THE HEALTH OF
THE CANADIAN ELDERLY
Prepared by Nancy Miller
Political and Social Affairs Division
WHO ARE THE ELDERLY AND WHAT DETERMINES THEIR
E. Marital Status
F. Geographic Location
HOW DO THE NEEDS OF THE ELDERLY AFFECT HEALTH
A. Increased Need for Services
B. Financing Services
C. Organizing Services
HOW CAN THE LONG-TERM HEALTH NEEDS OF THE ELDERLY
A. Providing Services Formally
B. Providing Services Informally
THE HEALTH OF THE CANADIAN
there is more to health in later life than age itself.(1)
are the elderly and what determines their health? How and why do their
health needs vary from those of other age groups? This paper considers
the implications of these and other questions for health policy and the
particular focus required to address the health concerns of an aging population.
It highlights efforts across the country to provide services and evaluate
their effectiveness in meeting the needs of our growing numbers of elderly
the 1980s, in line with expanded concepts of health and with the recognition
that aging in combination with other social changes poses particular demands,
governments across Canada recognized the need to "coordinate healthy
public policies" to meet the challenges posed by rapid and irreversible
social change.(2) Such public policies for the elderly need to
consider not just traditional health issues but also social and economic
strategies that foster greater equity for the aging population.
Canada, the Lalonde Report of 1974 was the first to recommend goals or
strategies for health. For the older population, the report envisaged
that the focus on curing illness should change to a focus on caring for
chronic diseases. Its overall approach was two-pronged; it proposed, on
the one hand, the reduction of mental and physical hazards for groups
(such as the elderly) perceived to be at greatest risk, while, on the
other hand, improving access to health care for these groups.(3)
A decade later, the Epp Report identified three national health challenges:
reducing inequities, increasing prevention of illness, and enhancing people's
capacity to cope. The particular needs of the elderly were to be addressed
by three health-promotion mechanisms (self-care, mutual aid and healthy
environment) to be implemented through public participation, strengthened
community health services and a coordinated healthy public policy.(4) In addition, several provincial
commissions, task forces and councils of health proposed action on health
goals for the elderly, focusing on financial and human resources, organization,
and management of health care in the context of an increasing elderly
WHO ARE THE ELDERLY AND WHAT DETERMINES
concept of "health" has changed over time to reflect the greater
understanding of key determinants of health status. The World Health Organization
has expanded the term to imply "a state of complete physical, mental
and social well-being, and not merely the absence of disease." This
concept was developed further in the 1986 Ottawa Charter on Health Promotion
where health was viewed as "a resource for everyday life" for
which the fundamental conditions and resources were seen to be "peace,
shelter, education, food, income, a stable ecosystem, sustainable resources,
social justice and equity."
understanding of factors that determine health has taken us a long way
from the assumption that more health care results in more health. The
health of the older population depends not only on formal and informal
provision of care but also on factors experienced over a lifetime, such
as housing, nutrition, occupation or daily activity, use of tobacco, alcohol
and other substances, and environmental circumstances. Thus, factors in
the physical and social environment of older people will have determined
their health status by the time they reach 60 years and will continue
to determine it as they age.
people live longer and healthier lives as a result of preventive measures
such as better sanitation, effective vaccines, and more healthful diets,
as well as curative measures involving pharmacological and technological
intervention. In spite of advances in public health, education, standards
of living, sciences and technology, however, disparities remain among
different groups within the older population, with such variables as age,
socio-economic conditions, gender, ethnicity and marital status all affecting
World Assembly on Aging, convened by the United Nations in Vienna in 1982,
established 60 as the threshold of old age.(6)
This baseline is primarily set for convenience, as a way of standardizing
the starting point for discussions about the elderly. As far as the practical,
physiological and psychological aspects are concerned, this choice of
age is open to discussion. In Canada, the age of 65 years is used for
the collection of statistical data and thus provides the most common first
reference point for this paper. In 1991, there were 3.2 million people
in the 65 and over age group in Canada. This group constituted 12% of
the population, an increase from 10% a decade earlier.(7)
the threshold set, the people who fall into the category of the elderly
are not a homogeneous group. The process of biological aging is continuous
from birth to death and varies considerably from one individual to another.
