of the age group 60 and over in all European countries. This is the result of the long-term decline in fertility in Europe. As to the working-age population, the previous fertility decline will manifest itself in a declining growth rate of this group in the near future. The aging of the population has progressed furthest in Europe, especially in the Northern and Western European countries, where the birth rates have been low over a long period. The projected ratios of the population 60 years of 24 Table 2. Projected percentages of the total populat ion in the age group 60 years old and over by sex in 1980 and 2000 Percentage of popu lation 2'. 60 years old in: 1980 2000 Both Males Females Both Males Females Country sexes sexes Eastern Europe Bulgaria 15.8 14.6 16.9 20.7 18.8 22.7 Czechoslovakia 16.0 13.7 18.2 16.6 14.4 18.8 German Dem. Rep. 17.0 15.0 23.8 21 .6 18.4 24.7 Hungary 17.2 14.9 19.4 19.7 17.1 22.2 Poland 13.1 10.8 15.3 16.6 14.3 18.8 Romania 13.4 11 .6 15.1 18.1 16.2 20.0 Northern Europe Denmark 19.4 17.4 21 .5 19.6 17.4 21 .6 Finland 16.0 12.5 19.2 18.0 14.9 20.9 Iceland 13.0 12.0 14.0 14.8 13.7 16.0 Ireland 15.4 14.3 16.6 13.0 11 .5 14.5 Norway 20.1 17.9 22.3 18.5 16.3 20.6 Sweden 21 .9 19.9 23.9 20.8 18.7 23.0 United Kingdom 19.9 17.2 22.6 19.9 17.8 22.0 Southern Europe Albania 7.0 6.5 7.6 9.4 8.8 10.0 Greece 17.7 16.1 19.2 21 .6 19.3 23.9 Italy 17.6 15.5 19.6 22.1 19.8 24.3 Malta 14.7 13.0 16.3 16.8 13.9 19.5 Portugal 14.4 12.6 16.1 16.1 13.2 18.8 Spain 15.0 13.0 17.0 18.7 16.7 20.7 Yugoslavia 11 .8 10.1 13.4 18.2 15.9 20.4 Western Europe Austria 19.2 15.3 22.8 20.0 17.1 22.7 Belgium 18.0 15.5 20.5 19.2 16.9 21 .4 France 17.0 14.0 19.8 18.7 16.3 21 .2 Germany, Fed. Rep. of 18.8 14.5 22.8 22.6 19.4 25.6 Luxembourg 18.2 15.8 20.5 22.4 20.6 24.2 Netherlands 15.6 13.5 17.7 17.7 15.5 19.8 Switzerland 18.3 15.8 20.6 21.5 19.1 23.8 Soviet Union 13.0 8.7 16.9 17.5 13.9 20.8 Source: World population and 11s age/se>e composit1on by country, 1950- 2000. Demographic estimation and pro1ect1on as assessed 1n 1978. Prepared by the United Nations Population D1v1s1on (document ESA/ P/ WP/. 65) . 25 Table 3. Projected numbers per 1000 of the total population in the age group 75 years old and over by sex in 1980 and 2000 Proportion of population ?_ 75 years old in : 1980 2000 Both Males Females Both Males Females Country sexes sexes Eastern Europe Bulgaria 39 33 45 57 47 72 Czechoslovakia 43 31 54 49 37 48 German Dem. Rep. 64 47 79 58 35 79 Hungary 45 35 55 55 42 68 Poland 33 24 43 42 30 53 Romania 33 27 39 43 33 53 Northern Europe Denmark 55 43 67 67 52 81 Finland 38 25 50 53 34 70 Iceland 39 34 44 47 43 51 Ireland 42 34 49 41 32 50 Norway 57 45 69 70 55 84 Sweden 62 50 75 76 60 91 United Kingdom 55 38 71 66 51 79 Southern Europe Albania 15 13 17 19 17 22 Greece 49 41 56 61 50 72 Italy 48 37 58 66 52 80 Malta 41 31 51 49 38 60 Portugal 33 24 41 44 32 55 Spain 39 30 47 56 44 67 Yugoslavia 30 24 35 41 29 52 Western Europe Austria 60 42 75 62 41 82 Belgium 55 40 69 57 44 69 France 56 39 73 57 41 72 Germany, Fed . Rep. of 55 38 70 61 37 84 Luxembourg 50 40 61 58 45 72 Netherlands 44 34 54 55 40 69 Switzerland 53 40 66 65 50 80 Soviet Union 34 19 47 43 24 60 Source World population and its age/sex compos1t1on by country, 1950 2000 Demographic est1mat1on and pro1ect1on as assessed m 1978 Prepared by the United Nations Population D1v1s1on (document ESAJP WP 65) age and over per I 000 of the working-age group are over 300 per thousand in Austria . Bulgaria . the Federal Republic of Germany. the German Democratic Republic . Greece. Italy. Luxembourg. and Switzerland (Table 5). Two measures of mortality , are the life expectancy of the elderly and the number of survivors per IO 000 survivo rs a t age 55. In 16 countries in Europe over half the males reaching the age of 55 live to 75 years of age and above. 26 Table 4. Projected numbers and percentage increase of the age group 60 years old and over by sex in 1980 and 2000 Populat ion 2'._ 60 years old (i n thousands) in : Indices 1980 2000 (1980 = 100) Both Males Females Both Males Females Both Males Females Country sexes sexes sexes --- Eastern Europe Bulgaria 1420 656 764 2 011 901 1 110 142 137 145 Czechoslovakia 2447 1 024 1 423 2859 1 222 1 637 117 119 115 German Dem. Rep. 3 315 1186 2129 3622 1498 2124 109 126 100 Hungary 1 850 779 1 071 2 218 944 1 274 120 121 119 Poland 4688 1 890 2798 6831 2905 3926 146 154 140 Romania 2 979 1 277 1 702 4649 2063 2586 156 162 152 Northern Europe Denmark 992 438 554 1 034 456 578 104 104 104 Finland 770 292 478 918 371 547 119 127 114 Iceland 30 14 16 41 19 22 137 136 138 Ireland 509 236 273 521 230 291 102 97 107 Norway 821 363 458 814 358 456 99 99 100 Sweden 1808 815 993 1 772 788 984 98 97 99 United Kingdom 11138 4 700 6438 11 279 4991 6288 101 106 98 N (Contd.) --..J N Table 4 (Contd.) 00 Population ;::: 60 years old (in thousands) in : Indices 1980 2000 (1 980 = 100) Both Males Females Both Males Females Both Males Females Country sexes sexes sexes Southern Europe Albania 192 90 102 367 174 193 191 193 189 Greece 1 651 738 913 2 247 988 1 259 136 134 138 Italy 10017 4 327 5690 13484 5 947 7 537 135 137 132 Malta 50 21 29 65 26 39 130 124 134 Portugal 1 419 587 832 1 842 727 1115 130 124 134 Spain 5615 2 380 3235 8112 3574 4538 144 150 140 Yugoslavia 2630 1115 1 515 4660 2023 2637 177 181 174 Western Europe Austria 1438 542 896 1 520 633 887 106 117 99 Belgium 1 789 757 1 032 2061 907 1154 115 120 11 2 France 9066 3680 5386 10734 4596 6138 118 125 114 Germany, Fed . Rep. of 11 464 4 225 7 239 13437 5582 7855 117 132 109 Luxembourg 65 28 37 81 37 44 125 132 119 Netherlands 2196 943 1 253 2 737 1198 1 539 125 127 123 Switzerland 1151 485 666 1 383 604 779 120 125 117 Soviet Union 34 749 10788 23961 54536 20809 33727 157 193 141 Source: World population and ns age/sex compos1tion bv country, 1950- 2000. Demographic estimation and proIect1on as assessed In 1978 Prepared by the United Nations Populat,on Or111s1on (document ESA P WP 65 ) Table 5. Projected ratios of the population aged 60 and over. to the working -age population (15- 59) for 1980 and the year 2000. Popu lat ion (in thousands) Population ratio Aged 15- 59 years Aged 2:_ 60 years ( ~ 60 /15- 59) Country 1980 2000 1980 2000 1980 2000 Eastern Europe Bulgaria 5587 5699 1 420 2 011 254 353 Czechoslovakia 9209 10430 2447 2859 266 274 German Dem. Rep. 10263 10237 3315 3622 323 354 Hungary 6585 6770 1 850 2 218 281 328 Poland 22495 25537 4688 6 831 209 268 Romania 13379 15164 2979 4649 223 307 Northern Europe Denmark 3049 3207 992 1 034 325 323 Finland 3062 3190 770 918 252 288 Iceland 138 173 30 41 217 237 Ireland 1 775 2480 509 521 287 210 Norway 2354 2673 821 814 349 305 Sweden 4832 5087 1 808 1 772 374 348 United Kingdom 33109 33904 11 138 11 279 337 333 Southern Europe Albania 1 522 2449 192 367 126 150 Greece 5 552 5 917 1 651 2247 297 380 Italy 34 541 35578 10017 13484 290 379 Malta 213 241 50 65 235 270 Portugal 5835 6991 1 419 1 842 243 264 Spain 22068 25736 5615 8112 255 315 Yugoslavia 14248 15604 2630 4660 185 299 Western Europe Austria 4516 4604 1 438 1 520 319 330 Belgium 6111 6491 1 789 2061 293 318 France 32490 34650 9066 10734 279 310 Germany, Fed. Rep. of 38074 35029 11 464 13437 301 384 Luxembourg 229 216 65 81 284 375 Netherlands 8751 9599 2196 2737 251 285 Switzerland 3918 3847 1151 1 383 294 360 Soviet Union 166952 183181 34 749 54536 208 298 Source World population and its age/sex compos1t Ion by country. 1950 2000 Demographic est1matIon and proIec11on as assessed m 1978 Prepared by the United Nations Population 01v1s1on (document ESA/P/WP /65 ) 29 Almost 70 % of the women reaching the age of 55 live to 75 and above in all the countries of Europe. The difference in life expectancy at age 65 between males and females is about 4 years in Northern and Western European countries, about 3 years in other parts of Europe. The global picture The figures presented in the United Nations Demographic Yearbook indicate specific countries that already ha ve a very large propo rti on of their populations (over 13 " 0 ) aged 65 years or more. They are: Austria, the Federal Republic of Germany, France, the German Democratic Republic, Norway, Sweden, and the United Kingdom . Countries with very low proportions (under 3 ° 0 ) of their populations 65 years or more are: Bangladesh, Ecuador. Honduras, Indonesia, Mali, and Zambia . The age st ructure of the population in developing and developed countries in 1980 and as projected for 2000 is shown in Fig. I . Several countries of Western Europe (e.g., Austria, Belgium, the Federal Republic of Germany, and the United Kingdom) have recently ( 1980) achieved zero population growth and will soon achieve a stationary state as a result of continuing replacement-level or sub-replacement fertility . Studies of countries give more specific figures. In Norway 12 " 0 of the population are 6 7 years of age and above and by 1990 that group will form I 3 "0 of the population , more than a fifth of the elderly in that country are over 80 years of age. In the Netherlands, New Zealand , and Scandinavia 70 "0 of all people live to be 65. Whereas only 3. 7 ° 0 of the non-Jewish population in Israel is over 65 years, 8.1 ° 0 of the Jewish population is in that age group. A population survey in Tokyo in 1975 showed that 5.6 " 0 of the population was aged over 65 years, and in Australi a (which many people regard as a young country") some 8.5 "0 of the population in the State of Victoria alone are aged 65 or more. Projections In 1970 the world population of people aged 60 years and over was estimated to be 29 I million ( or 8 "0 of the total popula t ion) . It is expected to reach 585 million in the year 2000, thus do ubling in 30 years, and representing an increase from 8 "0 to 9 " 0 in the proportion of old people. For the less developed regions the corresponding figures are, respectively , 137 million of the total populatio n (5.4 "0) and 354 million of the total population (7 "u) i.e., a n estimated increase of2.6 times in the numbers. Fig. 2 shows the percentage of the population aged 60 years and over in Europe in 1980 and the estimated percentage in 2000. The significance of such data is all the greater when account is taken of the likelihood that the number of people aged 80 years and over and the proportion they form of the total population will increase even more rapidly . For example, according to the demographic projections for France, by the year 2000 the proportion of the population aged 65 years and over is likely to have increased by 29 ° 0 as compared with 1970, whereas the proportion aged 30 Fig. 1. Age structure of the population (figures outside the circle show the population in millions) 57% 15 -64 year> years 65 + years 39% 0 - 14 years 1980 Developing countr ies 65 + 0-14 year> 66% 61% ;;; .. 15-64 years 65 + 2000 65 + 0 - 14 year> year> 1980 Developed countries 2000 WHO I OIJU Source : World Health Organization . Global strategy for health for all by the year 2000. Geneva. 1981 . 31 w N Fig . 2. Population trends in the European Region: estimated percentage of population aged 60 years and over r ./ 1980 -= r ~, 1 · -.:::,1_· < [ill < 10% 2000 r ~1' / "£ ~ 10-14% m 15-19% ■ ), 20% Source : World population trends and prospects by country, 1950 2000. summary report of the 1978 assessment. New York , United Nations, 1979. 80 years and over is expected to have increased by 42 'i0 and the proportion aged 85 years and over by 122 ° 0 . In developed countries during the forthcoming decades medical advances seem likely to reduce morbidity during the second half of life , and it is therefore permissible to forecast the further aging of the population. Furthermore, the movement of young people out of, or of the elderly into, certain regions and localities may result in still greater aging of some populations there than the fertility decrease alone would produce. Up to the year I 990 increasing numbers of persons aged 65 years and over can be expected in France, Ireland, Norway, Sweden, and the United Kingdom (England & Wales) . Thereafter a downturn is forecast until the year 2000. In Czechoslovakia and the Netherlands continuing increases are expected up to the year 2000 and in Bulgaria and Yugoslavia up to 1990 and 1986 respectively. (These are the last years for which projections have be~n made available.) It would appear, therefore, that the secular trends in life expectancy are complex and may vary significantly from one country to another. In general, there is an increase in life expectancy not only at birth but also at 65 years. Comparisons with life tables from earlier periods show that in two decades life expectancy at birth for males did not increase significantly but for females increased considerably ( 1951 - 1955, 73.5 years; 1974. 77 .6 years). But this trend towards an increase had almost levelled off by 1977. In the Netherlands life expectancy at 65 years for men has already levelled off or is even decreasing ( 1951 - 1955, 74. 1 years; 1974, 73 .8 years). The data from the Netherlands mean that in that country men of 65 years are, generally speaking, living no longer than their ancestors did some decades ago and so will not , by reason of aging alone, run any greater risk of becoming physically or mentally ill and therefore will not , as a group, make any more demand on services than their age group did 20 years ago. Because women in that country are living longer they are likely to make increased use of the health and social services. Moreover. women of80 years and over will have a higher morbidity rate than men in respect of both physical and psychiatric disorders . To sum up, the demographic data and trends show that in most European countries the aged population will increase during the next two decades in numbers and in proportion. Older women, who have a greater morbidity than men of the same age , will increasingly predominate and , as they become dependent , make a disproportionately greater demand on the health and social services. These trends are likely to affect developing countries also, to a lesser but more rapidly increasing extent, throughout the remainder of this century and during the early part of the twenty-first century. SOME EFFECTS OF THE MULTI-GENERATION FAMILY Two aspects of the multi-generation family seem to be especially significant. The first is the specific role of members of the older generation within their families and the influence, positive or negative, of their presence on the mental 33 I.,.) """ Table 6. Expectation of life at specified ages for each sex: latest data Males Age Age Age Country Year At birth 15 years 45 years 65 years Albania Algeria Austria 1978 68.4 55 .0 27.7 12.6 Belgium 1976 68.9 55 .6 27.6 12.3 Bulgaria 1977 68.2 55 .8 28.0 12.6 Czechqslovak ia 1975 67 .2 54 .0 26.5 11 .7 Denmark 1978 71 .7 57 .8 29.5 13.9 Finland 1975 67.4 53 .7 26.4 12.2 France 1976 69.9 56 .1 28.6 13.7 German Dem. Rep. 1976 68.9 55.4 27 .7 12.1 Germany, Fed. Rep. of 1978 69.2 55 .8 28.1 12.7 Greece 1978 72.9 59 .9 31 .6 15.3 Hungary 1978 66.1 53.3 26.0 11 .7 Iceland 1978 73.8 60.3 32 .7 16.7 Ireland 1975 69.0 55.9 27 .7 12.5 Italy 1975 69.8 56.8 28.6 13.3 Luxembourg 1978 68.3 54.5 27 .0 12.2 Females Age Age Age At birth 15 years 45 years 65 years 75.7 62.0 33.2 16.0 75.5 61 .9 33.1 16.0 73.5 60.5 31 .7 14.5 73.6 60.8 31 .9 14.9 77 .7 63.6 34.7 17.8 76 ,3 62.3 33.4 16.1 77.9 64.1 35.3 18.0 74.5 60.7 31 .9 14.8 76.0 62.4 33.6 16.4 77.6 64.3 35.2 17.5 72.8 59.6 31 .0 14.5 80.0 66.2 37.0 20.0 74.3 60.8 31 .8 15.2 76.1 62.8 33.8 16.5 75.8 61 .6 32.8 15.8 t.,; V, Malta 1977 68.8 55 .3 26.6 Monaco M orocco Netherlands 1978 72.0 58.2 29.7 Norway 1978 72 4 58 .5 30.2 Poland 1978 66.5 53 .8 26.8 Portugal 1975 65.1 54 .1 27 .3 Romania 1978 67 .3 55.5 28.1 San Marino Spain 1976 70.8 57 .6 29.5 Sweden 1978 72.5 58.5 30.4 Switzerland 1978 72.0 58 .2 30.2 Turkey USSR United Kingdom England & Wales 1977 70.2 56 .7 28.2 Northern Ireland 1977 67 .5 54 .3 26.5 Scotland 1978 68.2 54 .6 26.5 Yugoslavia 1977 67 .8 56 .0 28.4 Source Health Services in Europe 3rd ed Copenhagen WHO Regional Office for Europe 1981 11 .2 72.6 59 .7 30.4 13.1 13.8 78.7 64.7 35.7 18.2 14.3 78.8 64.8 35.6 17.9 12.5 74.9 61 .8 33.0 16.1 12.3 72.6 61 .0 32.4 15.2 13.1 72.4 60.2 31 .7 14.9 13.8 76.7 63.2 34.2 16.8 14.3 79.0 64.8 35.8 18.1 14.2 78.9 64.8 35.8 18.2 12 7 76.3 62.6 33.6 16.7 11 .7 74.i 60.6 31 .9 15.4 11 .8 74.4 60.5 31 .8 15.7 13.1 73.0 61 .2 32.4 15.5 health of other members of the household . The second, no less important, is the favourable or unfavourable effect that belonging to, and living in, a family may have on the mental health of the older generation. Family mental health covers the complicated interactions of all members of a family, in the past as in the present. The mental health of each member of a family is inextricably bound up with that of other members, influencing it and being influenced by it both favourably and unfavourably. In 1962 the WHO Regional Office for Europe held a seminar in Athens on mental health and the family . The seminar traced the developing interest in mental health problems of families to the clinical experience of child guidance workers who, it suggested , had been the first to realize that the healthy personality development of children could not be isolated from the behaviour or, in fact, the mental health of each of the pa rents. The mental problems of children or their parents needed to be looked at within the social context of the family, where no element could be changed without modification of the whole st ructure . Workers in this field, while quick to realize the advantages of this approach, have not always been aware of its full significance; they have tended to see the family as " environment" and overlook the influence of the child's behaviour on the parents' mental health . In some parts of the world there is still a tendency to analyse all mental health problems in terms of instincts and conditions, disregarding, or at least misunderstanding, the social and cultural aspects of family life . These limitations are to a great extent a consequence of the fact that concern for family mental health originated in the highly industrialized parts of Western Europe and America, where a very special type of family structure has prevailed for some time. It is interesting to note that , while the 1962 meeting discussed the increase in three-generation families in Europe, later a WHO expert committee recognized the existence of four- and five-generation families in the Region (WHO. 1972). In more recent years information about older people in families has improved so much that it has been used as a basis for curative and preventive action in more than one sector of the mental health field . Students of family mental health often show a preference for the perspective of the child and a bias towards the emotional aspects of the interpersonal relationships in play. The importance for the child of having grandparents is usually very much in the foreground of the family worker's mind and the role grandparents are supposed to have is, in the opinion of many, mainly that of kindly and persuasive parent-substitutes who are willing and able to compensate for the faulty or neurotic behaviour of father or mother. But grandparents are not only grandparents; people do not cease to be mothers and fathers when they grow o ld and there are mental health risks attached to the child/parent relationship between adults. Some are carry- overs from earlier years: overprotective mothers or tyrannical fathers can be just as overprotective or tyrannical in their sixties and seventies as they were in their twenties and thirties. In many cases the personality pattern of sons and daughters is equally persistent. particularly when the neurotic structure of the two generations is so 36 interlocked that the result is a true family neurosis . Conflict situations can become even more acute when relationships with in-laws are added; neurotic behaviour is often more troublesome when it involves intimate members of the family who are not blood relations. Contacts between the older and the middle generations may also lead to entirely new mental health problems. Especially important are those which result from the gradual shift of responsibility that inevitably occurs when the strength and, in many cases, the economic usefulness of the older generation are waning at exactly the time when those of the middle generation are increasing. The situation may create emotional strain in the latter group, which may not want to accept a responsibility that can be inhibiting thrust upon it. One other important aspect of the family role of the older generation is educational responsibility . Many parents are only too happy to divest themselves of responsibility for bringing up their children and expect the grandparents to be substitutes for them; this form of parent deprivation can have serious consequences. On the other hand, it would be a mistake to exclude grandparents from the education of children . It is essential to offer the child as early as possible a fairly wide educational choice and to do so grandparents must be included; the child needs a 'social exercise ground' where he can prepare himself to leave the intimacy of the parent/child relationship for the emotionally more detached life of play groups and school. Being brought up by two generations also helps children to acquire personal experience of the whole life cycle of man . The acquisition by a young person of a clear awareness of human life in its entirety not only strengthens the process of personality maturation but, in the right circumstances, also contributes decisively towards his assuming a healthy identification with his forbears and culture. HEALTH OF ELDERLY POPULATIONS To understand the health needs of the elderly and the aged it is necessary first to measure their health status. As long as they are viewed as sick, infirm, and incapacitated, rational planning for a programme of health care is impossible. During recent years there has been an increasing number of health studies of old people. The studies vary in design and emphasis. Many are concerned with special populations among the old : the sick, the destitute, or those who come to the attention of health services. Others are concerned specifically with local populations. While the findings from such studies may be pertinent for the special group studied, it is difficult to draw from them general conclusions of national or cross-national applicability. As a result, research in depth still suffers from a lack of basic knowledge about the situation of old people in general. Because of this certain popular assumptions are perpetuated in the public mind : that most old people are in poor health; that most old people are physically isolated from their families; or that most old people are living in poverty. To the extent that these assumptions are generally accepted they have serious implications for social and health policy. Old people tend to be treated 37 as a monolithic homogeneous group rather than as a heterogeneous section of the population with diverse needs. As a result , programmes for old people may offer too little flexibility and choice to those they are designed to serve. Health, as defined in the WHO Constitution, is "a state of complete physical, mental and social well-being and not merely the absence of disease". Thus, in an evaluation of the health status of any individual or group all the elements of health status have to be considered . As distinguished from the mainly subjective appraisals of well-being, objective evaluations are possible on the basis of disease and impairment, both, as major elements in health status, being capable of clinical determination and statistical compilation. Even with such data , however, studies show that the correlation between disease conditions on the one hand and disability on the o ther are not consistent. Persons with specific chronic diseases often regard themselves as being in good health because they can independently and satisfactorily engage in daily living activities. This is particularly true in old age. When people become old they often accommodate to chronic disease and discomfort, ignore the symptoms and continue with their activities as though the symptoms did not exist. Complaints that at one time would have been considered important enough to be called to the doctor's attention are often believed to be inevitable in old age and remain undiagnosed and untreated. While a succinct description of the health sta tus of the elderly and the aged as an appropriate basis on which to plan health services for them is difficult to achieve, the collection of different health-related data can be useful. For instance, mortality and morbidity statistics reflect the leading causes of fatal or chronic conditi_ons among different age and sex subgroups of the elderly and the aged and indicate, to some extent at least, the need for either preventive or curative action . Data on the use of hospitals and other medical services reflect the extent of services required to satisfy the medical needs of the different subgroups. Equally important is assessment of the proportion of old people in institutions or living at home bedridden, housebound, restricted in ambu- lation , or fully mobile . Such data reflect how well the old people function in their everyday living conditions and indicate the extent of domiciliary nursing care or social assistance needed . The rationale of interest in this aspect of health status has been summarized by a WHO advisory group meeting in Oslo in 1958, which considered that health in the aged is best measured in terms of function, and that degree of fitness rather than extent of pathology may be used as a measure of the amount of services the aged will require from the community. Bearing those considerations in mind, it is useful to review different sources of health-related data and their value in assessing the health needs of the elderly and the aged . Mortality rates The health care requirements of older individuals can be partially determined by the extent in this age group of certain illnesses leading to death . The three 38 leading causes of death, accounting for over 75 ° 0 of deaths in the age group 65 years and over, are diseases of the heart, vascular lesions affecting the central nervous system (strokes), and cancer. For the age group 45 - 64 the data are similar, except that the order is somewhat different , with cancer in the second place. Certain public health measures are already applicable in the control of both heart and cerebrovascular diseases and of some forms of cancer. Since knowledge of specific measures for primary preven tion of these diseases is still inadequate, an effective programme will be based mainly on secondary prevention, particularly health education, early diagnosis, and systematic medical control of diagnosed cases. It is also especially important to cover the period of early aging (from 40 to 45 years of age) with such a programme when the development of a disease (or condi tions increasing the risk of its development) usually begin. Certain preventive measures should be consid- ered for younger people. Prevention of coronary atherosc lerosis, for example, should start with the age group 20- 30 years. A population-based autopsy study in Europe showed that on the average more than 80 ° 0 of men aged 35- 44 years had fibrous plaques, calcifications, or other lesions on 20 ° 0 of the surface of their coronary arte ries. It is therefore clear that preven tion should start even earlier than this age. It is to be hoped that the marked decline over the past few years in the prevalence of fatal cases of cancer of the breast and the uterus, formerly the major cancers in older women, is attributable to the increased awareness and action of both the general public and health workers. Accidental death rates are more than three times as high for old people as for people of all ages. After the age of 65 deaths from all accidents ri se sharply with increasing age. Of the tota l number of accident fatalities among old people about 85 ° 0 can be ascribed to three causes: falls. traffic accidents, and fire or explosion of combustible material. About six out of every ten fatal accidents in the aged result from falls, most frequently at home. Much could be done in this field by improving safety conditions both in the home and in the streets. Morbidity and disability rates It should again be emphasized that old age is not necessaril y a time of ill- health , disability, and misery. When disability occurs in an old person it is owing to disease, and the pathological causes are commonly multiple. Some of the conditions are chronic in type and not amenable to complete cure, but a number are capable of improvement, many to a considerable degree. Other disorders in the elderly a re as readily treated and relieved as in younger persons, for example certain forms of anaemia, heart failure, and deficiency diseases. Hence thorough investigation of old persons with disability becomes of the utmost importance, because only then can rational therapy be instituted and the maximum relief achieved. Certain chronic diseases are more prevalent among aging persons than among younger people. They include cardiovascular disease, arthritis, cancer, orthopaedic impairments, mental illness, loss of hearing and vision, and 39 genitourinary disease. However, they affect aging people to different degrees and in different ways and need not result in disability . Disease processes in the elderly are often not only multiple but also insidious in onset and development. A large number of studies have concentra ted on demonstrating the amount of undiagnosed and unreported disease and disability in the o ld . Many old persons are at an advanced stage of disease when their conditions are fir t detected by health workers . Earlier diagnosis and timely intervention can prevent much disability and take up less of the health and welfare services. In an Edinburgh survey (Royal College of Physicians. Edinburgh . 1963) disability was recorded and classified according to severity and whether or not it was known to the general practitioner. A high prevalence of morbidity was found , much of it quite unknown to the general practitioner. In one sample 43 ° 0 of people over 65 had disability associated with their feet (5 .5 ° 0 unknown), 37 ° 0 had disability of the locomotor system excluding feet (21 °,;; unknown), 8 ° 0 had anaemia ( I " 0 unknown), and 12 ° 0 had disability from disease of the urinary tract (2.5 ''o unknown) . Perhaps the most signi ficant finding was that 27.5 'i'0 showed a recognizable degree of dementia , of which only 3.5 ° 0 was known . Many other psychiatric conditions were uncovered , mainly anxiety states and depressions . These findings correspond closely to similar studies undertaken in different countries and presented at WHO meetings throughout the European Region. 40 4 Clinical studies It has still to be realized in many health services that research is an essential ingredient in the organization of care and the development of preventive programmes. Without the active participation of medical schools and research institutions efforts to establish services to care for the old will not succeed, since personnel of the quality required will not be forthcoming to tackle the difficult tasks ahead. The problems associated with the care of the aged continue to grow and every major advance in medical treatment is likely to increase them. One oft he most urgent tasks in the present situation is to foster systematic inquiry into the most effective ways of applying existing knowledge and to evaluate different forms of care. In this way the optimal deployment of limited resources can be achieved. The relative neglect of gerontological disciplines provides an incongruous contrast to the magnitude of the health and welfare problems of the aged in modern society. Clinical , epidemiological, and basic scientific studies are needed. AGING IN RELATION TO DISEASE Much has been learned from basic research in animals , and recent longitu- dinal epidemiological investigations of human populations have contributed to our knowledge of the processes of aging. Information is accumulating which, in the near future , will allow better distinctions to be made between the manifestations of aging per se and the symptoms of identifiable diseases . Within the individual there is a selective decline in regulatory mechanisms, as for example in the immune system, the capacity to control body tempera- ture, and the capacity to metabolize therapeutic drugs. Recognizing that a heavy toll on the lives and functioning of elderly persons in levied by chronic bronchitis, high blood pressure, heart disease , malnutrition , diabetes, and mental disorders, WHO in recent years has promoted programmes and studies relating to these and other conditions associated with aging. 