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Introduction to
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gerontology
Dr. Safaa Hussein Ali
Associate professor of geriatric medicine
Ain Shams university
Cairo – Egypt
2018
ILOS

 1. Biology of Aging and Longevity
 WHAT IS AGING?
 Aging as a Coordinated, Malleable Process
 Key Themes from Studies of Invertebrate Models
 Delayed Aging in Mice and Rats
 AGING, CELLULAR SENESCENCE, TELOMERES,
AND CANCER
 AGING RESEARCH AND PREVENTIVE MEDICINE
 ANTIAGING RESEARCH: SOCIAL OBSTACLES AND
ETHICAL CONCERNS
2. Demography and
Epidemiology

 Aging of the Population in the United States
 Aging of the Population and Life Expectancy Around the World
 Life Expectancy at Different Ages
 Demographic Characteristics of the Aging Population
 Employment
 MORTALITY
 Leading Causes of Death
 DISEASE STATUS
 Prevalence of Common Diseases
 Health Care Utilization
 DISABILITY
 BEHAVIORAL RISK FACTORS
3. International Gerontology


 IMPLICATIONS OF GLOBAL POPULATION AGING
FOR HEALTH AND HEALTH CARE
 INTERNATIONAL COMPARISONS
 Overall Organization and Services Available for Older
Adults (see Chapter 15)
 Type of Health Care System
 Overall Organization and Services Available for Elderly
Persons
 Peculiarities
 Difficulties/Solutions for a Typical Geriatric Patient

 NEED FOR STANDARD ASSESSMENT OF HEALTH NEEDS

AND SERVICES ACROSS COUNTRIES
 geriatric medicine encompasses three
essential “bodies of knowledge.”:

•understanding the basic fundamentals
gerontology •of aging itself
•knowledge
•of the diseases that are more common in the aged than
in the

disease specific •middle-aged (such as Alzheimer’s disease), and

knowledge of

in geriatrics •how common diseases such as pneumonia,

hypertension, diabetes,
•or hypothyroidism differ in their presentation in old
age.
•Complexity, a focus on function,
complexity •and an emphasis on multidisciplinary coordinated
care management
•are each critical to geriatric medicine
 Ageing: the basics
Ageing (“aging” U.S.) vs. senescence
Senescence: “The decline of fitness components of an individual
with increasing age, owing to internal deterioration”
Michael Rose
Gerontology: The scientific study of the biological,
psychological, and sociological phenomena associated with
old age and aging
Geriatrics: The branch of medicine that deals with the diagnosis
and treatment of diseases and problems specific to the aged
Biogerontology: The study of the biology of ageing and
longevity
Biological Aging

 Biologist & gerontologist used concept of
senescence to explain biological aging
 Senescence or normal aging refers to a
gradual, time related to biological process
that takes places as degenerative processes
overtake regenerative or growth processes.

 Gerontology: How does ageing give rise to

ageing-related disease?

8
Characteristics of senescence are
as follows:

The universal process
The changes comes from
organism itself
The process occurred slowly
The process contribute to deficit

9
 According to biological approaches,
biological aging can be divided into 3
types

 Primary aging

 Is the basic, shared, inevitable set of gains or
declines governed by some kind of
maturational process
 Secondary aging
 Is the product of environmental influences,
health habits, or disease and is neither
inevitable nor shared by all adults
 Tertiary aging
 Refers to quickly deficit in the last few years
prior to death

10
Life Expectancy at birth

Human Survivorship
through History





Theories of Aging

 BIOLOGICAL THEORIES ON AGING
PROGRAMMED AGING RANDOM EVENTS
• Genetic life-span • Wear and tear theory
theory • Rate of living theory
• Genetic • Waste product
predisposition accumulation theory
theory • Cross-linking theory
• Telomere theory • Free radical theory
• Specific system • Autoimmune theory
theories
(Neuroendocrine • Error theories
theory) • Order to disorder 18
 THE BIG QUESTION
DEVELOPMENTAL—
GENETIC THEORIES

ENVIRONMENTAL—
NON- GENETIC THEORIES
 Genetic makeup  Due to random events that
determines factors occur over time
directly affecting aging  Aging caused by
 Programmed & environmental damage
directed in the body  Controlled extrinsically
 Aging is
Predetermined
20
 Programmed Ageing

 Aging and death are genetically determined and
are ‘programmed’ in organisms

Figure 1: The life history events of mammals, such as development, reproduction,21and

aging, typically occur in proportion to the entire lifespan.
 Genetic Life-span
Theory

 The length of life is genetically
programmed.
 One example is the lifespan of organisms.
 An organism’s life span is part of its genetic
makeup.