Age is one of the principal factors determining the nature and extent
of an individual's health and social needs, but within the elderly population
the oldest and younger members have lived through and been influenced
by different economic, social and political events.
observers speak of three categories of old people: those 65 to 75 years
are "young-old"; those 75 to 85 years are "middle-aged
old"; and those 85 and over are "old-old." Figures from
the 1991 census indicate that the age group over 65 years of age grew
by 17.5% between 1986 and 1991, while the population in the 75-and-over
age group, the heaviest users of health care services, grew by 21.7%(8)
fact that some diseases are age-dependent in that their origins and development
are directly related to age, is significant; Alzheimer's, Parkinson's,
strokes, and osteoporosis are in this category. The presence of these
diseases suggests two things; that ways of preventing them must be found
and that existing services must be adapted to address them. For example,
osteoporosis, which affects about 25% of postmenopausal women, may be
preventable. Given that "hip fractures related to osteoporosis result
in death in 12% to 20% of cases and in disability in up to 75% of surviving
patients," greater attention is required.(9)
Disease, a progressive degenerative disorder that produces dementia, provides
another example of why changes are needed. AD commonly appears after age
65, with the incidence increasing with age from a low of 3% for people
between the ages of 65-74 to a high of 47.2% for those over 84 years.(10)
Memory loss, followed by a slow disintegration of personality and physical
control, leads to the necessity for total nursing care in later stages.
the population ages, the health, social and legal challenges posed by
Alzheimer's Disease will be enormous. It has been suggested that on the
social front there is a need for supplemental support for caregivers and
greater sharing of resources between expanded home care and institutional
care. Some related legal issues are power of attorney for the victim and
voluntary euthanasia. Health issues include the lack of available institutions
for long-term care, particularly specialized units for AD sufferers, and
the need for research and for the education of physicians and nurses.(11)
diseases are chronic in nature, marked by long duration and slowly progressing
severity. People over 60 years of age are seen as members of a "population
at risk" with respect to heart and circulatory disease, cancer, arthritis,
rheumatism, diabetes and other diseases, all of which can be connected
to the aging process.(12) In a 1985 survey of Canadian seniors, 55%
reported arthritis-rheumatism, 39% hypertension and 24% respiratory difficulties.(13) The current focus on medical and institutional
responses is not always appropriate for conditions where certain functional
abilities are impaired but not acutely disrupted.
with other aspects of their lives, seniors are not a homogeneous group
in relation to their health status. In Canada, while approximately 80%
of persons aged 65 years and over report one or more chronic conditions,
only 20% report that their daily activities are so restricted that they
must seek assistance.(14)
Half of all seniors between the ages of 75 and 84 report a disability;
for those over 85, this increases to over 75%.
incomes for males and females decline after age 55 and the incidence of
low income increases.(15)
Unattached people aged 65 years and over, particularly women, are among
the poorest Canadians. Some diseases show a strong association with socio-economic
status; for example, the 1979 Canada Health Survey revealed that among
women aged 70 and over, the rate of chronic hypertension was lowest in
the highest socio-economic group and highest among those in the lowest
Health Promotion Survey in 1985 revealed that, as for younger Canadians,
the self-rated health of seniors varied strongly with social and economic
background, and not just with age itself. According to this survey, "those
in the upper-middle income group are far more likely to report excellent
or very good self-rated health than those in the poor or very poor income
categories. Those in the very poor income group are more than five times
as likely to report fair or poor health." In addition, "40%
of adults 65 and over in the very poor income group report activity limitations,
compared to only 11 % of those in the upper-middle income group."(17)
Health Promotion Survey also found a very strong relationship between
education and self-rated health, activity limitation, and happiness. For
example, of people over 65 years of age, 34% of those with elementary
education or less reported health that was only fair or poor compared
to only 7% of those with complete post-secondary education. It was suggested
that "health differences among people with varying levels of education
may have more to do with subsequent employment history than with educational
earnings before retirement also seem to have a clear influence on health
after 65 years. In a study using Canada Pension Plan data, a strong relationship
was revealed between average earnings in the 30 years before retirement
and death rates after retirement. The men with the lowest average earnings
were twice as likely to die between 65 and 70 years of age as the men
in the highest earning groups.(19)
Other studies have shown that life expectancies of people living in the
poorer districts of Montreal are shorter by nine years than those of their
Canada, life expectancy at birth increased steadily between 1975 and 1985.
