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.

Maladie chronique et vieillissement : un défi global

Conférencier : Howard Bergman, M.D., professeur et titulaire de la chaire D^r Joseph Kaufmann et directeur du service de
gériatrie, centre de santé universitaire McGill, Montréal (Québec); codirecteur du groupe de recherche Solidage, Montréal (Québec); directeur du réseau québécois de recherche sur le vieillissement et du Fonds de Recherche en Santé du Québec, Montréal (Québec); président du conseil consultatif, Institut du vieillissement, Instituts de recherche en santé du Canada, Ottawa (Ontario).

En préambule à sa présentation sur l’augmentation du fardeau des maladies chroniques et du vieillissement, le D^r Howard Bergman a montré une série de photographies de personnes âgées du monde entier. Les photographies offraient divers exemples manifestes de fragilité et de déclin, ainsi que des exemples de personnes âgées résilientes et en bonne santé, ce qui illustrait l’extrême hétérogénéité des personnes âgées.

Changements démographiques et épidémiologiques actuels
La population mondiale vieillit, et les changements démographiques et épidémiologiques associés à l’augmentation de l’espérance de vie et au vieillissement rapide de la population représentent l’un des défis de notre époque. On sait que la population des pays de l’Ouest vieillit, mais cette tendance n’est pas localisée : elle affecte le monde entier.

Globalement, l’espérance de vie augmente : au cours des cinq dernières décennies, l’espérance de vie a augmenté globalement de près de 20 ans, passant de 46,5 années vers les années 1950-1955 à 66,0 années en 2000-2005. Globalement, le taux moyen de croissance annuelle des personnes âgées de 80 ans et plus (3,8 %) est actuellement le double du taux de croissance de la population âgée de 60 ans et plus (1,9 %). On s’attend à ce que le groupe âgé de 80 ans et plus reste le segment de la population subissant la plus forte croissance (Figure 1).

La transition démographique a démarré plus tôt dans les pays plus développés, mais les régions plus pauvres sont maintenant sujettes à des changements similaires survenant dans un laps de temps plus court. Par exemple, une comparaison des transitions démographiques montre que le Mexique vieillit six fois plus rapidement que la France. Le D^r Bergman a présenté des statistiques montrant que d’ici à l’an 2050, 70 % des personnes les plus âgées du monde (80 ans et plus) vivront dans des régions en développement. Aussi bien dans les pays développés qu’en développement, les effets complexes d’une amélioration des conditions de vie, de l’éducation, des soins médicaux et de l’accès aux soins de santé favorisent la longévité. De plus, les personnes âgées des pays en développement vivent plus longtemps en raison d’une amélioration de la nutrition, des conditions sanitaires et du contrôle des infections.

Un tel changement a entraîné une augmentation de la prévalence des maladies chroniques et du nombre potentiel de personnes âgées présentant une invalidité. De telles conditions représentent des enjeux importants pour les systèmes de soins de santé. Le D^r Bergman a cité un rapport récent de l’Organisation mondiale de la Santé (OMS), qui classait les systèmes de soins de santé du monde entier en fonction de critères incluant la capacité du système de soins à améliorer la santé de la population, à répondre aux besoins en matière de santé, à assurer une qualité des soins, à faire preuve de réceptivité et d’égalité dans la prestation de ces soins (y compris envers les groupes vulnérables) et à montrer un bon rapport coût efficacité. La France arrivait en tête de ce classement. Les indicateurs de performance du Canada se situaient en dessous des valeurs attendues et étaient surpassés par ceux de pays que l’on pensait marginaux par rapport aux normes des pays développés, comme la Colombie.

Effort pour améliorer l’espérance de vie active
L’augmentation de l’espérance de vie, aussi bien dans les pays développés qu’en développement, est souvent associée à une augmentation de la durée de vie avec des maladies chroniques.

Les influences favorisant la longévité sont compensées par d’autres correspondant à des facteurs de risque pour l’évolution des maladies chroniques, comme de mauvaises habitudes alimentaires (ce qu’on appelle la « McDonaldisation » mondiale), une diminution de l’activité physique et une augmentation du tabagisme (notamment dans les pays en développement, à mesure que les sociétés productrices de tabac se détachent des pays développés de plus en plus antitabac). Une augmentation de la longévité entraîne également une exposition prolongée à des facteurs de risque pour les maladies chroniques.