41 NUTRITIONAL STUDIES There are many unsolved questions regarding the specific needs of higher age groups for energy and nutrients. Aged organs have a decreased metabolism because of the lower capacity of the single cell (Abu-Erreish et al., 1975; Chen et al., 1972) and /or loss of metabolizing tissue (Shock, 1972). Physical activity generally decreases with age, especially among the very old; while this lessens energy needs, it also increases the importance of the nutritional quality of the food taken. To obtain knowledge of the energy and nutrient requirements of the elderly in relation to body cell mass and energy output it is necessary to study the actual dietary habits of elderly populations, their medical and social circumstances, and the distribution and composition of their meals. Although several surveys of the dietary habits of elderly populations in Europe have been undertaken (Durnin. 1973; Macleod. 1974; Steen. 1977) knowledge is still inadequate. In 1959 the United Nations Food and Agriculture Organization (FAO) and WHO jointly sponsored a symposium on education and training in nutrition in Europe (FAO, 1960). The WHO Regional Office followed this up by organizing a study of nutritional programmes for the elderly in 1965° and a working group on the role of nutrition in public health in 1976, the special needs of the elderly receiving considerable attention. In 1977 a study of the public health aspects of the nutrition of elderly people living alone was undertaken by a WHO consultant in six European countries. 6 From these data , discussions. and the literature (Department of Health and Social Security, 1972; Steen . 1977) it has been concluded that overt malnutrition is rare in the elderly but does exist among a small proportion . Low intakes of specific nutrient s differ according to the country but include ascorbic acid , vitamin D, calcium. thiamin , and riboflavin . Overnutrition has been cited as a problem in some countries, but it has been noted that overnutrition from fatty diet s can al so be combined with undernutrition in essential proteins, minerals, and vitamins. The ri sk is greater among people who expend little energy because of low physical activity. Specific problems in the field of clinical practice include: the need for extra iron in the treatment of anaemia, which commonly occurs in the aged; the role of calcium and vitamin Dor protein in the treatment of osteoporosis; the use of high protein diets in the treatment of some liver diseases; the prevention of fluid retention; and the need for additional amounts of certain vitamins in the various clinical forms of hypovitaminosis . It has been pointed out that physiological changes in the senses of smell a nd taste may affect the food habits of the aged. There is an outstanding lack of direct knowledge in this field, the problem having been studied only in general terms. 0 Hartila, K. & Uhl E. Nutritional programmes for the elderly. Copenhagen. WHO Regional Office for Europe. 1965 (unpublished document EURO 221). b Steen, B. Public health aspects of nutrition of the elderly. Copenhagen . WHO Regional Office for Europe. I 977 (unpublished document ICP NUT 006). 42 Knowledge on the digestion and absorption of food is also limited. It has been stated that gastric and pancreatic secretions diminish with aging, that the amount of blood lipase decreases, but that the gastric emptying time is not changed. Intestinal galactose absorption has also been found to be delayed, and the same is claimed to be true of the absorption of amino acids. A joint FAO/WHO ad hoc expert committee on energy and protein requirements (WHO, I 973) defined the moderately active reference man as healthy, aged between 20 and 39 years, weighing 65 kg, and having an average energy requirement of 3000 kcal ( 12.5 MJ) per day. The reference woman, who is defined as healthy, 20 - 39 years of age, weighing 55 kg, and moderately active, has an average energy requirement of 2200 kcal (9.2 MJ). After 40 years, the energy requirements decrease by 5 ~0 in each decade for the next two decades, by IO " 0 between 60 and 70 years, and by another IO " 0 after 70 years. This means that after 70 years the average energy .requirements are 2100 kcal for a man weighing 65 kg and 1540 kcal for a woman of 55 kg. The FAO/WHO committee made no di stinction between the protein req uirements of adults and old people, and the minimum safe level of protein in take was put at 0.57 g of milk or egg protein per kg of body weight for men and at 0.52 g/kg for women. In practice thi s means that , in a developed country where the diet con tains protein of both animal and plant origin, a man weighing 65 kg should consume not less than 46 g of protein per day and a woman weighing 55 kg 36 g/day. Since the recommendations for protein intake rema in the same wha tever the person 's age once adulthood has been reached, and since the energy requirements decrease after the age of 40 years, the ratio of the energy derived from proteins to the total energy intake should increase progressively after that age. In practice most diets contain 11 - 13 "0 of energy as protein , and protein requirements are thus well covered in bo th adults and older age groups, i.e., the diet is adequate from the energy point of view. Carbohydrates, especially sugar, often form too large a part of the diet of old people, as is manifested in the increased prevalence of diabetes in a latent form in the older age groups. Most authors recommend that fats should not constitute more than a third of the energy intake. Ideally , the fats should consist of one-third saturated, one-th ird mono-unsaturated, and one-third polyunsaturated fatty acids. Joint FAO/WHO expert committees have dea lt with iron , vitamin A, thiamin, riboflavi n, ascorbic acid, vitamin D , and niacin requirements , but have made no special recommendations for elderly people as distinct from other adults. The prevalence of iron deficiency anaemia among the elderly appears to indicate that their capaci ty to absorb or utilize iron may be deficient. Instances of potassium deficiency have been recorded in elderly people and special care must be taken , especially with those receiving diuretic therapy, to see that their potassium intake is adequate . Little information is available about the calcium requirements of old people. It is possible that they are increased, but attention has recently been drawn to a possible vitamin D deficiency, especially in northern countries. Osteoporosis , which is commoner in elderly women , is a condition into which further research is warranted. 43 Except for energy requirements, therefore, the nutritional needs of the elderly are not decreased. There is a special need for adequate amounts of vitamins, especially C and D, and of minerals, especially calcium, potassium, and iron. It is generally not advisable that old people's diet should consist of soft or semiliquid foods; an element of roughage is essential in order to maintain the tone of the intestinal tract. For the same reason, adequate exercise and the avoidance of a sedentary life are desirable. In many developed countries malnutrition often leads to obesity, and this is almost certainly a factor that shortens life . The cause of obesity, especially in women, is often an improper dietary intake resulting from emotional disturbances. The following groups of elderly individuals are more likely to have nutritional problems: (I) those living alone , especially the housebound (2) those with physical diseases that make shopping or cooking difficult (3) the mentally ill (e.g .. the depressed) (4) the recently bereaved (5) residents of old people's homes (those in charge of such homes should be advised by dietitians). Older individuals eat better in company of their own choosing or if they have played some part in the actual preparation of the meal. In some old people 's clubs the members participate in the planning and preparation of the meals, this reflecting the importance of the social aspects. Sometimes visitors to housebound old persons bring their lunch with them so that they can eat together. The participation of dietitians in all geriatric programmes is considered to be of great importance. In addition to the claim made by many authorities that taste diminishes with advanced age, other factors said to be responsible for inadequate nutrition are poor dentition , cultural and traditional factors, lack of interest in food, lack of social activities, the disadvantage of cooking for one person only and eating alone, insufficent means to cover the purchase of appetizing (or even adequate) foods, difficulties in shopping resulting from impaired mobility and, possibly, poor intestinal absorption . The WHO advisory group on the public health aspects of the aging of the population that met in 1958 drew particular attention to apathy as a cause of malnutrition, especially in elderly persons recently bereaved. It suggested that apathy might be overcome by appealing to their taste and aesthetic sense, and that research was needed into ways of providing attractive food . They also recommended that courses in nutrition of the elderly should be included in the curricula of all medical , nursing, and social work schools. The problem of adequate nutrition of the elderly inevitably leads to the problem of their social care. In thi s the solutions are ultimately determined by their economic conditions, lifestyle, and the means at their disposal for dealing with their difficulties . 44 PHYSICAL PERFORMANCE STUDIES Optimum physical performance capacity In the young, physical activity leading to a balanced development of speed , strength, endurance, and skill is desirable. In adults, the aim of physical activity should be to conserve or increase the abilities acquired. In old age, physical activity is needed for the conservation of motor and functional capacity and prolongation of the active and productive period of life. Of the many attempts made to explain the reasons for the deterioration in the general state of health of middle-aged population groups one is that decreasing daily physical activity contributes to a lower level of physical fitness . This aspect was discussed by a WHO scientific group in 1969 (WHO, 1969). The interrelationship between health and physical activity has been studied by many investigators, and it has become evident that hypokinesia leads to a deterioration in musculoskeletal and cardiopulmonary function. There are also indications that physical inactivity increases the risk of ischaemic heart disease. It has, however, proved very difficult to relate the effects of physical activity to health in general. To describe the health effects of variations in physical activity the concept of physical performance capacity (PPC) is necessary. The PPC of an individual comprises different elements, which may be listed as follows: subjective exercise tolerance maximum aerobic power - (V o 2 ) max - and endurance, maximum aerobic endurance being usually defined as the maximum time a certain fraction of maximum aerobic power can be sustained maximum aerobic power and capacity maximum muscular strength and endurance neuromuscular coordination. Methods for measuring all these elements have been developed, but particularly for measuring maximum aerobic power and maximum muscular strength and endurance. Only those two variables will be dealt with here. Although comparable data on the PPC of populations in different parts of the world are very limited, there are indications that there is a marked decrease in the PPC of population groups in developed countries. This raises the question whether these groups would be better off if their PPC were higher and, if so, what level would be desirable and how it could be achieved. The scientific group came to the conclusion that no recommendations could be made at that stage, but that standard values could be derived from population groups that appear not to have been affected as yet (e.g., communities in some developing countries). The group was unanimous in its opinion that health would be promoted by the amelioration of any abnormally low PPC; it therefore gave much attention to the possibility of training for the different components of the 45 PPC. This was considered the more desirable because it was doubted whether man's usual daily physica l activity, both occupational and leisure. even if relatively high , could guarantee a sufficiently high PPC. While more research is needed to establish the intensity , frequency. durat ion, and type of physical activity required at all ages to achieve and maintain the PPC required for optimal health, the research already under- taken has produced some interesting findings relating to the prevention of disability and disease and is, therefore , of particular relevance to the health care of the elderly. Implications for aging individuals Lack of physical activity induces changes in cell metabolism and in the musculoskeletal, cardiovascular, and nervous sys_tems. In cell metabolism it is manifested in the alteration of enzyme activity; in the musculoskeletal sys tem in decalcification of bone. replacement of muscle tissue by connective tissue and fat, and nitrogen loss; and in the cardiovascular sys tem in tachycardia at rest and during exerci se in the supine and upright positions, ECG alterations, changes in the contractile properties of the myocardium, and !ability of cardiovascular regulation. In the nervous system changes in autonomous regulation occur and sometimes also there are psychoneurotic manifestations. Regular and adequate physical training increases both the morphological and the functional capaci ty of the human organism. Morphological adap- tation can be observed by changes in body shape, in the skeletal and muscular systems, and in the lungs. heart , and other organs. Functional adaptation manifests itself in, for instance, the relationship between maximum aerobic power and anthropometric and haemodynamic variables. Physical activity that is too great in intensity and duration, asymmetrical. or performed in an unnatural position or an adverse environment may cause overst rain of a part or the whole of the organism and induce local or general damage. An aim of occupational and physical medicine is to discover the causes of overstrain or damage and to prevent and treat it. One of the preventive and therapeutic measures employed for this purpose is regulated physical activity. Physical activity in preventing and treating disease Physical exercises have an established place in the treatment of several diseases and disorders and play a major role in medical and occupational rehabili- tation. In recent years occupa tional physical activity has decreased in many parts of the world. Parallel with this the spectrum of diseases has altered markedly, and this has stimulated studies on the prophylactic and remedial value of physical activity . /schaemic heart disease Interest in physica l activity as a positive health factor has during recent years been concentrated largely on ischaemic heart disease. Epidemiological studies 46 on occupational differences in mortality and morbidity have indicated that, in some populations, men in physically active occupations experience less ischaemic heart disease than those in sedentary work . In other populations, however, it appears that such a difference does not exist. The observed differences in morbidity or in different occupational groups may also not be conclusive; they cannot be ascribed solely to physical activity, since choice of occupation and different socioeconomic conditions may influence the charac- teristics of occupational groups in many ways. Epidemiological studies on former athletes are fewer than those on occupational groups and most have been undertaken among smaller groups. The longevity of athletes has shown to be either almost the same as, or higher than, that of the general population. However, as athletes are often a socioeconomically favoured group, the general population may not be suitable for comparative purposes. While participation in university sports does not affect longevity among students, several favourable characteristics have been observed in former endurance athletes, even at an advanced age. The majority have been found to have lower blood pressure, a larger heart volume, greater aerobic power, and less intense smoking habits than matched controls. In longitudinal studies of ischaemic heart disease some indices of habitual physical activity and physical performance capacity have emerged as signifi- cant predictors of ischaemic heart disease mortality. During a 12-year follow- up study, active life habits, a strong hand grip, a high vital capacity, and a low resting heart rate were associated with a lower than average mortality. The possibility of preventing ischaemic heart disease through physical activity in leisure periods would have obvious public health implications and deserves further study. While poor cooperation on the part of subjects has tended to discourage the initiation of study for primary prevention, studies of secondary prevention by exercise should be easier to carry out because people who have recovered from myocardial infarction are usually strongly moti- vated to participate in prescribed exercises. Groups with exceptionally restricted physical activity may also contribute to the study of the relation of physical activity to ischaemic heart disease: examples are the blind and subjects with certain handicaps of the locomotor system. Peripheral arterial disease In the medical treatment of peripheral arterial disease exercise has proved to be a potent therapeutic agent , effectively increasing the distance walked without pain. This justifies the conclusion that exercise may also play a role in the prevention of peripheral arterial disease, perhaps by stimulating the growth of a collateral circulation . Hypertension In normal subjects brief physical exertion causes a transitory increase in the systolic blood pressure but does not influence the diastolic pressure to any 47 major ex tent. In prolo nged exertion the systolic pressure increases initially but may then decrease with time. In pa tients with ea rly hypertensive disease brief exertion has been fo und to diminish the systolic and diastolic blood pressure, sometimes considerably. In patients with ort hostatic hypertension physical training has sometimes normalized their blood pressure when in a n i.:pright position. In some longitudinal studies of end urance training a hypotensive effect on the systolic a nd diastoli c blood pressure has been observed . This phenomenon has also been found in some studies of active elderly sport smen. Locomotor system Many complaints of ill-health, pain , and malfunctio n of d ;verse organs may be related to a subnormally functi oning muscular sys tem. There appears to be enough evidence to substantiate the assumption that weak muscles oft en cause the more passive structures of the body - e.g. the joints, ligaments, a nd connect ive ti ssue - to be overloaded a nd thus strai ned . Reflexes that normally protect these structures presuppose a musculat ure strong enough to be effective. The nutritio n o f bone and ca rtilage is highly dependent on the mechanical stresses and strai ns these struct ures undergo . The fl ow of lymph a nd intercellular fluid is stimulated by the intermittent loading and relaxing of the ca rtilaginous tissues in joints and intervertebral di scs , and the pull o f the muscles is the mai n source for the necessary changes in pressure. Physical activi ty has bot h an immediate and a long-term effect on the carti lage and is therefore of impo rtance for these passive structures. The correla ti on between certain disorders of joints and bones a nd untrained musculature is not fully elucidated , but a striking effect in many such disorders has often been observed with supervised muscle training. Many pai nful conditions in the muscles themselves are caused by incorrect use; unnecessa ry muscle tension in the shoulders , back , and legs can cause more or less chronic sore muscle states, the seat of pain probably being in the muscle connective tissue . How these conditions develop is not well known, but permanent overloading of small di screte parts of the muscles is probably the most common cause. Whether the ensuing soreness. oedema. and local hyperaemia are caused by anaerobic metabolites or by a reaction of the connective tissue is also not known . The la tter seems the more probable because of the resemblance of the signs and symptoms to those that develop 24-48 ho urs after local overloadi ng of t he muscles in untrained persons and in experimenta l animals. Proper training strengthens the con nective tissue in the muscle a nd may thus act as a prophylactic. In th is con nexion the importan.:e of being a ble to relax muscles has been emphasized frequently. One of the most commo n causes of disability in the older age groups is pai n in the back . In a grea t many cases this is caused by weak back muscles. Obesity The relatio nship of physica l activity to o besi ty has been the subject of extens ive studies bot h in experimental animals and in man . Obesity is not a 48 uniform syndrome. The imbalance between calorie intake and expenditure may, in many cases, be ascribed to reduced activity and to deficient adjustment of the appetite to calorie needs. There is substantial evidence that sufficient habitual occupational or leisure-time activity prevents obesity. Diabetes In mild diabetes and in the diabetes of older people regular physical activity improves metabolism and in some cases facilitates control by medication. Other organ systems The functional variables of the respira tory system are clo ely correlated with body dimensions . However, training may also affect them . This is shown in the increased maximum voluntary ventilation, vital capacity, and diffusing capacity of the lungs of athletes. While pulmonary function deteriorates with age, it has been observed that age changes are retarded by physical ac tivity . STUDIES OF CARDIOVASCULAR DISEASES Considerable progress was achieved in the treatment of cardiac patients during the 1960s, but since that time there has been little development in the prevention of cardiovascular diseases. The precise etiological fac tors behind atherosclerosis, hypertension , and ischaemic heart disease are not known . Some relationship has been shown to exist between ischaemic heart disease and such factors as smoking, lack of physical exercise, high serum cholesterol levels , hypertension, and stress, but it is not certain that any of these associations is causative. Even if it is, it is not known whether, in middle-aged subjects, a change brought about in a given factor would make it possible to reduce the subsequent incidence of the disease, either immediately or in the long term. Hence primary prevention is still limited to education, including general recommendations on the surveillance of arterial tension, nutrition and obesity, physical activity, mental st rain , and a healthy lifestyle. All these measures, excellent though they may be on several counts, are often difficult to accept in that they impose constraints that have to·be adhered to throughout life . Vascular disease Atheromatous arterial disease mainly affects the brain, heart , and lower limbs, the first being the most important cause of di sability in elderly people in Europe. Major cerebral infarcts resulting in hemiplegia and multiple minor infarcts, usually demonstrated as dementia , are frequent causes of admission to geriatric units for short-term or long-term care. Ischaemic heart disease, though a major cause of death , is less frequently a cause of disability . While in the elderly its combination with cardiac failure is of considerable importance 49 (Pomeranz. 1965) management of the latter has been considerably facilitated in recent years by the advent of modern diuretics. Peripheral vascular disease is a frequent asymptomatic finding in elderly people and rarely produces symptoms necessitating treatment. When it does, modern arterial surgery often prevents the need for amputation of limhs as in the not-too-distant past. At present there is no known effective way to prevent arterial disease, although many theories have been put forward . What is obvious is that the means, when discovered, is likely to include large-scale changes in the lifestyle of the population, not in old age but at a much earlier stage of life. Arterial hypertension A raised blood pressure is regarded as almost physiological in elderly Europeans and a wide range is acceptable (Anders·on & Cowan, 1959). In men the upper limits for systolic blood pressure are 195 mmHg (60 - 69 years), 205 mmHg (70 - 79 years) and 215 mm Hg (80 - 89 years). In women these are 200, 215 and 230 mm Hg, respectively. Corresponding upper limits of diastolic blood pressure are given for men as I 00, I 04 a nd I 08; and for women as I 02, 106 and I 10. Although hypertension, in the sense of a condition producing symptoms requiring treatment , is not of major importance in elderly people, it is a ri sk factor in the development of atheromatous disease and stroke. Multiple pathological findings in the heart are an outstanding feature of cardiac failure in the elderly (Pomeranz, 1962). The control of arterial hypertension and stroke is close ly linked with that of ischaemic heart di sease. Many people are unaware that they have hypertension . and of those who a re . a relatively small percentage receive adequate treatment. It should, however, be possible to achieve an appreciable reduction in complications such as cerebrovascular accidents through ea rly diagnosis, suitable treatment. rehabilitation , and health education . PHARMACOTHERAPY STUDIES Regulatory agencies in most countries of the Region are faced with a range of inte rrelated problems. both o ld and new. in the field of medication for the elderly . While the scope and nature of these problems differ widely from one country to another. all countries are spending increasing sums of money on pharmacotherapy for their aging populations. These drugs are often un- necessary , or are given for the wrong reasons, or lead to adverse reactions. some of which are more serious than the conditions for which they were originally prescribed; and all are inordinately expensive. According to Gibson et al. ( 1977), in the fiscal year 1976 the aged in the United States of America spent about 25 " 0 of the national total of US $11 200 million spent on drugs and drug sundries . On the average each elderly person spent over $ 100 that year on prescribed a nd non-prescribed drugs. If these trends continue it can be expected that by the year 2030 - when nearly 52 million people will be over 65 years and constitute 17 " 0 of the population - 50 expenditure on drugs by the elderly in the United States will constitute 40 "0 of the national total. In the United Kingdom, although the elderly represent only 12 ~0 of the population , they are responsible for approximately 30 ~0 of national health service expenditure on drug prescriptions (O'Malley et al. , 1976). Because the topic had been selected as a priority concern by a WHO technical advisory committee meeting in Munich in 1978, a technical group on the use of medicaments by the elderly was set up and met in 1980 in Thonex. It s task was to review existing pharmacological knowledge in relation to age; to define indications for the use of drugs in old persons; to consider problems of overdiagnosis. overtreatment, and polypharmacy; and to provide informa- tion on the more useful drugs for use in elderly patients. Prescribing patterns Where the proportion of elderly (60 years and over) in the population is very high (approximately 20 '.' 0 of the total population) it accounts for 50 "0 or even more of the total drug consumption . From the limited data available on prescribing patterns in different settings the group concluded that poly- pharmacy appeared to be the rule in acute hospitals and institutions. Psychoactive drugs appear to be universally used for mentally disturbed patients. Drug prescribing does vary , however, and to permit comparison between and within countries the use of the defined daily dose (DOD) was proposed , a procedure recommended by the WHO-sponsored Drug Utilization Research Group. Geriatric clinical pharmacology The important and sometimes subtle physiological and psychological changes that occur with "normal" aging might reasonably be expected to alter the response to and the elimination of drugs and/or change organ or receptor sensitivity. Some pharmacokinetic age differences have been documented and tend to be consistent with age-related changes in body composition: protein binding, hepatic drug metabolism, and renal excretion (Triggs & Nation, I 975; O'Malley et al.. 1976; Crooks et al., 1976; Richey & Bender, 1977). However, apparent age differences in metabolizing drugs are probably multifactorial (Vestal et al. , 1979). Pharmacokinetics Absorption Most drugs are taken orally, but no change from aging has been demonstrated in the rate or amount of drugs absorbed from the gastrointestinal tract. Distribution After absorption a drug rarely remains in the plasma only but is usually distributed to other parts of the body. At present there is insufficient evidence 51 to draw any general conclusions about the effect of aging on the apparent volume of distribution of drugs. In some (e.g. , nitrazepam , lorazepam, nordiazepam, and propranolol) it is unaffected. In others (e.g. diazepam, chloridazepoxide, and propicillin) it is increased (Castleden & George, 1979; Simon et al., 1972; Wilkinson, 1978). Elimination Since there is no reduction in drug absorption in aging, the elderly are at risk from relative overdosage of drugs because the pathways for their metabolism and elimination are inefficient. There are two major routes for eliminating drugs from the body: through their metabolism in the liver and through renal excretion. Most drugs are metabolized prior to their excretion via the kidney or in bile; few are not metabolized to any significant extent and are excreted, essentia lly unchanged, :n the urine. Changes in drug elimination rates are most important for drugs with a narrow therapeutic index, such as digoxin, aminoglycosides, and hypoglycaemic agents. Defective elimination means that the tissue concentration and therefore the pharmacological effect for a given dose of most drugs are greater in the elderly. This is a major cause of the increased incidence of adverse drug reactions in elderly patients. Renal elimination. It is now well established that the glomerular filtration and tubular secretion of drugs are reduced in aging even though there may be no clinical evidence of renal failure (Davies & Shock, 1950; Molholm-Hansen et al., 1970; Castleden, 1978). The blood urea and serum creatinine concentrations are often within the normal range despite a creatinine clearance of less than 50 ml per minute. While this is of little importance in relation to those drugs which have wide therapeutic ratios (e.g., penicillin), it is of considerable importance in relation to others; a clear correlation has been established for instance between renal function , aging, and digoxin toxicity (Smith & Haber, 1970). It is also unwise to use aminoglycosides in elderly patients unless there are facilities for estimating the plasma drug concentration. Hepatic metabolism. Since hepatic function and hepatic blood flow decrease with age, the elderly eliminate more slowly many of the drugs metabolized in the liver (Castleden & George, I 977). Work carried out on drugs with a high extraction rate has shown that they are eliminated more slowly, but no such evidence exists regarding drugs with lower extraction ratios. It is known, however, that their clearance rate is never quicker in elderly patients than it is in younger age groups (Triggs & Nation , 1975; Wilkinson, 1978). With drugs of low extraction rate it is important to remember that the induction of drug metabolism may be reduced in elderly individuals. Pharmacodynamics Although still at a preliminary stage, the study of alterations in pharmaco- dynamics with age strongly indicates that drugs which act upon the cerebral nervous system produce an enhanced response in a given plasma concentra- 52 tion. In other systems, particu la rly the cardiovascular. the response decreases with age . A major problem in thi s field is that many studies have compared geriatric patients with healthy young people. Thus pharmacodynamic differences apparently due to aging may in fact be explained by the existence of di sease in the elderly patients. This can upse t compensatory mechanisms that normally minimize unwanted effects., e.g. postural hypertension. Baroreceptor activity has been shown to decrease with aging, owing mainly to atherosclerosis but also partly to autonomic neuropathies (Gribbin et al., I 971 ). Diuretics also produce a greater sodium loss in old people because of their decreased ability to conserve sodium ions (Swales, 1979). Although there is also some evidence that end o rgan or receptor response decreases with aging (Vestal et al., 1979; Dillon et al.. 1980) further resea rch is required to study mechanisms at the molecular. cellular, and physiological level . Since it is not yet poss ible to draw up firm guidelines on all the effects of aging on drug pha rmacokinetics and dynamics, many more carefully designed studies involving healthy elderly volunteers are required . Self-care and self-medication Self-medication is practised at least once a year by 80 "0 of elderly people (Adamson & Smith. 