Discussion Session: Chronic Disease and Aging: The Challenge of Alzheimer’s Disease

Speakers: Dr. Bergman, Dr. Ménard, and Dr. Banerjee

Moderator: Paule Lebel, MD, MSc, CSPQ, FRCPC, Director, Centre d’expertise sur la santé des personnes âgées et des aidants (CESPA), Institut universitaire de gériatrie de Montréal; Member, Task Force charged with proposing a Quebec action plan on Alzheimer’s Disease and related disorders.

Dr. Lebel moderated a question period among three physicians tasked with proposing action plans or advising governments and institutions about healthcare decision-making and policy development aimed at better managing increasing numbers of patients with Alzheimer’s disease.

Dr. Lebel echoed Dr. Banerjee’s emphasis on the need for early diagnosis followed by the prompt provision of care and services that promote autonomy as the disease course progresses.

Dr. Bergman responded to a questioner’s concern that the model of care set forth in his presentation failed to account for service and resource disparities between urban and rural settings. Dr. Bergman acknowledged that there is unequal distribution, and that a possible approach could involve setting specific goals about the geographical locations of memory clinics to equalize access. He advocated additional remuneration and financial incentives to encourage professionals to practice in underserved areas. He further suggested that services such as telehealth could play a vital role in helping to cover rural areas with modest access to health personnel and services. Possible solutions to filling such care gaps, and meeting the needs of a heterogeneous population affected by dementing disorders (e.g., with multiple morbidities), could be yielded by pilot programs that seek to close these gaps and through service implementation strategies with 5-year objectives, tasked to meet specific goals in care improvement. Dr. Bergman urged input from practitioners sharing the questioner’s concerns.

Dr. Banerjee responded to a query from a physician concerned that a strategy that trains its resources toward early diagnosis could fail to take action at preventive stages. The questioner wondered how efforts aimed at lifestyle and behaviour modification could inform the national strategies discussed. Dr. Banerjee affirmed that England’s national strategy treats public education as essential to its approach. Communicating vital information about modifiable risk factors for dementia (e.g., the vascular risk factors, the correlation with diabetes and obesity) is part of the strategy. Without this component, Dr. Banerjee agreed, any national strategy on dementia cannot fully succeed.

Dr. Ménard was queried about the role of general practitioners in diagnosing dementia, and whether it is the case in France that the diagnosis may only be provided by a specialist. The questioner noted that there is a strong effort to enable family physicians to diagnose the disease, and to promote such training. Dr. Ménard described the responsibility of diagnosis as shared. Given that tests of 2–3 hours’ duration are performed, this is beyond the family physician’s scope and a geriatrician’s services are needed. However, pragmatic case management must be executed by the GP, he stated, and each family in France is required to designate a GP as this individual will request reimbursement. He emphasized the family physician’s role in initiating the diagnostic process, as the GP is often the one contacted about problems of memory and cognition. The challenge within the current system, Dr. Ménard explained, concerns patient tracking and case management. Physicians may be disinclined to manage cases of patients with dementia as these individuals may form a modest segment of their practice but consume disproportionate resources. He suggested that a useful change would raise the salary cap for case management; ultimately, all GPs would follow some dementia cases at various states of progression.

Dr. Banerjee added that a complication with diagnosing dementia in the primary care setting is that while diagnosing a case of severe dementia is easy, early diagnosis is challenging. Further, he quoted a study that found that over the last decade, physicians have become less confident in their ability to render the diagnosis, reflecting the sense that diagnosing dementia is perceived as complicated and time consuming. Many are anxious about whether they could correctly diagnose the condition. Dr. Banerjee offered that, under a different service and care alignment, wherein memory services would be folded into memory clinics, a wider array of diagnostic and management services could be accessed. Such arrangements are not yet common but are an evolution in healthcare provision he hoped would soon become customary.

Dr. Bergman noted that ever since the 1st Canadian Colloquium on Dementia in 1989, Canadian experts have emphasized the role of primary care in detection, diagnosis, and treatment. He disagreed that a GP could not make a diagnosis of dementia if the proper conditions for making a sound diagnosis were in place. Isolated GPs lacking a wider network to support the diagnosis and management may be hampered in doing so, but a physician situated within a group practice and a support system with trained nurses and appropriate information technologies can, if he or she is trained and works with sound criteria and available referral. He cautioned against general reliance on specialists such as psychiatrists and neurologists, who may not necessarily have the interest or training in detecting dementia. Dr. Bergman hoped to see an end to the practice of patients being “lost” by their general practitioners once they have been referred to secondary care.

Dr. Banerjee added that the situation is apt to change once healthcare systems better incorporate a category such as “GPs with specialist interest.” General practitioners with appropriate training in dementing illness are well situated to render such a diagnosis, but he noted that there are at present too few working within the UK (fewer than 10).

Alzheimer’s Disease: A Chronic Illness
The Alzheimer’s Disease Plan: England

Speaker: Sube Banerjee, MD, MSc, FRCPsych, Co-lead, Development of a National Dementia Strategy; Senior Professional Advisor, Older People’s Mental Health, Department of Health, England; Professor of Mental Health and Ageing, The Institute of Psychiatry, King’s College London.

Providing dementia care in the United Kingdom currently costs £17 billion annually and is rising. Given that Alzheimer’s disease is predicted to double in prevalence within the next 30 years, affecting approximately 1.4 million people, Dr. Banerjee stated that the need for an improved national dementia strategy in England is inarguable.

Dr. Banerjee, co-lead for the development of a National Dementia Strategy for England, observed that the costs for dementia—which are projected to reach £51 billion when the prevalence doubles — are already higher than the combined costs for cancer, cardiovascular disease, and diabetes. The majority of the money is spent on care placement, serving only one-third of those with dementia. A National Audit Office study found that money is being spent poorly, spent late, and spent on uncoordinated services.

The strategy, (published in full in February 2009), encompasses four main themes, Dr. Banerjee explained: improved awareness, early and better diagnosis, improved quality of care, and strategy implementation to improve patients’ quality of life.

Dr. Banerjee stated that the stigma preventing people from disclosing symptoms to professionals also manifests among healthcare providers themselves. The consequence is undertreatment at early stages: clearly, a diagnosis must be in place so that services can be accessed. False beliefs he described as pervasive include, one, the sense that dementia and memory problems are part of growing older and need not be addressed by a GP, and two, since disease process-modifying drugs are not yet available, nothing can be done to alleviate dementia’s effects. These beliefs persist despite abundant study data showing the benefits that accrue with psychosocial and educational interventions.

The aim for earlier diagnosis meets a formidable obstacle: only one-third of people ever receive a formal diagnosis and often only when it is too late for them to partake in decision-making.

The Department of Health has funded a pilot of a model of service provision in early intervention, the Croydon Memory Service Model. It represents an “evolution” of the memory clinic, according to Dr. Banerjee. Its services are aimed at early/moderate dementia. The service, which is designed to be reproducible, features clinical teams trained in generic assessment, uses referrals from GPs and social services, home assessment, manualized assessment with standardized tools, diagnosis and management planning, provisions for social care packages, psychological care, medication, continuity of care, and case review. He described the virtue of the model as enhancing the capacity to make the diagnosis well, deliver it well, and follow up with immediate individualized care and support. Follow-up detected significant quality of life improvements as well as drops in behavioural disturbances.
Improving quality of care involves advancing the message that services can enable people to live a good life with dementia. Modifying dementia services in general hospitals, providing intermediate and respite care, improving home care as well as care homes, and bettering registration can all improve quality of life for dementia patients.

The report’s final theme focused on delivering the strategy and calls for local implementation, regional support, and national coordination in the dissemination of information, research, and support for implementation. While the cost investment is significant, he notes that care homes cost approximately £7 billion per year. If only 10% of referrals to long-term care were delayed, the cost investment in the new strategy would break even, according to Dr. Banerjee.

He concluded that quality improvement in dementia care requires vision, system change, ambition in scale, investment, commitment over time, and leadership. The developing national strategy offers a simpler, more effective care pathway.

