EW HOPE FOR THE AGED The magazine of the World Health Organization April 1972 WORLD HEALTH UK: 20 p. USA: 0.50 WORLD HEALTH the magazine of the Work, Neale Organization April IOVE NEW HOPE FOR THE AGED A young boy in his grandmother's arms at Samarkand, Uzbekistan, USSR. (Photo by Jean Mohr ©) Contents New hope for the aged 3 Caring for the aged by Dr J. Cohen 4 Ballet for the young at heart photos by Erling Mandelmann . . . 10 The community link by Dr C. Bailer 12 Integration, not isolation by Liesl Graz 18 Age is no barrier by R. Pointu 24 Why we grow old by Professor F. M. Antonini 26 World Health appears in Arabic, English, French, German, Hindi, Japanese, Portuguese, Russian and Spanish. 2 new hope for the aged The problem of caring for the aged has taken on new dimensions in the 20th-cen- tury. As the quality of medical practice improves and as preventive medicine plays a more important role in our lives, the proportion of old people in our society increases. The result is an ever- growing number of old people—who may lack purpose, direction or hope. Often, in its eagerness to prolong life, society has neglected to utilize the vast potential of the aged. In some respects we have taken a step backwards. Primitive man revered age. The octogenarian was the village wise man. In agrarian societies, the aged played important economic and social roles as long as they were physically able to do so. They were not a problem— they were considered an asset. Often in 20th-century society those who are too old to keep up with the industrial pace are shunted to one side; those who are able to perform useful work are forced to leave their jobs because of arbitrary retirement policies. Fortunately, many are beginning to re- cognize the problem and to come to grips with it. Although knowledge about aging and the aged is limited, efforts are made to design programmes and policies for the old-age population con- cerning employment, income, security, health, social welfare, education and such community services as employment coun- selling, and information and referral ser- vice. These programmes and policies are not meant for the exclusive use of older people; they are also at the disposal of other groups in society. Inflation has become a permanent feature of most societies. The aged, on fixed incomes, usually suffer the most from the rising cost of living. Unlike other groups—students, labour union members or business people—they are not organ- ized and hence unable to pressure society into improving their living conditions. We are beginning to examine the positive contributions the aged can make to society. Economic and technological factors of employment of older workers, their pre-retirement and post-retirement programmes, income, security, social problems related to their mental health, the use of their leisure time, and their integration into community life are being investigated. While this issue of World Health cannot cover every facet of this wide problem, it does aim to emphasize some of its important aspects. Old age is a question that concerns us all—most of today's young will be the aged of tomorrow. ■ caring for the aged Old age is not a disease. It gives rise, however, to social problems. In many parts of the world, particularly in the developed countries, increased life expectancy has created vast numbers of people over 65. The table (page 6) shows the differences between the industrialized and the devel- oping countries, with regard to both life expectancy at birth and the percentage of the population over 65. There is, however, a link between old age and disease. Chronic disease becomes more common with increasing age. Old people are more likely to have multiple diseases and diseases that may accelerate the process of aging. The aged drag with them the diseases accumulated over a life- time—diseases of long duration requiring long-term care. In a WHO review of 29 countries, cardio- vascular disease was found to be the leading cause of death in most of the industrialized countries, followed by ma- lignant tumours. Other leading causes of death in these countries, in order of importance, were accidents of all ty- pes, influenza and pneumonia. Indeed, before the discovery of antibiotics, pneu- , monia was often called "the old man's friend". Many chronic diseases cause disability rather than death. They include chronic rheumatic diseases, chronic diseases of the chest other than tuberculosis (for example chronic bronchitis) and various forms of mental disease. In many coun- tries, their economic significance is by Dr Joshua Cohen WHO Headquarters, Geneva enormous. They may result in reduced productivity and increased expenditure of resources in the form of medical care. As populations age, chronic diseases leading to death, disability or discomfort become greater problems. Chronological age is not synonymous with biological age. Biologically, people age at different rates. It is impossible to determine the exact date of onset of old age, because the process is gradual. In many countries, 65 is considered the beginning of old age because it is the age at which people normally retire, and it constitutes a social milestone. The signs of aging include a reduction of the acuity of the various senses; an impairment in performance of the body's systems; psychological changes such as slowing of the ability to learn, deteriora- tion of the memory and decrease in mental efficiency; and biochemical changes in body tissues. These gradual changes lead to a decline in the total performance of the individual and in his capacity to withstand stress and to adapt to change in his environment. The social concomitants of aging are often of even greater significance. The cessation of active work can lead to physical and mental regression. Death of relatives and friends often means the isolation of the old. Loneliness and fear of the future may bring in their wake loss of morale and lack of interest in life. This lassitude can lead to a reduced interest in food, which, combined with reduced means, may result in malnutrition. The lack of interest in life may also bring on a deterioration in personal habits, some- times ending in dereliction. Short periods of forced immobility for transient illness may create permanent bedfastness. Care of the aged cannot be reduced to medical care alone. Health policy must be interwoven with social and economic policy to achieve effective care. The first step is preparation for retire- ment. This is primarily an educational activity, undertaken as the age of retire- ment approaches, and aimed at enabling retired persons to adapt themselves to their changed situations. Obviously, much knowledge and understanding of the life of the old, wisdom about life in general, sympathy for other people, and tact in presenting the case is required of whoever undertakes this activity. Many old people are capable of working after retirement if suitable employment is found for them. This solution may be satisfying both for the individual and for society. It may be useful to extend to the old the vocational guidance services usually reserved for the young. It may be possible to shift older employees to jobs which require a slower pace, and which do not involve competition with more active younger employees. In some countries, tax concessions could encourage part-time employment of retired people, but in some societies this solution may be economically unsound. Particular problems may arise among people who have held highly A retired Copenhagen couple in the garden of a government-subsidized home. The home, built with the co-operation of church and industrial groups, consists of two wings, housing 59 single pensioners and five married couples. (Photo WHO/E. Mandelmann) 4 4 • Country Life Expectancy at Birth* Percentage of Population by Age Group in 1970** Men Women 0 - 14 15 - 64 65+ Austria (1969) 66.4 73.3 25 61 14 Belgium (1959-63) . . . 67.7 73.5 24 63 13 Canada (1965-67) . . . 