22
Telomere theory
 Telomere is the tail of

 chromosome that is made of

DNA but has no genetic
information.

 Telomeres protect the ends of

chromosomes from being
degraded and fusing with
other chromosome ends.

23
Telomere theory
 Telomere theory is based on

 the fact that every time a cell

replicate, it loses part of its
telomere.

 The older the cell (the more

time it has divided), the
shorter the length of
telomeres.

24
 As the length of a telomere
decreases, changes may
occur in patterns of gene
expression that could affect
 both the functioning of the
cell and the organ system in
which it operates.

25


 Mutation accumulation theory

Even in a population free of ageing, death will none the less

occur, from extrinsic hazards such as disease, predators and
accidents.
Number alive

Peter Medawar
Nobel Laureate for the
discovery of immune
tolerance
Age
 • Recurrent, deleterious, GERM LINE mutations occur
• Fewer bearers survive to express later-acting
mutations
• The force of natural selection against them declines
with age
• These mutations can therefore reach a higher
frequency under mutation-selection balance
Number alive

Age

Early acting mutation, Late acting mutation,

most bearers still alive, few bearers still alive,
strong force of weak force of
natural selection natural selection
 The Pleiotropy or Trade-off Theory for the Evolution of Ageing

• Suppose there are mutations are beneficial in youth, but

at the price of a higher rate of ageing
• More individuals will survive to express the early benefit
than will survive to suffer the higher rate of ageing
• Mutations like this can therefore be incorporated by
natural selection

George Williams
American
evolutionary
biologist

Ageing evolves as a side-effect of natural selection in favour

of mutations that cause a benefit during youth
 Neuroendocrine &
Hormonal Theory
Denckla (1974)
Endocrinologist
Gerontologist
Aging Mediated in Brain
Functional Decrements
in neurons and
associated hormones
dictates aging rates
32
BIOLOGICAL THEORIES OF AGING
Wear and tear theory

 Suggest that the body is much like a machine
 The human body ages because it “wears out” over
time in response to the stresses of life
 Some kinds of exertion or activity promote vitality
and are essential to long life
 Other kinds of stressful activities are detrimental to
longevity

33


34
 Cellular theories
Hayflict 
Cells grown in laboratory culture
dishes only undergo a fixed
number of divisions at most before
dying, with the number of possible
divisions dropping depending on
the age of the donor organism

35
 Cellular Theories
The Hayflick Limit (1961)
Pre-1961: “All metazoan cells are potentially
immortal. Ageing not cell autonomous”

Leonard Hayflick
Fibroblasts: connective tissue cells, e.g. from skin

Hayflick and Moorhead (1961)

•Isolate cells from human tissue, place in culture vessel with nutrient
medium
•Cells divide and form confluent layer on vessel surface
•Discard half the cells, allow remainder to grow to confluency = one
passage
•Continue to passage the cells
•Cell replication slows and stops after 50 ± 10 passages: cells have
reached the Hayflick limit and undergone replicative senescence

Is replicative senescence the cause of ageing?

Cross-linking
In which certain proteins in human
cells interact randomly and

produce molecules that get linked
in such way as to make the body
stiffer
Free radical
Aging is due to molecules which
are highly reactive chemicals
produced randomly in normal
metabolism

37
 ‘Superoxide theory of ageing?’
Radicals Non-radicals
---------------------------------------------------------------------------
Superoxide, O2.- Hydrogen peroxide, H2O2
Hydroxyl, OH. Hypochlorous acid, HOCl
Peroxyl, RO2. Ozone, O3
Alkoxyl, RO. Peroxynitrite, ONOO-
Hydroperoxyl, HO2.
---------------------------------------------------------------------------
Reactive oxygen species (ROS)
Reactive nitrogen species (RNS)