Alzheimer’s Disease: A Chronic Illness
The Alzheimer’s Disease Plan: France

Speaker: Joël Ménard, MD, Professor of Public Health, Faculty of Medicine Paris-Descartes; Author, Alzheimer’s Disease Plan: France.

Dr. Ménard served as author of a report on the National Plan on Alzheimer’s and Related Diseases 2008-2012, commissioned by French President Nicolas Sarkozy. The report’s multiple objectives included advising on ethical concerns, research approaches, therapeutic methods, and care delivery. While efforts to further the patient-oriented national initiative continue, Dr. Ménard described the progress made in creating a national plan aimed at enabling researchers from differing domains (clinical care, research, government) to collaborate in long-term efforts to improve Alzheimer’s disease (AD) care at international, national, and local levels.

The initiative represented formal recognition that Alzheimer’s and related dementias meet criteria distinguishing key health priorities, according to Dr. Ménard. Specifically, dementia affects a large number of people; significant Disability-Adjusted Life Years are lost (DALYs); the incidence and prevalence of AD within an aging social demographic are growing; dementia produces significant emotional and practical difficulties for families and caregivers; and the condition requires complex medical and social care with correspondingly high costs.

The need for a national plan was also brought into focus as research better defined the growing burden of dementia in France. Dr. Ménard presented comparative data suggesting that the impact of AD compared to other illnesses such as cancer and cardiovascular disease is growing in significance, and in women specifically is now the most burdensome, producing the most DALYs lost.

The plan combines a concerted financial effort (200 million euros for research, 200 million euros for medical care, 1.2 billion euros for medico-social support) with a broader initiative to develop insights into the disease process and efforts to improve the quality of life of people with dementia and their caregivers. The committee reports to the Inspector General of Finance, and the Steering Committee and supervisory committees meet regularly. Finally, there is a working session with the President every 6 months.
The French national plan aims to facilitate the work of multidisciplinary centres. The goal is to attract new medical research teams and connect their work with existing teams, encourage young researchers to pursue dementia-related themes, and advance a national policy supporting PhD and postdoctoral researchers. There is also federal support for a scientific foundation aimed at attracting national and foreign researchers. The aim is to harmonize interprofessional efforts to coordinate the talents of those in different disciplines such as patient care, coordination and conducting of clinical trials, neuropsychology, neuroimaging, and biomarkers study.
The bulk of the research investments under the 2008-2012 Alzheimer plan is earmarked for basic research and biomarkers (70 million euros) and clinical research (45 million euros).

As a major component of the plan involves improving quality of life for patients and caregivers, part of the initiative includes developing better respite care services, funding facilities where families can be housed and patient day centres, and financing two training days for caregivers. Other initiatives include funding of memory clinics.

According to Dr. Ménard, the plan reflects a local vision that directly involves individuals, in addition to facilitating noninstitutional care programs.
Dr. Ménard concluded that the promise of such plans is that research and clinical advancements made in AD prevention and management will serve other chronic disease models and better patient care overall.

Panel Discussion: Chronic Disease and Aging: Applying the Chronic Disease Model and Preventive Care among the Aged

Speakers: Dr. Wagner and Dr. Clarfield

Moderator: Renaldo Battista, MD, MPH, ScD, FRCPC, Professor, Department of Health Administration, Faculty of Medicine, Université de Montréal (DASUM).

Dr. Battista moderated a discussion focused on modifying the manner in which chronic care is delivered to the elderly, as well as the applicability of preventive care measures to a frail older patient segment. He observed that speakers Dr. Wagner and Dr. Clarfield offered differing but pragmatic approaches.
Audience members addressed continued concerns about the consequences of modifying surveillance of patients receiving chronic care. Dr. Clarfield had echoed Dr. Wagner’s and Dr. Kane’s call to replace the practice of regularly scheduled follow-ups with visits prompted by alterations in the patient’s condition or in response to flares of illness. This prompted requests for examples of how teams and systems following this model currently function.