De plus en plus, les systèmes de soins de santé du monde entier vont devoir lutter pour gérer une proportion croissante de personnes âgées présentant des invalidités et des maladies chroniques; il s’agit d’un segment hétérogène de la population ayant des besoins variés. Ce fardeau est également porté par les personnes âgées elles-mêmes, leurs familles, les communautés et les sociétés. Une mauvaise prise en charge des maladies chroniques entraîne une invalidité. Si l’on peut réduire les taux d’invalidité, on améliora davantage l’espérance de vie.

Signes d’amélioration
Au cours de ces dernières décennies, les chercheurs ont remarqué une diminution globale du taux d’invalidité. Le D^r Bergman a cité des données provenant d’études longitudinales sur le vieillissement, qui montraient une forte corrélation entre les facteurs de risque associés au mode de vie et la fréquence de l’invalidité.

Aux États-Unis, une amélioration des habitudes individuelles en matière de santé a entraîné une augmentation de la survie et un délai de l’âge d’apparition de l’invalidité. Une mise en œuvre fructueuse de stratégies de prévention et de protocoles de dépistage (p. ex. : antigène prostatique spécifique, densité osseuse) a modifié l’apparition des mala-dies chroniques. De plus, l’amélioration des systèmes de soins de santé et les avancées pharmaceutiques et technologiques ont diminué le handicap lié aux maladies chroniques les plus invalidantes (hypertension, diabète, hyperlipidémie). De meilleures stratégies chirurgicales pour les maladies affectant les personnes âgées (remplacement d’articulation, chirurgie de la cataracte) ont permis de retarder ou d’empêcher l’invalidité. Enfin, des facteurs économiques comme une amélioration de l’éducation, des revenus et des conditions de travail ont amélioré la santé globale et diminué l’invalidité.

Nouveaux défis pour les pays en développement
La question fondamentale est de savoir si l’on disposera des ressources nécessaires pour répondre aux changements rapides des pays en développement. Les pays en développement connaissent des changements soudains dans un contexte de ressources limitées. Leurs systèmes de soins de santé ne sont pas adaptés à la complexité de la prise en charge et du traitement des maladies chroniques, de la fragilité et de la dépendance. Enfin, les changements socio-économiques et démographiques ont une influence néfaste sur l’évolution de la santé dans les pays en développement : les membres de la famille n’offrent plus un soutien comme avant, et de moins en moins de générations différentes vivent sous un même toit, à mesure que le nombre de femmes des pays développés qui se mettent à travailler (plutôt que de rester les personnes soignantes officieuses) augmente et que les enfants quittent leur village ou le pays à la recherche d’occasions économiques.

Selon le D^r Bergman, le fait de retarder d’un ou deux ans l’apparition de l’invalidité ou de la dépendance peut faire une grande différence et diminuer directement les besoins en matière de soins de longue durée et de ressources des établissements. La modification des tendances, vers une population plus âgée susceptible d’être atteinte de maladies chroniques et d’invalidité, demande des systèmes de santé répondant aux besoins des personnes qui souffriront d’invalidité et perdrons leur indépendance, tout en réduisant le nombre de personnes qui seront sujettes à ces problèmes.
Les stratégies poursuivies par les pays en développement ne sont pas toutes transférables. Le D^r Bergman a fait observer que le Canada repose sur une stratégie de dépistage et de traitement des personnes à risque, mais cela ne correspond pas aux ressources des pays en développement. L’OMS préconise une prévention en matière de santé et une promotion de la santé dans les pays en développement, avec une approche communautaire. Selon une étude citée par le D^r Bergman, si les professionnels de la santé communautaire mettaient en place des stratégies pour réduire la tension artérielle de 3 mm Hg dans la région Asie/Pacifique, cela pourrait entraîner jusqu’à un million de décès en moins dus à un accident vasculaire cérébral d’ici 2010. Une autre étude réalisée par l’OMS portait sur des interventions communautaires destinées à réduire la consommation de sel à Tianjin, en Chine. Ces interventions ont eu des répercussions importantes : amélioration des connaissances en matière de santé, diminution de la consommation de sel et diminution de la tension artérielle systolique.

