Increase in life longevity is a triumph for public health. But there is an inverse relationship between ageing population and resources. Making provisions to cope with the needs of the increasing numbers of elderly patients is paramount, says Dr Kailash Chand.
In the UK the fastest growing population is the over 80s. Presently 3 million will become 6.5 million in 2045. The over 65 group will jump from 10 million to 17 million by 2045.
Of the 15 million with chronic illnesses 7.5 million are over 60 years old using 70 per cent of the hospital beds and 50 per cent of GP consultations with an average cost of £8,000. The total cost of care for older people will swell to £4bn by 2016.
An Ageing Population
There will be four main groups of retirees and they will not be a homogeneous group. Each decade group will have different needs and requirement. In addition there will be groups of people greying with diverse life styles, cultural backgrounds, differing expectations, mosaic of financial circumstances, family composition, and resources.
They will have social isolation which is the biggest curse of industrialised nations. The ageing population is cursed with degenerative diseases, chronic long standing disease that will get worse as time goes by. The musculature may give way as will the joints and bones. The mentation may suffer which may lead to disengagement.
While we start looking at financial and social engineering for the ageing population we have to be cognisant of elderly dying in the community in nursing homes, care homes, retirement villages, sheltered and very sheltered accommodations. The care workers should be trained to accept that death will occur in the communal setting.
Ringing 999 and getting the ambulance fast to hospitals A&E departments and clogging up the system is escaping the issue. This is a menace and has led to a current crisis in A&E and urgent care areas - mixing acute illnesses withthe cohort of morbid elderly who have already exhausted all investigative processes, management of drugs and manipulations by surgeons. Security and elder abuse in any form or shape will need to be addressed.
There will be four decades of retirees. The first decade will be from 60-70 years, second decade will be from 70-80 years, the third decade from 80-90 years and the final curtain will fall in the fourth decade at 90-100 years. A few will survive to get the Queen’s Telegram.
60-70 with absence of disease (decade 1 of twilight years). This group will require an ageing organ service. They will need eye tests, oral cavity check up with dental health and tooth service, ears and hearing aid service, Podiatry and skin hygiene and bladder weakness. The list is endless. Most of them will be on preventive medicines for vascular disease, Lipid disorders, bone protection, BP management.
60-70 with presence of morbid conditions such as diabetes, hypertension, osteoarthropathy, ischemic heart disease, COPD, chronic kidney disease etc. This group will need a slightly more rounded approach, along with above mentioned ageing organ service.
71-80 years with absence of disease (decade 2 of the twilight years). This group will require a more intense approach with ageing organ service as well assystematic review of each and every organ to keep them in good condition for the next decade to come.
71-80 years with co morbidity (decade 2). This will be a challenging group, they might be vertical or horizontal , they might have had hypertension, diabetes, myocardial infarctions, heart failure, COPD, minor TIA, minor strokes, rheumatoid arthritis, Parkinson’s and chronic kidney disease. They will require a different approach. GPs involvement will be more frequent, nurse practitioners will have to be taught in the language of the ageing population and sympathetic /empathetic approach. Tick boxing and check lists have not worked, will not work in a caring society.
Beds will be required, purpose built, populations at large will have to be re-educated that care in the community is no less than care in the hospital. Consultants might have to head out in the community to heal the nation’s elderly population.
80-90 years still without significant morbidity (decade 3 of twilight years). This is the group that adhered to good values of a life of moderation, have accepted nutritional advice and managed to compress morbidity and have good genetic composition. They will have an ongoing need for easy access to an ageing organ service. The mentation, eyes, ears, hearing, oral cavity, teeth, nails, eyes, and joints along with posture and musculature will need looking into but they will still manage with much burden on the society at large.
80-90 years with significant morbidity (decade 3 of twilight years). This group is one with special mental health needs, physical health needs, drug management, personal hygiene, bath and shower needs, nutritional support, and care in the community with frequent visits to hospitals and GP consultations.
This group will exhaust investigatory resources easily. They will have special housing needs, skilled nursing facility, not the current nonsense type where any care worker without rhyme or reason calls 999 ambulance and put the very frail old person lying on a trolley in A&E for five hours only to be told they had a mild faint and returned to the care home. There will be need for community therapy, including physiotherapy and occupational therapy, and swallow assessments along with paramedic trained support staff to avoid hospital admissions. Sleep hygiene will have to considered as an important issue and not simply ignored.
90-100 years (decade 4, final years). This is the most vulnerable group and the majority will require placements. They will have received all possible attention from GPs, consultants, paramedics and nurse practitioners. They have had hip replaced or nailed, knees looked at, and hopefully placed in appropriate environment.
A major shift is required in training staff to care for them in the community and instill the philosophy of palliative care in those who care for this vulnerable group.
This group will have nutritional needs, hydration needs, skin integrity, financial protection, bowel, bladder and back issues and numerous medical conditions with loads of unnecessary drugs which they have accumulated over the years, which will need reviewing.
The compression of morbidity is a laudable idea and it will work for 25 per cent of the fit elderly population. This group will be called healthy ageing. They will have few morbid conditions. Will be vertical, walking , talking, eating, enjoying exercise, nutritionally well preserved and at the ripe old age of 95 have an acute illness and pass away pleasantly without being a burden on family or society.
Paradigm shift from hospitals to community care in entirety
There has to be an education of all, starting in schools, that people will die at home, or in flats, or in care homes and nursing homes. There has to be acceptance of the fact death cannot be avoided.
Accommodation/ options of living in communal settings
There will be changing requirements in different age groups and different cultural cohorts.
Fit old people could go on living independently for as long as possible in retirement villages with social interaction. Society will have to accept grey populations and its demands.
Purpose built secure bungalows, flats with wide doors and disabled toilets, special kitchens with ease of use, floors with good grips and furniture to suit the needs of ageing population with or without diseases will be required. Clutter will have to be avoided to prevent falls.
In the later years variable staffed accommodations with variable skilled facilities will have to be constructed to accommodate the very sick and very frail elderly with physical and mental needs.