For men, the increase was from 70.2 to 73.1 years while for women, it
was from 77.5 to 79.7 years. By 2011, it is projected that life expectancy
for women will be 84 years and for men 77 years.(21) Women outnumber men among
the elderly; in 1991, there were 138 women for every 100 men in the 65
and over age group. Among the population 85 years and over, women outnumbered
men by more than two to one.(22)
longer life span of women increases their problems of access to adequate
resources for health, including food, housing and services. In 1991, of
"primary maintainers," (i.e., those in a household who contribute
the greatest amount toward shelter payments) aged 75 and over, 52% were
female.(23) Older women
tend to be poorer than older men. According to the Health Promotion Survey,
about 57% of women over 65 are either poor or very poor, compared to only
47% of men.(24) The lower social and political status of
women affects their access to all resources, including health. The women
most likely to have such problems are those over 80 years of age living
in urban centres.
women reach the older age groups in greater numbers, they constitute a
significant part of the population vulnerable to diseases that lead to
institutional care, including dementia, coronary and arterial disease,
and musculoskeletal impairment. In 1991, of the population aged 65 to
74 years living in collective institutional dwellings, more than half
were women, while in the group aged 75 and over, women constituted close
to three-quarters of the population in such dwellings.(25)
the 65-and-over age group, however, hospitalization rates over the period
1980-81 to 1985-86 were higher for males than females.(26)
This raises concerns about differences in medical care for men and women.
At the 1993 annual meeting of the American College of Cardiology, researchers
pointed out that women with heart disease were treated differently from
men by physicians and with therapies developed primarily for men.(27)
Increasingly, there is a recognition that "women have not been well
served by the medical establishment and the health-care system."(28)
men and women experience age-related diseases, but stroke or cerebrovascular
disease provides an interesting example of how age makes a difference.
It is reported that "the relative risk of stroke is greater for males
at all ages. However, due to the preponderance of women among the oldest
age groups and the dramatic increase in stroke incidence with age, a greater
absolute number of women die from stroke. Sixteen percent of women will
eventually die of stroke, compared to only eight percent of males."(29)
elder abuse is not limited solely to older women, they are the most frequent
victims. As a societal problem, mistreatment of older people is still
accorded a minimal profile; yet abuse, whether it is physical, psychological,
material or due to neglect, can have devastating effects on the health
and wellbeing of the elderly. This problem cuts across health, social
and legal sectors and requires a coordinated vision and strategy.
affects health status in several ways. Some studies have reported differences
in the prevalence of certain age-related diseases among different racial
groups. For example, rates of Parkinson's Disease have been lower among
blacks than whites in the United States while cerebrovascular disease
has been higher among the Japanese and Chinese than among the population
in Western countries.(30)
Some studies focused on ethnic seniors' problems of access to mainstream
health care services, especially the language barriers to services for
those who do not speak either English or French. As well, the health habits,
expectations and preferences of seniors from some ethnic groups may differ
significantly from those of the general population in Canada.(31)
many people who move from one country and culture to another experience
stress, seniors are particularly prone to difficulties with adjustment.
In 1991, the majority of the immigrant population were under 65 years
of age but almost 800,000 people, or around 20%, were aged over 65.(32)
According to one report on mental health issues affecting immigrants and
refugees in Canada, elderly newcomers have particular needs: "They
exist as an isolated minority within each ethno-cultural community, depending
heavily on younger relatives for financial, social and psychological support."(33)
effect of immigration on the use of health care services is not clearly
documented. Some studies suggest that immigrant seniors seek out and use
the services of general practitioners more often than their Canadian-born
counterparts, but were less likely to follow through on referrals.(34)
Various efforts to adapt the curriculum of medical schools and to provide
hospital services sensitive to multicultural needs must also address the
particular needs of elderly immigrants.(35)
constitute a smaller proportion of the aboriginal population than of the
general Canadian population. In 1986, 10% of the Canadian population were
65 years of age and older, but this was true of only 4% of the aboriginal
population.(36) Growth in the over 65 group, however, may
come about as a result of increases in life expectancy and amendments
to the Indian Act permitting the reinstatement of adults in the
Indian population. The greatest concentrations of Indians are found in
the four western provinces (60%) and in Ontario (23%). The Inuit live
primarily in the Northwest Territories, while the Metis reside predominantly
in Manitoba, Saskatchewan and Alberta.(37)
Canada, older aboriginal people have many health problems that contribute
to a life expectancy below that of the general population: "Between
1976 and 1986, life expectancy at birth for status Indian males increased
from 59.8 to 63.8 years, and for status Indian females from 66.3 to 71
years ... Life expectancy for Inuit in the Northwest Territories was estimated
at 66 years in 1987."(38)
Native people in Canada suffer from diseases that are often preventable.