Selon le D^r Bergman, la recherche indique que les pays en développement ont besoin de mieux incorporer une approche communautaire pour les soins de première intention, afin d’offrir des soins aux personnes âgées ayant des besoins complexes. Il s’agit donc d’accélérer la tendance, et d’élaborer des stratégies facilitant la vie communautaire plutôt que de travailler à des projets de construction d’établissements (hôpitaux et maisons de soins infirmiers). De telles stratégies sont associées à une meilleure longévité. Les gouvernements doivent investir dans des stratégies supportant une participation de la famille et de la communauté, intégrer des ressources de guérison traditionnelle et former une main-d’œuvre attachée à retarder l’apparition des maladies chroniques et à en diminuer les conséquences.

Conclusion : Collaboration internationale et transfert du savoir pour faciliter des interventions efficaces en matière de santé
Des interventions efficaces doivent dépasser la réalisation de projets au sein d’une ville ou d’une municipalité, a déclaré le D^r Bergman. Il faut intégrer à l’échelle du système des améliorations destinées à retarder l’apparition des maladies chroniques. Il a encouragé les auditeurs à envisager la manière de contribuer à cet effort, et à intégrer l’information qu’il a présentée à leurs perspectives de recherche. Un effort pour coordonner les approches et améliorer les connaissances sur la fragilité, des études sur les interventions liées au vieillissement, et un échange d’informations et de politiques favoriseront un système de soins de santé cohérent et réceptif, pouvant répondre à ce défi global.

Chronic Disease and Aging: A Global Challenge

Speaker: Howard Bergman, MD, The Dr. Joseph Kaufmann Professor and Director, Division of Geriatric Medicine, McGill University, Montreal, QC; Co-Director: Solidage Research Group, Montreal, QC; Director, Quebec Research Network in Ageing/Fonds de Recherche en Santé du Québec, Montreal, QC; Chair, Advisory Board, Institute of Aging, Canadian Institutes of Health Research, Ottawa, ON.

Dr. Howard Bergman prefaced his discussion of the increasing burden of chronic disease and aging with a slide series featuring images of aging individuals from around the world. The photographs offered diverse examples of visible frailty and decline, as well as obvious health and resiliency into late age, highlighting the profound heterogeneity of aging adults.

Current Demographic and Epidemiologic Shifts
The world’s population is aging; the worldwide demographic and epidemiologic transitions associated with increasing life expectancy and a rapidly aging population is recognized as one of the challenges of our time. That the population of Western nations is aging is commonplace knowledge; however, this trend is not a limited but rather a worldwide shift.

There is an overall increase in life expectancy: over the last five decades, life expectancy at birth increased globally by almost 20 years, from 46.5 years in 1950-1955 to 66.0 years in 2000-2005. The global average annual growth rate of persons aged 80 years and over (3.8 %) is currently twice as high as the growth rate of the population aged 60 and over (1.9%). The 80-plus age group is expected to remain the fastest-growing segment of the population (Figure 1).

The demographic transition began earlier in the more developed countries, but poorer regions are currently experiencing similar changes within shorter time spans. When compared with demographic transitions in France, for example, Mexico is aging six times more rapidly. Dr. Bergman presented statistics showing that through 2050, 70% of the world’s older persons (80 and over) will be living in developing regions. In both developed and developing countries the complex effects of improved living conditions, education, medical care, and accessibility to health care are promoting longevity. Additionally in developing countries older adults are living longer due to improved sanitation, nutrition, and infection control.

This shift has led to an increase in the prevalence of chronic diseases and the potential number of older persons living with disability. These conditions pose important challenges to health care systems. Dr. Bergman cited a recent World Health Organization (WHO) report that ranked health care systems worldwide according to criteria that included the capacity of the care system to improve the health of the population, meet health care needs, assure quality of care, offer responsiveness and equity in the provision of that care, including toward vulnerable groups, and the cost efficiency of the system. France ranked first; indicators of Canada’s performance were ranked below expectation and were outmatched by countries thought to be on the margins of the developed standard, such as Colombia.