Dr. Wagner responded that the best use of such a system involves reliance on an electronic patient registry that carefully tracks conditions and the dates of major illness-related events. For example, doctors can access the database to monitor who, among his/her patients with diabetes, has not presented for a follow-up visit in longer than 3 months. It was reiterated that such a surveillance model is meant to serve a proactive model of care of planned interactions that involves partnership between patient and physician.
Physician-patient interactions would not conclude without some discussion of follow-up, which can be electronic rather than an in-person visit. The registry facilitates the gathering and accessing of critical information, such as the date of events. A good registry enables proactive care, Dr. Wagner stated. Improved systematic follow-up triggers visits at critical health junctures, and structures key health information according to its salience.

Other questioners voiced concern about events of psychological and social impact that affect health markers. Isolation and bereavement, for example, are correlates of health decrements. Dr. Clarfield agreed that these events impact health but can be hard to medicalize or approach objectively. Here he argued for the role of public health to intervene in this domain. Dr. Clarfield suggested that the numerous supportive communities developing for the aged in Israel could serve as a model. These communities function to prevent isolation and its consequences. He cautioned against the impulse to medicalize social problems.

This prompted consideration from listeners and the panelists on whether the model of chronic disease management could potentially lose sight of the individual person.

Dr. Wagner spoke of this loss as a consequence of the structure of research and data within the chronic disease/chronic care model. Individuals with chronic disease become identified and labeled as such, leading to theoretical and practical imprecision between addressing the person with diabetes versus management of diabetes per se. This may also be a consequence of the problem’s scale, he claimed: Dr. Wagner noted that 25% of people over the age of 65 have four or more chronic conditions. Improving management of multi-morbidity is essential. This necessitates an individualized approach, which may alleviate the forces that would contribute to generalizing patients broadly according to chronic health conditions. He noted that research is beginning to study the patient with specific interrelated health markers, such as heart disease plus depression.

The speakers were asked to elaborate further on the subject, given that acute hospitals are increasingly labouring to manage individuals with multiple diseases and nonspecific deterioration. How is the case for the chronic care model approach within the hospital to be made?

Dr. Wagner stated that children’s hospitals should be consulted as models, as they better integrate the role of the multispecialty practitioner and utilize a systematic approach. These hospitals are experiencing some success at caring for children with complex environmental and genetic problems, he claimed.

He further discussed creating closer links between public health and the chronic care model, based on his and colleagues’ experiences of working with the Centers for Disease Control and state health departments. There they have been implementing the chronic care model with quality improvement initiatives. Specifically, they have observed benefits associated with public health supporting the development of multilevel care systems. Public health can play a key role in facilitating development of community-based resources for providing care such as peer support and exercise programs. Public health can also facilitate the implementation of good information technology.

Finally, the issue of medical training was brought to the speakers’ attention. The panelists concurred that if medical education merely upholds and exemplifies the traditional healthcare delivery system, trainees will understandably opt out of primary care. Dr. Wagner and Dr. Clarfield concurred that if effective systems of care can be developed, trainees will choose it.

Chronic Disease and Aging: Prevention in the Elderly Person—Can We Get it Right?

Speaker: A. Mark Clarfield, MD, FRCPC, Head of Geriatrics, Soroka Hospital, Sidonie Hecht Professor of Geriatrics, Faculty of Health Sciences, Ben-Gurion University, Israel.

Dr. Clarfield suggested the need for greater nuance to two key terms: prevention and elderly. Preventive measures recommended are not always appropriate for frail elderly adults, who are a heterogeneous population—some 80-year-old patients have years of vigour ahead, whereas others may require institutional care.

While preventive care is increasingly advocated, he noted that doctors are temperamentally ill-suited to doing substantial amounts of preventive care. They are well-trained to note the signs of health impairment that precede health decrements, and therapeutic efforts are more effective at these earlier stages.

At later stages of life, the benefits that accrue to screening are more modest. Screening, further, may fail to detect problems due to biases, e.g., lead-time biases. The oldest patients have lower physiologic reserves, more comorbidities, and more polypharmacy. Good data about the oldest-old are scarce. Additionally, preventive care can be time-consuming and may lead inexorably toward aggressive interventions that may not coincide with the wishes or best interests of the patient. Some of the screening recommendations are not appropriate for the eldest frail patients. Therefore, Dr. Clarfield ascribed greatest importance to confronting the symptoms that patients report.