1978; Calkhoven. 1980) and it increases with age. In developing countries se lf-medication includes the taking of herbal concoc- tions and other drugs . As this is one aspect of se lf-care, the need for continuing education in non-prescription medicines should be an important considera- tion in the health care programme of a ny co untry (Adamson & Smith, 1978). Other studies have confirmed that the high consumption of medicaments by elderly people can lead to interaction with prescribed medication , to undesired side effects, and even to intoxication . Moreover, account must be taken of the fact that elderly people may suffer fro m impaired rena l function a nd reduced liver detoxifying capacity. Misuse or abuse of presc ribed drugs by elderly patients is not generally recognized unless the problem reaches emergency d imensions. Almost 20 "0 of the patients entering the geriatric se rvice of a general hospital display symptoms at!ributable to the effects of prescription drugs. The 1980 technical group considered strategies in relation to the most common questions asked. Is drug therapy required? Many symptoms from which the elderly suffer do not require treatment a nd often the cessation of a drug regimen leads to improvement (Burr et a l. , 1977; Learoyd , 1972). This means that a drug should not be used for a longer period than necessary and that all repeat presc ripti ons should be reviewed at intervals. The use of drugs a lso has to be combined with attention to mental health and social circumstances and should never be regarded as a substi tute for time spent in giving advice a nd practical help or in encouraging the adjustment ofan old person' s daily living pattern . Members of the technical group emphasized, however. that drugs should not be withheld on account of a patient 's age, part icularly when appropriate pharmacotherapy can improve his quality of life . 53 If drug treatment is required, which treatment is appropriate? In many instances the margin between therapeutic effect and toxicity is small, and a drug indicated for younger patients may be unsuitable for treating the same condition in elderly people. For example, in the treatment of gastric ulceration the administration of carbenoxolone to older patients can result in hypo- kalaemia, with all its likely complications. Is the patient being asked to take more drugs than he can tolerate or manage? As few drugs as possible should be prescribed, since the likelihood of toxicity increases with the number of drugs taken . The likelihood of errors in administration also increases. Which type of preparation should be used? Dosage, form , shape, size, colour, and similarity of capsules and tablets are important considerations (Mazullo, 1972). Many older people have difficulty in swallowing pills and there is a good case for prescribing liquids or effervescent tablets whenever possible. Suppositories may sometimes be the most suitable method of administration, e.g. indomethacin suppositories at night to relieve pain and stiffness from rheumatoid arthritis. Touch and colour vision are usually good in elderly people. This should be borne in mind when prescribing preparations to be used together. Should the standard dosage or schedule be modified? Elderly people require smaller doses of some drugs than young adults; the initial dose of thyroxine and the maintenance dose of digoxin are two examples. Lists of drugs that should be given to the elderly in smaller dose than normal can be found in most textbooks of geriatric medicine . Whenever possible intermittent sche- dules should be avoided; they are rarely followed with accuracy. What side effects are likely to occur? Drugs lead to confusion and vague malaise more frequently in older people. Again , lists of those which should be avoided are given in many textbooks of geriatric medicine. Should drugs be specially packaged and labelled? Drugs prescribed for elderly patients living at home should be packaged in containers that can be opened easily. The labelling should be clear. Can the patient living at home manage self-administration? The elderly patient should be taught to understand his drugs, particularly their import- ance to his wellbeing, and time should be spent in teaching him their use and administration. It may sometime be necessa ry to provide him with clear instructions in writing or suggest that he use a diary or calendar to record his daily drug administration (Wandless & Davie, 1977). Collaboration with a responsible and interested relative, neighbour, or friend can be helpful. But even with these and other precautions some drugs are best kept in the custody of others. Recent surveys have shown that many elderly patients living at home often have potent drugs prescribed for them when they are mentally unfit to use them responsibly (Shaw & Opin , 1976). It is imperative in such cases that a responsible relative should have charge of drug treatment. If there are no relatives it may be necessary for the community nurse to administer the drugs . Is there a need for continued medication? Because a drug such as digoxin has been prescribed for an acute episode, for example atrial fibrillation following pneumonia, there is no reason for its continued use once the acute 54 episode has been satisfactorily treated . The same is true of many drugs commonly prescribed. Treatment should be reviewed regularly to ensure that drugs no longer needed are discontinued (Burr et al., 1977; Learoyd, 1972). Elderly patients tend to hoard drugs (Law & Chambers, 1976). Accumulation of drugs is likely to confuse the patient and to encourage the use of outdated and probably inappropriate drugs. To aid in the review of medication patients should be encouraged to bring their containers to all consultations. Finally, it is worth stating again that the symptoms of elderly patients do not invariably require the use of drugs and that when they are indicated they must be used carefully. This applies particularly to psychotherapeutic drugs (Hollister, 1975; Learoyd, 1972). Compliance by elderly patients Compliance in this context refers to the punctiliousness of patients in following their physicians' orders. Although little studied before 1960, the subject has attracted great interest over the past two decades . As noted by Nemitz & Schellin ( 1979), age appears to be a factor contributing to non- compliance by patients at both extremes of the lifespan, in unsupervised children and adolescents and in adults after the age of 60. Non-compliance in drug-taking may take the form of: failure to take drugs at prescribed times; interruptions in the schedule; errors in dosage; and the combination of prescribed drugs with others. Compliance appears to be affected when many drugs are employed to treat multiple pathological conditions and by memory or visual impairments. Implications for research The Ninth European Symposium on Clinical Pharmological Evaluation in Drug Control ( 1980) discussed the control of drugs for the elderly, with particular attention to the inappropriate use of drugs in treating them. "Geriatric" drugs. An analysis of current regulatory provisions has shown that responsible bodies have not been consistent in their policy towards the use of drugs by the elderly. There are many differences between one country and another. Many products marketed and registered some years ago now require re-evaluation in the light of more recent knowledge. For some intended for self-medication the extravagant claim is made that they prevent , or arrest, symptoms associated with aging or even the aging process itself. Many of these are likely to be inefficacious and the safety of others is not always known. The Symposium agreed, however, that unless there are sound hypotheses regarding the use or dangers of these drugs, extensive evaluation of them is not justified. The value of specific agents for treatment of specific symptoms. The claim made for a limited group of prescription compounds that they relieve particular symptom in the elderly, especially those associated with vascular or cerebral function , is open to question . The proper basis for licensing such products is to demonstrate their clinical usefulness in terms of clinically 55 significant prophylactic or therapeutic effects or of a substantial improvement in social function. Proof of pharmacodynamic effects alone is insufficient. Because short-term impressions can be misleading more extended clinical work is required. Policy research. More background information is required for the development of optimal policies for medicaments for old people, e.g. on aspects such as: drug utilization patterns in old age; the factors that influence them; and the effects of exogenous factors (including smoking and drinking) on drug response in the elderly. It should be borne in mind that: (a) animal studies are unlikely to provide valid data on the effects of aging on the response to drugs; (b) some major changes in the response to drugs only become evident at the age of 70 or beyond and cannot be foreseen on the basis of findings in subjects in late middle age; (c) information obtained at the clinical level may point to a need for pharmacokinetic studies in the elderly in order to explain the findings; (d) the elderly population is not homogeneous and there must be caution in extrapolating findings from small groups; (e) data obtained from one part of the world are not necessarily valid for another, because aging does not proceed at a similar rate in all populations; (j) due attention should be paid to drug interaction problems in the elderly, particularly since they often use multiple drugs; (g) the inadequacy of data on the above matters at the time of licensing often renders it necessary to regard a drug as provisionally contraindicated in the aged, pending further work. Educational implications If drugs are to be used to the best effect by the elderly it must be simple for them to adhere to the dosage scheme. Ensuring this may involve special measures with regard to the dispensing form and the presentation. Many physicians need to be made aware of the need to adapt their prescribing patterns. Drug utilization studies, with a feedback to prescribers, may help to counter the tendency to polypharmacy. The elderly themselves also need to be approached by a direct educational campaign , with pharmacists playing an essential part. It should al so be made clear to the general public that many aspects of aging do not require, and will not respond to , drug treatment. Legislation Drug legislation in every country should cover all products (including those sold outside the drug trade because of re trictive legal definitions of the term "drug") claimed to improve or maintain health in older people. Regulatory agencies should also develop a total policy on drugs for the elderly in order to 56 avoid the sit uation in which restrictive measures against one drug regarded as ineffective or dangerous merely resu lt in a shift to another that is no better. STUDIES OF MENTAL DISORDERS Mental health problems in old age and their implications in different cultures There have been few attempts to explore systematically the relationship between mental health in old age and the many and varied transformations that social relations and psychosocial factors are undergoing in the transition from traditional to new social structures. It has been suggested that, if the social conditions of the aged , society's attitudes to them and to aging, and morbidity patterns in the elderly population in different cultures were taken into account in programme development, it would become possible not only to understand better the process of aging but also to organize social support and services for the aged more rationally. In st ructuring such programmes it is suggested that it will be necessary to answer three important questions. ( 1) Do the extent and pattern of mental morbidity in old age vary in relation to the general characteristics of the society- levels of urbanization. industrialization. employment, type of family structure, etc.? (2) Do societies differ with respect to the extent and types of psychosocial stress to which aged populations are exposed? (3) Are there protective or supportive systems in some societies more than in others that are capable of buffering the impact of stress? Most of the epidemiological and social surveys of the mental health of the aged have taken place in economically developed countries, and the evidence that would permit attempts at answering such questions is very limited. In developed countries the overall prevalence of mental disorders in the age group 60 years and over seems to be of the order of 30-35 ° 0 (Roth. 1973). Severe and irreversible disorders, including senile and arteriosclerotic de- mentia , constitute a relatively small proportion of this morbidity (prevalence 2.5 - 5.6 "0 , depending on whether the prevalence is reported for 60 years and over or 65 years and over). The largest category of mental morbidity in old age. as also in younger age groups , is depressive and neurotic disorders and ill- defined mild mental deterioration, which often has a neurotic overlay and may be more of social than of medical significance. This means that , contrary to widespread belief. a considerable proportion of the mental disorders in old age are either treatable or partly preventable; they are in any case modifiable by means that do not require elaborate technology or placing patients in institutions. This conclusion. however, should not lead to hasty optimistic inferences a bout the possibility of reducing the demand for institutional care for the aged. The burden on the health and social welfare services in the industrialized countries is not associated so much with the minor psychiatric illnesses and 57 borderline conditions between normal and pathological aging (which have a high prevalence in the aged) as with the subgroup of elderly patients suffering from organic brain syndromes of some severity. A study in the United Kingdom found that the 6.2 '.;~ of the elderly population with organic cerebral conditions contributed 46 % of patients admitted to geriatric wards and 15 % of those entering residential accommodation (Roth, I 973). Admitting that the majority of the old people in geriatric institutions do have signs of advanced cerebral and somatic deterioration , we are neverthe- less led to conclude that the demand for institutional placement is rooted in social conditions, expectations, and attitudes. It has been found for example that , apart from loneliness and social isolation, a predictor of admission to a geriatric institution is the onset of incontinence, regardless of the severity of intellectual and physical decline. Although incontinence is correlated with overall deterioration, the social embarrassment of the symptom probably affects the decision-making of the group or individual concerned more than judgement of its medical significance. Data for industrialized countries that have developed extensive geriatric institutional services indicate that social and economic pressure stemming from the organization of work and leisure, the structure of the family, housing conditions, etc. have undermined the ability and willingness of families and communities to accommodate their aged members. The process has changed the traditional system of values and thus also attitudes to old age. Available information on mental morbidity in old age in the developing countries does not permit a firm conclusion since the data from different studies vary, probably because the criteria for case identification and sampling have not been uniform . There is no consistent evidence, however, to support the view that traditional societies have a significantly smaller share of psychosocial disorders in old age than industrialized societies. Population studies have resulted in measures of the overall morbidity of aged populations ranging from 2 '.;0 in Taiwan and in Agra, India , to 33 '.;0 in a rural community in West Bengal , India . Since, however, almost all of the cases identified in the former two studies were of organic brain syndromes, and the proportion of such syndromes was of the same order in the latter study, it might be supposed that the difference in prevalence rates was associated with the different rate of identification of milder, mostly functional, di sorders among the old people. Certain qualitative differences have been documented in the commonest types of symptoms and underlying cerebral dysfunction between the de- veloped and the developing countries, particularly in tropical areas where post-infection encephalopathies are frequent among the aged. A fairly consistent and striking finding in reports from developing countries, however, is the very low proportion of old people with organic mental disorders among those consulting the psychiatric services. For example, out of 2322 patients seen over a two-year period in a psychiatric outpatient clinic in India, only 3. 7 ~0 were suffering from organic cerebral conditions, including disorders of old age. The very low rate of utilization of mental health services by the elderly cannot be explained by the shortage of institutional facilities, since the proportion of mentally disturbed old people is reported to be low even among patients attending outpatient clinics and rural health centres. 58 The discrepancy between the prevalence of mental disorders among the aged, which is comparable with that in industrialized countries, and the low referral rate is a problem that requires study. It can be conjectured that family support in the traditional kinship system, which ensures a relatively high social status for the aged , is a major factor in explaining the discrepancy, and that mild mental deterioration, even if present , is not perceived as a health problem requiring treatment. The important question is not whether the family system plays a role but how vulnerable such support systems are, and whether hope can be placed on their continuing effectiveness in the face of the rapid social changes taking place in most developing countries. On this question data allowing predictions are lacking. Indirect evidence from reports on the rising prevalence in the developing countries of conditions such as arterial hypertension and the association of such disorders with urbanization and changes in attitude suggests, however, that the traditional systems are vulnerable. Discussion on the possibility of strengthening supporting psycho- social factors and counteracting pathogenic influences are bound to remain on a rather general level until more systematic information is obtained on the relationship between social processes and the pathology of old age. At one time depression was believed to be extremely rare in non- industrialized societies, particularly in Africa. Recent studies , however, have demonstrated that depressive disorders do occur with a frequency comparable with that found elsewhere; no culture can be said to be free of depressive illness (Sartorius, 1973). An international study of depressive disorders coordinated by WHO has shown that in such widely different societies as Canada, Iran, Japan, and Switzerland patients with depressive illnesses have remarkably similar basic symptoms. Suicide, a phenomenon frequently associated with the anomie of com- petitive industrialized societies, appears to be strikingly frequent in some non- industrialized societies. A rate as high as 43 per million has been reported in southern India. Thus the cross-cultural picture of mental health problems in old age appears to be a complex one and there are extensive gaps in knowledge. However, even with such limitations it is possible to formulate three tentative conclusions: (a) the frequency of mental ill-health among aged populations does not seem to vary greatly between different societies; (b) the implications of mental ill-health for the way of life of the aged are different in predominantly industrial and predominantly rural societies; and (c) there are indications that the soc ial changes taking place in many developing countries may obliterate these differences. Suicide It has been suggested that further study is needed in Europe to elucidate the causes of suicide in the aged. as they may give a rough indication of the state of their mental health. Several studies have shown that over half of the elderly 59 people who have committed suicide were depressed at the time oft he act , while a smaller proportion were suffering from brain syndromes. Physical illness is an important contributory factor. Social factors are also known to be closely related to suicide, the clearest associations being with marital status, living alone (particularly as the result of recent bereavement) and to some extent lack of employment and loss of social status. Dementia In 1972, a WHO scientific group on psychogeriatrics (WHO, 1972) stated: It may be noted that where national mental health surveys are carried out with the aim of obtaining prevalence rates for all kinds of mental disorder. rates for disorders of old age tend to be underestimated . Surveys of this kind have produced estimates of the prevalence of senile dementia and arteriosclerotic psychosis. per 1000 persons, varying from 0.3 in one co untry to 1.5 in another. Although these different rates may to some extent reflect real differences. they probably result mainly from the methods employed. There has been a tendency not to record milder disorders such as neurosis, personality deviation , alcoholism, and mild or moderate degrees of dementia; probably only the most severe psychoses and dementias are recorded. By contrast, more intensive surveys limited to the aged carried out in Europe and Asia have shown that the prevalence rate of moderate or severe dementia may be as high as 5 "0 or more of the population over 65 years of age. Other data indicate that more than IO" 0 of the aged over 65 years suffer from some degree of dementia . ... As regards neuroses. field surveys have confirmed the results of studies made in general practice- namely. that neurotic symptoms are common among old people. and may cause considerable disability by restrict ing mobility. social interaction and enjoyment of life . Much neurotic illness- and even more serious mental illness- appears to pass unrecognized , possibly because in old age attention tends to be focused on physical illness. or because apathy, depression or hypochondria is are regarded as inevitable accompaniments of aging. Clearly more data are required on both institutionalized elderly mental patients and mentally impaired old people living in the community. Attention has been drawn at many WHO meetings to the necessity of obtaining comparable data for more or less the same stage of social, economic, and industrial development in order to evaluate certain types of treatment. The group summarized it thus: There is obviously an urgent need for more research on the methodology of epidemiological surveys among the aged so that the comparability of surveys may be improved. the rate of progress of brain syndromes assessed and the influence of social, cultu ral and other factors explored . Classification of psychiatric disorders in old age Among the problems of epidemiological studies is the lack of a generally accepted system of classification of mental disorders in old age. The WHO 60 scientific group on psychogeriatrics proposed a scheme to specify the conditions belonging to the area of psychogeriatrics, knowing however that not all of the categories in this scheme would find a separate place in an international classification of diseases. The scheme is as follows: I. Atrophic senile psychosis (a) (mild) psycho-organic syndrome (b) moderate senile dementia (c) severe senile dementia 2. Arteriosclerotic psychosis and other cerebrovascular diseases (a) mild psycho-organic syndrome (b) moderate psycho-organic syndrome (c) severe psycho-organic syndrome 3. Acute confusional state 4. Presenile dementia (a) Alzheimer syndrome (b) Pick's disease 5. Affective psychosis (a) late depression (b) late mania 6. Schizophrenia (a) late schizophrenia 7. Paranoid syndrome (paraphrenia) 8. Neurosis (acute psychogenic reaction, reactive development) 9. Changes of personality occurring in old age. The main categories, with the exception of 3 (acute confusional sta te), are all to be found in the eighth ( 1965) revision of the International classification of diseases (ICD). Category 3 and also the different degrees of psycho-organic manifestations in categories I and 2 have now been taken into consideration in the revision of the ICD. It has been urged that, if possible, the degree of deterioration should be recorded in epidemiological studies, at least as mild , moderate, or severe, because within one nosological entity (the chronic brain syndrome or atrophic senile psychosis) cases of mild impairment seem to occur that show little or no further deterioration. These may constitute a special group tha t ought not to be included under the heading " sen ile dementia" . The recording of degrees of severity will also increase the value of epidemiological studies by making it easier to study the natura l history of illnesses and permitting more accurate estimates of hospital bed requirements. 61 The additional detail could also be of value in the primary prevention of these illnesses. It has been argued that the categories "mild", "moderate" , and "severe" are imprecise and that more use should be made of standardized tests for intellectual deterioration. There is, however, often no relationship, and sometimes even an inverse relationship, between the degree of intellectual deterioration and the amount of behavioural disturbance associated with these organic psychoses. It should also be noted that categorization such as mild , moderate, or severe is intended usually to refer to the total effects of the illness and not only to intellectual deterioration. It was for this reason that behavioural deficits were separately defined and tabulated in the survey. 62 5 Research programmes Whatever may be the role played by genes, the fact remains that the vast majority of differential aging phenomena, such as differences in life ex- pectancy or premature senility and disability, are attributable to the environment. For man social conditions are important. Diet in childhood and adulthood, the type of education received, the profession, family and professional life (and particularly adjustment to them), intercurrent diseases, and social vices such as tobacco, alcohol, tranquillizers, and even television have as far-reaching effects on physical being as on personal ity. Our fate in old age is dec ided during our adult life , and in certa in cases during our child- hood . PREVENTING PREMATURE AGING AND DISEASE In recent years longitudinal investigations into aging have become more frequent and provide greater possibilities for adequate analysis of the changes developing during life. They are also of particular significance for judging individual characteristics in the rate of aging and enable observations to be carried out on the effects of particular factors . The prevention of premature aging depends more on social and cultural than on medical measures as such. Preparation for retirement, opportunities for part-time work, a certain amount of intellectual activity, life in the community, social contacts, and financial security are among the best means of combating premature aging. It can certainly be said that preventive measures should start from childhood, since premature aging is the direct or indirect consequence of everything that happens throughout life. However, a good start could be made from about the age of 50. It involves healthy living and eating, adequate physical exercise, and early treatment of such chronic diseases as hypertension, arteriosclerosis, cardiovascular disorders, and rheumatic diseases . Social environment and economic circumstances affect not only the health of an individual but also the aging process. Many factors under this heading are therefore similar to those in disease prevention . A WHO seminar on the health pror.ection of the aged held in Kiev in 1963 identified some of them. 63 Physical activity There is little doubt that physical exercise is as essential for the middle-aged and elderly as it is for younger people. However, it should be adapted to their capabilities and be medically supervised. Any form of sport that involves great physical and emotional strain should be avoided. From USSR data , it is known that physical exercise taken by the elderly should be regular. By maintaining a regime of movement it should be possible for many not only to preserve their functional potential but also to restore impaired adaptive mechanisms and improve their working capacity. Occupation The relationship of the health of the elderly to occupation, especially as it affects retirement , is of personal, social , and economic importance. It is recognized by many people that the age of retirement often bears no relationship to an individual's physical and mental capacity to work . Continued employment past retirement age has frequently been advanced as an argument for maintaining the elderly in physical and emotional health and for preserving their social and economic status in the family and community. Several participants in WHO meetings, however, have suggested that the oft- repeated statement that retirement causes deterioration in health requires further study, and that in this respect longitudinal studies from middle age to death would be particularly valuable. The normal retirement age varies from country to country and sometimes according to sex and type of employment. People in arduous occupations usually have a relatively early retiring age. Attention has frequently been drawn to the influence that community needs, economic circumstances, and increasing automation may have on national retirement policy, particularly with regard to flexibility in retirement age and sheltered or part-time post-retirement employment. It is believed by many that a national policy for the employment and retirement of elderly workers is necessary and that industry, labour, and the ministry of labour of a country should share in the responsibility for such a policy. A policy of this kind should provide for pre-retirement counselling early enough for adequate retirement plans to be made by the individual and for alternative employment (e.g., sheltered or part-time) to be arranged if desired. Wherever possible, committees should be set up to advise elderly people about occupations appropriate to their changing physical and mental capacities. Ideally, employers should serve on these committees and participate in financing pre- retirement programmes and counselling services. The development of leisure-time activities in earlier years can be good preparation for old age, for the proper use of leisure after retirement is one means of promoting health. Organized leisure programmes relating to the particular interests, a ttitudes, and aptitudes of elderly people should include creative, cultural, educational, and recreational activities. Some countries have special holiday programmes for active elderly people, and a few have individually planned programmes for those confined to their homes. To provide a basis for this more factual approach to the question of retirement age, there is a need for further investigation into the state of health 64 of old people, their capacity to learn and work, their attitude to work , and the factors that influence their desire to continue in full-time or to switch to less exacting employment. It is important that , like physical exercise, work should be changed or adapted to the worker's altered capabilities. Some authorities have gone so far as to hold that no retirement scheme should include compulsory complete cessation of work by healthy people, whatever their age. An occupation gives a steady dynamic pattern to life, affords a sense of satisfaction, and ensures the