Oxidative damage theory of ageing

Metabolic Theories
Focus on the
relationship between
metabolicrate and aging
Somatic mutation theories
Maintain that damage to
or mutations in the DNA
of somatic cell impair
protein manufacture and
therefore alter the
structure and functions
of cells, tissues and
organs 39
 Immunological Theory
 Walford (1969, 1979)
 Reduced T-cell function with age
 Decline in Immune System Function
 Immune System unable to distinguish between self &
non-self
 Age associated increase in autoimmune disorders
 Lupus, Scleroderma
Cumulative Oxidative Damage
during
Aging

 The hunt for lifespan mutants
Short lived or long lived?
Michael Klass (1983): First screen for long-lived mutants

Tom Johnson (1988): age-1(hx546) mutation

65% increase in mean lifespan
110% increase in maximum lifespan
Remains youthful for longer Tom Johnson

Cynthia Kenyon (1993): Mutations in daf-2

greatly increase lifespan

Cynthia Kenyon
WHY SO MANY THEORIES?

“Number of hypotheses is
generally inversely
proportional to the clarity
of the problem.”
--Frolkis
 Biology of Aging

 Aging at the Cellular and Molecular Level











Interventions in the
Aging Process

 
 Cell-based therapies
 • Hormonal therapies
 • Genetic manipulations
 • Dietary therapies
 • Other: hypothermia, exercise








 Models of Accelerated Aging
• There are a small number of rare, inherited, diseases, of which Werner’s
syndrome and Hutchinson-Gilford syndrome are the most celebrated, that
have been mooted as possible examples of “accelerated” aging.
• Some of the physical features and symptoms of these diseases do
resemble, at least superficially, some of the changes that typically affect
older people, including in particular changes in skin and connective tissues.
• Hutchinson-Gilford syndrome, sometimes called “progeria,” is now known to
be caused by mutations in the gene for LaminA,a component of the nuclear
membrane.
• Werner’s syndrome patients usually have mutations in an enzyme (“WRN”)
that has activity as a DNA helicase (unwindingcoiledDNA) and as an
endonuclease.
• Patients with Hutchinson-Gilford syndrome typically survive to their early
teens, and Werner’s syndrome patients frequently survive to their mid-
forties, about 10 years after the age of typical diagnosis.
• Werner’s patients resemble elderly people in some ways: they frequently
suffer from cataracts and premature graying of the hair,and by their early
thirties often develop osteoporosis, diabetes,and atherosclerosis.
• On the othe Werner’s syndrome patients, for example, do not show signs of
Alzheimer’s disease or other amyloidoses, hypertension, or immune failure.
• Mesenchymal tumors, which are rare in normal people, are about100-fold
more frequent in Werner’s patients,but the epithelial and hematopoietic
tumors characteristic of normal aging are not seen in Werner’s syndrome
patients.
• it seems at least equally plausible that the WRN mutation, perhaps through
alteration of cells responsible for connective tissue maintenance, induces
multi-organ failure through processes quite distinct from the changes that
impair some of the same organs in normal aging.
Demography and Epidemiology