The Effort to Increase Active Life Expectancy
Increased longevity in both the developed and developing worlds often results in a longer period of life being spent with chronic disease.

The forces driving longevity are off-set by forces that serve as risk factors for the evolution of chronic disease such as poor dietary habits (the so-called worldwide “McDonaldization”), reduced physical activity, and increased tobacco use (particularly in developing countries as tobacco companies shift their focus away from the increasingly nonsmoking developed nations). Increased longevity also translates into prolonged exposure to chronic disease risk factors.

Health care systems around the world will increasingly struggle to manage a high proportion of older persons with disabilities and chronic disease, a segment of the population that is heterogeneous and has complex needs. This burden is also borne by older people themselves, along with their families, communities, and societies. Poorly managed chronic disease drives disability. If rates of disability can be mitigated, further improvements in life expectancy will result.

Signs of Improvement
Over the last several decades, researchers have witnessed an overall decrease in the rate of disability. Dr. Bergman cited data accrued from longitudinal studies of aging that show strong associations between lifestyle risks factors and the incidence of disability.

In the United States, it has been shown that improvements in individual health habits have led to increased survival and postponement of the age of onset of disability. Successfully implemented preventive strategies and screening protocols (e.g., prostate-specific antigen, bone density) have changed the onset of chronic disease. Additionally, improvements in health care systems, along with pharmaceutical and technological advances, have reduced disability related to the most disabling chronic diseases (hypertension, diabetes, hyperlipidemia). Improved surgical strategies for ailments affecting older adults (joint replacement, cataract surgery) have delayed or prevented disability. Finally, socioeconomic factors such as improved education, incomes, and working conditions have produced overall health improvements and reduced disability.

Emerging Challenges in the Developing World
The key question is whether the resources will be available to address the rapid changes in the developing world. Developing countries are experiencing sudden changes in a context of limited resources. Their health care systems are not optimally adapted to the complexity of managing and treating chronic disease, frailty, and dependence. Finally, socio-economic and demographic shifts are exerting a negative influence on health outcomes in the developing world: family members are not filling in supportive gaps as they once were, and transgenerational households are on the decline, as developing nations experience increased numbers of women in the paid workforce (rather than remaining informal caregivers), and children leaving their villages or going abroad in search of economic opportunity.

According to Dr. Bergman, a 1-2 year delay in the onset of disability/dependence can make a significant difference and directly reduces needs for long-term care and institutional resources. A shift toward an older population at risk for chronic disease and disability calls for health systems that on the one hand reduce the number of people who develop disability and lose independence, but on the other hand are able to provide for people who do develop disability and are dependent.

Not all strategies pursued in the developed world are transferable. Dr. Bergman observed that Canada relies on a strategy of screening and treatment of high-risk individuals, but this is ill-matched to the resources of developing countries. The WHO advocates health prevention and promotion in developing nations incorporating a community-based approach. If community health professionals were to implement strategies in the Asia/Pacific region that lowered blood pressure by 3 mmHg, this could lead to as many as 1 million fewer deaths from stroke by 2010, claimed one study Dr. Bergman cited. Another study by the WHO concerned a community-based intervention aimed at reducing salt intake in Tianjin, China, which had important effects of improving health knowledge, decreasing salt intake, and decreasing systolic blood pressure.

Dr. Bergman stated that research points toward a need for developed nations to better incorporate the community primary care approach to providing care for older persons with complex needs. This means accelerating the trend away from creating more “bricks and mortar” facilities (hospital and nursing home beds) toward strategies promoting living in the community. The latter have been associated with greater longevity. Governments need to invest in strategies supporting family/community involvement; integrate traditional healing resources, and train a workforce focused on mitigating the onset and effects of chronic disease.

Conclusion: International Collaboration and Knowledge Exchange to Support Effective Health Interventions
Effective interventions must go beyond instituting projects in one city or town, Dr. Bergman stated. Integrating improvements aimed at delaying onset of chronic disease must occur on a system-wide level. He encouraged listeners to consider how they could contribute to the effort and put the information he presented into their research perspectives. The effort to coordinate approaches and add to the evolving knowledge on frailty, studies on aging interventions, and information and policy exchange will help promote a coherent and responsive system of care that can meet this global challenge.