Poverty, inadequate nutrition and substandard housing contribute to diabetes
and tuberculosis, diseases of particular concern for the whole aboriginal
population, and to the diseases of the circulatory system that are the
leading cause of death of aboriginal people over 65 years.
the broader social factors, the marital status of the elderly person has
been linked to the need for health and social services. With the increase
in divorce rates in Canada and the greater longevity of women, a high
proportion of the elderly live in single-person households without the
support of a spouse. An OECD report suggested that: "This is an important
trend, because there is a substantially lower institutionalisation rate
of married couples who can provide each other with mutual support."(39)
women who have been dependent on male spouses for economic support, the
problems of being unattached are even greater. In Canada, at the time
of the 1991 Census, more than three elderly males in four had a spouse,
while this was true of less than one in two elderly females. While one
elderly male in ten was widowed, one elderly female in two had this status.(40) According to 1990 data, many
of these women without spouses had a low income: "38% of unattached
senior women, compared with 26% of comparable men."(41)
isolation can sometimes accompany unattached status. People who are alone
may be deprived of emotional and physical, as well as financial, support.
Some studies suggest that mortality and morbidity are higher among people
who lack social support.(42)
1991, close to one third of seniors lived in rural areas and small towns,
both of which tend to be under-serviced by physicians and other health
care professionals who specialize in geriatrics.(43)
A Manitoba study found that "seniors who reside outside Winnipeg
are 1.6 times more likely to be hospitalized than their Winnipeg counterparts"
and noted that "`region effects' of this sort are not uncommon in
Manitoba." While pointing to the higher hospital-bed-to-population
ratio in rural communities as one contributing factor, the study also
noted the lack of availability of alternatives to hospitalization.(44)
HOW DO THE NEEDS OF THE
ELDERLY AFFECT HEALTH SERVICES?
Need for Services
population of the world is aging. Fertility, mortality and international
migration rates have over the years been the key determinants of change
in the age structure of a population. Today low fertility and mortality
rates combine to reduce the number of births and to increase the proportion
of people who are older. In Canada, it is estimated that the number of
people over 65 years will double in the next 30 years.
has been argued that "with increasing age the demand for health care
and personal services rises steeply."(45)
Thus, the aging of the population means that there will be more people
with more age-related diseases making demands on services established
to maintain health and to treat ill-health. In addition, shifts in family
structures, combined with the wider participation of women in the paid
labour force, make it more difficult for the family to care for elderly
relatives and more essential that support services be available in the
insist that any increase in demand can be linked to the current dominance
of the institution-based and curative approach to health care,(46) rather than to the biological aging process
alone. "Sociogenic aging," that is, a societal view that people
change significantly as they age, is also partly responsible for determining
perceived needs. Some critics of the biomedical model of health and illness
argue that this "has resulted in old age itself being defined as
a problem considered solvable through the receipt of services, essentially
medical services, at the individual level."(47)
are a number of reasons why an increased demand for services might accompany
old age. Some are related to broad determinants of health such as gender,
ethnicity, marital status; others are related to the state of physical
and mental health of a specific older person. Some are related to age-related
diseases; others are related to the way health care is financed and organized.
This last point is examined in greater detail in the following sections.
Canada, each of the ten provinces and two territories currently plans
and operates its own health care system with financial assistance from
the federal government. The Canada Health Act, passed in 1984,
re-affirmed the five basic principles of the Canadian health care system:
public administration of provincial health insurance plans; comprehensive
insurance coverage of all medically necessary services; universal coverage
of the population; portability of insured benefits; and reasonable access
to insured hospital and physician services. While the current health care
system in Canada is publicly financed, services are primarily organized
by private entities, physicians and hospitals. The role of physicians
and hospitals is subject to considerable debate; both are said to have
a major role in delivering services to the elderly and to be in some measure
responsible for their increased use of services.
does suggest that providing health care to the elderly in its current
form is costlier than providing it to the rest of the population. In 1974,
health care spending on people aged 65 years and over was 4.5 times greater
than for Canadians under 65 years. For those over 75, health care spending
was 6.7 times greater than for the under-65 group.(48) The need is to shift resources
from the present focus on acute care and curative measures to a focus
on long-term care and prevention.
increasing cost of health care for the elderly is a source of anxiety
for provincial governments, who have witnessed seven adjustments by the
federal government to the EPF formula since 1982.(49) The provinces' ability to
finance not only basic health care but also long-term care has been affected.