• Aging of the Population in the United States

• Aging of the Population and Life Expectancy Around the
World
• Life Expectancy at Different Ages
• Demographic Characteristics of the Aging Population
• Employment
• MORTALITY
• Leading Causes of Death
• DISEASE STATUS
• Prevalence of Common Diseases
• Health Care Utilization
• DISABILITY
• BEHAVIORAL RISK FACTORS
 Learning Objectives
• Describe the changing demographic
characteristics and longevity of the aging
population in the United States and
worldwide.
• Identify the leading causes of death and
common diseases affecting older adults.
• Gain understanding of the occurrence,
determinants, and consequences of
disability in the older population.
Squaring of the curve: ideal
situation
 Rectangularization of
Mortality
• The effect of social
improvements will be to raise
the survival curve upwards and
towards the upper right hand
corner. The presumed ideal
would be for everyone to
survive to some (as yet
unspecified) age, then die
relatively soon thereafter. This
alteration in the shape of the
survival curve is called
’squaring’ (or rectangularizing)
the survival (or life expectancy)
curve. Here is an example of
rectangularization over time:
 The demographic transition
• There are four stages to the classical
demographic transition model:
• Stage 1: Pre-transition
• Characterised by high birth rates, and high
fluctuating death rates.
• Population growth was kept low by
Malthusian "preventative" (late age at
marriage) and "positive" (famine, war,
pestilence) checks.
• Stage 2: Early transition
• During the early stages of the transition, the
death rate begins to fall.
• As birth rates remain high, the population
starts to grow rapidly.
• Stage 3: Late transition
• Birth rates start to decline.
• The rate of population growth decelerates.
• Stage 4: Post-transition
• Post-transitional societies are characterised
by low birth and low death rates.
• Population growth is negligible, or even
 Feminization of ageing
• The disproportionate life
advantage favoring
women over men
• has created a
progressive feminization
of the older population.
• Among individuals 85
years+, there are, on
average, 55 men for
every 100 women.
 The Generations (birth cohorts)
• Lost Generation (Born 1883-1900)
• Greatest Generation (Born 1901-1924)
• Silent Generation (Born 1925-1942…1946)
• Baby Boomers (Born 1946-1964)
• Generation X (Born 1964-early 1980s)
• Millennial Generation (Born early 1980s to early
2000s)

• Variation in experiences across and within cohorts

• Are the boundaries at all useful?
• Differences across countries challenging
Demographic Characteristics of
the Aging Population
• the elderly ratio, defined as the number of
persons aged 65 years and older divided
by the number of persons aged 20 to 64
years, multiplied by 100, is shown for the
total population and racial and ethnic
subgroups in 2000 and projected to 2050.
• more likely to live alone. A large proportion of
• men live with their spouses.
• Women are more likely to outlive their husbands not only
because they live longer but also because they tend to
marry older men.
• Modest percentages of older persons live with other
relatives, and a very small proportion live with
nonrelatives.
• Overall, women work less than men, but in a few countries, including the United
States,the percentage of women working rose during this time. In many
countries, there have been extremely large declines in the percentage of men
in this age group who work. For example, the percentage of men 60 to 64 years
old who were employed declined over this 25-year period from 76% to 47% in
Australia.
• An increase in societal wealth has been the main driving force for decreased
workforce participation, but other factors include obsolescence of the skills of
older workers, pressure for older workers to leave their jobs to make room for
younger workers in countries with high unemployment, and the growth of
 Medical Perspectives
Epidemiological Transition

1966 1981 1991

Pneumonia Cancer Cancer
Tuberculosis Hypertension CV Accidents
CV accidents CV accidents Senile disease
Infectious Dis. Accidents Pulmonary

