In the December 99 issue of SMA News, Dr Philip Choo described the challenge of delivery of care for the elderly.

The rapid aging of Singapore will affect many levels – the individual, family, society and country. Almost all households will have an elderly. In developing a plan to look into the potential problems of rapid aging, it is important to note its multifaceted nature and the approach undertaken has to be based on sound fundamentals that reflect a broad and varied approach.

Preparations in anticipation of the aging population, like one’s own retirement planning, requires time. It is essential to get the policies and service in place before a significant proportion of the population ages in the first decade of the next country.

It is important that each individual undertakes personal responsibility to ensure successful aging for himself. The focus is on adopting a healthy lifestyle, developing strong family bonding and ties, sound financial security and adequate housing needs. In this way the burden to family, health service and future generation will be minimised. Each generation takes care of itself without passing on the burden to the next. It is not feasible for a declining working population to support an ever increasing elderly population.

Families remain the major source of support for the elderly; however this burden will increase and support will have to be given to them in caring for their elderly. The elderly where possible and appropriate should live and be cared for in the community. Though we would encourage the elderly to live with their families, it may not always be their preferred choice. Those elderly who need institutional care should be provided for appropriately.

Geriatric Medicine was introduced in Singapore in 1988 with the conversion of Department of Medicine Unit I into a Department of Geriatric Medicine in Tan Tock Seng Hospital. There are currently three Departments of Geriatric Medicine in Singapore. From its earliest onset, the focus was on the old-old or frail elderly. The patients are usually above the age of 80 years with multiple medical problems. Syndromes very commonly found in this group include immobility, imbalance (falls), incontinence and impaired cognition (confusion).

The traditional system of care and the approach of organ-based medical specialties are generally suited to the younger, single-organ pathology patients. Families are however often overwhelmed by the unaddressed functional continuing needs of their "cured and treated" frail elderly relatives. Discharge of this group of patients from hospitals is frequently delayed, essentially due to the fragile and under developed community service. Inappropriate transfer to nursing homes under such circumstances frequently occur, creating unnecessary institutionalisation and loss of independence.

The aims of a geriatric service would not be to reduce the risk of deaths or prolong life but rather, maintain or improve the quality of live, reduce disabilities and promote independence. This can be achieved through prevention and early intervention programmes, appropriate holistic medical care, effective rehabilitation, organisation of support services and appropriate home placement.

What geriatric care does is to appropriately meet the varying medical, functional and social needs of elderly patients (Figs 1a & 1b). It is important for the physician looking after frail elderly patients to be closely acquainted with services outside the hospital settings as hospital stay is only a phase in the treatment and care of the frail elderly. The skills crucial to the Geriatric Physician apart from general medicine and geriatric medicine includes rehabilitation skills, knowledge of psychiatry of old age and a sound working knowledge of the range of available services in the community.

(Fig 2)

There are four components in a Geriatric Service. They are:

1. Services to maintain the well elderly

(Eg. Health prevention campaigns, Healthy lifestyle programmes, Case-finding programmes). All these aim at early detection of illness and prevention of lifestyle-related illnesses.

2. Hospital Services for the ill elderly

(Eg. Acute geriatric care, day hospital, outpatient clinics and specialised services such as memory clinics, falls clinics etc and rehabilitation services). These essentially meet the medical and functional problems resident in the common geriatric syndromes of the frail elderly.

3. Community Support Services

These are services which help the carers and elderly to be maintained in the community. There can be divided into two broad groups.

a) Health Services eg. Senior Citizen Health Care Centres (SCHCCs), Home Nursing Foundation (NHF), Domiciliary Medical Care.

b) Social Services eg. Home Help, Befrienders, Medical Services, Social Day Care.

4. Placement Services

These are for the very frail elderly where supporting them with community services would be inadequate. Placement services include nursing homes and chronic sick beds.

It can be seen that services for the elderly must have both continuity and comprehensiveness. The continuity allows the elderly to smoothly and easily proceed onto the most appropriate level of care as they experience increasing degrees of ill health and disabilities. The comprehensiveness enable the varying types of help needed by the elderly and their caregivers to be met. It is essential to have a central coordinating system that can efficiently plan and effect the nature of geriatric services and ensure their appropriate use.

It is important that all four components of the services develop at the same time and in the right proportions. An inadequate service provision in any one component would place a greater burden on the others as well as give rise to inappropriate utilisation and increased costs.

Geriatric medicine differs from other medical specialties mainly because it goes beyond traditional medical problems to encompass rehabilitation, community support and home placements. No hospital can have an effective geriatric department if there is no coordination or support from the community services. Under such circumstances, a geriatric department will able to attend to only the medical needs and at best fast-stream rehabilitation. It is also important to remember that community services, in turn, will need the expertise from hospitals.

From the patients’ viewpoint, continuity of care is maintained. Thus the same geriatric team follows them through each phase of acute care, rehabilitation, day hospital and supervision of community care. Movement from community to hospital, if required, can also be facilitated.

For the implementation of this seamless care the following would be essential: