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Healthcare Facilities for Elderly People

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 Healthcare Facilities for Elderly People

Changes in health care are not simply adding years services and legal assistance. Investment in research
to life—they are also adding an increased quality of and training to enhance the quality and cost-
life to those years. Older people make much heavier effectiveness of care is important. Rational planning,
demands on health and social services than do young supported by research evidence need urgent
adults. The most elderly make the heaviest demands attention. Emphasis need to be placed on setting and
of all. The very elderly also tend to be maintaining high standards of community, hospital
proportionately highly represented in the most and residential facility care. The work done in
intensive forms of non-home-based care (such as hospitals and the way in which this work interlocks
increasingly important. Identifying and assessing with that carried out by community and volunatry
need and then organising an appropriate response is organisations will determine the effectiveness of
essential. Elderly people can benefit from measures geriatric services. Old age can be a time of
to improve their health and well-being. Care of the continuing participation in the life of the community
aged will depend on the effectiveness, the adequacy and personal fulfillment. A holistic approach is
of provision and the degree of coordination of the required to respond to the challenges posed by
services. A comprehensive system must be evolved to increasing number of elderly population.
provide education, leisure activities, health, social

Advances in health care are not simply adding years to the people 65+have long-standing illness, over 70
life they are also adding increased quality of life to those percent of the people 80+ have some form of disability,
years. Most people can now expect to live to old age in 7 percent of people 75+ live in long- stay hospital or
developed economies. In developing countries, average care homes and this rises to near 30 percent for 85+, 5
life expectancy is less but their massive populations percent of the people 65+ and 20 percent 80+ suffer to
mean that the old are numbered in millions. The impact some degree from senile dementia, the number of people
of these demographic developments have been reflected 80+ will increase by 50 percent over the next 20 years
in medical sciences by increasing research and and will double over the next 40 years.1
knowledge, in society by improved services and among
elderly people themselves by increasing expectations in Demographic Revolution
health and social support. As the elderly are far more
likely than the young to experience health problems, By the year 2000, more than 410 million persons were
their use of health care facilities is high, and this of aged 65 and over, with about 41 percent living in
course is one of the reasons why planners are concerned developed countries. Sweden’s population has the
about the economic implications of increases in the size highest proportion of elderly persons: 17 percent. 2 By
of the very old population. With aging, the need for the turn of the century developing nations will have 59
support for old people becomes increasingly important. percent of the world’s population over 65, up from 54
Identifying and assessing individual need and then percent in 1985.3
organising an appropriate response is essential. The
elderly population is getting bigger. Simultaneously the
working population is declining. Estimates suggest that
within 50 years, the UK could see 25 percent of the
population supporting the rest.1 More than 60 percent of
 Design and Construction The Clinical Zone n 499

In 1985 China, India, the USA and the USSR each had in England.5 The number of people over 85 will have
more than 25 million citizens aged 65 and over. China grown by over uses its resources. In 1994/ 95 the NHS
had 80 million in 1985 and expects 240 million by 2040. (UK) spent £ 2,455 for every person aged over 85
By 2020, 72 per cent of people over age 60 will be in the compared with just £ 235 for every person aged 16-44.5
developing world.3 Japan has the highest life expectancy
at birth of any nation: 77.1 years (1985). The speed of Country Experiences
the aging of Japan’s population is remarkable. While it
took 45 years for the UK to move 7-14 per cent of its The elderly populations of many developing countries
population aged 65 and over, Sweden required 85 years are increasing rapidly. These demographic changes are a
and France 115. It took Japan only 26 years. The USA direct result of the success of socioeconomic
will reach the 14 per cent in 2010, or 66 years. The USA development that has led to declines in mortality rates at
will reach the 14 per cent. This worldwide demographic all ages and reductions in fertility.6 Adequate disability
revolution is a major success story of 20th century and life expectancy data are essential for planning health
(Table 34.3). and social policy but are century insufficient.
By the beginning of 1990’s an estimated 15.7 per Japan has put in place a health care financing
cent of population were aged 65 and over and 7 per cent system that gives essentially free care (only a 5% of
were aged 75 and over in UK. There were 23 people copayment is required) for all persons over age 70. The
aged 65 years for every 100 people aged between 15 and system for delivering health care emphasise
64 years, by the year 2030, 31 over 65 year olds will be hospitalzation a “Golden Plan” was announced in 1990
present in population for every 100 younger adults. 4 By for expanding home and community-based service
the year 2025, there will be more than 10.7 million particularly rehabilitation and adult day care.
people over

retirement age compared with 7.7 million in 1995, Japan is creating a national institute on aging. The Table 34.3:

Demographic region Population

Population structure andDeaths
Population dynamics (1990)
Probability of Life expectancy at
% 60+ (millions) 60+ (millions) 60+ dying (%) 60+ 60
Sub-Saharan Africa 5 25 1.3 49.4 15
India 7 59 3.3 48.9 16
China 9 101 5.4 41.5 16
Other Asia and Islands 6 41 2.0 44.9 16
Latin America and Caribbean 7 31 1.2 33.0 19
Middle Eastern Crescent 6 29 1.4 42.0 17
Formerly Socialist economies 17 57 2.7 36.3 18
of Economies
Established market economics 18 145 5.9 27.6 20
Demographically developing 7 286 14.6 43.8 17
group
World 9 488 23.2 40.1 17
Note: Demographically developing group includes sub-Saharan Africa, India, China, Other Asia, Latin America and
Caribbean, and Middle Eastern Creascent region.
Source: World Development Report 1993.
government policy for health care financing shaped faster rate than the younger population. The USA’s
distinctive Japanese patterns of elderly care provision. 7 population will be 13 per cent elderly by 2000 AD, 17.3
The financing system provided a hidden subsidy through per cent by the year 2020 and 21.2 per cent by 2030 AD.
national health insurance coverage of long-term USA is getting a late start on meeting the needs of long-
hospitalization-that encouraged high institutionalization term care in accord with sound principles of geriatric
rates of elderly in medical facilities.7 Public financing medicine. The health care for elderly is funded in four
for long-term elderly hospitalization, however, has ot basic ways: private health insurance, Medicare,
been matched by government attention to quality of Medicaid, and out of pocket expenditures. Old age is a
care, resulting in serious quality problems and reflecting territory populated largely by women. Because women
a social tradeoff between cost and quality.7 outlive men by an average of seven years, the ration of
Sweden has long been acknowledged as in the women to men increases sharply among the elderly.11
forefront of systematic development of social service, Longer survival brings women greater risk of living
medical care and geriatric assessment. Social security alone and in poverty, of having chronic illness,
systems are based on need. becoming frail, and being hospitalized and
China has a population with one in twenty elderly institutionalized.12 According to a recent study,13 the
(80 million). Its village system provides roles for elders. increase in life expectancy over the over the past 30
The guiding concept is of generations standing together. years is due in large part to the access to services
UK has been guided by the “Beveridge Plan” of provided through the medicare programme. Medicare is
1940’s in developing a “Cradle to Grave” set of social still a popular programme on which millions of older
entitlements. The state currently funds 70 percent of the people, disabled people, and their families depend. Total
estimated £ 10 billion cost of the paid care, but this will Medicare payments will be more substantially affected
fall to 50 percent over the next 20 years. Theoretically, by the expected increase in the absolute number of
this means private provision needs to increase from £ 3 elderly people.11 The projected increases in Medicare
billion to £ 15 billion, calling for a massive growth in expenditures will result largely from the increase in the
funding from the private sector.1 The demand on the size of birth cohorts and the proportion of each cohort
state purse will continue to increase at the same time as living to the age of 65.8 It is generally agreed that per
it attempts to contain costs. Long-term care will have to capita Medicare costs are rising so rapidly that the costs
be funded, at least in part, by those who require it, which of current benefits far exceed the contributions that were
means a carefully planned programme of pension, made bythe beneficiaries who now receive them. The
savings and specialist services. rise in the Medicare costs can be curbed if advance
Approximately 200 billion dollars are spent each directives and do- not-resuscitate orders are more
year on personal health services for the 29.2 million frequently discussed with younger patients (rather than
Americans (12% of the total population) who are over the last two years of life) and plans are made before
65. The elderly account for over one-third of health crises develop. Substantial cost savings are more likely
spending. Medicare and medicaid together cover to be achieved through health care-financing reform in
approximately two-thirds of health care expendiutre for which reimbursement mechanisms are designed to
older persons and a considerable proportion of these encourage the use of long-term and primary care
costs is incurred in the last year of life. 8 The proportion services aimed at maintaining functional independence
of the population over the age of 65 is expected to and avoiding hospitalisation. Such reform would require
increase into the next century, heightening concern integrating Medicare financing for acute care with
about health care spending.9 Life expectancy beyond the financing for long-term care. The objective would be to
age of 65 is also expected to rise. Estimates of the upper allocate care more appropriately while dominating
limit of average human life expectancy range from 85 to incentives for cost shifting. Care should focus on
100 years.10 The elderly population has been growing at preserving function, with careful consideration and
 Design and Construction The Clinical Zone n 501

