Independence and Economic Security in Old Age

Editors: Frank T. Denton,
Deborah Fretz and Byron G. Spencer
UBC Press, Vancouver, Toronto 2000
ISBN 0-7748-0788-1

Reviewed by: Dr. Goldlist

As a practicing geriatrician for over 20 years, I have always advised my patients (and others) to make sure that when they are old they are healthy and wealthy. I have been shocked over the years to see how often my sage advice has been ignored! Our knowledge about ensuring good physical health in old age is pretty rudimentary: eat properly, do not smoke, exercise regularly and pick long-lived parents. But a satisfying old age is also dependent on economic security. That is the topic of this excellent book, which summarizes a 3-year research program at McMaster University that started in 1995. The contributors are a distinguished group of Canadian investigators, and the book is firmly grounded in data.

Although not claiming to be comprehensive, the book covers many areas, all from a distinctly Canadian perspective. We are given mortality data (available functional data not being as accurate) that argue persuasively that, even if age 65 was once appropriate for defining old age, it is so no longer. The third chapter explains how population demographics are projected, and proves that the anticipated aging of the Canadian population is a robust finding, regardless of what fertility rates and immigration are assumed. I found Chapter 4, in which data and anecdotes about how seniors define independence are presented, both excellent and enlightening. There are several chapters that focus on older women. Once again, they are data driven and outstanding. I will not show my wife the chapter demonstrating that, among older women who live alone, those who have never married are financially much better off. Another chapter outlines the economic disadvantage of unexpected early retirement. Throughout the book it is clear that financial security is a tremendous issue for old age, one for which many Canadian are not adequately prepared.

This book is not meant specifically for physicians, but is a useful source of information for gerontological researchers. It is also of interest to anyone who anticipates growing old.

Decoding Darkness: The Search for the Genetic Causes of Alzheimer’s Disease

Rudolph E. Tanzi and Ann B. Parson
281 pages
Perseus Publishing, Cambridge Massachusetts, 2000
ISBN: 0-7382-0195-2

Reviewed by: Dr. Barry Goldlist

Clearly, the topic of Alzheimer disease (AD) is always of interest to a geriatrician such as myself. However, this book has a much wider appeal than simply for those with a particular interest in neurodegenerative disease. The book tells the story of Rudolph Tanzi and his part in the hunt for the genetic basis of Alzheimer disease. Since Tanzi started on the ground floor--in fact, he helped construct the ground floor--the book gives a wonderful overview of the development of molecular genetics as it pertains to AD. The structure of the book is superb, and the prose is clear; the author makes complicated concepts intelligible to the average reader, without ever seeming patronizing. The co-author of the book, Ann B. Parson, is an experienced science journalist, and I suspect her contribution to the book can be found in the elegance of the writing.

Why do I feel this book should have wide appeal, even to a lay audience? In addition to the skilled writing, the book can be read as a thrilling mystery story--albeit with the final mystery as yet unsolved. As well, it serves as a description of the process of medical science, from the inspired hunches of well prepared 'amateurs', to the smooth functioning of large academic laboratories, and further to the involvement of huge multi-national pharmaceutical companies and their indispensable role in drug development. Finally, it makes science 'personal' by giving glimpses of the foremost scientists in the field, describing their alliances and feuds, and their reactions to success and failure.

It was this last facet of the book that I found most interesting. The shifting alliances among the investigators (including break-ups within successful labs) remind me of Chaim Weizman's aphorism, 'great powers have no permanent friends, only permanent interests.' Tanzi himself seems like a very appealing individual, with wide interests (especially music) outside of science. He appears to be one of those rare individuals who is able to take his work seriously, without being too serious about himself. In fact, there are no real villains in this book. Tanzi himself hints at a hypothesis that I suspect might be true. The very nature of scientific breakthrough is predicated on competition. One can compare it to putting deadlines on labour negotiations; without them no serious bargaining ever occurs. Similarly, the thought that someone else might publish the 'breakthrough' article is a tremendous stimulus for an ambitious researcher. The big prize in this story was the discovery of the presenilin 1 gene on chromosome 14, the commonest cause of early-onset AD. The intense pressure, media scrutiny and cut-throat competition are clearly, and thrillingly detailed. For a University of Toronto faculty member such as myself, the result of the thrilling race was truly satisfying--the winner was Peter St George-Hyslop, the director of the Centre for Neurodegenerative Diseases at the University of Toronto.