transfer of experience to younger generations. Changing tasks (including reducing the volume and slackening the rhythm of work) to match the individual's capabilities also prevents vo luntary premature relinquishment of employment by the individual himself. The advisory group on the public health aspects of the aging of the population recommended that the WHO Regional Office for Europe should support such investigations with a view to establishing standards for measurement of physical and mental capacity of the elderly in relation to the requirements of various occupations. A similar recommendation has been made by groups studying premature aging. While different methodologies have been used for assessing workers in trades involving strain or hazard and women in work, all have included medical, social, and economic criteria. Since rehabilitation can be effected up to an advanced age it has been suggested that every gerontology centre or geriatric hospital should have a section for training physiotherapists in techniques for the rehabilitation and resettlement of elderly workers with disabilities. Nutrition The advisory group on the public health aspects of the aging of the population that met in 1958 agreed that the importance of nutrition and of the factors influencing nutritional status in the health of the aged could not be overemphasized . The relationship of nutrition and diet to aging and disease was regarded as a field in which extensive research was necessary. Particular attention was drawn to apathy as one cause of malnutrition, especially in the recently bereaved . It was believed that apathy in old people towards food can be overcome by appealing to taste and aesthetic sense, factors that are often overlooked by those responsible for the preparation and serving of meals. The group considered that training in nutrition and dietetics is important for all persons concerned with the planning and cooking of meals for elderly people and recommended that WHO should stimulate and support research on the special nutritiona: needs of the elderly in the Region . This, they emphasized, should include not only research on the important questions of nutritional requirements and the absorption and utilization of nutrients but also dietary and nutritional surveys and the establishment of standards of nutrition for the elderly. It also suggested that WHO, in cooperation with other international agencies concerned with nutrition, should study ways of providing the aged with the foods necessary to ensure their optimum health . Such studies should consider the important question of vitamin supplements, 65 enriched foods, and the provision of foods free or at low cost to elderly persons in need. Since that time national and local surveys have produced some useful findings (see Chapter 4). Housing Although housing factors are similar to those considered to influence disease prevention, some additional interesting points have been discussed at various WHO meetings. Throughout life, living in inadequate accommodation far from the location of work can contribute to physical and mental fatigue and so accelerate aging. In later life many people require different housing from that which suited them in their youth. Considerable advances have been made in obtaining information on housing for elderly people over recent years. In 1958 the information available to the advisory group on the public health aspects of the aging of the population showed that the tendency to construct small-unit homes had disrupted the three-generation structure of family life and left many old people without the close support of a family group. In some ways this had eased the conflict between generations living together, but it had increased the need of the elderly for community care. Reduced economic circumstances had also been responsible for isolating old people in less desirable and inadequate housing and forcing them to enter unsuitable institutions. The group, while agreeing that old people are better off in their own home surroundings, believed that more objective evidence in support of this view is desirable. This view was confirmed by a WHO technical advisory committee meeting some ten years later: while it is often said that old people would prefer to continue living in an inconvenient and unsuitable dwelling in a familiar area than to move to a modern house in an unfamiliar district, much more information on the subject is required. It has often been stated at WHO meetings that the provision of housing for the elderly should be a national responsibility, involving a definite housing policy for the aged. The construction or improvement of homes for old people should also have the approval of the health authorities, especially where public money is involved. The 1958 advisory group recommended that WHO should stimulate interest in the subject and support governments in any efforts they might make to establish housing standards designed to promote the health and well-being of the aged. Findings from studies undertaken were summarized a little later in the sixth report of the WHO Expert Committee on Mental Health (WHO. 1959) as follows: 66 Experience tends to show that accommodation which places the aged in the same establishment as their children , in one household, does not always meet with success. Still more does it seem a hardship and source of distress for old people when they a re housed in some setting far from their usual environment and away from the bustle of activity which formerly surrounded them. Old people's dwellings should be close to the community and the centres at which it gathers for ordinary activities and recreation, particularly in the case of those who have previously inhabited urban areas; they should be near shops, churches and places of entertainment. The accommodation of old people may be interspersed with family houses, so as to avoid the sequestration of the aged . In designing this accommodation, account must be taken of the physical deficiencies of aged people, their difficulties in moving about without support, their problems in negotiating stairs, their forgetfulness and the dangers this creates. Indoor climate The Committee suggested that there is a critical need to meet certain physiological and psychological requirements that are the result of the aging process. Older persons tend to need higher indoor temperatures than young healthy adults - generally speaking, a room temperature about 2- 3°C (5°F) warmer. Also, they require a more uniform distribution of heating from floor to ceiling to avoid chilling of their legs and feet. It is also preferable that heating systems in housing units occupied by the elderly should be designed to use fuel that requires the least possible physical effort to operate. Older persons, particularly those with cardiac disease, cannot endure very high temperatures, or even moderately high temperatures accompanied by high humidity. This is again because of their less efficient heat-regulating mechanisms. When and where possible, special attention should therefore be paid to cooling the atmosphere by mechanical ventilation or other means, not only for their comfort but also to prevent the stress on their physiological responses. Lighting The Committee recommended that lighting in dwelling units for the elderly should be quantitatively and qualitatively adequate, since the elderly need more and better light for the same tasks than younger persons. Glare from either artificial or natural sources should be avoided and special consideration should be given to locating light switches within easy reach and so placed that the way ahead can always be lighted. Noise Housing, irrespective of the type of occupant, should be located away from sources of exces5ive noise, but this is particularly important for the elderly because as a group they are less capable of adjusting to the continual stress of loud noise. Buildings in which elderly persons reside should be constructed of materials that reduce airborne sounds and impact noises, not only to protect the older occupants but, since many of them have hearing deficiencies, also to protect their younger neighbours from the loud conversation and playing of radios that some elderly persons indulge in. Design The elderly - like younger persons - require physical exercise, not only for its psychological value but also for the physiological benefit they derive from 67 improved circulation and appetite. Facilities should be provided for gentle exercise - for example, small garden plots and park areas for walking. Privacy is important to most people, but it appears to be even more important to older persons, to permit sedentary recreation and meditation. Since elderly persons are usually more susceptible to fatigue and have a decreased ability to perform the physical tasks of looking after the home, the design, layout, and installed facilities should be of such a nature and character as to make their routine tasks easier. The design should reduce the need for excessive walking during normal household tasks and should provide easy access to storage spaces without the need for excessive bending or reaching. Furniture that needs to be moved should be equipped with castors, and items not easily moved should be so arranged as to permit easy cleaning. Special thought is required in siting beds so as to facilitate bed-making and the care of an ill person confined to bed . Because elderly persons sometimes find climbing stairs tiring or difficult, consideration should be given to placing dwelling-units at ground level. In densely populated areas where this is impracticable, dwellings occupied by the elderly should be served by lifts. If this is not possible and changes of height are unavoidable, ramps with a gradual incline are suggested. Steps and ramps must in all circumstances be equipped with hand-rails . Devices to reduce the hazards of fire to an absolute minimum are essential, as older persons with impaired ability to see and to smell will not be immediately aware of a fire and, being unable to move rapidly, will be unable to escape from one that is well established . Fire hazards can also be reduced by the proper choice of building materials, careful planning of circulation, and the location of facilities . Any heating facilities with an open flame must be properly installed with adequate vents and safeguards. Siting Accommodation for the elderly should not be isolated from the rest of the community; it should preferably be integrated with homes occupied by younger persons, in order to create a more heterogeneous neighbourhood or micro-district. Since many elderly persons are not physically capable of operating motor-driven vehicles, it is necessary that these residential unit s should be located near public transport and close to community facilities. Services Householcl assistance when needed is another important factor in the prevention of premature aging and should be made available at critical periods throughout life to avoid unnecessary excessive strain at any age. For older people the social contact that home helps provide is as important as the practical help they give. WHO committees have also recommended that special consideration should be given to the provision of auxiliary community services to permit elderly persons to live independently for as long as possible . A residential pattern that has been developed in many industrialized countries is accom- modation in service apartments ("collective houses") . In these structures 68 additional services provided for the occupants include a service desk with someone on duty round the clock to assist residents coming and going, to receive and distribute mail, packages, etc., and to perform small errands; a restaurant; cleaning and sickbay services; and, in some cases, occupational and physical therapy services. In some countries meals-on-wheels and home- help services have been developed for elderly persons who cannot undertake housework or prepare meals for themselves. Appropriate placement The recent trend has been towards increased promotion of sheltered housing. A WHO expert committee on planning and organization of geriatric services (WHO, 1974) suggested that a much closer link between the housing and the social service departments of local communities would be of great benefit in achieving the appropriate placement of elderly people. It has also been suggested by the WHO working group on nursing aspects in the care of the elderly in 1976 that nurses working in the community could provide the necessary data on housing needs by personal consultation and detailed assessment of the individual's mobility and ability to carry out daily living activities. Leisure occupation Because of the difficulty in stimulating old people to take an interest in new subjects, it is important to educate people long before retirement in the value of leisure-time hobbies and activities. Pioneer work in this field has been reported from Czechoslovakia, the Netherlands, the United Kingdom, and the USSR. PROMOTING HEALTH For human beings the environment is not limited, as it normally is for plants and animals, to a set of edaphic or climatic factors . These certainly play a part , but for man social conditions are more important than the mean annual temperature or the altitude at which he lives. Health promotion hould begin as early as possible in life. The WHO advisory group on the public health aspects of the aging of the population drew attention in 1958 to the many facilities for preventive work that existed even then . It suggested that special preventive health services for the aged could be provided in consultative health centres wherever these are advisable and feasible, and identified health education and routine health examinations as two of the main means of promoting health and preventing chronic disease in the elderly. Health education The group maintained that health education, as it affects the elderly, is important in promoting and maintaining health and in preventing physical and mental ill-health and disability . Although it is most effective if begun in 69 childhood, many problems of aging can still be solved by the appropriate education of middle-aged and elderly people. It should include the main principles of healthy living: the maintenance of mental health , oral health , adequate nutrit ion , prevention of accidents, recognition of a reduced tolerance to drugs, the proper use of leisure , preparation for retirement and old age, and the utilization of preventive health measures. Health education was also seen as a means of promoting the appropriate utilization of existing health services. In I 958 techniques of health education were being developed in various countries, more extensively in such fields as family planning, nutrition, and communicable disease. In most European countries little attempt had been made to arrive at an objective evaluation of the health education methods and techniques that help to change people's attitudes and behaviour. It has often been suggested since that time that the mass media should be used to enlighten both the elderly and the general public (particularly people concerned with the formulation of public policies) on the problems and needs of the aged, including the social and emotional aspects of aging. The production and distribution of two different categories of publication have been recom- mended: one on aging for the general public, the other for interested public and voluntary agencies giving them information on the range of local se rvices and facilities available for the aged . Routine health examinations The aim of routine health examinations is the early detection of physica l, mental, and social deviations from health. It should encourage health educa tion and provide opportunities for defi ning with greater precision the term "health" as it applies to old age. It is suggested that such exam inations be carried out before retirement and be part of a pre-retirement counsell ing programme. The technique of multiphasic screening can be of value in the early detection of such diseases as tuberculosis, diabetes, anaemia, glaucoma, hypertension, and some forms of cancer. Detection of early conditions is the important consideration ; the iceberg phenomenon of unreported illness is well known. The 1958 advisory group suggested that at least two health examinations should be carried out during middle age: soon after the age of 40 and six months prior to retirement. Not all participants in WHO meetings throughout the yea rs have agreed with that suggestion. Some authorities consider routine health examinations expensive in relation to the results obtained, and discussions on this controversial subject continue. Comparisons of results of studies of the health status of populations carried out in Denmark , the Netherlands, the United Kingdom, and the USS R have tended to confirm their shortcomings, and a technical advisory committee on health care of the elderly tha t met in Munich in I 978 considered that scarce resources and trained personnel should not be diverted into such activ ities. A proper evaluation and assessment of the cost- effectiveness of routine health examinations were urgently needed and would not only determine their value but show the best form of case-finding and by whom it should be done. 70 Most people agree that old people should be protected from ill-timed intervention ; nothing but harm results from demonstrating the existence of several pathological states in an individual if none can be effectively treated or if services are not available for their relief. Once again the need is for well- planned research , with cross-national comparisons. HEALTH AND SOCIAL FUNCTION ASSESSMENTS Many group meetings over the past decade have identified the trend in the general public towards interpreting personal and family difficulties as being medical problems requiring intervention by health personnel. On the other hand, in any programme of case-finding it is important for health workers not to confine their attention to the purely medical aspects of aging. Such factors as loneliness, poor housing, inadequate diet , and lack of family support all have to be identified during assessments of health and social function . There are still many unanswered questions relating to these assessments. Target groups remain undefined. Should whole populations of, say, all people over the age of 75 years be included? Should only specific high-risk groups be included, and if so which groups? Research is also needed to establish the medical and social criteria that would reveal those individuals and families most in need and most likely to benefit from appropriate intervention. Criteria for assessment of health status In addition to subjective assessment of general health status and the minimum criteria defined for biological age, a WHO consultative commit tee in 1978 suggested that health status could be assessed more precisely by the following methods: the WHO standardized questionaire for cardiovascular diseases the WHO standardized questionaire for respiratory diseases examination for possible allergies interrogation about the presence of digestive, urinary, and sleep disorders digital examination of the rectum - digital examination of the vagina (or vaginal smears). Whenever possible, biological age tests should be undertaken in addition to the medical check-up. In any assessment of the old or very old it is important to be specific regarding their degree of activity, mobility, ability to communicate with their environment, ability to look after both themselves and their surroundings, and contact with those close to them. In a comparative assessment of the results of health status surveys of elderly persons by age group, it is essential to take into account the gradual elimination by death of the severely ill. 71 PREVENTION AND CONTROL OF DISEASE For people of all ages there are positive relat ionships of health to education, occupation, and nutrition. This is particularly true for the aged. To appreciate these problems fully it is necessary to understand the attitudes of old people towards themselves, and also their motivation . Participants at several meetings have referred to the difficulty physicians and other hospital-trained health workers experience when they have to think in terms of prevention rather than of cure. In health care of the elderly they need to consider disability, function , and rehabilitation rather than disease and tradit ional therapeutics. This necessary reorientation should be catered for; in many countries it is not. While specialization has produced many good results, particularly in younger people presenting a single condition, it is much less apposite for the elderly, whose problems are usually complex amalgams of multiple pathological processes and social , psychological , and economic factors. Disease processes in the elderly are often multiple and sometimes insidious in onset and development. Public health is concerned with maintaining and increasing the level of health in both the individual and the community and in promoting measures that will achieve this end. In the aged health is relative and health measures are aimed at maintaining or increasing the capacity of the elderly person for personal independence and self-care. Preventive as well as care facilities are of the utmost importance in a health programme for the elderly. At present certain public health measures are applicable in the control of heart disease , diabetes, tuberculosis, and some forms of cancer, but knowledge of specific measures for the prevention of other chronic diseases is still inadequate. A programme of physical rehabili- tation should be introduced early in the programme of acute medical care and be coordinated with one of emotional readjustment and continuing care in order to restore a maximum of social competence to the elderly and prevent further disability or bedfastness. Such a programme requires appropriate social welfare care. Domiciliary services should provide a further means of reducing or preventing disability and chronic illness. The kind and extent of health services will depend upon the physical , social, and psychological needs of the different older age groups, and carefully prepared surveys are required in order to assess the needs. For such surveys a critical evaluation of survey techniques is necessary. Improvement in the collection of census, mortality, and morbidity statistics will provide not only useful comparative data within the Region but also invaluable information upon which care programmes for the aged can be planned . In assessing the extent of ill-health caused by the chronic diseases it is necessary to measure their prevalence as well as the morbidity rates for the different age groups. A stroke control programme One example of a disease control programme was outlined at a meeting on cerebrovascular diseases convened by WHO in 1970. The aim of a stroke control programme is to apply, at community level , efficient measures for the 72 prevention of stroke and the detection, treatment , and rehabilitation of stroke patients. Facilities for the long-term follow-up of patients are essential to its success. The education and training of health personnel and of the public - by films , television, radio, pamphlets, and other educational material - form an integral part of the programme, which should be related to the community health services. Built-in continuous evaluation of the efficiency of the programme is highly desirable. The basic requirement for realistic planning of such a control programme in the community is reliable knowledge of the extent of the problem in the community concerned. Existing information on mortality and morbidity from cerebrovascular diseases is generally imperfect and, in some areas, non- existent. This situation could be improved by accurate information about the various forms of cerebrovascular accidents recorded on death certificates and in hospital records and by ad hoc population studies. The value of the latter is often greatly underestimated, but they have been given due recognition by experts at several WHO meetings. In some countries the existing mortality and morbidity recording systems are already being used as the basis for obtaining this information, and the method could also be used by other Member States at relatively little cost and effort. In developing countries surveys of the prevalence and incidence of cerebrovascular diseases could be undertaken by a special team working in a clearly defined area and using auxiliary personnel, while in developed countries cerebrovascular disease registers could be compiled along the lines of myocardial infarction registers. Alternatively, the existing myocardial infarction registers could be used. These cerebrovascular disease registers could serve as a basis for: - better planning of health services, including control programmes in the community - comparative studies of various types of management of cerebrovascular diseases - study of the natural history of the disease and research into its etiology - comparative national and international studies. Clearly defined terms should be used, and common protocols to facilitate international comparison would be essential. It is believed by some authorities that check lists of the symptoms and signs of cerebrovascular diseases comparable with those developed for ischaemic heart disease and peripheral vascular disease would also be useful. Any comprehensive community control programme in the community should cover: - prevention - detection and diagnosis treatment, including rehabilitation follow-up 73 education and training of professionals, auxiliaries and the general public evaluation of efficiency and effectiveness. IDENTIFICATION OF RISK GROUPS For the evaluation of physical health, mortality and morbidity are the most commonly used criteria. The possibility of using others for the measurement of levels of health was discussed by a WHO study group on the measurement of levels of health in 1957. As an outcome of research over the last few years on the epidemiology of chronic disease, the concept of risk factors has become established as a useful criterion for physical health. Risk factors are observable as measurable characteristics of clinically healthy subjects that make it possible to predict the incidence or prognosis of disease, injury, or handicap. Risk factors can be expressed in qualitative terms relevant to the type of population from which they are derived. Certain groups at high risk have been identified in industrialized countries. In the aging population (up to the age of 65) they are: those suffering from cardiovascular diseases leading to cardiac infarction (male majority); certain accident victims; and patients who have undergone serious operations. Among the aged there are those with certain sequelae from cerebrovascular diseases (e.g. hemiplegia) or with certain neurological conditions (e.g. Parkinson's disease). Other individuals at risk include persons suffering from respiratory diseases (e.g. chronic bronchitis, emphysema, asthma) and from the consequences of harmful lifestyle practices such as malnutrition , drug or alcohol abuse, or lack of adequate physical exercise. Demographers are able to enumerate or estimate on a regular basis selected groups that are likely to face particular risks with respect to their health or their economic and social status. Such groups include: very old people (say, those aged 80 years and over) aged people living alone (one-person households) aged women, especially the single and the widowed aged people living in institutions. By means of surveys data can be collected on five other groups: 74 - isolated old people (individuals or couples) childless old people aged people suffering from severe ailments or handicaps aged couples of whom one is seriously ill or handicapped aged people having to live on the minimum support provided by the state or social security, or even less. An individual may belong to more than one group. For instance, an 80- year old person who is childless, partially handicapped, widowed, and living alone in an isolated building with minimum resources would belong to seven groups and therefore be considered highly vulnerable. 75 6 Planning and providing services Modern gerontology rejects the concept of old age as an illness, yi.'!t the complaints of the elderly often reflect illness, not old age. This being so, the services provided for elderly people, the attitudes of those who work in the services, and the need for them to have a deeper knowledge of gerontology and geriatric medicine all require special attention. Although there is an increasing number of excellent clinical, laboratory, and sociological studies, the knowledge necessary to back up public health planning with regard to an aged population is not complete. What is particularly lacking is knowledge of how to influence human behaviour and attitudes. As in most areas of public health and social welfare, the information necessary to make a diagnosis of the situation is often already available, the choice of different solutions to the problem known. What we appear not to know is how to synthesize that knowledge , apply it, and mobilize human resources to implement the solutions. Although mechanisms through which programmes can be implemented vary according to the research and conditions of each country, they will in all instances need to be backed by sound information and willingness to convert knowledge into action . In 1958 a WHO advisory group reviewed the facilities that existed at that time to meet the health needs of the aged in the Region . Information from some Member States was scanty but , from the data made available, it was realized that the programmes that had been or were in the process of being developed differed widely both in content and extent , each country adopting a programme appropriate to its existing cultural , social , and health systems. The principle that there can be no common programme applicable to all countries remains valid . Since the 1958 meeting the concept of health care for the elderly has undergone considerable change. It is now believed that , whenever possible, old people should remain in their own home or at least outside institutions. But , wherever they live, their needs are often multiple and , self-care notwithstanding, a wide range of services and facilities will be required from the care systems. Their physical , social , and psychological needs require a multidisciplinary team approach in which physician, nurse , social worker, and rehabilitation therapist join their skills and knowledge to help old people 77 remain independent and also to assist their families to continue to afford their support. This implies not only the necessary health and social services but also adequate financial resources. The aims of health care for the elderly and the aged may be formulated as follows: (I) to sustain them in independence, comfort, and contentment in their own homes and, when independence begins to wane, to support them by all necessary means (2) to offer alternative residential accommodation to those who by reason of age, infirmity, lack of a proper home, or other circumstances are in need of care and attention (3) to provide hospital accommodation for those who by reason of physical or mental ill health are in need of skilled medical or nursing attention or both . The successful achievement of these three aims clearly depends on the extent to which those concerned appreciate, discharge , and integrate their individual responsibilities. If any one of the aims is not fully met , the difficulties in the way of achieving the other two are seriously increased (Royal College of Physicians, Edinburgh, 1963). It follows that care of the elderly involves much more than medical care. It can be provided only by a coordinated programme. A WHO technical group on services and systems of care for the elderly, meeting in 1980, specified the data countries need to develop appropriate and adequate services for their elderly populations. It emphasized that a clear distinction should be made between the services provided for the elderly and the services used by the elderly. It stressed the importance of a holistic approach and of taking into consideration the services already existing and the interrelationships within them. The following broad conceptual model for further development was suggested: - services subserving basic vital needs , e.g. housing, money life-enhancing services, e.g. clubs, transport - compensating services (when there is impairment or difficulty) - care services (when function is lost) . GENERAL CONCEPTS AND PRINCIPLES OF GERIATRIC SERVICES A WHO expert committee on geriatric services, meeting in Geneva in 1973, agreed on the following general concepts and principles in respect of geriatric services. 