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In 2011 ILC The Netherlands hosted the annual meeting of the ILC Global Partners and the Robert Butler lecture.The conference on "Integrated Care for Frail Older People" was held on 29th September 2011 in Leiden.

Everyone wants to get old, nobody wants to be old

In 2050, 22% of the population will be older than 60 years. What is the best policy in an aging society? How can we improve care for vulnerable older people? On September 29, 2011 the Global Alliance of the International Longevity Centre’s (ILC’s) organized the conference 'Integrated Care for Frail Older People’ in cooperation with the three Dutch organizations ZonMw, Vilans and Leyden Academy on Vitality and Ageing. During this conference professionals from around the world discussed these questions.

Frail older people
The Dutch women Hendrikje van Andel-Schipper lived from 1890 to 2005 and was with her 115 years in her time the oldest living person on earth. Her retirement lasted more than 60 years. She was almost blind, deaf and could hardly walk the last years of her life. She lived in a nursing home, was a fan of the soccer team Ajax and her mind was sharp to the end. Prof. Paul Schnabel, director of the Netherlands Institute for Social Research (SCP),
showed with this example that aging is different for everyone. It's a gradual process, with the common denominator that everyone wants to get old, but nobody wants to be old. Schnabel explains that at this moment in the Netherlands nearly 40% of the health budget goes to cure and care for people of 65 years and older. This means that ‘health care’ can almost be phrased ‘care for the elderly’.
The study ‘The fate of the vulnerable elderly’ shows that in the Netherlands about 25% of the population over 65 years is vulnerable, of which 85% live independently and 15% live in a nursing home. In nursing homes 81% of the inhabitants are frail. Frailty in older persons is a process involving the accumulation of physical, psychological and/or social deficits in functioning, which increases the risk of adverse health outcomes (functional impairments, institutionalization, death). In Europe we see different strategies regarding care-giving. Table 1 (to view click here) shows percentages of proved care if parents could no longer live on their own (data SCP 2002).

Table 2 shows the kind of care received (data SCP 2004) (to view click here). This table shows similar data as table 1. There is a huge difference in formal care in northern and southern European countries.

Quality of life
Professor Rudi Westendorp, director of Leyden Academy on Vitality and Ageing and member of the board of ILC-the Netherlands, thinks the debate about aging in the Netherlands should have a more positive tone. Society is afraid of the silver generation with all its socio-economic consequences. According to Westendorp there is no reason for panic. Dr. Robert Butler, Pulitzer Prize winner and ILC Global Alliance chairman who past away last year, also looked at older people in a positive manner. He did not see a problem but a challenge in improving their quality of life.
Why doesn’t society take care of older people automatically? Westendorp feels that - in terms of evolution - we are genetically programmed to like children much more than old people. Biologically seen do older people not contribute anymore to the survival of humans because their reproductive skills ended. In western countries age discrimination occurs a lot. Furthermore economic incentives are needed: older people should extend their ‘productive’ life and should be rewarded to continue working after retirement. Also the care system must change. Instead of focusing on research for treating diseases associated with increasing age - such as diabetes and dementia - Westendorp thinks more research on healthy aging is important.

Active clients
The WHO definition of long-term care is ‘The system of activities undertaken by informal caregivers (family, friends and/or neighbors), and/or professionals (health and social services) to ensure that a person who is not fully capable of self-care can maintain the highest possible quality of life, according to his or her individual preferences, with the greatest possible degree of independence, autonomy, participation, personal fulfillment and human dignity’. Dr Henk Nies, director of the Centre of Expertise for Long-Term Care (Vilans), feels we tend to forget that long-term care is about values in society and values of people. Often we see older people as patients and care recipients instead of clients. According to Nies it is important that the current welfare cure and care systems in the OECD countries are equipped to handle the growing number of older people. Currently the systems communicate poorly with each other: the status of welfare is low, while that of health care is high. Nies explains that the image of old people in society is changing. Seniors are increasingly seen as active clients who manage their own situation, rather than passive patients awaiting care. Thus a new policy is needed. Greater integration of care systems would solve many problems: one contact point for housing, care and welfare, instead of several. The program ‘Interlinks’ (http://www.euro.centre.org/interlinks) tries to unravel care for the elderly and provides an international framework for integrated care. Multidisciplinary teams as well as shared budgets are needed to improve this care.

Working together
Professor Betty Meyboom is chairman of the programme committee for elderly care (ZonMw) and responsible for the Dutch National Program for Elderly Care.  Through this grant program - commissioned by the Ministry of Health – solutions are sought to improve the care of elderly with complex health issues. The strength of this project is regional cooperation: over 550 different organizations in the areas of care, welfare and housing, work together with older people. Within the experiments and projects the needs and problems of the elderly are the focus.

ILC countries
According to Baroness Sally Greengross, co-president of ILC Global Alliance and director of ILC-UK, ageing and the increasing number of frail older people is an issue for al ILC’s. Frailty can cause older persons to lose their ability to function independently, experiencing a general feeling of exhaustion with low levels of physical activity. It is often associated with weight loss or cognitive impairment, depression and/or dementia as well as multiple co-morbidities (Fried et al 2001).
Greengross gives some examples by describing the situation in several countries. In India great spiritual strength is attributed to older people, which generates a lot of positive attention to the elderly and elderly care. The problem is that India has the second largest older population: 81 million (this number is growing). The health care system can not keep up with this: 66% of the elderly is vulnerable en lacks clothing, food and shelter. In France 80% of frail older people live at home, whereas in Argentina and in the Dominican Republic care for frail older people mostly takes place in hospitals. In Japan elderly care services are provided under either the welfare or healthcare system, but welfare services are scarce. In Israel 33% of older people are treated by social services, and government principal is for people who reside at home and are supported by a network of community services. In the Czech Republic general practitioners prescribe home nursing care and medication according to individual needs and 80% of people with long-term needs stay at home. Long-term care wards do exist but people are required to stay in bed. In the UK integrated care represents a concern to improve patient experience and to achieve efficiency and more value from health delivery systems. The current system for funding the social care system has changed. At present anyone with assets of more than £23,250 must pay the full cost of their care.
Whilst all ILC countries are dealing with ageing populations, the policy environments, key issues and challenges they face vary; integrated care is just one challenging example of this. Integrated care means a holistic approach to care, underpinned by effective shared assessment, communication, education, training and close collaboration to ensure more effective care delivery to prevent crises and promote early review and intervention.

Conclusion
What is the best policy in an aging society? Schnabel called a good and reliable income (pension) as a prerequisite. The combination of recovery and good follow-up is crucial. In addition, prevention in order to postpone a stay in a nursing home is important. Care and support close to home as well as the use of technical aids benefit older people.
In case you wish to grow as old as Hendrikje van Andel-Schipper? Then you should not smoke nor eat too much and provide enough money and social contacts. Or you can move to Japan, with over 40,000 centenarians.

Documents:

Opening Slides (PDF)
Presentation by Professor Axel Börsch-Supan (PDF)
Dutch National Programme for elderly care (PDF)
Worldwide trends and developments on integrated care for frail older people (PDF)
Integrated services in the context of long term care (PDF)
The frail elderly in The Netherlands (PDF)
ILC Robert Butler Memorial Lecture (PDF)
Closing Slides (PDF)
Conference report - Integrated Care for Frail Older People (PDF)
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