discussion of the costs and potential benefits of acute programmes of social and personal care (e.g. respite
care hospitalization. Such an approach may facilitate care, home helps, adult day care); services are allocated
limitations on the use of costly procedures that are based accoridng to need. Among goals commonly found in
on factors other than age, such as effectiveness of long-term care services in developed economies is the
outcome.14 It is felt that Medicare could be imporved by prevention of impoverishment (a major exception is the
the addition of comprehensive geriatric assessment, USA where the only available public funding is part of
coordination of care, and integration of short-term and public assistance for the poor medicaid).
long-term care. A recent study15 showed that Expansion of hospital, nursing home and com-
comprehensive geriatric assessment of older people munity-based services is recognised as necessary
living in the community has already proved to be adaptation to population aging in most developed
clinically effective and less costly than conventional countries.
care, since it helps reduce the need for nursing home Sweden has one of the most systematic approaches
admissions and other forms of extensive care. There is to long care system. A continuum of services is
also scope to offer Medicare beneficiaries more choice available to elders, including nursing home care and
in the health care plans available to them and to ensure housing. About one third of GNP goes for health and
that the government pay the same amount no matter social security.
what plan a beneficiary chooses. Elderly people who In UK, commerialism in long-term care has
want to receive care in more expensive settings or who burgeoned; in 1986, about 168000 of the 426800 beds
want to buy more benefits than come with the basic plan were in the private, non-voluntary sector.18
may do so, but at their own expense akin to the Federal In Australia, long-term care is mostly in the private
Employee Benefits Plan (FEHPB). Under FEHPB, the sector counting retirement villages, hospitals and
federal government sets its dollar contribution to the nursing homes operated by voluntary agencies and
premium, offers a large choice of plans to its employees private corporations. State governments provide a
during annual! open-enrollment period, makes smaller portion of aggregate service.19
information available to its employees to help them In Japan, the government announced (in 1990) a 10
choose wisely, and monitors the plans to make sure they year “Golden Plan” for the welfare of aged, in
are fulfilling their contractual obligations.16 preparation for having a population of 16.3 percent
elderly in 1000 AD and 23.6 percent in 2020,
Long-term Care Systems approximately the proportion expected in Sweden and
Germany. The comparable proportions expected in the
Long-term care is the lifeline for all elderly persons USA are 12.8 percent and 17.2 percent and in the UK
currently in nursing homes and who live in the 15.4 percent and 18.7 percent. Japan at present is well
community.17 The prevailing bioethical model of below the other countries (at 10.3%). A prominent
decision making, with its emphasis on individual feature of the plan is support of family care gives in a
autonomy and life-sustaining medical care at the very way that permits them to continue in paid employment
end of life, is inadequate. It is inadequate because the away from home during working hours. It also includes
chronically ill person who depneds on multiple supports systematic development of personnel and faiclities,
for survival, in a nursing home or at home, cannot particularly in the community a tripling of spending in
function as an isolated person in making decisions any the 1990’s compared with the 1980’s. Day care services,
more than in the rest of daily life: that person’s intimate including functional training will be provided in 10,000
involvement with family and professional care givers centres in 1999. The programme will innovate
necessitates their “domicilliary care support” centres, offering home
17 visiting, counselling and care coordination. The plan
participation. examplifies attempts to systematize and balance the
Most developed countries have publicly supported