78 (l) In many developed countries the aged are a vulnerable population of great numerical importance, and therefore require special attention. (2) In planning geriatric programmes, the emphasis should be on all aspects of prevention. (3) The holistic approach should be adopted in handling the complex medical and social needs of the aged, which should always be considered in relation to the family and the community. (4) A system for the delivery of geriatric services of a high standard is needed, and should be established as an integral part of the general health services. (5) The services must be oriented to the family and community, and integration and coordination should be the main pattern in their development. (6) The spectrum of services should be wide, and it should be possible to establish different levels of care. This will permit the introduction of the concept of progressive care in the broad sense and of continuity of care, the two main principles in the care of the aged. (7) The services should be available to all the aged who need them, and developed with the close participation of those using the services. (8) A continuous evaluation mechanism should be built into the system for the delivery of services that will enable the policy-makers and those providing care to introduce changes in the system whenever necessary. Just as a health care system should not be developed without reference to the problems of aging and the aged, so the problems of older people should not be considered without reference to those of other groups within their society. Governments struggling to provide an equitable distribution of resources are often faced with pressures to favour one group at the expense of another. It is essential, however, when resources are limited, to allocate them preferentially to the most deprived people. In most countries these are the elderly poor. STEPS IN PLANNING AND ORGANIZING HEALTH CARE SERVICES FOR THE ELDERLY A WHO expert committee on the planning and organization of geriatric services which met in 1973 (WHO, 1974) considered the following steps necessary: a situation analysis; the formulation of alternative tactical approaches to the problems, with a study of their implications in terms of cost and effectiveness; selection of a plan, based on discussion of the alternatives and balancing of the political, cultural, social, and economic considerations against estimates of the biological, psychological, and social effects; im- plementation of the plan selected; and evaluation of the results achieved. As was emphasized at the technical discussions at the Twenty-sixth World Health 79 Assembly in 1973, modern methods of management in health administration should be more widely applied in the planning, development , and operation of geriatric services. Another vital point raised by the expert committee in connexion with the planning of geriatric services was that all too often it represents a compromise between political forces and the interests of those providing care. Consideration should be given to the needs and expectations of the elderly and the extent to which they are being met. In some countries such as the Netherlands and Switzerland elderly people participate effectively in the planning and organization of the services proposed and developed for them. The chances of successfully implementing plans for the development of geriatric services are also highly correlated with the degree to which those implementing a service have participated in its preparation. STRATEGIC PLANNING The degree to which the care system is financed, owned, or regulated by national authorities varies from country to country; it ranges from loose control or voluntary planning to tight control. Voluntary planning implies the cooperation of the different interested groups, both among themselves and with the planning agency. Indicative planning aims at guiding these groups towards achieving certain norms and standards indicated as desirable, but not compulsory. A central planning agency, for example, may present an estimate of the resources needed on the basis of current demand. These are compared with the resources the system is able to generate (almost invariably lower than the amount demanded) and the resources that would be required if the criteria for the national health plan were met. The incentives provided by central government are supposed to emphasize the latter in preference to the former. In normative planning legal codes and sanctions compel adherence to the norms and standards defined in the plan. The elaboration and implementation of a plan for geriatric care should generate information that can be fed back to the planners to enable them to prepare alternatives. It is from consideration of these that informed decisions can be made. SOME ECONOMIC ASPECTS OF HEALTH CARE Financing geriatric care There are several ways of financing health care for the elderly. The cost may be borne by the individual himself, by an insurance company, or by a third party. Systems of payment may be based on services rendered (fee-for-service), hours worked (salaried system), or the number of people to be served (capitation fee). The cost of care is less of a barrier to its use if payment is made either in advance or by a third party. Income grants to elderly people must be accompanied by information on how to use them. Fee-for-service payments to health care personnel may, if not controlled, encourage the 80 providers to offer an excess of services. The state may either have total responsibility for the social security of the elderly or complement family , community , and voluntary efforts. If the latter, the responsibility goes beyond one of financial support since subsidies without development of services could result in inflationary costing of all the care provided. Efficiency of health care for the elderly The quest for the type of service suited to a country's needs should take into account the allocation, deployment, organization, and utilization of available resources. As a priority, the functions of all subsystems must be specified within an integrated system, and complementary resources must be developed and utilized in the required proportions. Without integration, specialization in subsystems is inevitably inefficient; different elements of a programme will develop in isolation, causing gaps or duplication of services. For example, early discharge from hospital may release an acute bed for another patient's use, but if complementary elements such as home care and community services are not available when required the service is inefficient. From a technical point of view, too, the best care is not efficient if the users are not satisfied. Most consumers desire not only health maintenance and improvement but also a service that has humanity and amenity. A comprehensive service is composed of many elements, which cost varying amounts for development and maintenance. Without jeopardizing che attainment of the objectives, a continuous effort should be made to substitute less expensive for more expensive facilities and services. Evaluation involves cost-benefit or cost-effectiveness analysis to compare the advantages and disadvantages of options. The spectrum of services Something that needs to be said repeatedly and acted upon is that the creation of environments enabling aging persons to realize their full potential will increase the probability that they will contribute to society. This in turn will render redundant the well-worn exhortation that they should be integrated into society; they will be integrated. Concern has sometimes been expressed about the fate of elderly people in the rapid urbanization that , in many developing countries part icularly, has been dramatic and is likely to be even more so in the future. The available data, however, show few adverse effects. Greater importance must be assigned to changing family structures and functions , the rest rictions migration places on family contact , and poverty. To help health and social service personnel to take the right action at the right time, a conceptual framework in the provision of comprehensive care is one that recognizes the interacting health needs of families and elderly members as they progress through sequential developmental phases, assists them to remain independent in the community, and supports their efforts to assume responsibility for their own health and welfare. 81 All options should be made known to the elderly and all appropriate services made available. Cost-effectiveness in care The health care systems of many developed countries face rising costs, high expectations on the part of both consumers and providers, and increasing demands for the quality of practices to be evaluated. A central issue is whether it is possible to reach a consensus among consumers, funding agencies (e .g. governments and sickness funds), and the health care team. Although many health care systems function on the basis of standards for hospital building, medical education, licensing, staffing, equipment, and safety, guidelines for treatment are much more contentious as they can be interpreted as infringing on clinical freedom. In 1980 a WHO-sponsored workshop reviewed European and North American experience of such guidelines in chronic degenerative disease , paying special attention to their impact on the cost and effectiveness of the care provided .0 Although cancer, cardiovascular disease , diabetes, rheumatic disease, and mental illness are not confined to the highest age groups, all are conditions or diseases that affect elderly people. The workshop found that guidelines exist in many of the participating Member States, consisting as a rule of recommendations by governments, insurance agencies, or health professional groups and reflecting the interests of those groups and the purpose for which they were originally devised . Included in them are planning norms or policies, clinical " best practices", educational standards, environmental health standards, and process guidelines of the type found in medical care model programmes. A methodology for the economic appraisal of alternatives in health care has begun to emerge, but there are a number of unanswered questions, such as the range of costs to be considered and the method of measuring benefits. Given such problems, interdisciplinary studies of the cost-effectiveness type are likely to be more acceptable than studies of the cost-benefit type, in which attempts are made to value results in money ter s. There is no single simple method of making a community-wide choice; it will often depend on ideological policies. The key to better decisions will therefore lie in the interaction between various forms of explicit analysis (such as economic appraisal) and the decision-making process itself. All analytical techniques incorporate value judgements, and there is a danger that decision- makers could commit themselves to these unknowingly. Used intelligently, economic appraisals can give more information about one aspect - but only one aspect - of choices in health care. Assessing the cost-effectiveness of guidelines Although the best way of obtaining more systematic evidence on the cost- effectiveness of guidelines would be to undertake full studies, such studies are 0 Guidelines for health care practice in relation to cost-effectiveness: report on a WHO work- shop. Copenhagen, WHO Regional Office for Europe. 1981 (EURO Reports and Studies, No. 53). 82 likely to remain few in number owing to methodological difficulties and the cost of investigation . Instead, it would be more profitable and expedient to undertake an initial assessment based on factors associated with the deriva tion and implementation of guidelines. These are as follows: - objectives in making recommendations - source of recommendations - type of organization of health care - knowledge of the epidemiology of the conditions in question - existence of standard-setting bodies - level of resource input or cost of care - phase of care - structura l, process, or outcome nature of guidelines - research base of recommendations - use of guidelines in education and training - flexibility of guidelines - system for review of guidelines - incentives for adoption of guidelines. In addition, a number of intermediate indicators can be used , such as informal feedback from providers and consumers and /or evidence of changes in attit udes or practices. Guidelines ultimate ly have to be assessed against a background of changing circumstances in health care, the sometimes conflicting values of health care providers, resource providers , and consumers, and other govern- ment policies in health care, such as cost-containment. Nevertheless , it is widely believed that guidelines are worth while, since they offer an oppor- tunity to achieve a more rational use of health care resources and, far from imposing rigid restrictions on providers, provide a stimulus to improve the quality of care and, in certa in circumstances, may even justify the allocation of additional resources. Furthermore, they may provide benefits in the fields of health care research and education . THE PRIMARY LEVEL OF CARE Principles of a primary health care system A primary health care system should cover the entire population on a basis of equality and responsibility. It should include components from the health sec tor and from all other sectors whose interrelated actions contribute to health. Primary health care - consisting of at least the essential elements 83 included in the Declaration of Alma Ata - should be delivered at the first point of contact between the individual and the health system. The other levels of the health system should support the first contact level of primary health care to permit it to provide the essential elements on a continuing basis. At intermediate levels more complex problems should be dealt with. More skilled and more specialized care and logistic support should be provided, and staff with higher training should provide continuing training to primary health care workers and guidance to communities and community health workers on practical problems in connexion with all aspects of primary health care. The central level should coordinate all parts of the system and provide planning and management expertise, highly specialized care, teaching for specialized staff, institutions and laboratories, and central logistic and financial support. Medical and social services for the aged should form an integral part of the general services for the entire population . This requires close cooperation at a ll levels between the health and welfare services and between public and voluntary bodies. Although many agencies, departments, and organizations may participate in providing services for the aged and should be encouraged to do so, areas of responsibility should be clearly delineated to ensure adequate provision while avoiding duplication of services. The best interests of the aged are served when the health programme is coordinated with other services such as welfare, housing, education, and employment, all functioning as components of an integrated programme of care at national, district, and local level. A long-term approach in this field is desirable so that the development of care programmes for the elderly corresponds to the de- mographic evolution that is taking place. Formal care A concern of medicine Because it is known that in the upper age range the likelihood of occurrence of physical or mental illness is high, some authorities believe in the periodic examination of older people by their own physicians. They in turn may wish to consult specialists in geriatric medicine. Many diseases if recognized at an early stage can be cured, or at least controlled or stabilized. Although multiphasic sc reening as a preventive health measure is a controversial subject, in some countries it is included as an essential component of the health services. In others long-term results of the procedure are still being assessed. It has been suggested that a simple screening system can be used to collect information on the following : demography; type of household; social and family background ; economic circumstances; perform- ance in the activities of daily living; continence; defects in sight and hearing; mental disturbance; immobility, or mobility with help; lack of comprehension; and ability to get in and out of bed, eat, dress, and manage personal hygiene. Particular attention should be given to systems whose 84 disturbance - resulting in dizziness, loss of balance, fits and falls, shortness of breath, and pain - is a threat to independence. The clinical diagnosis should also be recorded when appropriate. A nursing concern Because its primary responsibility is to assist individuals and groups to make the most of their functions within varying states of health and at all stages of life, nursing is involved in caring from conception to death, in health as well as in illness. In addition to care in acute, chronic, and terminal illness, nursing should therefore help the healthy elderly individual to maintain wellness. Nurses should act as educators, rehabilitators, and catalytic agents. Where they work independently, their intervention can often prevent an impairment caused by aging from becoming a disability. In collaboration with other disciplines, nurses can also encourage the community to develop well- structured systems to provide information on elderly persons at risk or in need. Extreme care must be taken, however, not to invade personal privacy; elderly people have rights like other people, including the right to take risks if they so desire. The occurrence of unreported physical, mental, and social illness in older people has been noted frequently and it is recognized that there are many important unmet needs in the community. Active attempts to identify the elderly at risk and to meet their requirements should be an essential part of any health care programme. In developed countries morbidity increases markedly at about 70 years. While preventive measures should ideally have been operating throughout the whole life-span of an individual , it is suggested that a beginning can be made by seeking out the older age groups. A WHO working group on nursing aspects in the care of the elderly that met in 1976 recognized that the social crises and physical and mental deterioration to which old people are particularly susceptible are often interrelated. It suggested that in all settings and in all cultures nursing intervention at crucial moments in the lives of elderly people and their families could have a positive effect. Where the nurse and physician are the active nucleus of the primary health team they are in a strategic position to perceive and recognize the first signs of impairment or difficulty and to act promptly. Nursing intervention alone is often all that is required . If the nurse at this level functions independently and is able to admit into and discharge from the health care system. referral to other members of the health or social teams may not be necessary and this could achieve a dramatic reduction of the cost to the patient in terms of suffering, and to the country in terms of resources. But nurses must first be educated to accept such responsibility and be willing to be accountable for their individual practices. Nursing care should include teaching self-care to the elderly person and his family, the nurse remembering that emotional and physical disturbances as well as age can sometimes inhibit learning. She should also decide which tasks could be performed by other workers and by other levels of nursing personnel. But it is important for her to avoid fragmentation of care; time, people, and resources must be organized so that care is comprehensive, prompt, and 85 effective. A high level of communication skill is essential for the efficient administra tion of such care. Where assessment of an individual or group reveals the need for referral the nurse , because she has comprehensive knowledge of each worker's role and sphere of competence, should be able to know which sources of assistance to turn to and present all the options. The efficient and effective utilization of nurse manpower in prevention and rehabilitation could bring far-reaching benefits to governments and to the elderly populations of the future. The potential value of this network of educated and experienced health workers has yet to be fully realized; they are often in a unique position to help the individual, from an early stage, to give up the habits and practices likely to lead to disease or disability in later life and develop those contributing to health in old age. Where other primary health workers are employed the nurse, if given responsibility for their teaching, supervision, and support, will be able to extend her scope still further. Comprehensive plans to maintain the independence of the elderly can then be coordinated at individual , family, and community level. A concern of social work Lack of knowledge and of contact between health and social service personnel often results in an inappropriate level of care. In recent years , in response to changing needs and developments in technology, new professions have developed, among them in some countries of the Region medicosocial work . Sometimes there are separate organizations, each with its own clientele, its own criteria for admission into the system, its own budget, and its own accounting system; the result is gaps, duplication , barriers and , above all, confusion for the patient and his family. If the resources and the greatest possible cooperation of the family are to be sought, the approach to it needs to be sensitive and considerate. The members of the family can be helped to adopt as constructive and responsible an attitude as they are capable of by the social worker's skill, tact, and understanding, and above all by avoidance of criticism and reproach. The social worker's skills are often of crucial importance in securing the cooperation needed to get the patient into hospital for treatment in the early stages of disability . During the patient 's stay in hospital the social worker must ensure his support by friends and family so that he can return after discharge to their care. The social worker is best able to decide when to call in the meals-on-wheels and home help services that compensate for the gaps created in the family by the increased social and geographical mobility of its members, and to provide other services that were perhaps never actually provided to the extent that the present generation tends to imagine. Home helps have become key persons in services for the disabled and aged. In many countries there has been a sufficient number of efficient and willing housewives from whom to mobilize quickly a large work force that has required little training. But with the present economic recession all resources must be used efficiently. In some countries a more careful selection of personnel and introductory courses is needed, while 86 in others a home help service has yet to be initiated. An International Council of Home-help Services has been formed with a view to improving the situation. Other social services that assist old people to live in safety and comfort include laundry, hairdressing, minor adaptations to homes, provision of aids and appliances, and library facilities. Community services include holiday clubs, luncheon clubs, welfare centres, pre-retirement training programmes, transport facilities, ergotherapy, hobbies and craft centres, and cookery classes especially designed for elderly single men . Many of these are organized by the elderly themselves. The team approach Members of the primary health care team should together have sufficient knowledge to make a total assessment either in the elderly person's home or at the clinic, and thus be able to plan a coordinated course of action . It is worth stressing that unless these health and social workers are appropriately trained the physical, mental and social diagnosis, treatment , rehabilitation, and after-ca re will not be adequate. To assist the primary health care team in developing good health care for their elderly patients, specialized services for the elderly should be provided by personnel who have received the necessary advanced education or training. A WHO expert committee, meeting in Geneva in 1973 (WHO, 1974), took a health centre as a model for the focal point of care of the elderly. Such a centre could provide, through the primary health team, the necessary link for domiciliary, community, and hospital services. The primary health team would consist of social workers and nurses as well as medical practitioners. Representatives of voluntary agencies and religious advisers would also use it for giving and receiving information . The physician specializing in geriatric medicine at the local hospital would visit the health centre regularly to: - organize an ascertainment ("seeking out") service to detect early illness - conduct outpatient sessions - stimulate and encourage local physicians in the care of their elderly patients. Other specialists would attend as required and be available to give advice to those concerned with building for or rehousing elderly people, to social workers, and to voluntary agencies. In turn the geriatrician would benefit from the experience gained at the community level. But the elderly individual and his family or friends would gain the greatest benefit of all ; they would know that from, or through, the staff of the centre they could obtain all the help. advice, and information they needed. The committee suggested, on the basis of previous studies, that 70 was the appropriate age for the first regular assessment. It was estimated that only a small number of elderly people of this age visited by nurses working from the 87 centre would need to be referred to a physician; any social and ancillary services required could often be organized by the nursing personnel. Liaison with secondary and tertiary levels The outpatient sessions at the centre should be run on traditional lines using, if necessary, the day hospital for patients who required further investigation. The hospital service for elderly people should be an integral part of major general hospitals . The components should be: - a geriatric unit for illnesses requiring assessment and therapy, including rehabilitation - outpatient services - day hospitals - continuing treatment (long-term) beds, including beds for terminal care. There should be good communication and cooperation between the general practitioner and the hospital , the former being kept fully informed about his patients. The staff should always bear in mind the fear that old people have of hospitals and of being transferred to and from institutions. For that reason contact with , and visits from, members of the primary health team, whom they already know, should be frequent and be encouraged by the team's hospital colleagues. A corollary to day hospitals would be night hospitals - to relieve relatives of the burden of caring for restless old people who by day are quite easy to handle. Transport facilities should be available for this and for other purposes. The overall aim of the service is to support the elderly person and his family in meeting their medical and social needs. Psychogeriatric services In the past the definition of a psychogeriatric patient was based on the diagnosis, and included patients with irreversible and generally progressive pathological conditions of the brain : senile and pre-senile psychosis and psychosis with arteriosclerosis. The presence of these three forms of psychosis distinguished psychogeriatric from geriatric patients, and a distinction has been drawn between those who, because of loss of cerebral function, cannot manage without help and those whose inability is what might be expected, given their age. Two WHO meetings (WHO 1959, 1968) regarded the problem in the rather wider perspective of the mental health problems of aging and of the aged. The second defined old age as "that period of life when impairment of mental and physical functions becomes increasingly manifest by comparison with previous periods of life". Nearly all mental disorders in the adult may be combined with the effects of aging; and aging, both physical and mental, can 88 occur at almost any stage of life. For statistical purposes however an arbitrary threshold is fixed usually at 65 years. The meeting added the following: Psychogeriatrics is ... a branch of psychiatry concerned with all the mental disorders of old age, but particularly with those that first emerge as significant after the age of 65 years. Psychogeriatrics is concerned with the various forms of mental disorders of old age, their epidemiology, origin, prevention, development, and treatment. Most people would agree that the psychogeriatric patient should usually be cared for in the context of a comprehensive geriatric service. At the same time, in common with people in all age groups, he should be able to enter and leave the medical - including psychiatric - service. Because the psychiatric condition of old people with functional syndromes can change very rapidly, services for their care need to be flexible and community and hospital care needs to be uninterrupted. Non-availability and inaccessibility of services, inadequacy of staffing, and lack of financial resources are common difficulties. Outdated and inap- propriate legislation. lay and professional bias against mentally ill old people, resistance to change among professionals, and inadequate research prevent services for the aged from being used to the full. Long-term hospitalization should be the last resort and take place as late as possible, but it would be entirely wrong to ignore the need until it becomes imminent. Steps to avoid long-term hospitalization should be taken very early in the old person's history of contact with social and medical care agencies, in at least four fields, those of (a) organization, which concerns government, local authorities, and private bodies; (b) manpower, which concerns pro- fessionals and voluntary workers; (c) voluntary agencies representing the consumers; and (d) legislation . More basic operational research, systematic teaching, training, and education are required. The screening of elderly people at risk of mental diseases to permit early detection and treatment, adequate supportive social services, and an integrated community psychogeriatric service are all needed. The living habits of old people should change to take account of changed attitudes towards retirement, and more attention should be paid to preventing the effects of loneliness and social isolation; and the financial support they receive from state and private means should match the rising cost of living. Public policy towards health care of the elderly should be redefined and professional policy re-examined so that the psychogeriatric services play an increasingly important part in the totality of health care. Institutionalization can be prevented at three levels- primary, secondary and tertiary. Primary prevention of institutionalization can be achieved by: (I) primary prevention of physical illness and disability (2) prevention of loneliness and isolation (3) early detection and treatment of physical illness and disability and of psychiatric symptoms 89 (4) efficient and adequate health and social services (5) well trained service personnel. Secondary prevention of institutionalization- by which is meant dis- charge from hospital care as soon as possible-can be achieved by: (I) adequate diagnosis, treatment, and care leading to rehabilitation and resocialization (2) stimulation of visits by relatives and friends (3) an efficient and well organized network of integrated services operat- ing within the community and prepared to receive the patient back into it and to give support to his family (4) coordination and cooperation between intramural and extramural services. Tertiary prevention of institutionalization- by which is meant the prevention of deterioration in long-term patients-can be achieved by: (I) adequate follow-up treatment and care (2) separation of mildly and seriously demented patients (3) stimulation of visits from, and contact with, the outside world (4) close cooperation between the various caring agencies. An efficient system of registration of patients and of old people at risk of becoming patients is particularly necessary because it offers the possibility of surveillance and early detection of illness and disability. In the next 20 years or so many countries in Europe will face a considerable increase in the demand for social and medical services for the care of physically and mentally ill old people. Many of their medical and social organizations are as yet poorly prepared for such an increase. Provided they are mobile , psychogeriatric patients can often use the outpatient and day services. One of the great advantages of day hospital care is that it also gives relief and support to the old person's family or person caring for him. Day hospitals are usually linked to a hospital - either general or geriatric - while day centres are mostly provided by local authorities or voluntary organizations. Both provide at least one meal a day, and in day centres facilities for bathing, foot care, and hairdressing are invaluable features. Efforts often have to be made, however, to encourage elderly people and their families to make full use of day hospitals and day centres. Apart from the organized services, people within the old person's immediate environment are also concerned with his care. Despite reports to the contrary, studies have shown that many people have children who are devoted to them, but their increased mobility leaves their elderly parents on their own. It has also been shown that, provided that families know that 90 formal services will come to their aid if and when needed, they are often willing to care for quite disturbed members. Other mentally infirm elderly persons are frequently helped by neighbours (or others in their community) who shop, cook, undertake small repairs, and contact the required health or social services as necessary. Many old people are in the wrong place: at home or in welfare homes instead of in hospital; in hospital when they do not need to be there; or in geriatric units because they have no home or there is no room for them in a welfare home. Attempts to correct the situation by exchanges of patients have been unsuccessful ; vacant beds in hospitals are quickly filled with new admissions, and the demand for welfare home accommodation appears unlimited. In deciding which patients require residential care, need for nursing care has been used as the criterion. elderly patients who should be in hospital rather than in a welfare home being classified into three groups: patients needing hospital or medical treatment, these being suitable for admission to acute wards patients confused or disturbed to a degree that requires continuous psychiatric nursing (to be distinguished from mildly confused patients who do not require professional psychiatric nurses and are suitable for transfer to welfare homes) patients who are immobile, incontinent , and /or in need of rehabili- tation . Those with only limited mobility do not need the attention of trained nursing personnel but may need welfare homes or housing with ground-floor accommodation or lifts. The question of appropriate levels for the continuing care of the elderly is of urgent importance. At a meeting on the subject in Helsinki in 1980, participants pressed for the establishment of assessment procedures making use of all the relevant expert knowledge in a systematic way. They recommended that systems of care for the elderly should be organized , modified , and evaluated so that service needs, both administrative and professional, are subordinated to the needs of patients and potential patients. Informal care services Selj~help The "rediscovery" of the elderly in recent years has led in developed countries to the rediscovery and reformulation of traditional concepts of care. Self-care, family care, and voluntary care, previously taken for granted and , in some instances, even derided , have assumed new significance and produced their own advocates at government , professional, and agency level. Un- fortunately the concepts and terminology are often ambiguous or inapt. A WHO working group meeting in Berlin in November 1980 to discuss appropriate levels for continuing care of the elderly used the term "self-care" 91 to denote act1v1t1es performed by the individual on his own behalf and "informal care" as meaning "self-care and those caring functions carried out by fami ly, friends, neighbours, volunteers and voluntary agencies". Under this heading they included care given by all individuals and groups other than those professionally trained, formally organized, and paid to provide care. Self-care has broad connotations. It must include all those activities adult persons perform in order to live independently, those relating to body functions, personal hygiene, housekeeping, budgeting, mobility, and social relationships. In recent years it has come also to mean self-diagnosis and self- treatment as well as health-related behaviour. One aspect is healthy living and the avoidance of a lifestyle likely to endanger physical or psychological health. The working group suggested that the specific meaning of tho:;e health precepts in the daily life of the elderly, in so far as the latter differ from younger age groups, requires better definition and description. The aspect concerned with self-diagnosis and treatment raises con- troversial questions. While the perception of illness by the individual is a frequent precursor of self-referral for treatment , self-diagnosis and self- treatment (except in relation to minor illness and injuries) should not be seen as an alternative to, or a substitute for , informed medical and nursing care. Certain forms of self-care, especially in relation to common illnesses and disease prevention, are clearly beneficial and economic, and their discontinu- ance would place an unbearable strain upon formal services. Widespread and effective health education - especially at younger ages - can produce good results. But the application by the elderly population - some already confused or insecure - of precepts of self-care, including diagnosis and treatment, requires careful and selective evaluation. The boundary between self-care and self-neglect may be ill-defined; self-care has been found to have limits in old age. In the age group 60-{;9 years, for example, approximately 36 % are capable of looking after themselves; in the group 75 - 79 years, 21 %; but the percentage decreases with age, and of those 85 years and over only 20 ~ 0 are capable of self-care. While it has not been possible to identify an index of aging upon which to base care needs, it has frequently been agreed that health in the aged is best measured in terms of function , and that the degree of fitness rather than of pathological impairment is a measure of the amount of services an elderly individual will require . Family roles Another important aspect of informal care relates to the family of an elderly person. Evidence from all parts of the Region confirms that the greatest, most immediate, and most continuous support of the elderly comes from their relatives. Not only do they frequently supply material support, including housing, they also provide personal physical care and through their very existence personal psychological security. They are frequently the go- betweens in contacts with the organized health and social services. A major objective of the latter should be to support, rather than to supplant, this invaluable caring service. 92 Many old people. however, do not have relatives, and others live far away from family and friends. Family patterns have changed in the industrialized countries and are changing in the less developed countries; younger gener- ations are moving to other areas to find employment, and women, the traditional providers of care, are assuming new responsibilities outside the family. The increased age of the elderly populations inevitably means that their sons and daughters are likely to be elderly also . Reliance upon the family must , therefore, be selective. Hitherto the ma in contribution of care has come from the women in families; many have sacrificed time, friendships, and careers to care for aged parents. But not all family relationships are so benevolent ; elderly relatives are sometimes abused, as babies and young children are . The prevalence, causes, and implications of abuse require urgent examination if it is to be eradicated. The primary health team nucleus of medical and nursing practitioners could play a leading part in it s prevention . Families find the management of confused elderly relatives and of dying elderly relatives particularly stressful. Both situations involve physical, psychological, and socia l strain . Help and information on how to cope with them are required by both lay and profess ional persons. and the former should know that they may expect to receive immediate advice and help in the form of practical and psychological support from members oft he health service when and wherev~r they need it. Nursing management under these circumstances should include careful attention to the "carers" as well as the "cared-for" and appropriate action on behalf of both . Neighbours, friends and volunteers Traditional community relationships still exist in many developing countries and also in parts - particularly the rural and stable areas - of industrialized Member States. The modern urban world. however, is characterized by mobility, anonymity. and relationships based on criteria other than pro- pinquity. Any planning and implementation of services should therefore be based upon community characteristics. The doctor and nurse living in the community should. if not a lready in possession of such information, have easy access to it. Help from neighbours and other volunteers usually takes the form of surveillance, transport , shopping, social visiting and, at times but far less frequently, assistance with persona l care. Reciprocity is an important element, research findings suggesting that such care is more acceptable to older people if they are able (sometimes unfortunately also , if they are permitted) to provide some kind of se rvice themselves. At a WHO liaison meeting with governmental and nongovernmental organizations, held in Luxembourg in 1978. several of the nongovernmental organizations said that it was an important element of their policy to have elderly volunteers helping their peers- help by the elderly as well as for the elderly. How far good neighbourliness can be st imulated by external invervention is unknown , but what is known from research findings is that the most sensitive work with neighbours is at the primary level. With their knowledge of 93 community relationships the team there can be helpful in ensuring that the network of assistance. encouragement, and relief services does not dis- integrate if and when the elderly individual is temporarily transferred to a hospital or other residential accommodation . The WHO working group discussing appropriate levels of care empha- sized that family and community care should be seen as a very important component of. not an economical alternative to, a network of formal services providing care. Ideally. formal systems of care should give adequate support to informal systems. and informal systems should be educated to make appropriate use of formal systems. Support for informal systems of care Numerous back-up services in self-care have evolved in many Member States, ranging from home helps to sheltered housing, from holiday schemes to meals-on-wheels. A WHO working group on nursing aspects in the care of the elderly also pointed out several aspects of care in which suitably prepared community nurses could play a far more significant and effective part than the findings of various studies suggest they do. SECONDARY AND TERTIARY LEVELS OF CARE While old people should be able to receive the help and advice necessary to enable them to remain in their homes, each person has the right to be admitted to an institution if and when his condition warrants it. Acute care The elderly person most often finds his life taken over by staff who have little or no knowledge of aging and the changes it brings when he has an acute illness. His anxiety or even his confusion on being removed from familiar surroundings is underestimated at best and misunderstood at worst. Equally, staff expensively trained to function promptly and efficiently in emergency situations frequently feel frustrated and exploited when they have to continue to care for an elderly person weeks after the acute condition has been dealt with. A physician or surgeon is unlikely to be happy to see an "acute bed" continue to be occupied after the pneumonia has been cured or the fractured femur reduced. As a result. mutual resentment is built up to a disastrous extent. Early planning for discharge is a prerequisite of continuity of care and nurses and medicosocial workers share the responsibility for it. What appears to be very often lacking - and this has been a finding in many studies - is collaboration and coordination; no one member of the team sees coordination as his or her responsibility. It has been suggested that mutual learning experiences as students would facilitate later cooperation and collaboration. It would certainly enable the members of various disciplines at each level of the system to appreciate each other's role, sphere of competence, and capacity. 94 In some hospitals the transfer o f a pat icnt to hi s home is a gradual process, social workers and therapists o rganizing services so that the patient is able to try living at home again for one o r two days. Othe rs return to day hospital s or day centres for severa l hours each day, thus enabling their famili es to continue their own lives a nd employment while at the same time ensuring that the elderly persons have someone in attendance a t night . Opportunities to instruct the patient a nd those who will take ca re of him in the future are presented while he is in hospital. If any arc to be responsible for measuring medici ne, renewing dressings, or perfo rming other tasks, their learning under supervi sion will fac ilitat e the patient 's reha bilitation . Long-term care Accidents a nd chronic di sease in people of middle age have increased the proportion of people who a re either sick o r incapacitated for many years in their old age . Of these a considerable number require lo ng-te rm care. At a meeting in Florence in 1970, a WHO wo rking group on education and training in long-term and geriatric ca re adopted the fo ll owi ng definition of long-term ca re: Long-term care is ta ken to refer to the treatment and re-education of individuals with lasting disa bilities in an attempt to res to re them as far as possi ble to their former state of health , independence and ability to partici pat e in co mmunity life. To achieve o ptimal res ult s it requ ires early diagnosis o f illnesses lia ble to m use las ting disability and continuing ca re at ho me, in hospital o r in purpose- bu ilt residential se tt ing in an a tt empt to reduce o r limit dependence a nd relieve distress. A WHO wo rking group o n reha bilitatio n in long- term and geriatric ca re ( I 974) recognized that there are situa ti o ns in which the soc ia l, economic, a nd psychological factors indicate that ca re in an institution is the most humane solution - even when medica l needs may not appea r to justify it. It was suggested that , to be effective, assis tance should be based o n an analysis of t he reasons for the need ( or demand) for a serv ice. There is a tendency to place the burden of so lving socia l and economic problems o n the medica l profession, for instance, the public finding it easier a nd mo re acceptable to present the elderly person 's problems in terms of sickness or unwellness . Long-term care includes evaluating the physica l, mental, and soc ia l conditions of old and inva lid persons a nd , if possi ble, rehabilitating them and assisting them in coping with impairment s, functiona l limitations, and /or disabilities. It a lso ai ms at postponing the rate of deteriora tion and providing long-term or perma nent residential o r o utpa tien t services, together with different form s of assistance in the ho mes of persons who are unable to manage their lives without help . It should be conceived as a continuous process of rehabilitation , which begins as soon as a di so rder likely to lead to disability is diagnosed . Shelte r, kindness, and comfort are not enough; if invalidism and inertia are to be avoided emphasis has to be placed on the individual' s capabilities, not on hi s impairment s a nd di sabilities. 95 Nursing homes In the past , nursing homes were often institutions with home-like charac- teristics, used for patients with limited handicaps in need of daily nursing care. In many countries now, however, nursing homes are used mainly for patients with advanced handicaps and1or serious disease; they consequently require considerable numbers of personnel and much technical equipment. They should not need the special diagnostic and therapeutic resources of clinics. In some countries there are nursing institutions ("homes") designed for special categories of patients, for instance the mentally ill. In others, units for the physically ill are combined with unit s for the mentally ill. Nursing care in these institutions is likely to be given by a team of nursing personnel of various ca tegories. It is vitally important that such a team should be led by a professional nurse with appropriate educatio n in gerontology and rehabili- tation as well as in team management. The standards of care in many residential institutions (and especially in long-stay hospitals) in the Region arc recognized to be unacceptable. This severely affects the morale of the staff and, in turn , has a depressing effect upon recruitment , as is shown in many countries by the reluctance of nationals to enter geriatric care and the consequent employment ofa high proportion of temporary foreign-born staff at all levels. Such staff are often not fully familiar with the beliefs, habits, or even the language of the elderly people for whom they care , and thi s cannot be reassuring to persons already anxious about their health and their relative helplessness. Poor recruitment and low standards reflect the past and present underfinancing of geriatric care, its partial separation from other parts of the hea lth system, and the ineffective and inefficient use of reso urces and manpower. Frail or confused patients frequently need more nursing than medical care and should not be subjected to the strict administrative routines characteristic of the majority of hospital systems. The imaginative involvement of family members in residential and hospital care is important and is often facilitated when patients are accommodated close to their homes. Over the years, experts have advocated the setting up of small local nursing homes run by appropriately qualified nursing staff who can call in o ther professionals <1. and when required . Another need strongly emphasized at WHO meetings in recent years is for the authorities to lay down standards to be observed in all establishments caring for the aged. There should be statutory regulations providing inter alia for the control of such establishments by qualified persons. The use of voluntary workers in long-term care In recent years it has been reported at a number of WHO meetings that volunteers are performing tasks of increasing value and importance in the long-term care of handicapped persons. However, there are wide variations between different countries in the extent to which the services of volunteers are mobilized and organized. The efforts of volunteers provide one means by which the community can express its concern for its less fortunate members. Volunteers perform such valuable tasks as friendly visits to the housebound 96 (whether at home or in an institution), telephone calls, assistance with shopping, and participation in other aspects of rehabilitation. In residential institutions for long-term care volunteers can, under supervision, perform limited nursing duties, undertake errands, and organize activities such as social gatherings, dances, outings, film shows, and lectures. Above all, they can provide old people with a link of inestimable value with the community at large. In some centres the employment of a full-time organizer has transformed the range and quality of such work . Her task usually includes the organization of voluntary service and of publicity campaigns about voluntary schemes through articles in the local press, parish magazines, and other local news sheets . In an attempt to mobilize support she may visit and give talks to social clubs and other organizations. She also plays an important part in interviewing volunteers, showing them around the hospitals in which they are going to work or taking them on visits to groups of aged and isolated people who would like to receive voluntary help. She may also prepare professional staff to work with volunteers, introducing them and outlining the potential help the latter may give the former. She keeps in contact with trade unions as required and, with recruitment in view, may give talks to staff of local industrial concerns, senior classes of high schools, and young people's clubs. She also keeps in touch with volunteers, encouraging them and organizing social events for them in order to generate a sense of purpose. If the organizer plays some part in the placement of volunteers, this will help to make the process less haphazard, thereby obviating the risk of the wrong type of work being given to a volunteer. It can be confusing and discouraging for a voluntary worker to begin a job full of eagerness, only to find everyone too busy to give a guiding hand. A simple introductory course provided by a senior nurse is uf help in enabling the volunteer to understand the work she is being asked to undertake. It also increases her effectiveness. CONTINUITY OF CARE Long-term c:ne units In some countries long-term care and rehabilitation form a special branch of geriatric medicine, while in others they have been incorporated as essential activities in general hospitals . Often a certain number of beds are set aside for them. Whereas conditions vary from one country to another or even within a country, the basic needs of disabled people are similar wherever they are. Since the elderly usually constitute the largest prop0rti0n of the disabled , the creation of some type of treatment unit that specializes ir geriatric and long- term care and is situated within the hospital complex is needed in all countries. It was envisaged by one WHO working group that elderly patients who had been admitted to acute wards would be transferred to such units at an early stage. 97 This group also reco111mended that long-term units sho uld be attached to hospitals where medical, nursing, social work, and physiotherapy students are trained so that their curricula co uld include learning experiences in long-term care . The un its should contain an assessment unit in which patients with complex problems involving psychiatric, social, and psychological as well as physica l aspects can be assessed on a multidisciplinary basis . From such an assessment individual programmes of care can be planned for each patient, whether he is returning to his own home, or going to a general hospital or some other residential institution. If genera l practitioners - both medical and nursing - are brought into close relationship with the long-term care unit si tuated in the area they serve, greater continuity of care sho uld be possible. Such an arrangement is also likely to be of mutual benefit to a ll practitioners; hospital specialists have much to learn from the genera l practitioners' intimate knowledge of patients and their environments, and contact with members of the geria tric team should help to increase awa reness among community health workers of the sign ifica nce of insidious cha nges in their aged patients. Linkage of day hospitals and day centres with medical and psychiatric units may a lso facilitate prompt care for physical or psychia tric complica tio ns. For those partially dependent but capable of se lf-ca re, support has been recommended in the form of domiciliary se rvices o r flexible arrangements between hospi tal and home, or both , to enable quick transfer from one to the ot her as required . It has been emphasized many times tha t, when long-term ca re is required, shelte r a nd adequate material facilities do not suffice; specially ed uca ted a nd understa nding staff is essential. Rehabilitation The pat ho logica l changes in many chronic diseases are irreversible. This does not mean that the physical, emotional, social , and voca tio nal changes they bring must remain irreversible. Research and technical progress ha ve furnished many new methods of treatment which have brought about a re- eva luatio n of the concept of disability . These deve lopments, together with the approac h consisting of treating the " tota l individual", are summed up in the term .. rehabilitation" . Experience has shown tha t with rehabilitation many of the undesirab le effects of chronic diseases and disabilities ca n be minimized , a llevia ted, or even eliminated. Rehabi lit a ti on is the essential part of tertiary prevention, prevention of the development of adverse effec ts of di seases lead ing to permanent disability. Emphasis on the rehabilit a tion of yo unge r persons has a strong appeal because it may result in a longer period of productive work; but a strong case ca n be made economica ll y for rehabilita ting a grea ter number of older disabled people. O lder people who a re handicapped have frequently no resources whatever and are most likely to become dependent o n public aid for suppo rt unless they can be restored to useful living. Reha bilitation often provides the maximum return on public funds by ena bling them to resume independent living, a nd it always achieves soc ial and personal gains that are beyond meas urem1.:n t in econom ic terms. A follow-up se rvice in the home 98 after the patient leaves the hospital or the rehabilitation centre is essential. Aging and aged patients are perhaps the largest single group that would benefit from an extension of home care to provide them with rehabilitation services after their discharge from the hospital. The addition of medica l rehabilitation to the conventional services has enabled many elderly men and women, previously considered hopelessly crippled, to regain their functional independence and continue to live without burden to themselves or their environment. Rehabilitation of the aged can be summarized as reactivation, resocializ- ation, and reintegration. In reactivation an aged patient who may be passive, lethargic, and physically and socially immobilized is encouraged to live an active life in his own surroundings again . In resocia lization he again makes contact with his family, friends , neighbours, and community after his illness, and is thus no longer "separated" from them. In reintegration he is restored to society, participating fully in normal life and, in many instances, resuming a full-time or part-time occupation according to his ability and capacity. Rehabilitation may be necessary not only for the old people themselves but also for their families. It should be possible for all members of the health team to undertake rehabitation, but it is the responsibility of the nurse in particular. In nursing every act should be an act of rehabilitation, success being marked by a progressive withdrawal of nursing care. Rehabilitation is a service, not a speciality; it is designed to maintain or recreate a situation of independence where the individual can function to the full within his capabilities. Day-care units (e.g. day hospitals and day centres) are connected to general hospitals, nursing homes, or service centres and can be used for diagnostic and therapeutic purposes and as part of home care. Physical therapy, dietary treatment, and the initiation and supervision of drug therapy are examples of their activities. Day-care units, when attached to hospitals, have the further advantage of being used by other patients. Hospital-based mobile services to support handicapped patients in the home can also be used in certain instances for assessment and therapeutic procedures. A further advantage is that they provide a consultative se rvice for primary care personnel. Outpatient departments (e.g. polyclinics and dispensaries) are as a rule not equipped to accept severely handicapped elderly patients, whom it usually takes a long time to examine. Experience shows that this type of work can be performed more advantageously by long-term care units ; by being able to carry out even extensive examinations in their outpatient departments they often shorten the stay of patients in long-term care clinics. Home care of the ha;1dicapped is facilitated if they can be medically examined in outpatient departments at regular intervals. A well organized outpatient department for long-term care is therefore essential to supplement care provided at home. CARE OF THE DYING One of the last things a dying person can do is to help others to lea rn about dying. Yet rarely is he allowed to do so. When the dying person is old, his 99 dying could be an especially valuable and enriching experience. But our ability to understand, accept, and cope with dying and death is very often arrested early in life and may not attain its full potentiality even by the time of our own dying. For the dying person nursing should provide the continuous human care that can make the last weeks of life not a period of humiliation, deprivation, and suffering but rather a valuable and instructive last experience. In addition to alleviation of the physical symptoms of distress, psychological, social, and spiritual needs must be met. All members of the health care team need to be aware of and attentive to local customs and to the psychologica l, cultural, and religious aspects of dying. An environment that is both comfortable and acceptable should be created. Individual needs and approaches to death are different. The knowledge and experience of those providir:g care can be a source of great strength and comfort both to patients and to their relatives and friends. But this awareness of individual needs is not always reflected in the arrangements made for patients, particularly those who die in hospitals. Most wish to have some degree of privacy, but this is often not prov;ded, even when it could be a rranged with little difficulty. The dying patient's family and friends should also be helped to have as much contact with him as they reasonably want and to face the situation realistically. Practical assistance as well as psychological support may also be needed. After death the religious , social, and cultural aspects of bereavement ,1eed to be observed :md appropriate facilities made available. Help and comfort are likely to be especially needed, and for some time, when the bereaved person is an elderly spouse. A WHO consultative committee noted in 1978 that lay helpers are often afraid of dementia and death. These conditions are also stressful to professional staff at primary. secondary, and tertiary level , and it has often been said at WHO meetings that more advice and experience in the handling of dementia and dying are required in the training of all health personnel. In relation to dying. expenence is being gained in some countries through the growth of the hospice movement. Attempts should be made to share this experience with other health workers throughout the system and in other countries. DIVISION OF RESPONSIBILITY Although integration and coordination should take precedence over the division of responsibility, it is useful to define the persons or bodies responsible for the different services and, within broad limits, to delineate responsibilities. (I) The individual has a personal responsibility for planning early in life for his needs as an old person. As an old person, he should be encouraged and offered every opportunity to remain a part of the community, to enjoy his 100 rights and privileges and, where fit and able, to assume his duties and obligations as a member of the community. (2) The family should accept and assume responsibility for meeting the health and social needs of its aged members and help to mould a social attitude to the problems of old age in which they are seen , not as a burden, but as an inseparable part of a phase of life . (3) The voluntary organizations should continue to play an important role in pioneering and, in some countries, often assume major responsibility for services for the care of the elderly. When administering services for which there is a real need , they should be assisted and encouraged by the public authorities . ( 4) The primary health care team is, in most countries , in the best position to assess the needs of elderly people in the context of their total environment and the social, health, and psychological care required. It is their professional responsibility to become better informed in gerontology and geriatric medicine. (5) District and local governments may assume or share responsibility for some or even all of the above activities. Health and welfare services, particularly home care, are best organized to meet community needs at the local level. Moreover, where there is no other competent body, they should be responsible for standards at establishments caring for the aged and for statutory regulation and control of such establishments by qualified persons. This would ensure minimum standards of care and make it possible to evaluate the quality of the care provided . (6) National governments are best able to: - collect demographic material and vital statistics - promote gerontological research - collect, and make available, information about the needs of the elderly - stimulate the development of health care programmes for the elderly - study ways of financing health care programmes for the elderly - promote special housing programmes for the elderly and establish standards for the construction of new buildings and modernization of old dwellings. especially where public money is involved - ascertain that the public are aware of all the services available and all the options open to them - develop educational programmes in health care of the elderly for health and social service personnel - promote educational programmes to help the general public to understand aging and the aged . IOI An important point made ma ny times over the past 20 years was again made by a WHO consulta ti ve committee meeting in 1978. It is not enough that services should be provided; they must be backed by a system of counselling so that potential users know how a nd where to obtain help. Ma ny of the aged tend not to use avai lable serv ices a nd it is vi ta ll y importa nt to know why. It has been suggested that the fo rm and ent ry points of hea lth care systems are frequently unclear to potential use rs. All possible effo1 ts should therefore be made to make elderl y persons fam iliar with a nd confident about all the options ava ilab le to them. If no t used, the best of se rvices will achieve nothing. SOME POINTERS TO RESEA RC H A review o f ex isting se rvices was presented to a WHO technical group on services and systems of ca re for the elderl y that met in Helsinki in 1980. The rev iew was composed of international comparative studies, representative nationa l surveys on socia l and healt h serv ices from se lected countries, and selected studies o n vario us fields o f serv ices for the elderly (including information , work , ho using, hea lth services, and other social services). One major sec tion on survey eval ua tion stressed the need for more objective studies. Various impo rta nt methodological weaknesses concerned the conceptual framework, the differing terminology, a nd the division between medica l and socia l geronto logy . The majority o f studies undertaken were cross-sec tiona l; the need for longitudina l and future-oriented studies is apparent. The group no ted that the development of services is oft en undertaken by energetic and enthusiastic people who have limited interest in and understand- ing of the establishment o f educa tio n mechanisms. The se tting up of data systems for objective eva luation is thus of prime importance. Data should be separa te for the yo ung elderly a nd the old elderly, since their characteristics and needs a re differen t a nd to aggrega te them can obscure differences a nd thus lead to planning errors. Although traditions in geriatric se rvices and the stages of deve lopment in countries vary, there was a consensus that the aging process has certa in common features everywhere and therefore in principle there should be a number o f uni versa l and common aspects tha t sho uld be sought ou t. Another working group, meeting in Berlin la te r in 1980 to discuss appropriate levels for continuing care of the elderly, a lso recommended that the emphasis in resea rch should be shifted towards the study of services in action , including evaluation, and away from broad epidemiological and social surveys. The group suggested tha t particular importance should be attached to the study of experimental schemes, often initiated at local level , through which administrators and practitioners have adapted formal systems to reduce disjunction between services, improve communication, and make services accessible a nd relevant. The volume of thi s innova tory work was thought to be considerable and the collectio n, analysis, and dissemination of existing materia l to policy-makers, administrators, and the hea lth and social workers could have considerable effect. Careful synthesis of existing know!