US Department of Commerce: Economics and Statistics Administration

Global Aging into the 21st Century – 2000
• As in younger individuals, heart disease is by far the most common
cause of death, followed by cancer.
• The five leading causes of death—heart disease, cancer, stroke,
chronic lower respiratory tract disease, and Alzheimer’s disease
account for 69.5% of all deaths.
• Alzheimer’s disease, which in the past was rarely assigned as the
underlying cause of death and was not on the list of leading causes
of death, was the seventh leading cause of death in older persons in
2000 and in 2003 rose to the fifth leading cause of death,
responsible for 3.7% of deaths. This is still likely a gross
underestimation.
• On this logarithmic scale, a straight line increase indicates an exponential increase in mortality rate
with age. An exponential increase is present for all causes of death and parallel increases are seen
for heart disease, cerebrovascular disease, and pneumonia and influenza.
• The exponential rise with age for Alzheimer’s disease mortality is substantially steeper.
• The mortality rates for cancer and lower respiratory tract disease do not maintain as steep a rise
with increasing age, perhaps because the people who contribute in large part to these categories
are smokers, who die at younger ages and are less represented in the oldest segment of the
population.
• Diabetes mortality rates also do not showan exponential increase with advancing age, again
because diabetic patients may die disproportionately at younger ages.
• The one condition in this figure for which the mortality rate slope becomes steeper with advancing
age is accidents. Although motor vehicle accidents are an issue of real concern in older persons, it
is important to note, there are four times as many deaths from other types of accidents, primarily
falls, as from motor vehicle accidents.
 DISEASE STATUS
Prevalence of Common Diseases
 Health Care Utilization
• With increasing age, the number of physician visits increases steadily,and
persons aged 75 year
• there is a clear trend in both, with acute problems decreasing steadily with
increasing age and chronic problems rising with age and accounting for
almost 60% of office visits in persons aged 75 years and older.
• For every 1000 persons aged 65 to 74 years there are 259 hospital
discharges in a year, and for every 1000 persons aged 75 years and older
there are 427 hospital discharges in a year
 Incidence rates of specific cancers in men (top
panel) and women (bottom panel) by age. SEER
Cancer Statistics Review 1973–1998.
• both incidence and prevalence of dementia increase with age, with a
steep rise in prevalence after age 80 years, when the prevalence in
women becomes somewhat higher than in men.
• The incidence data show a clear rise in women to age 90 years and
older, but some leveling off in men after age 85 years.
• this relationship between incidence and prevalence indicates that
mortality occurs about 3 to 5 years after diagnosis.
DISABILITY
104
• The Figure shows results from the English Longitudinal Study on Aging, a
nationally representative sample of older persons in England.
• It demonstrates the prevalence according to age and sex of poor physical
performance, documented as an SPPB score of ≤ 8 and gait speed of < 0.5
m/s.
• Performance below these cut-off points has been demonstrated in
longitudinal studies to be strongly associated with multiple adverse
outcomes.
• Poor performance affects only about 10% of persons in their sixties but the
prevalence rises rapidly in the seventies and attains very high levels in
persons above age 80 years. Women have higher rates of poor
performance than men at all ages.
• The interplay among time of disability onset, duration of disability,
and time of death determines the number of years that older
individuals live in the disability-free state, termed active life
expectancy, and the number of years spent in the disabled state.
BEHAVIORAL RISK FACTORS
• An important role for epidemiology is to elucidate risk factors for
disease, injury, and disability
• Although certain risk factors that are potent predictors of major
diseases in middle age may have less or no impact at old age, most
behavioral risk factors continue to be important throughout old age
• Cigarette smoking, for example, continues to predict mortality even
in smokers who have survived past age 65 years, and stopping
smoking even in old age is associated with better outcomes.
What can explain this
phenomenon?
 Disability Statistics

• 1 in 5 Individuals will
suffer from some
kind of disability

• Data shows that half

of senior 65 + have
a disability

US Department of Commerce: Economics and Statistics Administration

Disabilities Affect One-Fifth of all Americans – 2000 Census Brief
 Key Clinical Points

• Improvements in survival over the last century have resulted in a

population with a large proportion of individuals who will survive to
advanced old age.
• Although there is much useful information gained by observing
individual diseases responsible for mortality and disability, a full
picture of disease status in the older population should include
consideration of co-occurring diseases.
• Disability status measures are the best predictors of adverse health
outcome, as disability measures capture the impact of the presence
and severity of multiple pathologies, as well as the potential
synergistic effects of these conditions, on overall health status.
 International Gerontology
• highlighting the consequences and implications of the global aging of
the population.
• In the economic area, population aging will have an impact on economic
growth, savings, investments, and consumption, labor markets, pensions,
and taxation.
• Also, this phenomenon will have a direct bearing on the intergenerational
and intragenerational equity and solidarity that are the foundations of our
societies. In the social sphere, population aging will affect health and health
care, family composition and living arrangements, housing, and migration.
Some of the inadequacies of health professional education and health care
delivery systems in meeting the chronic health care needs of aging
populations around the world are discussed.
 International Gerontology
The second section of the chapter describes how health care systems
around the world are preparing to deal with patients with
multiple chronic, degenerative diseases.
Information is provided about developed countries in four continents including
Canada and United States for North America; Iceland, Norway, United
Kingdom, France, and Italy for Europe; Japan for Asia; and Australia for
Oceania.
China is discussed as an example of the preparedness of the more densely
populated developing countries and those with the fastest growing economies.
For each country, the following information is presented: the principal
characteristics of the health care system; the organizational approaches
and the services available for older adults; and positive aspects, weaknesses,
and specific peculiarities. Each nation’s description ends with
a description of what would happen in a hypothetical example of an
87-year-old widow hoping to return home after suffering a stroke
with motor and speech deficits.
• The third section of the chapter illustrates the difficulty in
addressing these epidemiological changes without a global,
standard way of assessing the needs of older individuals. The
chapter describes the development of a minimum data set of
information that can be applied, independent of nationality,
language, and culture, to any health care setting.
• Finally, the chapter discusses the evidence that the unprecedented
demographic changes, which had their origins in the nineteenth and
twentieth centuries, are continuing well into the twenty-first century.
• The number of older persons has tripled over the last 50 years but it
will more than triple again over the next 50 years. In contrast with
the slow process of population aging experienced by the more
developed countries, the aging process in most of the less
developed countries is taking place in a much shorter period of time,
and is occurring on larger population bases. Such rapid growth will
require far-reaching economic and social adjustments in most
Aging Global Population
• The increase in life expectancy has
been paralleled—especially in
• the western world—by declining
fertility rates. has produced profound
effects on the labor market, the
financial resources, and other societal
factors.
• One example is the potential support
ratio, i.e., the number of persons
aged 15 to 64 years per one older
person aged 65 years and over.
Between 1950 and 2000, the potential
support ratio fell from 12 to 9 people
per each person 65 years or older.
• By midcentury, the potential support
ratio is projected to fall to 4 working-
age persons for each person 65 years
or older. Potential support ratios have
• These countries have among the highest life expectancy at birth,
• well over 80 years for all but theUnited States and United Kingdom.
In the next 50 years, the percentage of older adults will almost
double in each country, estimated to reach over a third of the
population in Italy and Japan
• More alarming, the dependency ratio (ratio of inactive population
• aged 65 years and older to the labor force) is projected to be close
to 50% in France, Italy, and Japan by 2020. This means that, for
every older adult, there will be only two persons in the labor force.
• over the period 2020 to 2050. By that time in Italy, for every retired
older adult, there will only one person in the labor force
 An 87-year-old widow who was living at home independently
and presented to an Emergency Department with signs of an acute
stroke would be evaluated immediately.
 Europe: United Kingdom
• Type of Health Care System
• a comprehensive National Health Service
(NHS), funded from taxation and (mainly)
free at the point of delivery and a system
strongly based on primary care, both as
provider of first line medical management,
and as gatekeeper to secondary care.
• At least five types of health care provider
can be identified, including GPs, hospitals,
newerNHS models, private providers, and
local government.
 Overall Organization and
Services for Elderly Persons
• General Medical Practices:
• They undertake routine medical care for acute and
chronic illnesses, including most immunization, vascular
prevention, and screening of those older than 75-year-
olds (once, but no longer, mandatory).
• The GPs are responsible for long-term prescribing and
medication review. They provide the primary medical
care for all care home residents. GPs under take a 3-year
training programme, 2 years of which is spent in hospital
specialities, but only some GPs will have training
experience in geriatric medicine.
• Hospitals
• Emergency admissions are via GPs, or open-access emergency
departments.
• Geriatric medicine is a well-established specialty, second in size only to
anaesthesia. Geriatric training involves 5 years of higher specialist training
following 3 years of junior hospital posts.
• Most geriatricians also practice general internal medicine, in particular for
unselected medical emergency admissions.
• Some subspecialization occurs, including falls, movement disorders,
continence, orthopedic, and old-age psychiatric liaison.
• All-age stroke medicine has emerged as a separate subspecialty, with the
majority of stroke physicians being geriatricians (not neurologists).
• The majority of older persons will not be admitted to hospital under a
geriatrician, however, and a lively debate continues about how to define the
most appropriate specialist for a given patient. Geriatricians
• operate in multidisciplinary teams including nurses and
• various therapists. Some have duties outside hospital (community
• Acute medical emergencies are usually
admitted to a single admissions ward
under the care of a general physician,
pending triage to specialty-based wards
(including specialist acute geriatric
medicine).
• Most older people will be discharged home
from these wards, but postacute
rehabilitation facilities (sometimes away
from the main hospital site) are common.
• Elective surgical patients will usually be
“preassessed” and admitted on the day of
operation.
• Those suffering complications or requiring
prolonged rehabilitation will often be referred to
geriatricians.
• In recent years, the UK government has made a
major effort to reduce waiting times for elective
surgery, which are rarely more than 3 to 6
months now, mostly benefiting older people.
• Old-age psychiatry is also well established, but
usually provided by separate psychiatric NHS
organizations, with variable levels of integration
with geriatric medicine.
• Over recent decades, they have concentrated on
community-based services and have few in-
patient beds. Older people with dementia who
suffer a crisis are more likely to be admitted
under physicians or geriatricians.
• There is virtually no remaining hospital-
• based long-term care.
• Newer Models of NHS Provision
• telephone
• consultation and triage service
• nurse-led,
• open-access minor illness facilities
• intermediate care
intermediate care
• to minimize acute hospital admission rates
• reduce
• length of stay.
• Models
• home rehabilitation
• rehabilitation provided in care homes
 Private Providers
• 5% of total UK healthcare expenditure mainly for elective surgery.
• joint replacement or cataract surgery, private sector providers
undertook up to 30% of operations, encouraged by long NHS
waiting times.
• private providers have supplied the majority of care home places,