68.8 75.2 31 61 8 Central African Republic (1963-64) 33 36 42 55 3 Chad (1963-64) 29 35 45 53 2 Chile (1960-61) . . . . 54.4 60 39 56 5 France (1968) 68 75.5 25 62 13 Gabon (1960-61) . . . 25 45 33 61 6 Germany (Fed. Rep.) (1966 - 68) 67.6 73.6 24 63 13 India (1951-60) . . . . 41.9 40.6 42 55 3 Indonesia (1960) . . . 47.5 47.5 45 53 2 Italy (1960-62) . . . . 67.2 72.3 25 64 11 Netherlands (1968) . . . 71 76.4 27 63 10 Pakistan (1962) . . . 53.7 48.8 47 50 3 Peru (1960-65) . . . . 52.6 55.5 45 52 3 Portugal (1959-62) . . . 60.7 66.4 29 62 9 Spain (1960) 67.3 71.9 28 63 9 Switzerland (1958 - 63) 68.7 74.1 24 65 11 Togo (1961) 31.6 38.5 45 53 2 Yugoslavia (1966 - 67) . 64.7 69 28 65 7 *Source: United Nations Demographic Yearbook, 1970. Dates in parentheses indicate years covered by national surveys. **Source: UN Population Division, Population Projections by Age and Sex, by Regions and Countries, 1965-85, Medium Variant. responsible positions, and those with special skills. Many of these people could use their skills in less developed countries. Because of their age, they would not con- stitute a threat to younger indigenous people, as sometimes happens with foreign experts. Old people require the shelter of a home more than ever, but often the home in which they have lived most of their lives is unsuitable. Living with children often creates its own problems, but it is some- times the only answer. Some countries provide separate apart ments linked to the home of one of the children, so that parents and children can have some of the advantages of proximity without all its disadvantages. A separate pace and a different mode of life can be maintained in each household, but the old can get help from the young and, in turn, they can assist in the care of the grand- children. Both alternatives are more hu- mane and cheaper than institutional solutions. Some countries build special settlements for old people. These consist of separate dwellings with common faci- Caring for the aged Occupation plays an important role in the care of the aged. The 82-year-old lady (left) is making a paper tree in an Amsterdam home for the aged. (Photo WHO IE. Schwab) The cobblers (right) live in a 350-acre Israeli village inhabited by 1,100 old people. They continue to ply their trade despite their "retired" status. (Photo WHO/ T. Farkas) lities for dining and cultural activities, household assistance and simple medical care. In others, blocks of flats have been set aside for old people. These should form part of a broader community and should be within easy reach of the community facilities. Old-age homes should be res- tricted in size and run as homes in the real sense of the word and not as ins- titutions. In a number of countries, old people who are capable of living on their own, but find it difficult to cook, are provided with hot meals every day, sometimes at a nominal cost, sometimes free. Household assistance may also be provided. Again, this is more economical than institutional care. Old people require social life no less than the young. In some countries, social clubs for the old have been formed. Those who cannot leave their homes have special problems. Radio and television keep lonely old people in touch with the outer world. However, they cannot replace the companionship provided by visits from social workers and volunteers in the corn- munity, nor can they replace the hobbies and other occupational activities that can be stimulated by these visits. The social care of the aged, in addition to its intrinsic value, has a great influence on their health care. It is an important means of preventing hospitalization, for in the absence of adequate social care, old people tend to gravitate towards hospitals. The chronic sick and the aged should be provided with health facilities in or near their homes. Ambulatory health care is less costly and more humane than in- patient care. Much valuable educational, protective and curative help can be given in the home by visiting nurses and other health workers such as physiotherapists and chiropodists. General practitioner and group practice services will function better with the support of these health and social workers. Day care centres for medical and psychological care, and for physiotherapy and occupational therapy, promote social contacts and companionship for the chronic sick, while at the same time allowing them to return daily to their own homes. They are invaluable for rehabilitation, which aims at putting people back on their feet and restoring function as fully and speedily as possible. Hospital out-patient departments have been developed in some countries, and they provide valuable consultative services. They also provide follow-up services after in-patient care. Their efficacy is based on their ability to provide patients with the same type of care that they would receive as in-patients. They must avoid duplicating care that can be provided outside the hospital. Only if these services have been found inadequate for the situation should the patient be hospitalized. Hospitals are the most complex and costly element of the health services. Old people occupy a high proportion of hospital beds in many countries. General practitioners and hospital out-patient services also deal with a high proportion of old people. In addition, more and more old people are entering mental hospitals. This increase may be due more to social neglect and to the attraction of better conditions in mental hospitals than to 7 actual increased mental disorders. Hospi- tals for long-term care of physical illness and disability naturally have a pre- ponderance of old people. All this has led to the creation of separ- ate medical services for the aged in some countries. This may be an expensive and inefficient solution. It may have been adopted as a reaction to a general preoccu- pation with acute episodes of disease and lack of interest in the patient as a whole in his environment. Much of so-called "acute care" is, in fact, an acute exacerbation of a chronic disease situation. However, patients with problems requiring long-term care are often placed in hospitals which, in spite of being expensive, may lack the facilities needed for rehabilitation, social care and psychological support. One solution is the creation in general hospitals of special units for rehabilitation. These special units can provide longer-term care than that offered by the acute ward, but not neces- sarily for the rest of the patient's life. There will always remain, however, a residue of patients who require hospital- ization for very long periods. Facilities for these patients should be kept to a human scale. There is nothing more depressing, for patients and staff alike, than large impersonal institutions. Patients should be as close to their homes as possible, so that they can be visited frequently by relatives and friends. Health services are not buildings and equipment alone. Their most essential component is health manpower, suitably trained for the job. In addition to doctors and nurses, health personnel today include a large number and bewildering variety of professions. Specialization is the key- note in every profession. The development of health personnel, their education and training, their subsequent retention and their efficient utilization, require careful planning and implementation. In view of the attractions of the more glamorous institutions for acute care, methods for retaining health personnel in ambulatory services and in hospitals for long-term care may have to be improved. These health manpower questions constitute the most crucial problem for the health services in most countries today. The costs of health services are rising everywhere. This is due to their increas- ingly complex technical nature, to in- creasing population coverage, to higher pay for health workers, and in many countries to the increased need and demand created by the aged and those with chronic disease. Serious problems arise when the