As for the value of screening, he advised that data on mortality and life expectancy yield important information. The healthiest quartile have 10 years left to live and may see some benefit from screening, but those with poor health markers, often in long-term care, have often less than 3 years.
Dr. Clarfield further recommended considering the sensitivity and specificity of tests. In a context of finite resources, it is important to avoid the testing spiral. Further, it is essential to note risks as well as benefits to screening: for example, there is a risk of perforating the colon on colonoscopy. Patients should be involved interlocutors and physicians must remain cognizant of their values—patients may not want aggressive testing. This is particularly so when it comes to mammograms, where benefits can be modest.

He then recommended pursuing prevention measures within comorbidity. An example he outlined concerned falls prevention. He advocated identifying a vulnerable patient subgroup, e.g., those on Coumadin, at which to direct specific preventive measures.

Involving other health professionals to maximize resources, and improved health behaviours, may yield better benefits than screening. He identified the four primary areas of risk-factor modification: smoking cessation, moderate alcohol consumption, adequate intake of fruits and vegetables, and exercise.
At advanced stages of life he advised reconsidering or discontinuing pap smears, PSA testing, and coronary calcification measurements. In turn physicians should reconsider or commence moderating polypharmacy, assessing falls risk, and checking vision and hearing. Dr. Clarfield concluded that prevention can be effective if it is well-targeted. Clinicians should review available evidence and add their own clinical judgment. Preventive measures can benefit the elderly, but the risk-benefit ratio changes unpredictably with advancing age and frailty.

Chronic Disease and Aging: Applying the Chronic Disease Model to Older Persons

Speaker: Edward Wagner, MD, MPH, FACP, Director, MacColl Institute for Healthcare Innovation, Group Health Cooperative, University of Washington.

Dr. Wagner observed that primary care is increasingly dominated by chronic illness and geriatric care, but the status quo model of the structure and provision of primary care is ill-suited to the changing population that it is serving.

Primary care serves a growing population of heterogeneous individuals with multiple chronic illnesses. The pressures thereby placed on primary care are giving rise to evocations of the “demise” or “collapse” of primary care. A large portion of patients are receiving inadequate evidence-based care that fails to control their chronic health conditions. Further, primary care visits are largely devoted to routine management of these conditions.

Physicians increasingly struggle to provide adequate, evidence-based care, but studies show that the time required to comply with evidence-based practice requirements would exceed the standard workday by several hours.
Dr. Wagner suggested approaches to improve healthcare outcomes under these circumstances. One, patients must receive adequate drug therapy; two, patients must self-manage their conditions and take greater responsibility for their health status; three, preventive interventions must be provided at timely intervals (with secondary prevention and early detection being key); four, there must be evidence-based monitoring and self-monitoring; and five, care must feature adequate follow-up tailored to the condition’s severity. Good surveillance is essential due to the fluctuating nature of chronic illness.
Dr. Wagner stated that, depending on the illness, roughly half of all patients or fewer are receiving evidence-based treatment for their conditions. For example, one-quarter of patients reporting depressive symptoms receive treatment or referral for treatment.

Discussing the “quality chasm,” he noted that the current care system is unequipped to handle the challenges described, and no increase in applied effort will improve a system failing at a structural level. Measures such as team changes, case management, patient reminders, and patient education have resulted in improved outcomes. Changes showing the greatest impact are those that educate patients to better manage their conditions. Other effective measures alter the organization and delivery of care. Further, use of nonphysician team members, planned encounters, modern self-management support, specialized care management for high-risk patients, and population management using electronic registries are effective.

Fundamentally, the most productive healthcare interactions result from the interaction between an informed, active patient, and a prepared practice team.
Such interactions take the form of the “planned visit,” using patient data, team and practice organization, and decisional support to assure productivity.
The most important IT enhancement is implementation of a patient registry that includes every patient who meets certain criteria for high risk (the presence of one or more chronic illnesses). This facilitates well-organized interactions. Registries can be a rapid source of information (patient details, medications), aid planning, and serve as a valuable tool for monitoring performance across the practice.

He emphasized that the vast majority of the population prefers a primary care physician; countries with better primary care have better health outcomes; and U.S. states with higher primary care/population ratios have reduced costs and better quality. He promoted primary care’s ability to marry gerontology with effective chronic disease management. Primary care must do this if it is to survive.

Discussion Session: Chronic Disease Care

Speakers: Dr. Kane and Dr. Butler-Jones

Moderator: Liette Lapointe, PhD, Associate Professor; Director, Business and Management Research Center, Desautels Faculty of Management, McGill University.

Dr. Lapointe, an academician whose research interests include resistance to information technology and the implementation of information systems in the healthcare industry, moderated the discussion between Dr. Kane and Dr. Butler-Jones.

Both presenters had considered chronic disease’s role in healthcare resource utilization, and the burden of chronic disease on patients themselves and the society at large. Dr. Lapointe noted that three uniting concerns bridged the speakers’ presentations. They both discussed the extent to which aging is properly seen as a challenge; both addressed which health and policy achievements qualified as indices of success (e.g., cure versus care, how to best assess outcomes, and the best provision of resources); and, finally, both considered how health professionals in clinical care and those that work with governments can ensure improvements in managing aging and chronic disease on a systemic level, highlighting the role of information technology in the process.

Dr. Kane was queried on the value of making changes at the level of medical training to better meet the challenges of frailty, disability, and dependency among aging adults. Dr. Kane offered doubt that medical schools represented the best site of intervention due to several factors. Training methods and content tend to be conservative and challenging to alter. Further, given the delay between instituting philosophical and practical change and when effects manifest, change may be excessively belated and the information possibly anachronistic. Finally, trainees may enter the clinical context with the correct knowledge, but the environments in which they work may be inhospitable to change.

Dr. Butler-Jones concurred, adding that there is no single site at which to make the changes necessary to better deal with the increasing chronic disease burden. He added that interventions should not ignore the medical schools, however, given increasing interdisciplinarity among healthcare professionals, as well as the mobility and dynamism between academic, clinical, and policy contexts. These represent multiple target points for new research findings.

Another issue raised was that of the Baby Boomer generation and the effect their entry into the ranks of seniors will have. Does the size of the demographic mean that they are bound to reshape health policy? Dr. Butler-Jones affirmed the notion, noting that the generation has altered society at every stage of life. Dr. Kane in turn challenged the suggestion, noting that the greatest changes they stand to institute come in the form of their advocacy for their parents’ generation. Once they themselves become infirm, their capacity to serve as radical advocates for themselves or for wider change within the healthcare system will be compromised.

Dr. Kane was given the opportunity to elaborate several of his ideas on optimizing healthcare delivery in an environment of burgeoning chronic disease prevalence. He had advocated eliminating regularly scheduled follow-up consultations in favour of primary care utilization based on change in health status. Rather than seeing this as a reduction in follow-up visits, Dr. Kane described the practice as one that facilitates systemic tracking of chronic illness.

Dr. Butler-Jones agreed that this revised approach to follow-up care could enhance monitoring. Other forms of patient tracking outside of regularly scheduled follow-up appointments could improve patient health behaviours, he stated, citing study data finding that weekly/bi-weekly calls from a nurse reduced subsequent emergency room visits, and improved treatment adherence.

Dr. Kane was challenged on his suggestion that team-based care leads to inefficiencies and fails to alter outcomes. Dr. Kane advised that team approaches can experience success when team participants have well-defined roles and adhere to them, and function with trust of their partners. Research and clinical experience has shown that collaborative care can instead be duplicative and an inefficient use of time.

As up to one-third of current health professionals are nearing retirement age, panelists were asked to consider the severity of shortages in primary care availability and how patients’ access to primary care practitioners might be assured.

Dr. Kane responded that if the importance of primary care is not affirmed institutionally, governmentally, and societally, the crisis in care availability will worsen. Remuneration must be improved, and costs must be recouped in the context of an economic model that accounts for reduced hospitalization and crisis visits. The sustainability of the healthcare system depends on the society’s ability to meet the challenge of chronic disease, and investments must occur in primary care rather than large hospitals.

Dr. Butler-Jones hoped that more effort would occur on the level of training to encourage practitioners to enter the field, rather than continuing to foster a sense of elitism and upholding the specialist as the model practitioner.

Chronic Disease and Aging: A Public Health Perspective

Speaker: David Butler-Jones, MD, MHSc, LLD(h), FRCPC, FACPM, CCFP, Chief Public Health Officer of Canada.

While the challenges posed by chronic disease to Canada’s aging adults justly occupied the attention of the conference’s participants, Chief Public Health Officer of Canada Dr. Butler-Jones urged participants to refocus attention on the value of aging. While rising rates of chronic disease are a formidable problem, he observed that aging adults remain key contributors to society and that aging with chronic disease is preferable to dying young. He noted that aging is not the problem; how we live makes a difference—it is not just a matter of length of life.

Public health comprises a set of programs and services but is also a way of “understanding the causes of the causes.” According to Dr. Butler-Jones, public health efforts facilitate better understanding of the interrelationship of physical health and the social environment. Public health is uniquely positioned to advise other sectors, provides leadership in promoting healthy aging, and is capable of engaging valued partners across society to build healthy, enabling environments.

Public health acknowledges the importance of supporting health throughout the life course, and that health outcomes are an end stage of a lifelong trajectory. For example, poverty in infancy is associated with a doubled stroke risk in later life. He also noted that public health research has produced insights on the interaction of forces that serve as determinants of health, such as the relationship between social markers, chronic conditions, and health vulnerabilities. Dr. Butler-Jones discussed his 2008 Chief Public Health Officer’s Report on the State of Public Health in Canada, stressing that understanding the determinants of health is essential as they provide the context and direction for prevention and interventions. He also noted that mortality in the recent SARS and listeria infection outbreaks in Canada were associated with underlying chronic conditions. An aging population elevates vulnerability.

Other important factors in aging and chronic disease vulnerability include poor self-rated health and lack of social connectivity. Those without close social networks (family, friends, colleagues, etc.) have twice the risk of dying of those not socially isolated.

Regarding the prevalence of chronic disease among aging adults, Dr. Butler-Jones noted that approximately 85% of those aged 65-79 and more than 90% of those 80 years and over reported at least one chronic disease in 2005.
Dr. Butler-Jones emphasized that the approach to chronic illness should not pose preventive care against clinical care but focus on their coordination and improvement. He discussed disease-specific interventions, and noted that healthy living should not be seen in opposition but as an opportunity for interaction and cross over, for example, in terms of interventions and risk factors. The broader perspective appreciates contextual factors that improve health and build healthy environments, such as promoting those community features and infrastructures that support healthy aging (e.g., more liveable, safer communities that enhance social support and connectedness, illustrated by the example of the Age Friendly Communities Model).

Key examples of where aging and chronic disease intersect and where there are public health opportunities for healthy aging include the domains of fall prevention (involving design and infrastructure at the community level, plus awareness, education, assessment, exercise, hazard reduction, etc.), mental health, better caregiver support (one in 12 Canadian seniors provides care to another senior with a long-term health problem), emergency preparedness, elder abuse, and promoting age-friendly communities. Finally, he noted that seniors are not merely a vulnerable population but represent a key resource in the community, and are essential partners in public health efforts promoting effective healthcare improvements and safety planning.

Chronic Disease and Aging: Two Separate or Related Problems?

Speaker: Robert Kane, MD, Professor and Minnesota Chair in Long-Term Care and Aging, University of Minnesota, School of Public Health.