As a preface to each chapter, Tanzi and Parson tell a bit of the story of the Noonan family, a large, Boston area kindred afflicted with early onset AD. This reminds the reader of the urgency that researchers feel in their race to understand the disease. One of the clear heroes in this book is the pathologist George Glenner who first characterized the nature of cerebral amyloid, a tremendous impetus for further research. He and his second wife established day centres to help care for victims of AD. Glenner was continually re-energized by his clinical work in those centres, once again providing a clear reminder that the passion shared by these researchers is not merely intellectual. It is worth reading this book to get a glimpse of that passion.

Another Small Step in the Battle Against Parkinson’s Disease

Neuropathological studies of the brain tissue from patients with Parkinson's disease (PD) reveal the presence of Lewy Bodies in dopaminergic neurons, although no one is sure whether these bodies are causal or a result of the disease process. Two individual proteins, a-synuclein and ubiquitin, are found to accumulate in the Lewy Body inclusions and, recently, research on these proteins has led to some interesting speculation about the causes of some rare familial forms of PD.

Missense mutations in the gene encoding the a-synuclein protein were found in families with an inherited autosomal dominant form of PD, and various mutations in the PARKIN gene were discovered in families with a rare autosomal recessive juvenile form of parkinsonism (AR-JP). A recent study by Shimura and colleagues has now provided a possible link between the mechanisms of disease for both types of familial PD. Knowing that parkin is a ubiquitin ligase, and speculating that parkin and a-synuclein might interact, they found that parkin regulates the degradation of an unusual form of a-synuclein through the attachment of ubiquitin. Ubiquitination of a protein by ubiquitin ligase usually targets that protein for destruction in the proteasome.

a-synuclein is a small phosphoprotein thought be to involved in synaptic vesicle transport. Normal a-synuclein has a tendency to form aggregates but neurons can get rid of these aggregates by labeling them with ubiquitin and targeting them for degradation, a system that apparently fails in patients with PD and AR-JP.

In contrast to the situation in patients with sporadic PD, the brains of AR-JP patients do not contain Lewy Bodies. Shimura et al. surmised that parkin might be required to catalyze the ubiquitination of a-synuclein; absence or impairment of parkin might lead to the accumulation of non-ubiquitinated a-synuclein. They found an interaction between a-synuclein and also found that the a-synuclein species interacting with parkin was glycosylated, giving it a larger molecular weight. The failure of mutant parkin to ubiquinate the glycoslyated a-synuclein means that neurons cannot degrade this form, leading to its accumulation in the brain. This suggests that the accumulation of glycosylated a-synuclein may be associated with the loss of neurons in AR-JP patients. To further support these studies it would be necessary to prove that other parkin substrates accumulate in the brains of these patients as well. Results of this kind have, in fact, just been provided by another study showing that another parkin substrate Pael-R (parkin-associated endothelin receptor-like receptor) does indeed accumulate in the brains of these patients. We'll await further research!

Sources

1. Shimura H, Schlossmacher MG, Hattori N, Frosch MP, Trockenbacher A, Schneider R, et al. Ubiquitination of a new form of a-synuclein by parkin from human brain: Implications for Parkinson's disease. Science 2001;293:263-9.
2. Imai Y, Soda M, Inoue H, Hattori N, Mizuno Y, Takahashi R. An unfolded putative transmembrane polypeptide, which can lead to endoplasmic reticulum stress, is a substrate of parkin. Cell 2001;105:891-902.

The Structure of Long-Term Care in Canada

Madhuri Reddy, MD, FRCP(C)
Associate Editor,
Geriatrics & Aging.

Background
Institutional long-term care (LTC) is expensive for both the individual and society.¹ As Canada's population ages, there will be growing pressure for institutional beds and greater interest in reducing or delaying admission to an institution.²

The structure and financing of LTC varies widely not only among, but also within countries.³ The Canadian health care system is federally-based, and although both federal and provincial levels of government contribute financially to the LTC system, individual provinces are ultimately responsible for the delivery of health care services.⁴

In anticipation of the growing population of frail elderly, several countries are in the process of reforming their LTC systems. There is a trend to change the purpose of nursing homes (NHs) to provide mostly for clients with complicated care needs.³ Researchers worldwide are investigating how to correctly determine clients' needs and how to create instruments that can appropriately assess these needs.⁵ LTC placement criteria are being optimized, alternatives to LTC are being explored, and many countries are expanding their community and home care services.³

Single-Entry System in Canada
In order to make the process of LTC placement more efficient and streamlined, a 'single-entry' system has been introduced in several Canadian provinces.