increase in health service costs exceeds the increase in the nation's gross national product. Irrespective of the method of financing, society has a limit to the investment it can make for health care and the care of the aged. This limit applies not only to money, but also to human resources invested in social services. Societies must face the difficult problem of determining priorities. Until recently, disease control was considered the best method of increasing longevity. However, it has been calculated that, if the diseases constituting the leading causes of death could be cured, life expectancy at birth would increase by only about five years. The increase in life expectancy at age 70 would be con- siderably smaller. People would die of other diseases at a slightly more advanced age. Research, aimed at increasing longevity by delaying the actual aging process, is 8 A 99-year-old pensioner takes time off from his newspaper to chat with the directress of a nursing home near Lausanne, Switzerland. (Photo WHO/ C. Huber) \ Residents at an Amsterdam home for the aged engage in a game of draughts (chequers) while the challenger waits his turn. The Amsterdam home also has a billiard room and a card club. (Photo WHO/E. Schwab) In a Copenhagen apartment, a domestic worker does the heavy chores for an elderly woman. Regular domestic help is one of the most needed services for the elderly. (Photo WHO/E. Mandelmann) being mooted in a number of countries. If this research proves successful, it is thought that it could not only add about 15 years to life, but also add life to years by postponing the onset of frailty. The application to man of methods tried out experimentally on rats is being considered. These include restrictions of food intake, protection from radiation, and the use of substances known as immunological agents and anti-oxidants. How would the success of these or other appropriate measures affect health policy? The prolongation of the period of life now known as old age would, by itself, postpone, but not change substan- tially, existing social and health problems. It would also postpone, but not eliminate, the problems of providing medical care for those unable to take care of themselves —the disabled, the incontinent, the dis- orientated. While all this may be some relief for the individual, it would not solve the associated problems of society. What would be some of the social implications of increasing life expectancy at 70 by 15 years in this way? The pro- portion of old people in the population would increase considerably. Biologically they would become old at a later age. If they were permitted to go on working beyond the existing retirement age, what would be the effect on a technological eco- nomy? Would it be possible the find suit- able employment for people whose skills have become outdated and whose re-train- ing poses many problems? How would younger people react if top positions were retained for prolonged periods by old people, and what effect would this pro- longation have on technological and economic development? If, on the other hand, people were forced to retire at the age of 65, would the added years of poten- tial vigour but enforced leisure be a bless- ing or a curse? What would be the reaction of the economically productive age group burdened with additional economic and social responsibilities? Would the aged, by force of numbers, energy and available time, assume a new social and political importance? How could the earth be exploited wisely in order to sustain the additional people? How could the environ- ment be controlled in order to accommo- date them? While we give serious thought to the postponement of aging, we should give equally serious thought to the social implications it will bring. ■ 9 photographs by Erling Mancelmann ballet for the young a Dancing makes the heart grow younger. These old people, many of them over 80, take jazz ballet lessons in Copenhagen twice a week. Before attempting some of the more complex dance steps, a member of the group loosens her muscles (above). The dancing master (left photo) teaches chorus-line techniques, while an elderly pianist provides the music. Group dancing is one of the best ways of stimulating both physical and social activity. t heart 1111 111111 1 i, I ' Service flats for the aged, Paris. Of the 20 arrondissements or districts in Paris, the 13th is one of the oldest. Situated in the southern part of the city, it is the home of the famous Gobelin tapestries. It is also the site of a community-wide experi- ment in the care of the aged. Since 1965, gerontologists, sociologists, psychologists, psychiatrists, physiotherapists, occupational therapists, nurses and group organizers have been working together in an integrated approach to the problems of the elderly. From the beginning, the aim was to find practical ways of meeting the psycholo- gical, material, social and health needs of the old in the arrondissement. By old people is meant people over 65, the legal retiring age. One of the basic principles advocated in all countries is to maintain old people at home in the interests of independence, though in practice the prin- ciple is all too often abandoned. The arrondissement has 160,000 inhabi- tants (180,000 projected by 1980), of whom 22,000 are over 65. Many of these old people live in decrepit buildings scheduled to be torn down to make room for new apartment houses. Quite often they can be rehoused in the district, sometimes they go to live in an institution, and occasionally they are expelled to other arrondissements. It is difficult to gauge the social conse- quences of such rehousing. There is no doubt that tragedies occur. Some of them have been reported. There have been cases of very old people who had lived in the arrondissement for 30 or 40 years and who survived for only a few months when they were rehoused in an unfamiliar part of the city. For many old people, life becomes a state of constant apprehension once they find out that their homes are to be torn down in a few years' time. As against that there are some who regarded moving as a dire catastrophe but who have in fact found a new lease of life and are well satisfied with their new surroundings. Fortunately, the 13th arrondissement has an active residents' association which pro- tects the interests of those who have to be rehoused. Builders of new blocks on the site of old buildings are obliged to offer tenants replacement accomodation as near as possible to their former homes. As part of the reconstruction scheme, service flats have been built for old people, largely sponsored by the Paris City Council and consisting of individual studios with communal facilities and a resident nurse in attendance. However, the housing prob- lem is far from being solved if a policy of maintaining old people at home is to be pursued. At present there are 165 of these service flats and by 1980 there will be 400. It is hard to give a precise estimate of future needs, but handicapped people have to be housed as well as the elderly, and it seems unlikely that 400 will be enough. But new housing for the aged is not always the answer. Recently a new build- ing was opened, reserved primarily for retired people in the arrondissement. Of the 80 places available, only 40 were ap- plied for. Elderly people often refuse to leave their dwelling place, no matter how uncomfortable it may be. Old age brings with it a strong psychological need to remain attached to objects, surroundings and situations that are familiar, and with- out which the individual may feel utterly lost. What is the answer to this problem, and to others which seem equally intractable? Where does the solution lie? Surveys on old people and their needs and desires can lead sociologists, physicians, social wor- kers and administrators towards the basic the commun by Dr Clauce Balier Visiting Physician to the Paris Psychiatric Hospitals and Secretary-General of the 13th Arrondissement Gerontological