Care of the Elderly Throughout the World A Discussion of How Countries Worldwide Are Providing for Their Aging Population

by Mary Jane Horsfall Large, R.N. CHE

Robert N. Butler calls the time we are in the “longevity revolution” and says that there are 5 great issues that concern society today. They are: can we afford the growing number of older persons, will there be a stagnation of society and the economy, will there be intergenerational conflicts, will older people become the ruling class creating a gerontocracy and to what extent is ageism constraining societal thinking about population aging?

We need to address all these issues in looking for solutions to worldwide aging.

It is apparent that in the developed world there are more similarities than differences in the services, philosophy and care provided to the elderly.

Population ageing is a growing global issue. Life expectancy has increased more in the past 50 years than in the previous 2000. 2000 years ago the average life expectancy was 22 years. In 1950 it was 46.5 and today the global average life expectancy is 65.6 ranging from a low of 38 in Sierra Leone to a high of 80 in Japan. The current projected increase in global life expectancy by 2020 is to 72.1 and by 2045 it will be 76.6. The effect of AIDS in developing counties, particularly in Africa, may significantly alter these projections. In spite of this it may be that by the middle of this century living to age 150 is possible.

According to a NGO Committee on Aging fact sheet prepared in 1999 for the International Year of Older Persons the population of those over 60 is projected to be 600 million by 2001 and 1.2 billion by 2025. Coping with this growth is the challenge.

The same issues arise in all industrialized countries:

In response to their aging population Singapore has established a tribunal for the Maintenance of Parents that requires that children provide for their aging parents. The parents can and do press claims for support against their children if they do not comply.

Other issues include:

It is not unusual to have 5 generations alive, active and well or to have 80-year old children looking after 100+-year old parents.

In the introduction to a 1997 conference held by the International Association of Homes and Services for the Ageing (IAHSA), in Barcelona, Spain, Sheldon Goldberg, then CEO of the American Association of Homes and Service for the Aging stated that “The next millennium will not dawn on business as usual. We are being propelled into the future with such great speed that it compels us to use new methods, ideas and approaches. We are bound only by the limitations of our minds and experience and our capacity for leadership in the midst of change.”

We in North America are only now being affected by the low birth rates and increased longevity that Europe has dealt with for the past three decades. The countries of Africa, the Middle East and most of Asia have high birth rates, early death rates and cultures that make the elderly invisible and expect families to care for them.

It is predicted that in Japan, which has a declining birth rate, an exception among Asian nations, the average age of the population will increase at a greater rate than previously expected. Typically care of an elderly parent fell on the shoulders of the daughter-in-law. These women are aging themselves and the physically heavy burden of such demanding work places them in a precarious situation. There are nursing homes but admission is restricted by the district in which the elderly person lives. The average wait for a bed is 3 to 4 years. Those who cannot enter a nursing home in time must go to a hospital for the elderly where care is essentially medical with little assistance with the activities of daily living. There is a general lack of information about home care services.

The Japan Housing and Loan Corporation gives low interest loans to those building barrier free and energy efficient housing. In order to help keep people independent, consumer goods and spaces are not designed for a special group but are adaptable as people age. The hope is that by introducing universal design standards in codes and guidelines, age segregation is not created.

The concepts include designing dwellings that are liveable for 30 years after they are built, and are safe, comfortable and usable. Changes in floor levels are to be minimal and dwellings are to be adaptable to meet the evolving needs of an aging person. Implementation of these guidelines means the removal of obstacles that might create risk. It is expected that in the future there will be incentives to renovate existing dwellings to be barrier free as well.

In Japan there is legislation to promote the development of technical aids. Large companies are taking up the challenge of producing goods at reasonable cost. For example Toyota has designed passenger seats that turn and move out of a van to make it easier for a person to sit on or rise from the seat. Yamaha has produced power units that can be installed on existing wheelchairs. Mikuni has developed a hydraulic lift that can be easily installed in a bathtub. Consumers complained that designs are unattractive so there are now guidelines being developed that include not only engineering standards but also the more abstract standards of adaptability, usability and aesthetic appeal.

The Parliament of the European Union has an influence on health care and social policy development in member states. There is a growing gap between EU and non-EU countries in the quality of care provided.

Those in the EU see the challenges as similar to those in North America - maintaining a labour force, a brain drain of knowledge and skills, financing of pensions, increasing levels of service required, housing and staffing of health and social services. Well-off seniors in northwest Europe are moving to southern countries (Spain, Portugal, Italy) and expect the same level of service and care they can get at home.

The trend in these countries is for private developers to build large continuing care retirement communities. Facilities are described as institutional care, which is based on a medical model, residential care that provides nursing care and ADL and home care. The breakeven between institutional care and home care is calculated to be 2 hours of care per day.

In Spain urban development no longer provides apartments that are large enough for multigenerational living. Sons and daughters are obliged to pay a share of the monthly cost of nursing home or community care for their parents.

In Sweden 46% of those over 90 live in nursing homes or homes providing care, in spite of an initiative by government to pay the cost of modifications to individual homes and the availability of home care.

In 1998 Egypt introduced a universal health care plan to cover health services for children, working women, the unemployed, elderly people and widows. It is expected that the extended family will provide for ageing relatives.

In China population aging has occurred rapidly, with underdeveloped supports to accommodate the changing demographic. While increase in longevity in developed countries typically happens over a period of 50 to 60 years in tandem with increasing socio-economic development, in China it is estimated that this ageing process will happen in just 18 years and in Shanghai in only 6 years.

As a result of China’s policy of one-child families the country has low fertility negative growth, and the population has become more urban. Responsibility for care of the elderly is now falling upon society. The change to a market economy has led to a weakening of traditional values, ethics and morals.

The old age security system is in turmoil. Between 1950 and 1970 retirement dues were deducted from wages but companies declared them as profits and have long since spent the money. A new system is being developed that combines an accumulative pension payment with one that covers current expenses for the now-retired. The traditional family old age care model is under attack. The reality is that there is no system of care for the elderly outside of the family.

In Great Britain a recent survey found that most people preferred to live in a retirement community or nursing home rather than with family. Long term care in the UK is expensive but an increase in public spending is unlikely. The quality of services depends on the financial state of the local health authority. A successful program in the U.K. that is being copied internationally is Abbeyfield Housing.

This project, which provides for the frail aging but independent elderly, may be the answer to the provision of a quality, low cost environment. The 1000 Abbeyfield houses worldwide are located in residential neighbourhoods near shops, transportation and community centres. Residents make their own rules for the home, have their own rooms and bathrooms and are encouraged to stay involved in the community. There is usually a live-in housekeeper who prepares two meals per day and offers support. Volunteers manage the projects, assist with chores and visit residents. It is felt that the prevention of isolation and loneliness delays or prevents the need for institutional care.

Latin America, according to demographic studies from 1990-2005, will experience a substantial reduction in fertility and mortality rate with a consequent growth of its ageing population. As with China, changes in Latin America will occur quickly allowing little time for adjustments in society. Long periods of institutionalization is the established tradition in the region, supported by voluntary organizations. It is common practise for residents to have to work for their room and board and there is little concern for the quality of life of the residents.

Human ageing worldwide is one of infinite variety depending on economic, cultural and political circumstances.

Those who are leaders in the care of the elderly must be open to new ideas and capable of decisive action because some of the old ways are not working and because elsewhere others have done better. From one another we can learn how to make the most of our resources, how best to serve our clients and how to measure our progress in building better systems and services.