- 102 edge derived from research already carried out is also likely to be more cost- efTective. In the face of demographic change, the need for increased and well conducted research in gerontology and geriatric medicine is self-evident. Adequate resources should be provided as a matter of urgency, and will have the extra benefit of helping to attract staff of suitably high calibre. 103 7 Education and training The education of health workers and the general public has emerged as an area of high priority in almost every WHO meeting on health care of the elderly. Yet over the past decade comparatively little progress appears to have been made. One major reason suggested for this is that in gerontology and geriatric medicine the definitions are imprecise and the terminology confused. EDUCATION AND TRAINING OF PROFESSIONALS There has been a deplorable neglect of gerontology and geriatric medicine in the curricula of students of health professions in the majority of Member States. One oft he reasons suggested for the neglect is historical : from medieval times, systems of care for the poor, the handicapped, and persons with permanent disability also catered for the relative ly small number of people who survived into old age . Therefore, more often than not, the o ld were given custodial care only . Again, advances in science and technology over recent decades have influenced the development of medicine and of those who practise it. Many physicians have become specialists in diseases of specific organs or body systems, or in the use of diagnostic or treatment techniques. Dramatic improvements in the treatment of acute illness have resulted; but although some of the advances in medicine have brought benefit to large numbers of elderly people in the form of relief of suffering from parkinsonism, control of depressive illness, or treatment of oedema from cardiac conditions, it is cure and the management of acutely ill patients that have come to be regarded as being more rewarding than the care of patients with long-term conditions. Thus workers in the field of acute conditions have been accorded prestige and esteem , and students have been persuaded to view that field as being more satisfying and desirable . Dramatic surgery and miracle drugs have impressed lay people as well as professionals, and politicians and other fund-providers have tended to subsidize the more glamorous fields rather than health care programmes for old people. In the more industrialized countries especially, old people are not always held in great respect. As many elderly people have to accept a lower income on reaching the mandatory retirement age, they are susceptible to what has been 105 described as the "rubbish-dump syndrome" that of being unwanted and sometimes even ignored . In turn . those caring for such people are given little prestige. Another significant factor is the absence of any substantial body of knowledge in gerontology and geriatric medicine to serve as a basis for study. This may be attributed to many causes, among them the extreme complexity of problems in the field and the absence of any suitable methodologies for studying them . However, modern ep idemiology and advances in computer and medical science and technology have made it possi ble to close many of the gaps in knowledge, and it can be said that there now exists a sound scientific basis for the teaching of gerontology and geriatric medicine. A WHO meeting in Florence in 1970 on education and training in long- term and geriatric care considered that there is no sha rp line of demarcation between many of the di sa bilities of middle age a nd old age and it consequently discussed the physical , psychological, and socia l aspects of long-term care for both age groups. An earlier group in Kiev in 1963 had discussed the training of professional and auxiliary personnel as one of ten items on its agenda . It saw national institutes of gerontology as the hub of all research. training, and information on the subject and as coordinating centres. The 1970 group noted that medical services and medical education (and the economic resources of both) were still, seven years later, geared to hospitals, cure, and acute illness. It called for a preventive approach with personnel recruited and trained specifically for long-term care and rehabilitation , ready to work with elderly disabled persons and their families and friends in their homes. It emphasized that training should be informed by research and reflect the tea m approach. Even now, in many countries the education of personnel in gerontology and geriatrics, ifit exists at all, is chiefly through short and in-service courses; although formal educational programmes have increased in number and range, there is still an absence of coordination. Many such courses were said by a WHO technical group on se rvices and systems of care for the elderly meeting in 1980 to be essentially ad hoc, task-oriented . disciplinary rather than multidisciplinary, and with little theoretica l and conceptual content. "The confusion between 'medical' and ·social' models and the competing self- interest of different professional groups impede development." The picture throughout the Region varies, however , as the directors of national institutes of gerontology heard at their meeting in Tokyo in 1978. They have also made frequent reference to the importance of education and training at other meetings and have given the subject priority for research, in relation not only to medicine but also to nursing, social work, and allied health professions. Early in 1981 , a working group met in Copenhagen to discuss teaching gerontology /geriatric medicine and establishing a clearing-house on curricula. WHO had seen the need to define ed ucational requirements in gerontology and geriatric medicine, an important component of the regional strategy for attaining WHO's objective of health for all by the year 2000. At this meeting it was reported that WHO sought to develop a network of centres throughout the Region , each to be capable of serving as an 106 educational base to provide the necessary experts and teachers in the field of gerontology and geriatric medicine. But it was recognized that it would require a sustained and determined effort to persuade the deans of medical schools in Europe to offer encouragement and resources to the essential, interrelated, but general disciplines such as primary health care, preventive medicine , and geriatric medicine. The group drew attention to ce rtain constraints in the education and training of professional staff. At university level it is often thought that geria tric medicine is synonymous with internal medicine; many people do not realize that geriatric med icine is not a hospital specialty only. The medical profession also tends to cling to the one-to-one doctor1patien t relationship, not realizing - or not willing to rea lize - that care of the elderly today is complex and requires the adv ice, skill s, and care of many disc iplines. This is shown by a longitudinal study of 14 countries in the Region; only 15 " 0 of the questions are medical , the majority relating to function , attitudes, and pattern of living. Yet care is still often thought ofin terms of medical procedures and institutionalization . The group gave education and training high priority , considering it from the standpoint of the community, of the individual , and of the health professional. Teaching objectives The group spent considerable time on consideration of suitable teaching objectives in health care of the elderly and the following were agreed aims: - to encourage a human and positive attitude towards old people and to demonstrate the satisfaction and fulfilment that come from profes- sional involvement with the elderly and their families - to produce an understa nding of demographic factors and social changes in the aging of soc ieties - to secure an understanding of age-related changes in the context of human development and an appreciation of the causes of disability in old age - to teach the special features of disease in old age and the problems of therapy , those of drug therapy requiring special consideration - to expound the principles of rehabilitation and their application to the elderly, a major objective being the attainment and maintenance of optimum physical, social, and mental function for each individual - to demonstrate the importance of working as a member of a multidis- ciplinary team with full understanding and appreciation of the roles and skills of physicians, nurses , rehabilitation therapists, social work- ers, and other team members - to show the importance of acquiring skill in communicating effectively with the elderly and those involved in their care, this being done in such 107 a way as to lead to fuller understa nding of the importance of the family and the social network of ca re - to ensure understanding of the importance o f individual liberty , so that the elderly retain the maximum possible choice of a nd control ove r their own lifestyles and the manner in which they face dying - to impart knowledge of what services are ava ilable to old people and the ir families, with specia l emphasis o n the community aspects, and to emphasize the essentia l interdependence oft he se rvices and the need for effective cooperation between them and fa milies a nd o thers caring for the aged. The group believed that those o bjec tives cou ld p rovide a suitable basis for the establi shment of courses in health care o f the elderly . How the objectives are rea lized must depend upon loca l conditions and resources. Schools and colleges shou ld give careful considera tion to such courses, treating them as a ma tter of high priority. Content of curricula In their discussion paper on the implications for the hea lth professionals of hea lth ca re for the elderly, Svanborg & Willi amson recommended that students should receive instruction in the biology and physiology o f aging as pa rt o f general courses on those subjects.a In that contest, ce rtain body systems, including the nervous system, the circ ulato ry a nd locomoto r systems , the spec ia l senses, a nd the immunoreactive system are of special importance. In pharmacology classes at ten tio n should be given to the pharmacodynamic and pharmacokinetic changes associated with aging. Student s need to appreciate tha t growing old is as much a no rma l part of development as adolescence or any other stage of the life cycle. Thus, in behavio ural sc ience classes, they should be introduced to the sociology a nd psychology o f aging within their own society, including consideration o f age-related cha nges in cognitive and mental function. _Student s adequately trained in gerontology would be equipped to assimilate, during their clinical years , the essen tial s of care of the elderly as a fundamental part of their clinical studies. Such an introduction to the field of geriatric medicine would ensure that a suffic ient number of medica l students would be a ttrac ted to its practice when qualified. Ma ny authorities need to run a special course in geriatric medicine , a llocat ing a specified amount of curricular time to the subject. A WHO semina r meeting in Kiev in 1963 to consider the prevention of premature aging had a lread y recommended that, in spite of the danger of overloading the curriculum, in o rder to benefit from the geriatric teaching given in connexion with normal training in the d iffe rent medical specialties, the medica l student needed a fai r knowledge of bas ic age changes. It was therefore a matter of urgency that specia l lectures in gerontology be given by a Unpubli shed WHO document EU R/ HCE/80/ 1. 108 gerontologists as a part of all basic science curricula at a relatively early stage in clinical studies. Members of consultative committees and working groups have also given much consideration to students' learning experiences in the field and have suggested that they be helped to appreciate the importance of social factors in health status and in the response to treatment and rehabilitation. Special attention should be paid to the problems of loneliness, isolation, and family dispersal, in so far as they may readily lead to apathy and inactivity in the elderly . Measures to counteract these adverse factors and to strengthen and foster family support should be demonstrated. Students should be helped to realize the importance of encouraging a healthy lifestyle even in old age and to avoid the belief that it is no longer important at that age. Particular attention should be paid to the preservation of social life and the widest possible range of interests for old people. During this period the student's training in gerontology should be made use of in caring for individual elderly patients and supporting their families. At this stage also students should realize the importance of age-related changes, as shown, for example, in altered reactions to disease, in atypical symptomatology, in changed response to drugs, and in changes in the immunological system. They should be given ample oppor- tunity to appreciate the often subtle differences between changes due to age and those due to disease. Thus, a higher erythrocyte sedimentation rate, a higher systolic blood pressure, or some degree of shortness of breath may be normal or physiological in old age whereas in youth or early adulthood they would invariably indicate disease . This involves the consideration of normal values (reference values) at different ages, special attention being paid to the complex problems arising from the existence of the grey areas that lie between normality and disease . The extent of these grey areas increases with age and it is important that students should learn to be aware of them; only in this way will they understand when medical intervention is indicated and, equally important, when it is not. It is well known that overtreatment of older patients is common and that the incidence of iatrogenic illness is increasing. Emphasis must therefore be placed upon normal old age, and students should have an opportunity to see the essential normality of age in its proper perspective by observing healthy old people coping with life in ordinary family and community settings. Rehabilitation underlies all geriatric endeavour and students must be helped to understand its importance. To do this, much greater emphasis should be placed on function and loss of function, this calling for a greater understanding of the skills exercised by those in the professions of nursing, physiotherapy, and occupational therapy and by others dealing with groups of patients for whom restoration of complete normality is unlikely. While striking improvements sometimes occur, even in very aged patients, the student must learn that in a significant proportion only meagre gains can be expected. Partial rehabilitation and partial restoration of function have often not been regarded as affording adequate professional satisfaction for physicians. with their traditional interest in acute illness and its cure. However. as the numbers of aged patients increase, students will have to adjust themselves to the idea that many of their patients will achieve only 109 limited improvements. They must understand that, however limited the restoration of function may appear to the physician, it may be vitally important to the patient as a sign of restored independence, a step towards a more normal existence, an improvement in the quality of his life . Students must also be helped to accept the constant reality and indeed normality of death in advanced age and appreciate the physician's ro le in terminal care of the dying patient. It is a lso important for students to understand the physical, emotional , and psychological stresses experienced by their nursing colleagues and others involved in the care of dying or permanently disabled elderly persons. Only through such understanding will they be able in the future to ensure that excessive burdens are avoided. This requires familiarity with aids and applia nces as well as an appreciation of staff patient ratios . Teamwork and the frank discussion of mutual problems are perhaps especially necessa ry in terminal care, which must always form an importa nt and substantia l part of geriatric medicine. Family members must always be seen as the primary supporters of elderly patients and thus in need of educa tion and counselling. Students should be given the chance of seeing this aspect of family life and of understanding how important it is to involve family members in discussions on management and on the objectives of treatment. Emphasis must a lso be placed on the continuing role of members of the multidisciplinary team even after the patient has died; here too the role of the primary care physician is invaluable. This type of comprehensive geriatric care can on ly be achieved through multidisciplinary team effort, and especia ll y through close collaboration between community workers and hospital staff. The fundamental role of the primary care physician must be stressed, the need to ensure that he is able to achieve hi s full potential. Students will more readily understand from seeing the multidisciplinary team in operation that its total effectiveness is greater than that of its individual members. To work effectively in multidisciplinary teams, health care students need to acquire knowledge of and respect for the skills and expertise of others. According to a WHO expert committee in 1974, " from the point of view of planning for geriatric services, the primary health care team represents, for all countries in the world, the basic unit". The working group that considered education and training in 1970 also recognized the need for the medical student to become acquainted with social medicine in action a t the primary level. The group saw it as " an integral skill which he will need in dealing with the problems of contemporary medical practice". It added: " Even if such developments in the education of medical students were to take place soon (and progress in medical education moves slowly), it might take a decade before their effect is reflected in general practice. The problems are urgent now and likely soon to become more pressing". Geriatric medicine as a practice specialty In departments staffed by health professionals devoting all or a major proportion of their time to the care of the elderly it is easier to provide the 110 broad training required by both undergraduate and postgraduate students. Such departments are able to offer the opportunity to see old people in all settings, demonstrate the multidisciplinary team in action, and show that highly trained professionals can derive deep professional satisfaction from this field of work. Where such specialist services do not exist or are not envisaged, it is essential to establish academic departments of health care of the elderly to meet these vitally important teaching needs. In the United States and in many countries of the European Region there is opposition to the recognition of geriatric medicine as a valid practice specialty. This is partly because of traditional objections within the profes- sion, partly because of the profession's understandable reluctance to be further fragmented. It is probable that pressure of public opinion and the increasing demands arising from the growing numbers of the aged in almost all countries will eventually lead to wider acceptance of geriatric medicine as a specialty. If so, recognition may come about through gradual evolution. EDUCATIONAL ISSUES BY PROFESSION Physicians All students should be introduced to gerontology at an early stage of the curriculum so that they are left in no doubt about the importance of the subject or about the inescapable fact that, throughout their professional careers, the health care of older patients is likely to form a large and increasing part of their work. This is so for students in both developed and developing countries. Geriatric medicine and long-term care provide opportunities for giving substance to concepts that have proved difficult to communicate to students, such as the intimate relationship between the physical, psychological. and social aspects of disease. Greater emphasis given to it will help to engender the holistic concept of medicine and psychiatry that contemporary medicine demands. In curricula still bound by tradition it has been difficult to introduce teaching in the behavioural sciences. The problems encountered in the practice of geriatric medicine and long-term care provide excellent opportuni- ties for bringing to life some major themes in those sciences and for developing teaching around them in cogent and concrete ways . For example, the growing proportion of elderly people separated by distance from close relatives, the effect of this on the possibility of their having to be treated in institutions, and the relationships between bereavement, isolation, and suicide exemplify the phenomena of anomie and social isolation. The change in status brought about by retirement or lasting di sability. and the loss of prestige. income. and opportunities for soc ial contact that may ensue. highlight the significance of social role . Elderly people have a relatively small share of the wealth and assets of affluent societies, and poverty is one of their most consistent social characteristics in all countries; its bearing upon mental and physical health 111 and on the chances of being able to survive within the community exhibits the relevance of social class and income to health. Aging is one stage of human development , and in its investigation biological, socia l, and cultural view- points are all apposite. As the aging of communities is closely assoc iated with declining birth and mortality rates and growing affluence , it presents an important facet of the critical problem of population control. And perhaps in no other field of medicine are the problems of organization of the medical services and evaluation of the results of care in the community or in an institutional setting so far-reaching in their effects, not only on the quality of medical care but a lso on the quality of life itself. The stimulus and challenge of the subject and its relevance to pressing contemporary issues in medicine and society give it genera l educational value beyond its immense practical importance. However, its very complexity demands careful planning of the curriculum, detailed organization of theoretical and practical work, and the use of a wide range of educational techniques. A subject so wide-ranging and complex is in danger of appearing diffuse and difficult to assimilate unless education and training are so planned that the different components of courses are seen to be interrelated in an orderly, coherent, and meaningful manner. Postgraduate and continuing education Continuing and postgraduate education in gerontology and geriatric med- icine must be provided at many levels for physicians at different stages in their careers. Well-constructed courses should be provided to emphasize the principles of modern geriatric medicine a nd to acq uaint physicians with significant advances. The courses should be in universities, which should accept this task as an important contribut ion to the societies they se rve . For physicians with special responsibility for the elderly, e.g. those working full- time or part-time in nursing homes or con tinuing care units, longer and more extensive courses shou ld be provided . Certain groups of physicians, including those who intend to become primary care physicians, require special consideration. They should have a period of training in geriatric medicine; one of six months has been recommended for this purpose. Those training in psychiatry and in general medicine should likewise be required to have experience in geriatric medicine, since the care of the elderly will form an increasing part of their work. In some Member Sta tes the care of the aged a nd chronica ll y ill devolves mainly upon geriatricians and psycho- geriatricians, but these specialties have not been developed everywhere. Where they have practitioners should be thoroughly competent general clinicians in their own fields . While their training will have provided them with a firm scientific foundation for their work, it should also have endowed them with an appreciation of the diffuse multipathological character of disease in the aged, the close relationship between physical and mental health, and the character- istic intertwining of each with family circumstances and socia l environment. As so many disorders in the elderly tend to be diagnosed only at an advanced stage, training should lay strong emphasis on prevention, diagnosis , and active interven tion at an early stage. It should promote skills in rehabilitation 11 2 and resocializa tion as well as in administration, organization, and leadersh ip. The training o f a geriatrician should also prepare him to display humane consideration and concern in giving care to terminally ill patients so that the terminal stage of illness is never looked upon as an unfortunate and embarrassing int rusion into normal clinical life. Long-term care is no t easy to teach and , as it involves a new emphasis, ed uca tors of the highest q ualit y are required in o rder to endow it with prestige. But un til tha t prestige has been earned , it wi ll be difficult to attract gifted people into the field. The rec urring problem of nomenclature was raised o nce more in a consultation on teaching gerontology /geria tric medicine held in Copenhagen in 1981. The wo rd "geriatric '" ofte n has a strongly negative effect, the partic ipants felt, not onl y on patients and their fam ilies but also on hea lth wo rkers. Whi le the term "geriatric medicine" is genera ll y more acceptable, it has the disad va ntage of suggesting that the scope is exc lusi vely medical. The term " health ca;-e" broadens the scope and was recommended for use by WHO. More recently, di scussions have been held on the ques tion of who ought to provide special courses on healt h care of the elderly and the 1978 United States report on aging and medical education - the so-called Beeson report 0 - has been used as a background document. It argues powerfu lly for education in geronto logy and ge ri a tric med icine in medical schools and concludes that thi s could be achieved through the recognition o f geron tology /ge riatric medic ine as an "academic spec ialty", bu t not as a "practice special ty". It urges the appointment of we ll-t rained teachers of the subject in eve ry medical school so that a ll future doctors receive a so lid groundi ng in the ca re of elderl y people . Nurses Nursing ca re of the elderly includes appropriate support for patien ts who require continuing ca re ei ther in the comm unit y o r in instit ut ions. For it to be successful , deliberate educational policies and tactics a re required with a view to inculcating a positive a pproac h. At present educational constraints prevent nursing from ad opting the necessary approach to the care of the elderly. Studies of nurses in hospitals and homes of the elderly report inadequate specialist knowledge, adhe re nce to regimes promoting dependence, and no evidence of any systematic assessment of individual nursing needs resulting in proper plann ing, execut ion , a nd eva lua tio n o f ca re. Although steps have been taken in a few Member States in recent yea rs to include community nursing care and health ca re of the elderly in general nursing courses, the o rientation of nurse education is still towards yo unger acutely ill patients in hospital s and routine performa nce of tas ks in tha t setting . In the ma ny WHO consultative committees, advisory groups, and other meetings o nly brief or ind irect references have been made to the need for reorienta tion in nursing education . A working group di scussing public health aspects of aging populations in 1958 observed that surveys in countries of the a Document issued by the National Academy of Sciences, Washington , DC. USA. I 13 Region had revealed "a serious shortage of all professional and technical personnel qualified to care for the elderly, as we ll as a lack of research workers in gerontology and geriatrics". It was not