institutional and community-based aspects of management-major goals and essential service.20 The
comprehensive geriatrics, the social and medical key function of case management is to develop
components and the housing and family considerations. integration of services. the specific interventions of case
The plan calls for primary prevention, rehabitation and management include: liaison activities to appropriately
prosthetic extending, to housing and other integrate clients into the health care system, health
environmental modifications to assist mobility and other promotion, counselling, disease prevention, health
functioning. education and screening, and community resource
In the Canadian province of Manitoba, a set of well- linkage. The case management team usually consists of
integrated elements of comprehensive geriatrics can be nurses, therapists and social worker. To provide
found. The financial framework is tax-based plan of comprehensive services to aged there is need to develop
universal coverage of health. A strong home care co-operative relationship and mechanisms for
programme makes possible the maintenance of patients information exchange with providers at all system levels
with their families for as long as feasible. that will serve as a bridge across the great divide
In the USA, a novel approach to systematizing is between all levels of care.
the Social Health Maintenance Organisation (SHMO). Triage- a non-profit organisation has been able to
The key feature is “Case Management” offering provide a broader range of comparable services for its
framilies’ advice and service. The SHMO pool funds population at the same cost as Medicare and Medicaid.
from Medicare (primarily an acute care programme for Moreover, vulnerable persons were able to remain at
elders) and Medicaid (acute and long-term care home and presumably with greater life satisfaction than
programme for the poor). In 1990, a congressional in a nursing home.21
commission advocated a geriatrics- informatic plan for Triage (the process of establishing criteria for health
universal coverage of long-term care through social care prioritisation) permits society to see cases in the
insurance, with a supplementary role for private context of diverse moral perspectives, limited resourc
insurance. The policies offer indemnity payments for and competing health care demands. Triage planning
individuals determined by physicians to need nursing offers a useful model for identifying and eliminating
home care. wasteful medical care. Prioritising cases require a triage
Case Management has evolved as a flexible, method that is rational, fair and consistent-evaluating
pragmatic and compassionate strategy for improving prospective cases according to seniority, acuity
client access and care continuity within fragmented (severity) and risk.
systems of health care continuity within fragmented The Living At Home Programmes fill gaps in the
systems of health care and social services. The first existing social service/medical care system by co-
generation case management programmes have been ordinating service for groups of frail elderly at risk for
designed for various settings that serve different target institutionalisation, thereby allowing them to remain at
populations with varying social, medical and home.
psychological needs. This proliferation of categorical Hospice (which focus on support for dying patient
case management progrmames is a mixed blessing. and their families), is not an institution but a service that
While a categorical focus reflects both historical and may be rendered in various settings and the care is
public financing priorities, it creates a potentially covered by a few insures.
duplicative and an inefficient system in an era of limited There is growing movement to develop Adult Day
resources. Efforts are being made (in USA) to introduce Care facilities to provide treatment for the patient assist
accountability demonstrating value-added benefits and families in making adjustments and finding aid. The cost
identifying best practices for structuring case of care is less than of nursing home.
management-client focused. The first step is reaching
agreement on two critical dimensions of case
 Design and Construction The Clinical Zone n 503