• Most dentistry and optometry is privately provided (mixed-economy).

 Local Government Authorities
• Local authorities are commissioners of “social care,” but
this includes domestic and personal home care
(provided either directly or through private agencies),
including:
• meals at home, and daycare, and funding for care home
placements, including respite care.
• Some home-based social care schemes are very
intensive and sophisticated, such as specialist intensive
home support for people with dementia.
• resources are limited, and response times are often
slow, causing prolonged hospital stays
 Peculiarities

• development of intermediate care rehabilitation

• Not all models have a strong evidence base to support
their effectiveness
• Community case management by specialist nurses
intends to provide preemptive care to people living in
their own homes at high risk of hospital admission in a
crisis.
• Case loads are about 50 per nurse.
Difficulties/Solutions for a
Typical Geriatric Patient
 Developing Countries: China
Type of Health Care System
• China is an excellent example of the future prospects for countries of
the third and fourth world.
• In China, fertility rate dropped from 5.8 to 2.4 in just 10 years, from
1970 and 1980, and life expectancy increased almost 30 years, from
35 to 64 years, between 1950 and 1980. Thus, the transition, which
took around 150 years in more developed countries, took 50 years in
less developed countries, and only 10 to 20 years in China.
• If current demographic rates in China are similar to those of
developed countries, its economy and social welfare institutions are
more similar to less developed countries.
 Type of Health Care System
• The health care system in China is funded by a combination of state,
social insurance, and private payments.
• In general, costs of primary health care are covered only in part by
the state. Employees of the industrialized sectors are covered in part
by the social medical insurance, financed by contributions by both
the employee and the employer, and subsidized by the state.
Farmers, who account for 60% of the total population, are covered in
part by a cooperative medical insurance subsidized by the
government at both the state and local levels.
• These insurances cover both medical and drug costs up to 50% to
100%, depending on the types of care received and sectors in which
the care receiver is employed or was employed before retirement.
• As a result of the rising health care costs and limited coverage of the
existing social medical insurance, health care cost increasingly
becomes a burden to the majority of aged persons.
Overall Organization and Services Available for Elderly Persons
Care for elderly persons in China is administratively divided into two
categories—medical services and residential care—which are supervised,
respectively, by the Ministry of Health and the Ministry of
Civil Affairs.
Hospital care is the most frequently sought by aged persons.
China’s medical system was not originally designed to meet the chronic
illnesses of elderly persons and there is a lack of well-trained professionals
such as geriatricians and geriatric nurses.
Although general hospitals in large cities currently tend to have geriatric wards
to meet the needs of a rapidly growing aged population, physicians are usually
not systematically trained as geriatricians. Indeed, few medical schools
currently provide such training.
a lack of other options make the elderly population rely on acute care when
they have to deal with health issues.
• To reduce overuse of acute care resources
• to develop community medical services. To attract elderly people away from
large hospitals,
• most of the costs
• a growth of a variety of services targeting the older
• population in the community, including rehabilitation and nursing
• care.
• The narrow coverage of the existing insurance programs, which
• only cover approximately 60% of elderly persons living in urban
• areas and less than 10% of those in rural areas, is a serious barrier
• for elderly persons needing access to health care. A considerable
• proportion of the urban elderly population and the majority of the
• rural elderly population have to rely totally on themselves and their
• family to pay for medical services.
• Another problem of the health care system in China is the lack of
coordination between medical care and social care in terms of service
organization and finance. When an elderly patient is discharged from
hospital, it is likely that they will find it difficult to locate appropriate
intermediate care between hospital and home.
• Long-term care facilities are confined to providing residential services under
the regulations of the local bureaus of civil affairs. Very few facilities have
qualified nursing staff to provide professional nursing care. For those who