Association 12 Medical care facilities are located near the apartment building. Patients at the nearby geriatric hospital return home as soon as possible. (Photos WHO/E. Schwab) Daily contact between the elderly and people of other age-groups is encouraged. outline of a general plan, but the proper use of facilities, the adaptation of standard equipment to individual require- ments, and the active participation of old people in measures taken to meet their own needs depend on continuous co-oper- ation between the users, the technicians and the administrators. This co-operation is vital: the retired people of tomorrow will have neither the same needs nor the same desires as those of today. Decisions taken now and carried out in a few years' time may then already be outdated. Planning for old people must be not just a patchwork of isolated measures, but a long-term co-ordinated effort to avoid the pitfalls of segregation and isolation that still beset old-age care in many places. With these objectives in view, the 13th arrondissement Gerontological Association focuses its attention on the community link. This non-profit, privately run organ- ization has about 600 members, mostly retired people, who pay a nominal mem- bership fee. The governing board includes city officials, representatives of the various social services and private individuals in- terested in old-age problems. Primary aim of the Association is to create a dynamic relationship between retired people and the rest of the community. This is no easy task, since old people tend to become pas- sive, dependent and turned in on them- selves in a society that takes a negative view of old age amounting almost to an attitude of rejection, an attitude diffi- cult to indict because it is subtly hidden behind an easy conscience in which pity turns out to be the dominating emotion. Information is the key to dialogue. Some people have the one-way attitude to infor- mation, which for them means telling old people about their rights and options and never mind what the old people have to say for themselves. A two-way flow of information, however, would naturally lead to the discovery of new solutions. In 1958, the Mental Health Association of the 13th arrondissement was set up by Dr Paumelle. I joined his staff as health service psychiatrist. The purpose of the Association was to set up a pilot organ- ization to meet the psychiatric needs of the 14 TT Pottery painting is one of the crafts taught to the elderly. A wide range of activities is open to retired people. I The Four Seasons Club is a favourite meeting place for the old people who live in the 13th arrondissement. Physical exercises are performed to the beat of the music. (Photos WHO/E. Schwab) arrondissement. Specifically, it was an at- tempt to reduce as far as possible the risk of mental patients losing contact with their human surroundings and being re- jected by family and friends. Such an approach means avoiding hospitalization except as a last resort. The psychiatric hospital serving the ar- rondissement has only 175 beds, about one per 1,000 inhabitants, whereas the norm in Paris is about four per 1,000 inhabitants. Currently, half of these beds are occupied by old people. It was obvious that, if nothing was done, the hospital would soon be filled with the aged, instead of serving as a place for psychiatric treatment. Al- ready, doctors in the neighbouring hospital in Ivry were disturbed about the number of elderly people in hospital who could have been treated at home. The complete lack of co-ordination between the hospital and the home-treatment services made it difficult, if not impossible, to discharge patients. Lack of organization meant that patients from the other side of Paris were also being sent to Ivry, thus aggrav- ating their isolation. Fortunately, the social security services have helped improve care and conditions for old people who are severely handicap- ped, as a temporary measure, until special homes with medical care provided can be built. New residential homes and service flats in the arrondissement are gradually absorbing the less seriously handicapped as well as healthy old people. The author- ities have agreed to reserve a certain num- ber of beds in a hostel for medium- or long-term care, and a geriatric unit has been set up in the hospital at Ivry for acute cases. A few months ago a day- hospital was opened. The main goal, now achieved, was to link hospital and community services so that the maximum number of patients could return home. Our constant preoc- cupation is to reintegrate the elderly into the community. We try to avoid turning them into medical or even psychiatric cases when the problem is really social. There is the classic case of the old lady who lives by herself on the sixth floor of a condemned building with no lift. She becomes de- pressed and is taken away to end her days in the hospital. In cases like this the neigh- bours alert the social services, but more to ease their conscience than anything else. It is difficult to get the elderly population to take an active part in their own affairs and press for better conditions. Old age brings with it specific psychological reac- tions that we spend a great deal of our time trying to correct. Passivity, for ex- ample, usually taken as normal behaviour in the aged, is in fact in most cases a sign of chronic minor depression. Old people in the 13th arrondissement have five clubs at their disposal, open every afternoon. They are intended for people who are well adjusted but might otherwise be isolated and withdrawn from social life. The oldest of these clubs has its own separate premises and has about 150 members. Another is located on the ground floor of a social welfare office. Three of the clubs are run by professional organizers and the other two by voluntary workers. The organizers concentrate on a group approach and try to make club members develop their own activities—lectures, de- bates, slide projections, arts and crafts, record sessions, cultural outings, card tour- naments and so on. Eventually the organ- izers hope to withdraw completely, leaving the members to run the clubs by them- selves. However, there is one major draw- back. The clubs cater to old people who are looking for ready-made entertainment rather than social activities to which they have to contribute themselves. They tend to become dependent on the club, and thus even more passive, particularly as the club is a sort of institution, with its own rules and traditions. The last thing we want to do is to contribute to this passivity and encourage dependency. For this reason we employ a social psychologist who super- vises the activities of the group organizers. Integration of the elderly into the com- munity should not be achieved by institu- tionalized means but should as far as possible take spontaneous forms. Gradually, retired people in the 13th arrondissement are beginning to take a more active role in the Gerontological 15 >~ = Y lBa. "'R R'~ Association. They have asked for and obtained increased representation on the board and hence have a bigger say in Association policy. A public relations com- mittee, set up two years ago, helps in infor- mation activities and organizes monthly lectures, now attended by 250 to 300 people. The audience is made up of people who are about to retire or have already retired. Subjects discussed include mental health, dietetics, disease prevention, hous- ing, economics, sex, and so on. Older people participate actively in the debates that follow the lectures. Informa- tion of this sort has proved to be a useful tool in helping the aged to cope with their problems. It gives them greater independ- ence, and encourages them to take balanced decisions in matters that affect them directly. Information is not only for the elderly, but for all members of the geriatric team. I think it is important that we study how information is circulated, received and passed on. After all, about 20 different professions are concerned with care for the aged, full- or part-time, and we have to devise the most effective way of working together. Something should also be said about voluntary workers, the training courses given for them by the club organizers, the training of the technical staff and many other subjects, but this article cannot attempt to be exhaustive on such a rami- fied subject. There is one particular section of the older population whose problems go unre- cognized, or are at best poorly handled: people who, though not entirely dependent, still need some help. They tend to retreat into a shell as their field of interest narrows, and lose the capacity to express their needs and desires. Some have failed to overcome physical handicaps; others are psychologically inhibited. Whether these inhibitions are rooted in childhood expe- riences or are simply due to the unenviable position of old people in modern society, it is often hard to say. A considerable proportion—about a third—of all old people fall into this cate- gory, half-way along the scale between dependence and independence. Their pre- dicament is poorly understood, with the result that facilities which could be made available to them are not used to best advantage. They are classified either as social problems, which means their diffi- culties are put down to the normal hazards of old age about which nothing much can be done, or medical cases, whereupon they are simply packed off to the nearest geri- atric or psychiatric hospital or to some inferior institution. It seems that the best way to help these old people is by a combination of services: day treatment centres, and home visits by medical staff and social workers. The aim is to avoid hospitalization where possible, and to help the old people who have to be hospitalized to cope when they come out. With this sort of service, medical care and rehabilitation can be carried on at home, and domestic help is provided to take care of the housework. There are two day treatment centres already in operation in the arrondissement. They concentrate on giving the elderly psychological support, helping them to adapt to new circumstances, supervising their rehabilitation, and developing social interests. They try to renew the old people's interest in the world around them and to show them that some recuperation of their capacities is possible. In the case of people who have become isolated and turned in on themselves, the day treatment centre often provides the means to avoid a hos- pitalization that could be final. Gerontology is still in its early stages, and a great deal remains to be learned about the elderly and their problems. In the 13th arrondissement we have made a start, but we realize that we still have a long way to go. ■ At a guidance centre, information about specially organized museum visits, cinemas at reduced rates and day trips is offered. In addition, services such as hair-cutting and styling are available. For some, these services are of great personal value. (Photo WHO /E. Schwab) 17 integration, not isolation by Lies! Graz Life expectancy is on the rise. Already in many industrialized countries, a child born today will probably live beyond the traditional threescore years and ten. There comes a time in a man's life when he can no longer make his full contribution to society, when the scales are tipped so that society must contribute to him. This period is known as "old age", and 20th-century society, particularly in the industrialized nations, has to face it. There is no precise definition of old age. Many feel it begins when a man qualifies for pension payments. This varies between 55 (for women in most eastern European countries and in Italy) to 70 (in Norway and Ireland). Others set 65 as the arbitrary commencement of old age. Whatever the dividing line, man's wants and needs do not change drastically when he reaches it. Old age need not be a dress rehearsal for death. With the exception of the physically infirm, most old people continue to cherish the simple acts of daily living. Their needs include intellectual, cultural and even physical stimulation. They want to belong, if society will only let them. Retirement presents special problems. As man grows older, his ability to adapt to changing conditions diminishes. Hence, when he makes the transition from an active to an inactive life, it is paramount that he continue to use his faculties or they will atrophy. Most gerontologists feel that activity counteracts many of the symptoms of senility. Studies of "senior citizen centres" or "golden age day clubs" show that participants are much less likely to have mental or physical disorders than non- participants. The studies take into account the fact that balanced, happy people are more likely to join such groups than are people with pre-psychotic personalities. Retirement is much more difficult for men than women. At retirement age, women continue with some of their activities. They are happy to devote more time to the home, which most of them have had to keep up before and after working hours. This acknowledged double role of working women—married or single—is why most countries grant old- age pensions to women earlier than to men. On retirement, many men are apt to hang around the house or spend most of the day in the tavern. Incipient alcoholism of newly retired workers is not uncommon in France and Switzerland. Regular paid or volunteer work is probably the best way for retired people to remain integrated into the surrounding society. Even though the work may be only a few hours a week, it puts the older person in regular contact with the outside world and provides a rhythmical punctua- 18 This Dutch couple' (he is 85 and she is 71) met and married in an apartment house for older people. In the same building, an 81-year- old woman eats a breakfast prepared in a central kitchen and delivered to her flat through a hatch with openings on the corridor and inside the flat. The meals are placed in the top compartment of the hatch, while the rubbish is placed below. Shopping services are also available. (Photo WHOIE. Schwab) ' Integration, not isolation In the industrialized countries, the nuclear family consisting only of parents and children is becoming more common. Isolation and a feeling of loneliness are among the more serious problems of old people in these coun- tries. One notable exception is Japan, where family ties are strong and aged parents live with their married children. The traditional family structure is generally unchanged in the developing countries. Old people live with their children and grand- children. They are respected as community sages, and their advice is valued. <— On a public bench in Denmark. (Photo WHO/ E. Mandelmann) An old Indian, a Punjabi village wise counsels a young girl. A Japanese grandfather takes pleasure in listening to his grandson play music. (Photos WHO/E. Schwab) tion for days and weeks that can other- wise stretch out into a wasteland of time. The work may have nothing to do with the retired person's original profession. In New York, for example, retired people have been recruited as "foster parents" for lonely, hospitalized children. This work has real value to society. Both the children and the retired people benefit. Retirement is an art, and like other arts, it must be taught. An increasing number of companies are preparing their em- ployees for retirement. They offer courses, on company time, for employees that have two or three years to go before retirement. Employees are told about community services (housing, activities) and instructed in dietetics. They are given serious explanations about the mechanisms of aging. Of all the problems that face the elderly, loneliness looms the largest. In most industrial societies—with the notable ex- ception of Japan—the nuclear family is the norm. A man and woman live with their children until the children grow up and form new nuclear families. The result is an older generation