Health Care Facilities Hospital-Based Service (Acute Care)

Older people make much heavier demands on health and Age is an inaccurate means of classifying health cre
social than do young adults. The most elderly make the need, alternative organisational approaches that avoid
heaviest demands of all. The very elderly also tend to be age-related admission policies need to be rapidly
proportionately highly represented in the most intensive developed to avoid age-rationing of health care. In the
forms of non-home-based care (such as hospital based use of specialized acute care unit, emphasis should be on
inpatient care). In addition to having their highest rate of rehabilitation, independence in self care, and detailed
hospital admissions this group also have a much longer planning for home discharge.
average length of stay in such care when compared to
other sections of elderly population. Elderly people with
In-patient Care
acute illness present a particular challenge for the
service seeking to provide the most effective clinical Various models that have evolved are:
management of their condition and to maximize their
level of independence. Elderly people will often have Age-defined approach (usually 75 years and over)
several problems coexisting which require skillful provides a ward environment and care team.
assessment and treatment, but their functional capacity
will be equally as influential in determining both Integrated approach all acutely ill persons are
recovery and future living status. Older people need admitted to an acute medical ward, which deals with
support to enable them to enjoy active, fulfilling and other groups and are care for by a group and are cared
independent lives. for by a group of physicians.

Nursing Home Need-based approach there are separate elements of

geriatrics and general medicine but the decision about
In the USA there are more nursing home beds than acute which team takes care of patient is governed by his/her
care hospital beds. There are between 6 and 7 thousand care needs.
acute care hospitals with a total of approximately one It is the success in achieving recovery rather than
million beds. Three quarters are run for profit and a the response to illness per se which is the real test of the
large proportion of these are run by organisations that quality of hospital services. Integrated multidisciplinary
own several or chain of nursing homes.21 The key staff services where access to care is independent of age but
is administrator. Nursing home care in the USA is is determined by need for care offer the best value.
presently a 30 billion dollers industry. 22 Nursing home In Italy an innovative model of health care-acute
care represents about 20 per cent of total spending on care orthopedic-geriatric unit offers several advantages
health care for the elderly.14 The quality of medical care
over traditional models: decreased patient mortality and
provided in most American nursing homes is far from
length of hospital stay, a lower incidence of
optimal.22
complications, and less need for specialist consultations.
Utilising nurse practitioners to provide health care
Cost/benefit ratio is very low. The model has also
for nursing home patient has been tried at
become a valuable teaching tool and a rich source of
Massachusetts. Nurse Practitioners provide not only a
pathophysiological and clinical data for geriatric
substitutive role to that of medical care but also a
research.24
complimentary one should be instrumental in enabling
policy decisions that encourage the full utilisation on
Long-term Care
nurse practitioners.23
The aim of long-term care facilities should be to allow
the old person to have maximum dignity and self-
determination. The elderly person’s environment should rehabilitation has become evident reflected in the
provide a sense of security and cheerfulness. Emphasis development of orthopedic geriatric and rehabilitation
should be on personalized care, retention of personal units. Their particular advantage is that all staff involved
possessions and own washing and bathing facilities, may accept and develop similar techniques and
well-designed modern environment and right to privacy. approaches so that whole of the patient’s treatment
There is broad range of facilities available for elderly round-the-clock is consistent.
people who require long-term care and support who can
not manage within their own homes. The health services The Day Hospital
in the UK continues to provide “long-stay geriatric
beds”, which usually care for elderly people who require Day hospital follows a medical, paramedical and nursing
nursing care. The local authroity social service model. The facility is provided by a statutory and
department provides places in homes for the elderly. The voluntary agencies. Day hospitals attempt to dissociate
private sector provides places in homes for the elderly. the diagnostic and therapeutic aspect of hospital
The private sector provides places in private nursing treatment from the hotel aspect which requires patients
homes as well as in rest or residential homes; the not- to be looked after at night and throughout the weekend
for-profit and voluntary organisations also provide some when no investigation or treatment is being carried out.
residences. and nursing home care. In UK all patients in The Day Hospital also allows a closed and prolonged
NHS long-term care are under the supervision of a supervision of patients suffering from chronic diseases
consultant in Geriatric Medicine or Psychiatry. Those so, if isolated completely from hospital care, would
inhabitents of nursing homes are under the care of almost certainly deteriorate and require readmission.
individual general practitioners. Nurse staffing tends to In the UK, the department of Health and Social
be low in most of the long-term care setting. Social Security allows two geriatric day hospitals and two
interaction with patients in seen as one of the hallmarks psychogeriatric day places for every 1000 people aged
of goods quality nursing in long-term care wards. 65 and over in the catchment area served by these
Slowing down of hospital discharge rates, improved services.23 Most of the patients attending day hospitals
facilities for rehabilitation and recovery and hospital suffer from stroke or disease of locomotor system
based respite and longterm care settings. Social (arthritis, etc).
interaction with patients is seen as one of the hallmarks Ideally day hospital patients should be transported
of goods quality nursing in long-term care wards. in well-heated vehicles with comfortable individual
Slowing down of hospital discharge rates, improved seats with safety belts. A vehicle may carry 6 to 10
passengers and requires to be equipped with lift which
facilities for rehabilitation and recovery and hospital
will take both disabled people and patients in
based respite and long-term care need to be encouraged.
wheelchairs.
A comprehensive service requires the provision of acute,
Day hospitals provide a reception area, a dining and
rehabilitative and continuing care. Slow- stream
general activities area, therapy area, consultation and
rehabilitation is very important. placement in long-term
treatment rooms and staff rooms. Efficiency and cost-
care should only take place after a complete
effectiveness of a day hospital will depend on the care
multidisciplinary assessment and the team making the
with which appropriate patients are selected. The
decision should review the longterm outcome on regular
importance of audit in improving effectiveness of use of
basis.
day hospitals cannot be overemphasized.