Geriatrics represents the intersection of gerontology and chronic disease care. The elderly predominate in chronic disease. Gerontology includes various syndromes and involves managing multiple simultaneous problems across multiple domains (physical, social, economic). Both imply the need to find better ways of delivering care (effectiveness) and to control costs (efficiency). Success in chronic care must be measured in terms of actual versus expected clinical trajectories. Strategies to improve chronic care involve reorganizing care delivery systems.

To promote proactive primary care with improved decision support, more effective disease management and better care coordination (e.g., medical home) are needed. Patient empowerment is central. A critical question is whether there is a business case for better primary care. Can more active care actually achieve subsequent costs savings through reduced resource use? Getting physicians actively involved in primary care will involve removing barriers such fee-for-service payment, which is the anathema of chronic disease care. Dr. Kane supported the creation of incentives (financial, recognition, practice satisfaction) for doing the right thing. Dr. Kane stressed the need for measures that would increase efficiency. For example, we should eliminate scheduled return appointments and instead base revisits on clinical trajectories.

Donna Spevakow, RN, MSN
Lisa Hamilton, RN,MSc

Chronic Non-Cancer Pain (CNP) is a clinically complex and common phenomenon in the older adult. Data suggest that CNP is undertreated in older adults who are likely to suffer from arthritis, back problems and joint disorders. Left untreated, CNP in the older adult can lead to depression, sleep disturbances and decreased socialization.

Recently, the problem of untreated CNP was investigated at the Toronto Rehabilitation Institute, a tertiary rehabilitation centre and a teaching hospital of the University of Toronto. A survey to determine pain prevalence and severity was conducted in a patient population consisting of complex continuing care, geriatric, acquired brain injury and stroke rehabilitation. One hundred and ten patients were able to verbally respond to the survey questions, and results showed that 47% of the patient population experienced CNP and 39% of those with pain rated it as severe. At that time, no structures were in place within the organization for the assessment and management of CNP.

This evidence led to the creation of a clinical interprofessional CNP task force which had the goals of establishing a patient-centred, interprofessional approach to CNP rehabilitation using "best practice" evidence, preventing unnecessary suffering and improving outcomes in rehabilitation.

Clinical practice guidelines included information on cultural consideration in pain assessment and management, an initial pain assessment form, and a pain flow sheet to evaluate effectiveness of interventions. Pain assessment scales were made available in 14 languages. Three categories of therapeutic approaches were identified within the guidelines: pharmacological, physical and psychoeducational. These guidelines were then developed into policies.

In order to achieve consistent use in the clinical practice setting, all clinical staff needed to be knowledgeable about the guidelines and policies. To this end, the CNP task force developed an innovative teaching tool--a colourful poster that serves as a quick reference guide for both physicians and patients.

In addition, an educational program was developed for front-line staff. Staff attended a one half-day workshop where, using a case study, they reviewed the pain assessment forms. A second half-day workshop on specific physical modalities was offered to the Registered Nurses who had attended the previous workshop, and to physiotherapists. A full-day workshop was offered by an expert in guided imagery.

Patient and family education is also a crucial component in management of CNP. Recognizing this need, the task force developed an educational booklet entitled "Chronic Pain and You," available in four languages: Chinese, Portuguese, Italian and English.

Other outcomes of the initiative are that links have been established with the Comprehensive Pain Program at Toronto Western Hospital, University of Toronto Centre for the Study of Pain, and that a medical pain specialist is now available on-site for consultation.

We hope that this issue of Geriatrics & Aging will update our readers on the management of pain in the elderly. We have a series of excellent articles including an overview of the biology of pain, a summary of pain management and assessment in the elderly, the principles of palliative care and the management of pain in patients with dementia. We also have a summary of the Toronto Western Hospital's Chronic Pain Program. Topics for our regular columns include 'Syncope in the elderly' (Cardiology column) and chronic lymphocytic leukemia (Cancer column). Enjoy!

Donna Spevakow is a CNS at Toronto Rehabilitation Institute and Lisa Hamilton is a CNS at York Central Hospital. They were Co-Chairs of this Initiative. Toronto Rehab received the Health Care Papers National Best Practice Award at the Ontario Hospital Association Convention, November 2000 for this interprofessional Non-Cancer Pain initiative.