left alone, with an increasing proportion of women. In 1969, there were 19 million people over 65 in the USA, and 11 million of them were women. A majority of these women were widows, while 70 per cent of the men were married. The place of residence takes on par- ticular significance for the elderly. The retired person spends an increasing pro- portion of his time at home, and finally, as going out becomes physically difficult, the home can become his entire world. While owning a home or apartment gives the retired person a sense of well- being and security, the disadvantages often outweigh the advantages. The home may be lacking in modern comforts or be too far from public transport. Little by little, the stairs may become less ne- gotiable. Feeding the furnace and remov- ing the garbage can become formidable tasks. Some communities are beginning to build specially conceived housing for the elderly. They offer two alternatives— grouped housing and integrated housing. Grouped housing, consisting of small houses or flats designed for older people and concentrated in one area, have been built in a number of countries and take many forms. Such housing, which qualifies for government subsidies in a few coun- tries, simplifies medical and nursing care. Help is provided for bathing, household tasks and emergencies, and some organ- ized social activities. The residents find companionship among neighbours of their own age. Integrated housing is based on the idea that old people should not be treated as a group apart. It calls for scattering the elderly among people of other age groups. In many countries, economic reality has led to a paradoxical situation. Older residents remain in their homes, which are often too large for them and sometimes lack modern conveniences. At the same time, large young families are cramped into small modern apartments. In Sweden, attempts have been made to work out exchanges of big houses for small apart- ments, with a system of financial com- pensation. In some countries, ground-floor flats in new housing projects are reserved for old people. Builders often receive government subsidies for such flats. Elsewhere, old people are given grants to help pay the rent in new housing. The major advantage of integrated housing for the elderly is the stimulation of being among people of all ages, especially children. Park spaces are used mainly by children and retired people, and they get along well together. Also, people living in integrated projects can live near members of their family with- out actually sharing their home. The trend in most countries has been to keep the elderly out of institutions and in their own homes. It's much cheaper for society to provide the necessary services to the elderly at home than to pay for institutional care. Home help, or house- keeping aides, provides a solution to the problem of keeping the elderly at home. Sweden and Switzerland recruit neigh- bours—often themselves newly retired— to help the elderly with household chores. These housekeeping aides should have some training in dietetics, first aid and the psychology of the aged. Many old people seldom have proper hot meals. Some communities have at- tempted to remedy this situation by pro- viding a "meals on wheels" service. Several days a week, nourishing hot meals are brought to old people who are either incapable, too apathetic, or without the proper facilities to cook for themselves. There are many simple things that can make life for the elderly much easier. When telephone lines are scarce, old people should be given priority. If nec- essary, the telephone installation should be subsidized. Back and muscle ailments sometimes make it difficult for old people to cut their toenails, forcing them to be confined to their room. Outside help is needed. Shampooing can be a special problem for the older person who suffers 22 4— Hand-rails are nearly everywhere in the municipal housing for the elderly in Amsterdam. A two-way communication system is provided in each flat. This device makes the elderly feel secure in the knowledge that help is never far away. Even the toilet is provided with an alarm button. Old people relax over a friendly game of billiards in a club-like atmosphere. The bar (right) gives the room a warm, un- institutionalized feeling. (Photos WHO/ E. Schwab) spells of dizziness when he bends his head into the wash basin. Here again, a little help can mean a world of difference. Even when an old person's stay at home requires re-arrangement or re- building of the home itself, it is cheaper for the community to pay for the work than to set up and maintain yet another bed in an institution. Building changes for people in wheel- chairs may include the installation of ramps, widening of doors, lowering of sinks and wash-basins, and raising of toilet seats. Sometimes rooms must be re-arranged to eliminate dangerous cor- ners, and toilet facilities close to the bedroom must be added. Municipal model housing for the elderly has been constructed in Amsterdam. Single people have bed-sitting rooms with vestibules, wash-basins, toilets, cupboard space and emergency bells. Couples have two-room flats. Assembly and recreation rooms are equipped with special circuits for people who are hard of hearing. But despite efforts to give the residents privacy and independence, this housing takes on some of the aspects of an institu- tion. The flats have no kitchens, and residents take their meals together. There are no private baths or showers. Autho- rities who planned the centre felt that so many of the residents would require help in bathing, that it would be better for all of them—including those who could manage alone—to use central facilities. Swedish authorities favour large com- plexes subdivided into clusters of 10-15 private rooms, each with a toilet and washing facilities, gathered round a common dining— and sitting-room. Each room has a minimum of 12 square metres. Emphasis is placed on the private rooms rather than the common rooms, and private rooms are often made larger than the 12-square-metre minimum at the ex- pense of the common room. The reason is that the communal sitting-rooms often breed apathy; they are used for sitting and little else. The "sitters" do not have the same sense of responsibility for the well- being of another person that they have when visits are exchanged, even if only from one room to another next door. While most communities lack the means of providing ideal care for the aged, much better use can be made of the facilities available. Geriatric centres are needed to provide advice to relatives of old people and to act as clearing-houses for information on living accommodation and social services. From birth, man is part of society. He remains part of it until his death, and his old age is an integral part of his life. ■ 23 age is no barrier An international association of athletes ranging in age from 40 to 89 is out to prove that sports are not the pri- vate province of the young. The Inter- national Association of Veteran Long- Distance Runners, founded five years ago, has a membership of more than 600 in 27 countries. The senior member is an 89-year-old speedster who recently was clocked at 39 minutes for the 5,000-metre run. Some 70 per cent of these athletes discovered the joys of long-distance run- ning between the ages of forty-five and sixty. Beginning in 1968, they competed in by Raymond Pointu marathon (42 kilometres) and 25-kilo- metre races in alternate years. While winning is important, it is not nearly so important as the thrill of competition and the satisfaction of keeping in top physical condition. The performance of some of these septuagenarians and octogenerians would do credit to men two decades their junior. The first competition was a marathon in Baarn, Netherlands, in 1968, follo- wed by a 25-kilometre run in Bensberg- Refrath, Germany, in 1969. The two events were repeated in Skovde, Sweden, and Karlovy-Vary, Czechoslovakia, the next