Special Units Within The Service

During last two decades a gradual specialization within

 Design and Construction The Clinical Zone n 505

Psychogeriatric Service assessment of need led by social service department, in

which all agencies and professional disciplines
The aim of psychogeriatric service is to deploy and collaborate. On the basis of such assessment a care
enhance the skills of the health profession in meeting the manager will be appointed to take the lead in ensuring
needs of the mentally-ill old people, and in supporting the services identified by the assessment are delivered.
those who care for them. A psychogeriatric service This role will include the commissioning of the social
normally accepts any referrals of persons aged 65 and care components of the individual’s care package. Social
over within a defined geographical area. In UK workers and some helps deliver such form of service to
generally the catchment area is the size of 200,000 elderly people in their own homes.
people, of whome some 15 per cent will be aged 65 and Many old people attend day centres, lunch and
over. Three basic hospital facilities are essential-an recreational clubs. Respite care can be a major
acute assessment or admission unit, a long stay unit, and importance in allowing dependent older people to
facilities for day patients. remain in their own homes.
Wherever possible, admission units should be in Collaboration is crucial for the delivery of effective
general hospital, for elderly patients. If such a unit is to community care. Discharging an elderly
receive all inpatients from a comprehensive district person from the hospital requires careful coordination
service, then it will need about 1 bed/1000 old people, a between health services both in the hospital and the
3 0-bed ward will usually be appropriate for a typical community as well as social services, other agencies
health district. such as housing departments, and of course, patients,
Educational interventions to improve understanding their relavites and carers. For effective collaboration, it
of mental health for elderly should be considered to is imperative that all players should be clear about their
address the inadequacies in contemporary mental health roles and responsibilities.
care.26
Home Health Care
Community Care
In the UK many social services departments have
As older people increase in number and live longer, they developed their home help services based around a
are making society aware that old age offers much wider range of tasks being provided in response to
opportunities and challenges as well as problems. The individual need than was previously the case. The
majority of the people will continue to live in potential for a joint health and social care approach to
community either with their spouse or children or domiciliary care for older people is being examined via
members of the family or alone. the provision of domiciliary workers who undertake
The nature of services provided in community is both the functions of district nurse auxiliaries and local
critical in determining successful outcome of care for authority home care workers. This model has particular
old people who do have needs. The multidisciplinary merit in meeting individual need across the health-social
primary health care team is a cornerstone in the care of care divide.3
the elderly which can organize itself in such a way that A problem in the provision of home health care for
some of this need is ascertained and problems are elderly people is the limited number of family members
recognised early. Community nurses have a major role available for caregiving. Current trends suggest an
in caring for elderly. Specialist nursing services, increasing emphasis on the family as an appropriate
community psychiatric nurses or palliative care nurses caregiver.27 Patient care provided through outpatient
are an important adjunct to general community service. clinics and Home Settings offers such alternatives. In
National Health Service and Community Care Act recent years home care become increasingly high-tech,
1990 (the UK) requires a combined approach to the including intravenous infusions, parental nutrition,
supplemental oxygen, monitoring devices,
degenerative diseases.
chemotherapy and pain management as well as dialysis. The logical place to carry rehabilitation of the old
These resources can permit the treatment of patients people is in their own homes. A selection of elderly,
with severe chronic illnesses in their homes, but theydependent patients can be cared for in their homes after
can also permit care managers to send patients home short-stay hospital discharge and benefit from primary
from the hospital sooner than the patients and families
home care intervention programme in terms of improved
may wish. Overall, home services may save 30-50 per medical and functional outcome and less long-stay
cent in costs compared to costs for the same service hospitali- zation.29 However, rehabilitation facility may
provided in hospital. The major savings come from be organised within a seperate geriatric unit, provided it
moving the charge for hospital room. There are is equipped to deal with acute medical emergencies or
opportunities for innovative home care programmes. may be done in an integrated fashion with internal
What people want is the security of care that a medical-
medicine. Rehabilitation patients often need the full
nursing team can bring to their homes rather than the range of investigation facilities, require surgical
power of hospital technology in their houses. 28 procedures and referral to specialist opinion. Separate
rehabilitation units can be made to work, provided that a
Respite Care very structured approach to rehabilitation is maintained
using clear objectives, monitoring and discharge
Given the importance of familiar surroundings to many planning. Specialist rehabilitation units, orthogeriatric
older people (and especially those with dementia) units, stroke units and day hospitals have shown the
30
models of respite care involving care workers looking evidence of effectiveness.
after the person in their own home are becoming more
common. Health Promotion