benefit from the social medical insurance, expenses related to long-term
care are not covered by the program.
• There is currently no long-term care insurance, though the need for such
insurance is growing rapidly.
• there is a long tradition of family members caring for their
elders at home. However, recent demographic changes
have resulted in older persons living longer and have led
to a decline in the availability of care by their families.
• Long-term care institutions for elderly persons can be categorized by
sources of funding as follows:
(1) municipal institutions
• where funding for investment and operation directly comes from the
local bureaus of civil affairs as public expenditures on social welfare
and these institutions are owned by the city governments;
(2) institutions funded by state enterprises in the urban areas or by
township government in the rural areas and these institutions are
owned by collectives; and
(3) institutions funded and owned by private investors.
• Three types of elderly persons become residents in the long-term
care institutions: those who have no income and family, those who
either themselves or their direct family members made publicly
recognized contributions to the state, and all others who need care.
• For the first two types of elderly residents, the institutional services
are paid for by the government agencies of civil affairs. For the last
category, services are charged to the care receivers and their
families.
• Peculiarities
• Due to the cultural tradition of family care for the elderly and the
scarcity of institutional long-term care resources, the overwhelming
majority of the aged remain at their own homes when they are in
need of care.
• However, the high rate of women’s labor force participation and the
reduction in the nation’s birth rate has seriously challenged this
tradition. China has implemented a family planning policy, which has
dramatically reduced the average number of children per family. An
unexpected consequence of such a policy is that more and more
people grow old in an “empty nest.”
• To meet the need of elderly persons while keeping the
tradition of family care, families in urban areas have
started to look for in-home caregivers. As there is an
oversupply of labourers in rural China and
• many migrate to urban areas seeking a job, there is a
reservoir of potential in-home caregivers, most of whom
are women. As caregivers only have limited education
and skills Institutional long-term care for elderly persons is
still underdeveloped, with currently insufficient capacity to
meet the demand.
• Lack of funding for services, shortage of professional
trained providers, and inadequacy in regulations to control
the quality of care in these facilities are currently the
major concerns about the development of elderly care
services in China.
 What type of treatment and services would likely be offered to an
87-year-old widow who was independent in ADL functioning,
cognitively
intact, and living in her own house but with few social
supports who suffers a stroke with motor deficits and speech and
swallowing troubles?

• Difficulties/Solutions for a Typical Geriatric

Patient
 NEED FOR STANDARD ASSESSMENT OF
HEALTH NEEDS AND SERVICES ACROSS
COUNTRIES
• Standardized assessments that consider
systematically several relevant
• areas appropriate to specific settings can
provide evidence of
• health and health service needs across
settings and locations. One
• such suite of comprehensive assessments
has been developed by an
• international group of researchers
gathered in a not-for-profit corporation,
 interRAI

• InterRAI is a crossnational collaboration of

geriatricians, researchers, and policy-
makers, primarily experts in long-term care
issues, dedicated to developing
assessment systems. Its members come
from 26 nations
• InterRAI, since 1990, has worked to design second generation
assessment systems characterized by comprehensiveness and
health care setting specificity.
• Also, following their implementation, InterRAI has used the
experiences of one nation to inform others, and to develop innovative
research approaches using the data generated by these
assessments. In 2006, InterRAI released a “suite,” covering all of the
major health care sectors devoted to eldercare, thus creating the third
generation of instruments.
• In particular,there are assessment systems that address the following
populations:
frail elderly persons in the community, home care, assisted living,
nursing homes, postacute care, palliative care, acute care, and inpatient
and community-based mental health.
• These standardized instruments offer the opportunity to doctors,
nurses, families, advocates, administrators, and public payers to track
changes in the older adults’ status across settings and over time.
THE FUTURE OF AGING