The Results are in and the Lucky Winners are

The results of the readership survey are in and the winners have been selected. Thanks to all of you who took the time to provide us with important feedback. As we said in the survey, we value your opinion!

Now, to the winners…

Reflecting our nationwide distribution, the winners of the survey come from across Canada.

Congratulations to our Grand-Prize winner of $1000, Dr. Rod Rabb of Richmond, ON and his administrative professional Mary Kavanaugh who wins $100. We hope you find a great way to spend the money!

Our runner-up was Dr. Wesley McKee of Saskatoon, SK and his administrative professional Nancy Downey, who will split $600 in winnings. In third-place was Dr. Jaime Caro of Dorval, QC and his administrative professional, Nicole Boyte, who will divide up $300.

Once again, thank you to the hundreds of people who participated in the survey and particularly those who identified topics, which are of particular interest to them. Those of you who specified surgery in the elderly as an area of interest no doubt enjoyed our surgery updates on Minimally Invasive Surgery and Total Joint Replacement. Keep your eyes open for the October issue on Perioperative Care.

The group who asked for more information on Skin Disorders and Nutrition will enjoy some upcoming articles this year but will be particularly pleased in 2002 when we will have entire issues dedicated to these topics. For those interested in Travel, see our Events and Conventions on page 10.

Many of you identified a problem with our current size and found the article continuations frustrating. We welcome additional commentary on this subject, as we are considering on moving to a regular magazine size for 2002. You can reach us at info@geriatricsandaging.ca.

Congratulations once again to our lucky prize-winners! Enjoy the rest of your summer!

Long-Term Care: It is Worth the Investment

In most jurisdictions, the number of people residing in long-term care (LTC) facilities at a single point in time is usually greater than the number of people who are in acute care hospitals. Yet far greater resources, both human and financial, are invested in acute care hospitals. Most of this disparity is, of course, quite appropriate. Acute care hospitals, with their short length of stay, actually treat many more patients than do LTC facilities. LTC facilities are primarily places of residence, with medical care added on where appropriate, and the expensive high tech approach of hospitals is neither wanted nor needed.

Despite this, it is difficult to believe that current resources in nursing homes are even remotely adequate. These resources are not just financial, although finances are certainly an issue. In the last few years in Ontario, the routine reimbursement for nursing home physicians has decreased by 25%. As well, in order for a physician to bill, the new rules require that he or she have face-to-face contact with the patient. No remuneration is provided for conferences with the rest of the health care team. This is making it increasingly difficult to convince physicians that being an attending physician in a LTC facility is worthwhile. Remuneration to the homes has not kept up with 'medical inflation,' and each year it seems that fewer personnel with professional qualifications are actually working in our LTC facilities. Even the physical environment of many LTC facilities leaves much to be desired. Lack of governmental funding for construction means that in many provinces private companies are the predominant providers of LTC.

However, there is also an information gap in our LTC facilities. Part of this is because of a general lack of knowledge of medical issues in the nursing home setting. Only in the last two decades has any significant effort been invested in advancing medical care within the nursing home by conducting research on these residents. Numerous articles have attested to the fact that improved care can benefit a number of objective outcomes, such as incontinence, falls and fractures.

In this edition of G&A we have a superb series of articles on Heart Disease in the Nursing Home, edited by one of North America's leading geriatric cardiologists, Wilbert Aronow. There are articles on stable coronary artery disease, congestive heart failure and endocarditis prophylaxis. Two other articles in this series, acute coronary syndromes and pacemakers, will appear in a later issue. Our own Associate Editor, Madhuri Reddy, reviews the structure of LTC across the country, and Gina Bravo discusses the details of LTC in Quebec.

There is also an interesting article on quality indicators in LTC by Jean Chouinard. I believe that the fundamental reason for the lack of resources invested in LTC is the societal belief that it is not worth the investment. Obviously, as a geriatrician, I believe that LTC is absolutely worth the investment and establishing guidelines for quality LTC is of crucial importance. Unfortunately, it is often more difficult to measure quality in LTC, as the simple measures (mortality, return to work etc.) that are relevant in acute care are not necessarily so in LTC facilities. When colleagues of mine, who previously were unconcerned about quality in LTC, have parents or grandparents admitted to LTC facilities, it is amazing to watch them transform into believers! If we believe that the frail elderly in nursing homes (and not just our own family members) deserve quality care, we must work towards it. The first step in that effort is defining and measuring quality indicators.

Let us not forget that many of us will end up in LTC facilities, when quality of care will suddenly become of paramount importance. Enjoy this issue.