until the 1970s that serious attention was given to the role of nurses in providing health ca re for the elderly . In 1970 a WHO working group on educat ion and training for long- term and geriatric care stated categorically that rehabilitation and long-term care of people of a ll ages requ ire nursing sk ills of the highest order, those probably being the most important factor in ensuring the welfare o f such patients. The group considered it essential that training in long-term care be provided for a ll levels of nursing staff, including the most numerous and least qualified groups. It recognized that only a core of fully trained nursing staff wou ld be available for such work and tha t they must provide both the leadershi p and the teaching and supervision of the a uxi liary staff who assisted them . This was the fi rst group to speak of sociomedical care, recognizing that the needs of long-term patients were often o utside the strict ly medical field . Basic nursiny education Like their medica l colleagues, nurses are attracted to work in the rapidly expanding branches of medicine requiring considerable technica l ski lls and carrying prestige. Nursing education has over the years become hospital - oriented, di sease-oriented , and doctor-oriented . Few programmes in the countries of the Regi on have trained nursing staff to carry out the health- o riented or commun ity-o riented care required to meet the needs of the well or disab led elderly . A WH O working group on nursing aspects in the care of the elderly that met in 1976 noted that in most countries of Europe basic nursing education programmes are dominated by theory and practice concentra ting on the care of the acutely sick in hospital and providing little or no background for assessing or meeting needs in ot her areas . If nursing staff are to make a contribution to the care of the elderly, the gro up declared, their education must be changed. Among its suggestions was learning experience preparing nursing personnel at all levels to function as genera l practitioners capable of providing hea lth care for the healt hy and sick of a ll ages . All c urricula should provide some gerontology theory focusing on theories of human develop- ment, aging, self-care, hea lth promotion, and community hea lth , and should inc lude the development of di sease, disability, and socia l dysfunction. Opportunities should be provided for nursing students beginning thei r basic nursing educat ion to work with elderly persons in the fa mily or com munity in both urban and rural areas. They should be ab le to participate in inter- disciplinary work, gaining knowledge and app recia tion of the roles of other health and soc ia l service workers and of disciplines in other sec tors. Educational objectives should be clearly formu lated and curricula specifi- cally directed to them . Appropriate stimulating methods of instruction, both practical and theoretica l, should be used, group instruction being sup- plemented when possib le by semi nars and discussions. The individual needs of st udents should be catered for; personal tutors could stim ulate and reinforce 114 mot ivation. Systematic evaluation should be undertaken by teachers and supervisors of the student's performance in pract ica l and theoretical work , bu t care should be taken to preserve a constructive and healthy ed uca tiona l atmosphere giving encouragement and a feeling of securi ty ; assessment should no t be permitted to inhibit spontaneity or to discourage the studen t from free discussion . In this sphere of work not only are factua l knowledge. clinical skill , and judgement needed: so also is an influence shaping the motiva tion and attitudes of students a nd promoting sensitivi ty to the problems of their patients. As important topics such as cultura l differences. social status, and problems of poverty and loneliness are sometimes difficult for yo ung people to grasp full y, sociology and psychology as well as physiology and pathology should be regarded as subjects nursing students should study. They need to be aware of the possible effects of institutional life so that , before becoming in vo lved in the institutional care of elderly people, they are acqua inted with at least some of the difficulties and frustrations that may face their patients. Nurses in train ing should also be taught to use objective meas urements in keeping records. Being in contact with pa tients for weeks and even months, nurses who receive appropriate training a re well placed to use standa rdized measurements of thei r patients' effectiveness in everyday tasks, intellectual deterioration, impairment of understanding, genera l behaviour, adaptation to life, a nd concern for personal appearance. For the maintenance of his maxi mum independence, the main component of any nursing assessment will be deta iled analysis of the elderly person's capacity for self-care, i.e. the practice of ac tivities that individuals personally initiate and perform on their own beha lf in maintaining life, health , and well-being. A high proportion of auxiliary nursing personnel have received no training but are engaged in giving direct nursing care to the elderly . Many of them take decisions every da y affect ing the quality of care received by elderly people, particularly long-term care. The role of the auxiliary in the nursing team thus requires careful definition . At no level should personnel be a llowed to perform nursing tasks wi thou t some fo rm of training. Postbasic nursing education lnservice and cont inuing education programmes should be provided for nursing personnel engaged in a ll services. The professional nurse caring for the elderly at home or in charge of or working in a nursing home requires more knowledge about the manifestations of multiple pa thology. She also needs to know more about the genera l and specific ca re of elderly people and about the contribution of other members of the interdisciplinary team whose expertise should be sought when appropriate. Care in the hospi tal and the community requires. among other things, a thorough knowledge of the process of aging and of the psychological, sociological, and hea lth-orien ted aspects of care - of its person-oriented rat her than its disease-oriented aspects. The working group on nursing cons idered that all nursing personnel wishing to ma ke a life-time career in the care of the elderly need special education on a formal and continuing basis. Fully trained nurses should 11 5 lend cohesion and provide leadership within the staffing structure of long- term care units. For their special tasks within the team they need a well- conceived and adequately financed training programme of the highest quality. Their teachers should be highly qualified and drawn from a va riety of disciplines. Refresher courses are required to keep them up to date and to renew or maintain their interest. The population at large should be educated to understand the normal physiological and psychological changes that come with advancing years and be helped to recognize and accept them as a part of life. Enjoyment of life, social contact, and independent mobility could be much improved by timely advice and assistance from nurses on such matters as foot care, hearing, eyesight, nutrition, prevention of accidents in the home, and the provision of household aids. In providing such care nurses should be tra ined and motivated to detect not only physical but also socia l and psychological problems in the patient's family and social group, and to consider the participation and solicit the cooperation of support groups outside the health services such as voluntary organizations and cultural groups. In many situations the elderly do not require direct care from a professional nurse; it is better to use auxiliary nursing personnel. The ed ucation programme of the nurse as leader of the nursing team should therefore include elements of administration to promote effective team management and knowledge about learning and teaching, for the teaching not on ly of the elderly and their famili es but also auxiliary personnel. Education and training of other caring professions WHO has paid little attention to what are called in some countries "professions supplementary to medicine" but are, especially in health care of the elderly, "professions essen ti al to the practice of medicine". Working groups over the years have reiterated the need for teams to include these professionals and the importance of members working together with a common aim. It has been repeated more than once that training programmes should be developed that help the therapist to appreciate that the most important consideration is training in self-care activities. The suggestion has been made that all therapists should be trained to make detailed case studies containing systematic observations on the patient's social background, personality, initiative, intellectual assets, and capacity for independence. The pace at which the rehabilitation programme aims to restore indepen- dence must be sensitively adjusted to the patient's personality resources, his needs, and the manner in which he responds to the steps he is helped to take. To force the pace may undermine the main objective of care. Enterprise and imagination are needed to explore all the ways in which the handicapped person may take inderc:1dent decisions and action. The abili ty to act and decide for himself may be all the more treasured because con tact with the physical and social world has inevitably become constricted by the handicap. The physiotherapist should be prepared for this work by appropriate training and equipment to keep all her patients active, occupied, and interested. 116 Speech therapists should join the team where needed. They too should be patient-centred rather than department-centred and be trained to cooperate wi th other therapists. Just as for nurses, the personal, emotional, familia l, and social dimensions of rehabilitation should be emphasized throughout training. The handicapped patient at home needs visiting therapists to rehabilitate him there. The therapist should be given training in teaching the family and patient to continue practising daily what they have been shown and be taught how to assess whether the home environment is one where remedial exercises will be carried out. She should be trained to judge when to advise the family to make modifications in the home and buy equipment. Technological advances in the management of handicap have greatly facilitated life at home for disabled and aged people. However, they need to be applied far more widely. Some of the resources of the communi ty health service should be energetically devoted to this end . Therapists must be shown in their training that work with the disab led in the community is rewarding in its results, otherwise the difficulties in recruitment will continue. In the course of training at all levels the instruction given should always be related to the functions to be subsequently performed. Teaching should therefore be reinforced by practical demonstrations and case work and opportunities provided for the knowledge acquired to be applied in practice. In shorter courses of training the main emphasis has to be on practical skills that have to be thoroughly acquired in the course of supervised personal experience. At higher professional levels a firmer and more extensive theoretical foundation is needed, but a certain amount of theory is helpful at all but the most rudimentary levels. In some countries the professions of physiotherapist and occupational therapist do not yet exist. Without a career structure that offers adequate salaries and promotion the able people required will not be recruited into this kind of work. It will then be undertaken on an unskilled or haphazard basis, with inevitable adverse _effects on patients. Education of social workers Social workers will eventually work in hospital or in the communi ty and for both they need academic and practical training. The most serious limi tations to such training are lack of sufficient practical work and of persons capable of supervising the students. The continuing education of social workers after they have begun work will help to sustain their confidence and professional morale. Social workers make an important preventive contribution before dis- abi li ty is far advanced . They are responsible for mobilizing the resources of the family and for making contact with welfare and voluntary services to assist the family in enabling the patient to live a reasonably independent life. They susta in the family's morale in caring for a disabled relative, by making it realize that a thoughtful and concerted effort is being made to ease its burden. During training they should learn to think in terms of the family as a whole and to be a lert to the effect of an ailing relative on other members. 117 The family 's resources must be buttressed by moral support, socia l help , and material assistance. Financial support for the family, some members of which may have to give up paid work, is of special importance in building and sustaining the morale of relatives and patients alike. But this pri nciple has hitherto found little applica tion . Education of administrators If the health care team is to work purposefully towards the common goal of helping elderly people to live a social life as full, varied, and satisfying as possible, those administratively responsible within the organization must receive a systematic education that enables them to understand the goal and strengthen and unify the attempts to achieve it. In the case of medically trained public health administrators, such an educa tion often needs to be brought into line with the changes that have occurred in the past three or four decades. Public health is now dominated by the related and overlapping fields of geriatrics and mental health, chronic handicap, and long-term care. Planning in the long term for these services requires an adequate background of epidemiology and the socia l sciences and a capacity to plan cooperative endeavour within teams of workers drawn from disciplines with differing outlooks and traditions. In many countries the public health or regional health administrator is in a specially advantageous position to take the initiative in coordinating the activities of primary hea lth care teams, local authority health and welfare services, and hospital services. This is an essential prerequisite for successful cooperation in many forms of medical and social care, but in particular that for elderly, long-term, and psychiatric patients. The administrator should, therefore, become fully familiar with the work, outlook, and duties of all the workers employed in each of those fields. Because his outlook should be patient-centred, too, his tra in ing must from an early stage include contact with patients. EDUCATION AND TRAINING OF NON-PROFESSIONALS Education of the aging and the elderly themselves While we need to lea rn a great deal more about aging and the aged there is, nevertheless, much we already know that is not applied. Lives lost in the European Region attributable to smoking, alcohol and drug abuse, and reckless driving exceed a million a year, quite apart from the disabilities and the unnecessary and costly load they place on the Region's health resources . Many simple measures are not yet widely applied because of the lack of a political consensus which, in turn , depends upon public support and public education. Much health damage is self-inflicted. For many health problems, too, curative action has a limited effect. Yet countries are slow to respond to knowledge that lifestyle and the environment have major effects on health . While the promotion of health cannot be pursued irrespective of cost, effective 118 health po licy requires a coordinated effort, no t only by government but also by every segment of society. Hea lth action during the past 30 years has been devoted ma inly to dealing with the hea lth problems arising rat her than to preventing the problems from arising. The emphasis has been on cure or remedial trea tment rat her tha n on hea lth promotion and disability a nd di sease prevention . To achieve hea lth for a ll will require a fund a menta l reorientation of prio rities that will have major implications for research , manpower training, ed ucation, information, and eval uation as well as for the heal th services. The proposed WHO regional stra tegy calls for more cost-effective ways of do ing what is done a nd needs to be done, so tha t resources can be released to do what is cu rrently left undone. The key to putting thi s regiona l stra tegy into effect is o rganized primary health care to which a ll people of all ages have access and th rough which people are helped to ass ume greater responsibility for their own health so as to ensure an enhanced o ld age. To fulfil such responsibilities people have to be well informed . To inform them is an important funct ion of hea lth personne l. E-ducation of families Because most disa bled and most o ld people conti nue to be cared for a t home, the ed uca tion of their fam ilies must not be overlooked. It would be wrong to ass ume that care at home is always good care; even when it is the best the fa mily ca n provide it often leaves much to be desi red in the quality of the nursing, nutrition , reha bilitation , a nd general psychological ma nagement. Since care at home usuall y continues for an indefinite period it must be reinforced by help from the hea lth a nd socia l services. Nurses, who usually have the confidence of the community, are in a strategic position to teach, demonstrate, a nd impa rt informa tion in simple everyday la nguage that families understand, accept, and act upon. Modern concepts of rehabilitation should a lso be explained, the fam il y encouraging the patient to reach the level o f self-sufficiency of which he is capable. Transfer to hospi tal as required - either for treat ment or in order to provide some relief for the fam ilies - should be facilitated and their lea rning experiences continued in that setting. Education of voluntary personnel The work of vo lunta ry agencies is usua ll y based on altruistic concern rather than on existing personal relationships . These agencies a re regarded as formal but flexibl e community orga nizations whose knowledge of loca l conditions makes them va luable intermediaries between lay ca rers and the official services. They can be useful sources of identification a nd referra l a nd it is therefore essential that they are fed with a ll up-to-date relevant information to assist them in these functions. In some developed countries such agencies exerci se a resea rch and /o r pressure group function. The former function is importan t since it furnishes fact s on which service policy formulation , programme direction , and action can be based ; in the latter function the agencies act as social advocates on behalf of the elderly, playing an important I 19 role in bringing vital needs (deficiencies, gaps, rights, and injustices) to the notice of the government concerned . In these capacities they form an integral part of the local, national , and in some instances international network of care. For these reasons it is desirable that any teaching they receive should be given by members of the health care team. 120 REFERENCES Abu-Erreish, G. et al. Studies on fatty acid oxidation by isolated perfused working heart of age rats. In : Congress abstracts. X International Congress of Gerontology, Jerusalem, 1975. Adamson, K. A. & Smith, D. L. Canadian pharmaceutical journal. 4: 80 ( I 978). Alzheimer, A. Cb/. Nemmheilk. Psychia1., 18: 177 ( I 907). Anderson, W. F. & Cowan, N. R. Arteria l pressure in healthy older people. Clinical science. 18: 103 (1959). Archer, J. A. et al. Journal ojclinical im·estigation. 55: 166 (1975). Axelsson, U. et al. Frequency of pathological proteins (M co mponents) in 6,995 sera from an adult population. Acta medica scandinurica, 179: 235 ( 1966) . Beer, R. S. et al. Proceedings of the Royal Society . 125 ( I 937). Bielschowsky, M. Journal of psychology and neurology, 5: 128 ( 1905). Bierman, E. L. A.ging and endocrine function. In: Dano n D. ct al., ed. Aging: a challenge /0 science and society. Oxford, Oxford University Press. 198 L Vol. I. pp. 235 - 241. Birren, J .E. Handbook o{aging and the indiridual. Chicago, C hicago U niversity Press. 1959. Bloq, P. & Marinesco, G. Semin. med. Paris. 12: 445 (1892). Bourliere, F. The assessment of biological age in man. Geneva. World Health Organization. 1970 (Public Health Papers, No. 37). Brondfonbrener, M. et al. Circulation, 12: 557 ( 1955). Broman, G. E. et al. The density of selected bones of the human skeleto n. American journal of physical anthropology. 16: 197 - 2 11 ( 1958). Bromley, D. B. The psychology of human aging. London . Pen guin Boo ks, 1966. Brozek, J. Physique and nutritional status of ad ult men. Human biology, 28: 124- 140 ( 1956). Burr, M. I. et al. Age and ageing , 6: 38 ( 1977). Calkhoven, J.E. Huisarts en 11 ·etenschap, 23: 226 (1980). Castleden, C. M. Prescribing for the elderly. Prescribers • journal. 18: 90 - 94 ( 1978). Castleden, C. M. & George, C. F. The effec t of ageing on the hepatic clearance of propranold. British journal of clinical pharmacology, 7: 49 - 54 ( 1979). Chen, J. C. et al. Regulation of mitochondrial repi ra ti o n in senescence. Journal of cellular physiology, 80: 141 ( 1972). Clark, F. Le Gros. The employment problems of elderly men. /11: Ho bson. W .. ed. Modern trends in geriatrics. London , 1956. Comfort, A. Test-battery to measure ageing rate in man. Lancet. 2: 1411 (1969). Crooks, J. et al. Pharmacok inetics in the elderly. Clinical pharmacokinetics, I: 280- 296 (1976). Davies, D. F. & Shock, N. W. Age changes in glomerular filtra ti on rate , effective rena l plasma flow. tubular excretory capacity in adu lt males. Journal of clinical im·estigation, 29: 496 507 ( 1950). Department of Health and Social Security. Priorities fo r health and personal social sen ·ices in England. A consultatit•e document. London. H. M.S.O .. I 976. Dillon, N. et al. Clinical pharmacology and 1herape111ics. 27: 769 - 772 ( 1980). Duckworth, W. C. & Kitabachi, A. E. American journal of medicine. 53: 41 8 ( 1972). Durnin, J. V. Nutrition. /11: Brocklehurst , J.C.. ed. Textbook of geriatric medicine. London. Churchill Livingstone. 1973, pp. 384. Esquirol, E. Des maladies mentales. Paris. I 938. Vol. 2. p. 44. 121 FAO Nutrllion Meetings Report Ser ies. Nu. 26. 1960 (Educalion and /ruining in m11ritio11 in Europe: report of a Symposium). Farmer, P. et al. Journal of neuropathology and l:'xperimental neurology. 35: 367 ( 1976). Gherandache, C. N. et al. In : Gitma n. L. , ed. Endocrines and aging. Springfield . Illi nois. Thomas. I 96 7. p. 76 Gibson, R. M. et al. Age ddTnences in health ca re spending. Fiscal year 1976. Social sernrity hulletin. 40: 3 14 ( 1977). Gregerman, R. I. & Bierman, E. L. In : Williams. R. H .. ed. Tex tbook of<'1uioainology, 5th ed. Ph tladelphia. W. B. Saunders. 1974. p. 1059. Gribbin, B. , et al. Effect of age and high blood pressure on baroreflex sensitiv ity in man. Circulation research . 29: 424 431 ( 197 1 ). Hannesson, G. Korpermasse und Kurperpropurtionen der Islander. Reykja vik. , I 976. Hemsell, D. L. et al. Journal ofclinica! endocrinology and metabolism. 38: 476 ( 1974). Herskovits, J . 1\1. The ph ysi-.:a l for m and growth of the American Negro . Anthropologischcr An::eiger. 4: 293 ( I 927). Hirano, A. , et al. Brain . 84: 662 ( 1961 ). Hollingsworth, J. W. e( al. Cnrrelations between tests of aging in Hiroshima subjects. An at tempt to define " phy,iologic age" . Yule journal of biology and medicine. 38: 11 ( 1965) . Hollister, L. E. Journal oj the Am erican Medical Associalion. 234: 195 ( I 975). Jones, H. E. & Kaplan, 0. J . Psychological aspects of mental diso rders in later life. In : Kaplan. 0 J., ed. Men tal di.wrders in later li/i• , 1956. Khosla , T. & Lowe, C.R. Height and weight of British men. Lancet. I: 742 (1968). Law, R. & Chambers, C. British medical journal, I: 565 ( 1976). Learoyd, B. M. Medical journal of Australia , I : I 131 (1972). MacLeod, C. C. et al. Nutrition of the elderly at home. Ag<' and ag<'ing 3: 209; 4: 49 ( 1974). Makinodan, T. et al. Reduced humoral immune activny in long-lived old mice: an approach to elucidating it s mechani sms. Immunology, 31 : 903 - 911 ( 1976). Marquer, P. & Chamla, M. C. L ·evolution des caracteres morphologiq ues en fonction de !'age chez 2089 Frarn;ais de 20 a 91 ans. Bulletin <' t memoires de la Societe d'Anthropolog ie de Paris. 12 (2): I - 78 ( I 961 ). Matsuyama, H. et al. In : Luthy. F. & Bischoff, A .. ed . Proceedings of the Fijih In ternational Congress of Neuropathology. Amsterdam. Excerpta Medica, 1966. pp. 979 - 980. Mazullo, J . M Clinical pharmacology and therapeutics. 13: 157 ( 1972). Molholm-Hansen, J. et al. Renal exc reti on of drugs in the elderly. Lancet , I: 1170 ( 1970) Nemitz, I. & Schellin, J. L. Un aspect particu lier de la pharmacotherapie: la compliance. Rl'l'ue mi-dical<' de la Suisse romande. 99: 451 ( 1979) . Obersteiner, H. Arch. Neural. Inst. Unil'. Wien , 10: 245 (1903). O'Malley, K. et al. Geriatric clin ical pharmacology and therapeutics. In : Avery. B. , ed. Drug trl:'atment. Edinburgh. Church ill Livingstone. 1976, pp. 123- 142. Pacaud, S. Le vieillissement des aptitudes. In : Binet , L. & Bourliere, F .. ed. Precis de gerontologie. 1955. pp. 40. Parker, G. H . American naturalist. 63: 97 ( 1929). Pomeranz, A. Pathology of the heart with and without ca rdiac failure in the aged . British heart journal, 27: 697 ( 1965). Rabinowitz, D. Annual reriew of medicine. 21: 241 (1970). Richey, D. P. & Bender, D. Pharmacokinetic consequences of aging. Annual ret>iew of pharmacology and toxicology, 17: 49- 65 (1977). Roth, M. et al. Nature, 209: I 09 ( 1966). 122 Roth, M. The principles of providing a service for psychogeriatr ic patients. In : Wing. J. K . & Hafner. H .. ed . Roots ofe,,aluation . Londo n. Oxford University Press. I 973. The Care of the elderly in Scotland. Edinburgh. Royal College of Physic ians. 1963 (Publication No . 22). Ryckewaert. A. et al. Varia tions scion l'iige et le sexe de l'epai sseur du pli cutane mesure au d os de la main. Rerue franraise des hudes cliniques et bioloyiques. 12: 803- 806 ( 1967). Sartorius, N. Culture a nd the ep idemi ology of depression. Psychiatria, neuroloyia, ne11rochiruryia, 78: 479 487 ( I 973). Scheibe!, M. E. & Scheibe!, A. 8. Structural a ltera tio ns in the agi ng brai n. In : Danon, D. et al.. ed. Ayiny: a challenge to science and society. Oxford , Oxford University Press, 1981, Vol. I, pp . 4- 17. Schochet, S . S. et al. Acta ne11ropatholoyica. 23: 342 ( 1973). Shaw, S . M. & Opin, L. J. British medical jo11rnal. I: 505 ( 1976). Simchowitz, T. Nissl-A l::heimer Arheiten. 3: 268 ( 19 11 ). Simon, C. et al. Zur pharmakokinetik von propicillin bei ge ria trisc he patienten im vergleich zujungeren erwachsenen . Drntsche medi::inische Wochenschriji , 97: 1999- 2003 ( 1972). Smith, T. W. & Haber, E. Digoxin intoxication: relatio nship of c linica l presentation to se rum digox in concentration. J1mmal o/'clinical inrestiyation, 49: 2377 - 2386 ( 1970). Steen, 8 . Nutriti on in 70 year o lds dietary habi ts and body composition. Niirinysforskniny, 21 : 20 1 ( 1977). Swa les, J. D. Pathophysiology of blood pressu re in the elderl y. Aye and ayeiny. 8: I 04 - 109 ( 1979). Triggs, E. J. & Nation , R. L. Pharmacokinetics in the aged: a review. Journal ol pharmacokinelics and hiophar111ace111ics, 3(6): 387- 418 ( 1975). Vestal, R. E. et al. Reduced beta-adrenoreceptor sensi tivity in the elderly. Clinical phurmacology and 1herapeU1ics. 26: 181 - 186 ( I 979). Walford, R. L. The im11111noloyic 1heory of aging. Copenhagen, Munksgaa rd , 1969. Wandless, I. & Davie, J. W. British medical journal, I: 359 ( 1977 ). West, C. D., et al. Journal of' clinical endocrinology, 21 : 1197 ( I 96 1 ). WHO Technica l Report Series, No. 17 1, 1959 (Menial health proh/ems 1,{aging and 1he aged: Sixth Report of the WHO Expert Committee on Mental Health). WHO Technica l Repo rt Series, No. 436, 1969 ( Op!imwn physical performance capaci1y in ad11/t s: Report of a WHO Scientific Grou p). WHO Technical Report Series. No. 507. 1972 (Psychoyeriatrics: Repo rt of a WHO Sc ientific Group). WHO Technical Report Se ries, No . 522, 1973 (Energy and prolein requiremenls: Repo rt of a Joint FAO/WHO ad hoc Ex pert Committee). WHO Technical Repo rt Series, No. 548 , 1974 (Planning and oryani::alion ofgerialric serl'ices: Report o f a WHO Expert Committee). Wilkinson, G. R. Effects of liver disease and aging on the disposition of diazepam, chlo rdiazepox ide, oxazepam and lorazepa m in man. Acta psychiatrica scandinarica, S274: 56- 74 ( 1978) . 123 Annex WHO MEETINGS RELATED TO THE CARE OF THE ELDERLY This book was prepared entirely from materia l previously issued in the reports on the following meet ings. No new material has been int roduced by the author. I. Advisory group on the public health aspects of the aging of the population. Oslo. 1958 (document EU RO 11 2) 2. Expert co mmittee on mental health . Geneva . 1958 (W HO Technical Report Series. No. 171) 3. Expert committee on the public health aspects of housing, Geneva. 1961 (WHO Technical Report Series, No. 225) 4. Seminar <' n mental health and the family. Athens, 1962 (Public Health Papers, No . 28) 5. Seminar on the hea lth protect ion of the elderly and the aged and the prevention of premature aging, Kiev, 1963 (document EURO 245) 6. Scientific group on optimum physical performance capaci ty in adults, Geneva, I 968 (WHO Technical Report Series. No. 436) 7. Scientific group on psychogeriatrics. Geneva, I 970 (WHO Technical Report Series, No. 507) 8. Working group on education and trainin g in long-term and geriatric care . Florence, 1970 (document EURO 5301) 9. Meeting on cerebrovascular diseases: prevention, treatment and rehabilitation, Monaco, 1970 (WHO Technical Report Series, No. 469) 10. Expert committee on energy and protein requirements. Rome. 1971 (WHO Technical Report Series. No. 522) 11 . Expert committee on planning and organization of geriatric services, Geneva , 1973 (WHO Technical Report Series . No. 548) 12. Working group on rehabilitation in long-term and geriatric care. Copenhagen, I 974 (document EU RO 4803) 13. Working group on nursing aspects in the care of the elderly, Berlin, 1976 (document ICP/HSD 010) 14. First meeting of directors of national institutes of gerontology, Copenhagen, 1976 (document ICP;PHC 002(1)) 15. Working group on the organization and operation of long-term ca re services, Uppsala, 1977 (document ICP/HSD 013) 16. Second meeting of directors of national institutes of gerontology, Bethesda, I 977 (document ICP/PHC 002(2)) 17. Consultative committee on health care of the elderly, Copenhagen, 1978 (document ICP/ADR 017) 18. Third meeting of directors of national institutes of gerontology, Tokyo, 1978 (document ICP/ADR 015) 19. Technical advisory committee on health care of the elderly , Munich, 1978 (document ICP/ADR 018) 20. Meeting with governmental and nongovernmental organizations on health care of the elderly : liaison meeting, Luxembourg, 1978 (document ICP/ADR 016) 124 21. Technical group on the use of medicaments by the elderly, Thonex, 1980 (document ICP/ADR 042) 22. Fourth meeting of directors of national institutes of gerontology, Weimar. 1980 (document ICP/ADR 015) 23. Technical group on services and systems of care for the elderly, Helsink i, 1980 (document ICP/ADR 041) 24. Ninth European symposium on clinical pharmacological evaluation in drug control, Schlangenbad, 1980 (EURO Reports and Studies, No. 50-) 25. Working group on appropriate levels for continuing care of the elderly, Berlin , 1980 (document ICP/ADR 026) 26. Workshop on the cost-effectiveness of recommending standard patterns of long- term care, Munich, 1980 (document ICP/ RPD 802(S)) 27. Expert committee on disability prevention and rehabilitation, Geneva, 1981 (WHO Technical Report Series, No. 668) 28 . Consultation on teaching gerontology /geriatric medicine and establishing a clearing house on curricula, Copenhagen, 1981 (document ICP/ADR 045) 29. Working group on behavioural studies related to care of the aged, Lubeck, 1981 (document ICP/ADR 054) 30. Conference on nursing and medicosocial work in care of the elderly, Cologne, 1981 (EURO Reports and Studies, No. 79) 31 . Working group to define means of prevention of disability in the elderly, Cologne, 1981 (EU RO Reports and Studies, No. 65) The indi vidual chapters draw on materia l from the fo llowing meetings: Chapter 1: I, 5, 6, 10, 11 Chapter 2: 2, 6, 10, 14- 18 Chapter 3: I, 4, 5, 11, 29 Chapter 4: 4, 6, 7, 9, 10, 21, 24 Chapter 5: 1- 31 Chapter 6: 1- 31 Chapter 7: I , 5, 8, 12, 13, 15, 17, 18 125