The promotion of health through education, disease

Informal Support
prevention and health protection are beneficial in old
age. Programmes include: detection and treatment of
Depending on the need of aged, the type of support
hypertension, smoking cessation, exercise, healthy
provided by families varies enormously. The factors
eating weight control, psychological preparation for
influencing this interaction include: the nature of the
retirement, and social welfare.
housing of the elderly person and of the family, the
Spurred on by Health of the Nation (the UK)
quality of the family relationships, the attitude of the
initiative, Age Concern has introduced a national health
elderly person towards independent living, and financial
promotion programme, Ageing Well. The prominent
considerations.
feature of its pilots is the use of its senior health
mentors, trained old people who give advice to their
Rehabilitation
peers. Nurse Practitioners in adult health, family
practice, and gerontology must expand their repertoire
Rehabilitation has to work from consumer’s perspective
of health promotion and health maintenance strategies to
to enhance autonomy. The challenges are the concurrent
meet the needs of the elderly
effects of aging, multiple pathology, different priorities 31
and expectations and the rapid onset of disability during women.
acute illness. Epidemiological information is vital if a
rational approach to the price of rehabilitation is vital if Role of Traditional Medical Practitioners
a rational approach to the price of rehabilitation is to be
built up. There is need to develop cost-effective menas Many simple health activities do not require extensive
to control the burden of illness caused by chronic professional training or major facilities and equipment.
 Design and Construction The Clinical Zone n 507

Health workers based in clinics or in their own US Census Bureau International Population Reports
communities play an importnat role in delivering these Series 95(78): Washington DC, 1987.
services. The traditional health practitioners have 3. Kinsella K: Ageing in the third world US Census
Bureau International International. Population Reports
enormous potential as public health workers and
Series 95(75): Government Printing Office,
providers of essential clinical services, if governments Washington DC, 1988.
can give them the appropriate training, information and 4. Donaldson RJ, Donaldson LJ: Essential Public Health
incentives. Medicine. Kluwer Academic Publishers 357-87, 1993.
Terminal Care 5. NHS Executive: Annual Report 1994/95. NHSE,
Leeds, UK, 1995.
Care of dying must be patient-centered, holistic with due 6. Jitapunkul S, Bunnag S, Ebrahim S: Health care for
attention paid to physical, emotional, social and spiritual elderly people in developing countires: a case study of
need and to be comprehensive, it must be team care. Thailand. Age-Ageing: 22(5): 377-81, 1993.
7. Kobayashi Y, Reich MR: Health care financing for the
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Design and Construction The Clinical Zone n 509

APPENDIX A

Age dependency ratio in OECD countries

Country 1990 2000 2010 2020 2030
UK 23.0 22.3 22.3 25.5 31.1
France 20.9 23.3 24.5 30.6 35.8
Germany 22.3 25.4 30.6 35.5 43.6
Italy 20.1 22.6 25.7 29.3 35.3
USA 18.5 18.2 18.8 25.0 31.7
Japan 16.2 22.6 29.5 33.6 31.9
Average for all member countries 19.4 20.8 22.9 27.6 33.3
Source: Organisation for Economic Co-operation and Development-ageing populations: the social
policy implications, Paris 1988.
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