Long-Term Care in Quebec: Its Structure and Impact on Older Adults

Gina Bravo, PhD
Head, Department of Community
Health Sciences,
University of Sherbrooke
Researcher, Research Centre,
Sherbrooke University
Geriatric Institute,
Sherbrooke, QC.

Introduction
Over the past 30 years, as in all provinces across Canada, the population has aged rapidly in Quebec. From 1901 to 1971, a span of 70 years, the proportion of people aged 65 and over increased by only 2.1%: from 4.8%-6.9%. By comparison, it will rise by 21% in the next 70 years. In fact, according to recent projections, 28% of the people living in Quebec will be over 65 by the year 2041.¹

While a majority of older adults consider themselves to be in good health, a significant proportion suffers from impairments that require long-term care. The Canadian Health and Activity Limitations Survey established the prevalence of physical impairments among people aged 65-74 years old at 31%; it is 55% in those over 75. While most elderly individuals live with family members, partially compensating for their impairment, many live alone or with a spouse who also suffers from impairment.²

A Historical Perspective

Introduction of new services
In response to the increasing health care requirements of an aging society, provincial health authorities developed a broad range of services adapted to the needs of the aged.

Age Integration in Long-Term Care

Peter Uhlenberg, PhD
Jenifer Hamil-Luker, MA
Department of Sociology,
University of North Carolina,
Chapel Hill, NC, USA.

Towards the end of life, many older people experience physical decline that forces them to depend upon others for care. This loss of independence, never an easy life transition, is often made more difficult by the limited opportunities that those in long-term care (LTC) have for interacting with other people. Yet, as all sensitive medical professionals know, older adults in LTC, like people at every other stage of life, need meaningful social relationships in order to thrive. Thus, it is unfortunate that long-term care institutions tend to be highly age-segregated, providing few chances for older residents to develop and enjoy friendships with children and young people. It is not necessary, however, that social isolation and age segregation be the common experience of those in LTC. This article reports on efforts to promote intergenerational relationships in LTC, the potential benefits of greater age integration, and research findings of what conditions facilitate positive outcomes from exchanges between children and older adults in LTC.

Benefits of Age Integration
Nursing homes, assisted living facilities and day care providers are increasingly bringing the young and old together on a regular, formally planned basis to build enduring, mutually beneficial relationships.

Indicators of Quality Care in Long-Term Care Facilities

Jean Chouinard, MD
Medical Director,
Complex Continuing Care Program,
SCO Health Service,
Ottawa, ON.

Background
The likelihood of admission to a nursing home (NH) is very much age-related. Roughly 5% of patients over the age of 65 live in institutions; this proportion rises to 50% for people aged 90 and up. With cutbacks in health spending, and the rising demand for this type of care, the NH populations are becoming increasingly frail and often have multiple coexisting active health problems on a background of precarious homeostatic reserve. Currently, over 50% of our inpatients are totally dependent on help for their care. Only 15% of these inpatients can ambulate independently. Such patients are also at much higher risk of complications. In our facilities, the yearly incidence rate of pneumonia is 200% (!), with a case fatality rate of 30%. Between 5 and 10% of patients admitted to Ontario Chronic Care Facilities will develop a pressure sore every quarter. Annual mortality rates in institutions range from 15 to 30%.¹

Some definitions--in much abridged version²
A care process is a series of sequential or parallel interactions among clinicians and between clinicians and patients aimed at a given outcome.

The Global Aging Phenomenon and Health Care

Alexandre Kalache, MD, PhD,
Chief, Ageing and Life Course (ALC),
World Health Organization,
Geneva, Switzerland.

Ingrid Keller, MSc, MPH
Associate Professional Officer, ALC,
World Health Organization,
Geneva, Switzerland.

Introduction
Within the next few decades, one of the defining features of the world population will be the rapid increase in the absolute and relative numbers of older people in both developing and developed countries. We are currently at the threshold of global aging. Worldwide, the total number of older people--defined as those over 60 years of age--is expected to increase from 605 million in 2000, to 1.2 billion by the year 2025.¹ Currently, approximately 60% of older persons live in the developing world, a number that is expected to increase to 75% (840 million) by the year 2025. Figure 1 shows the proportional increase of older persons among the total population for some developing countries as compared to the Canadian population.

In the year 2000, in a number of developed countries, there were, for the first time, more people aged 60 and older than there were children under the age of 14.¹ Population aging could be compared with a silent revolution that will impact on all aspects of society. It is imperative that we are adequately prepared for it: the opportunities and the challenges are multiple.