two years. These veteran runners are constantly in training, and their performances actually improve. In the first 25-kilometre run in 1969, average time for the first six finishers was 2 hours 34 minutes. Two years later the average time dropped to 2 hours 29 minutes. In 1969, the last six finishers averaged 5 hours 32 minutes. In 1967, the last six finishers bettered the 1968 time by 16 minutes. Also, the percentage of runners who failed to finish dropped from 14.3 to 12 per cent. Oldest finisher in the 1969 race was 77. He was clocked in 4 hours 39 minutes 54 seconds. His per- formance was improved on by the oldest finisher in the 1970 race—a youngster 24 Wit An 80-year-old gymnast in Hungary gives a demonstration. (Photo Interfotol WHO) \ At Briickenau, Federal Republic of Germany, 95 runners between the ages of 55 and 72 compete in a 5,000-metre race. A 56-year-old man won in 19 minutes 22 seconds, while a 66-year-old completed the course in 22 minutes 10 seconds. (Photo L. Sirman C)) Karel Hrbek, a 73-year-old Czechoslovak, competes in the 25-kilometre international road race at Karlovy Vary, Czechoslovakia. (Photo CTK ©) of 71 who did the 25-kilometre course in a blazing 3 hours and 58 minutes. The most amazing performance, though, was turned in by Sadanaga, a former Japanese Olympic runner At the age of 31, at the Rome Olympics, Sadanaga ran the 25 kilometres in 2 hours 35 minutes 11 seconds. At the age of 41, running in the International Association of Veteran Long-Distance Runners' 25-kilometre event, his time was actually faster- 2 hours 23 minutes 52 seconds. Sadanaga has run 30 kilometres a day every day for the last 20 years, without missing a day because of ill health. The organizer of the association is Dr Van Aaken, a German physician. He strongly recommends daily jogs of from 20 to 30 kilometres, beginning at a slow pace and increasing the speed gradually. He feels that such a training schedule is a good safeguard against obesity and circulatory troubles. In fact, the original purpose of the International Association of Veteran Long-Distance Runners was to test Dr Van Aaken's theories. The next marathon will be held in the Federal Republic of Germany following the Olympic Games in Munich, allowing the association members to be both spectators and participants. ■
why we grow old Interview with Professor Francesco Mario Antonini Director of the Institute of Gerontology and Geriatrics, University of Florence, Italy World Health: When can the aging process be said to begin? Prof. Antonini: Biologically speaking, at birth. But the human organism is a com- plex of functions, not a simple cell, and I would therefore say that in humans aging begins at the end of the growth period. The opinion is held that the longer the growth period the later will aging begin and, consequently, the longer the life span will be. Conversely, this means that all the factors that stimulate development tend equally to hasten aging, and those that retard growth also delay the onset of old age. The aging process affects both the cell and the connective tissues that support the cellular structures. It may be more evident in the latter. W. H.: How can aging best be under- stood? Prof. Antonini: A very good example is the effect of aging on vision. Loss of vision and of the eye's power of accommo- dation is a continuous process directly related to the passage of the years. How- ever, people become aware of it only at intervals. They are perfectly happy with their glasses for two or three years, then suddenly they cannot see properly and must have a new pair, just as if their sight had deteriorated from one day to the next. What has happened, of course, is that the gradual loss of sight passed unnoticed as long as the organism was able to com- pensate for it, but no longer. Aging affects the whole organism and makes ever greater demands on the com- pensation mechanisms that maintain the complex equilibrium—homeostasis—nec- essary for life to continue. But a point is always reached when further compensa- tion becomes impossible. Sickness and perhaps death then ensue. This reduction in the organism's ability to regulate its functions is one of the most typical manifestations of aging. It is pro- gressive and continuous, and may therefore be described as a physiological pheno- menon. If a man of 30 years of age is considered to be at the height of his powers (100%), at 90 years of age he will have lost 15% of the speed of his reflexes, and more than 60% of his maximum lung capacity. The foregoing is important to help understand why older people have a re- duced resistance to disease, which in turn sets up a number of vicious circles affect- ing their health. If you wish to try out an automobile, a few short trips at low speed will not tell you much, and the weak points will prob- ably emerge only during a long journey that includes stretches at high speed and hill climbing. Similarly, if an aging organ- ism is observed at rest, it may seem sound and, in many respects, function as if it were young. The many weaknesses appear only when a strenuous effort is required or when circumstances impose a sudden stress. There is an old Tuscan saying "Se sei vecchio e non lo sai, sali l'erta e lo vedrai", which may be rendered "If you think you are not growing old, climb a hill and see". The comparison with an automobile may serve to illustrate another idea. A car may be out of action because one single part—battery or distributor for instance— is defective or because all the essential parts of the engine have become worn out at more or less at the same time. In the one case, changing the defective part will make the car as good as new, while in the other, even if the whole engine is replaced, it will not be long before the brakes, the sus- pension and all the rest break down in their turn. W. H.: Why do many mammals have a shorter life than man? Prof Antonini: Childhood certainly lasts much longer in man than in any other animals. Similarly, sexual maturity comes later and a longer time is needed for the individual to acquire a degree of independ- ence enabling him to fend for himself. Other mammals are already complete individuals at the age of a few months, when human children are totally without defence and unable to provide for them- selves. The latter are dependent on their mothers and their families until six or seven years of age, do not reach sexual maturity until 15, and continue growing, at least in certain respects, until between 23 and 25 years of age. The brain of a monkey at birth has already attained 70% of its maximum development, expressed as weight, which is fully reached after six to twelve months <— In a strict biological sense, aging begins at birth. (Photo WHO/E. Mandelmann) 27 of life. The human brain has only reached about 23% of its weight at birth and is not completely developed before about 25 years of age. One advantage that man draws from these differences between him and animals and the slow succession of the various stages of his development is a greater facility in adapting to his environment. These circumstances may also explain his longer life span. W. H.: Have attempts been made to pro- long the life of certain mammals? Prof. Antonini: Such attempts have been made, and one of the few effective methods appears to be a starvation diet. Certain experiments, first made long ago by McCay and frequently repeated since, have given consistent results. One group of rats is given a normal diet while another, from the same stock, is given a balanced diet but low-calorie diet for 1,000 days. Subse- quently, both groups are given identical, normal diets, and it is found that those subjected to the starvation diet live almost twice as long as the others. No really satisfactory explanation has been found for these results, but the low- calorie diet certainly has the effect of slowing down the development of the rats subjected to it, and must have some connexion with the prolongation of their lives. W. H.: In your opinion, can aging be avoided? Prof. Antonini: The nucleus of the cell contains the genetic memory and all the information that makes it possible for life to continue. The nucleus directs the syn- thesis of the essential substances, the pro- teins, which are typical for each animal species and for each individual. The infor- mation that serves for the synthesis of the proteins is coded in the very long molecules of nucleic acid, DNA. This DNA molecule is twisted in the form of a double helix and is composed of a long sequence of simpler molecules, called bases, that may be com- pared to the letters of an alphabet and form series of "words". The information contained in the DNA is transcribed onto another nucleic acid, RNA, which, in the A continuing tie with the community con- tributes to happy aging. (Photo WHO/ E. Mandelmann) Listed below are maximum life spans of domestic animals and animals in captivity. These are extremes which are only exceptionally reached. The average life of a dog, for instance, is between 13 and 17 years. The develop- ment of animals is different from that of man. For example, a monkey is born with a brain weighing 70 per cent of maximum and its complete growth is achieved within a year. At birth, man's brain represents approximately 23 per cent of its final weight, which is attained around the age of 25. Captive animals are protected against predators and this may contribute to extend their life span. On the other hand, the ecology of animals in their natural habitat may be different from that of captive animals. The exact effect of captivity on animal life span is still not known. Source: Handbook of Biological Data, Saunders, Philadelphia, 1956. INDIAN ELEPHANT 57 YEARS RAVEN 69 YEARS DOMESTIC DUCK 19 YEARS HOUSE MOUSE 3 YEARS ffTz o92w4 .-e--.1 • OMESTIC DOG 34 YEARS cytoplasm of the cell, is translated into molecules of proteins which will be differ- ent according to the different sequences of RNA. It seems apparent that a small dis- turbance in this chain of events could cause errors in transcription and translation, by a process comparable to the effect of background noise in making a radio broad- cast unintelligible. Similarly, a random disturbance in the translation into protein of the information contained in the DNA molecule may produce a wrong protein that may have no function or may even have a hanuful effect. Thus mutations due to aging, radiation, and abnormal bonds between the DNA bases may increase the background noise to a point where the message becomes nonsense. An ever-greater number of mis- takes thus occur within the cell and lead to functional changes, disease and finally death. W. H.: Can biological science perhaps find an answer? Prof. Antonini: Recent developments in biological science do seem to point to the possibility of modifying, to some extent, the background noise and limiting the errors of transmission that may be held to produce the most serious effects on the organism. It might thus be possible not only to protect this complex and highly important DNA molecule against interfer- rence, but also to learn more about its structure, to synthesize it and even to modify or, better still, control its function by a process of induction through stimu- lating the formation of enzymes and other protein compounds. Such compounds are of great significance in the economy of the organism and their absence is now known to be a factor in certain diseases and also in aging. The phenomenon of induction has been studied for some time, and a number of substances and even some viruses have already been identified as having the property of selectively inducing the formation of certain organic molecules with specific functions. W. H.: Are any tangible results to be expected from such work? is the most promising field for research in gerontology. However we are still far from any practical applications. The transplantation of organs offers other possibilities but entails biological difficulties that have still to be overcome. Great advances have already been made in the substitution of whole organs or of parts made of synthetic materials, and still greater things may be expected, even though these brilliant and futuristic tech- niques can be practised on only a small number of individuals, circumstances being what they are. The prevention of aging implies, pri- marily, the prevention of certain functional disturbances. If the function of an organ is to be maintained at a satisfactory rhythm, it must be stimulated. The first rule for growing old wisely is to keep physically active and mentally alert, and to maintain one's normal place in the structure of the group and of society. Excesses and too strenuous efforts are, of course, to be avoided, but even more dangerous is the cessation of all activity. The temptation simply to give up should be fought at all costs. Some degree of deterioration, whether physiological or pathological, is, however, inevitable, and certain modern techniques are available to help various organs to continue functioning effectively. For in- stance, you can give a new lease of life to a patient with poor sight simply by providing him with a pair of glasses ena- bling him to go out and about as he wishes. Other prosthetic devices bring similar benefits. Today there are artificial kidneys, electrically-worked pace-setters for cardiac patients, and many other devices that are more than just methods of treatment, since they also serve to prevent other diseases and complications. ■ For many aged people, hearing-aids and spectacles are essential for continued performance and already obtained, it can be said that this contact with friends. (Photo WHO/C. Huber) Prof Antonini: On the basis of the results 30 As the quality of medical service improves, man's life span increases. But what is man doing with his added years? How is he making the transition from working days to lei- sure days? What is society doing to maintain his physical and mental health? The current issue of World Health, devoted to old age, attempts to an- swer some of these questions. Ge- rontology, the science of aging, is relatively new. A generation ago it wasn't as important as it is now. A generation hence it will be much more important than it is today. The May issue of World Health will deal with man and his environ- ment, another problem that has re- cently come to the fore. Must foul air, polluted waters and ear-jangling noise be the price we pay for civi- lization? We don't think so. World Health will discuss what man is doing to control his environment— and what might be done. As the working week becomes shorter, as vacations become longer, sports play an increasingly impor- tant role in our lives. Athletic activ- ity can make us happier and heal- thier. A forthcoming issue of World Health will be devoted to sports and their relationship to health. How can we derive maximum benefit from physical exercise and games? Many diseases of yesterday are no longer major problems in mod- ern, industrialized societies. But other diseases take their place in the health statistics. What are we doing to stop the spread of heart disease, for example? Better health in the developing countries is absolutely essential for economic and social take-off. How is the health aid being channelled? The answers to these and many other questions of the day can be found in the issues of World Health. If you think information about these subjects—written by leading authorities in their fields—is worth paying for, please fill in the order form. You will then receive World Health regularly. for healthy reading "World Health" ORDER FORM Please enter my subscription to World Health as follows: Sw. fr.* 1.20 12.— 2.20 22.— 3.— 30.— One year: ** I I Two years: ** J Three years: ** I enclose cheque/postal order in the amount of Name: Street: City: Country: • or equivalent in local currency. Subscriptions are entered for the calendar year. us $ * One Year Two Years 8.— Three Years 31