In 1986, it was estimated that the national cost of health-related long-term
care was between 15 to 25% of health costs and somewhere in the order
of $5 to $10 billion annually.(50) Institutions specifically for the aged took
some $1.3 billion in 1982-83 at a time when the federal government paid
the provinces less than $73 million dollars for this purpose.
addition to the financing required for long-term institutional care, funds
are required for home care and for rehabilitative measures. For older
people, health is more than freedom from illness; it also involves the
need to preserve one's functional capacities and autonomy. Thus, both
measures to maintain people in their homes and rehabilitative care to
ameliorate and restore physical and mental functioning take on particular
concerns often predominate over concerns of efficiency and equity in the
delivery of health services. According to some Canadian researchers, these
costs may be due in large measure not to the declining health of the elderly,
but rather to a health care system that focuses on curative rather than
preventive measures, relies disproportionately on physicians rather than
other health care providers, and favours hospitalization and institutionalization
rather than home care.(51)
This view was reiterated in relation to health care systems throughout
the OECD area. A 1988 OECD report noted that: "inadequate attention
is being paid to long-term care for the disabled and chronically ill,
to preventive medicine, to the impact of environmental and behaviourial
factors on health status and to the provision of care in non-institutional
older age itself, or the response of health care systems to older age
lead to a major increase in services? In Canada, it is reported that most
seniors, except when hospitalized just prior to death, use medical services
no more often than younger adults. According to a large-scale Manitoba
study, "59% of health care services are used by about 5% of the senior
population (mostly the very elderly) and the largest costs are incurred
just before death."(53)
Factors other than age are suggested by the fact that the incidence of
surgery as part of hospitalization is increasing for the non-elderly as
well as the elderly population. Thus, 37% of all hospital discharges of
elderly people in 1987, up from 29% in 1975, were related to surgery.
For the non-elderly population, surgery was involved in 55% of all hospital
discharges in 1987, up from 50% in 1975.(54)
can and do influence the amount of care made available, including the
number of procedures and interventions offered. It has been suggested
that "78% of the increase in health care costs in industrialized
countries over the past 25 years was due to the number of physicians and
to the number and level of services they provide per patient. Only 22%
was due to demographic factors including population aging."(55)
are in turn influenced by the availability of medical technologies and
pharmaceutical products. A 1988 OECD report noted that: "technological
advances have greatly increased the potential for sustaining life, although
often irrespective of a patient's future quality of life, or even his
or her ability to function autonomously."(56) Such issues are non-medical
and should involve non-medical as well as medical personnel.
proliferation of medical technologies raises significant questions about
their use to sustain and to prolong life. Medical intervention can now
avert mortality in many instances of acute illnesses that would have resulted
in death a few decades ago. Difficult ethical questions are being raised
about "how to assess the value of additional therapy, how far expensive
technology and intensive treatment should be used in sustaining the lives
of terminally ill or senile patients, and to what extent such treatment
should be financed out of public funds."(57)
issue of prescription drugs and their apparent overuse by seniors is another
area where physicians are seen to bear some responsibility. Currently
in Canada, people over the age of 65 are the largest consumers of legal
drugs and are increasing the number of prescriptions purchased annually.(58)
This is at least partially due to the higher number of people with chronic
diseases but also to the growth of the pharmaceutical industry and the
rapid development of new and often competing drugs. Some observers suggest
that part of the higher medication use among the elderly results from
inappropriate over-prescription and poor coordination by health professionals.
prescriptions affect the health care system in two ways. One result is
the higher costs for provincial prescription drug programs providing free
coverage for people over 65 years. Provincial drug plans vary considerably
across the country. In general, the western provinces have universal plans
covering all residents, while the central and eastern provinces cover
seniors and social assistance recipients. In Ontario, the cost of free
drugs for seniors was estimated to be $1 billion annually and to be rising
by 17% a year.(59)
other result is the fact that between 5% and 15% of seniors entering hospital
are admitted with a drug-related problem - from too many drugs, from the
wrong dosage of drugs, or from a failure to take drugs properly.(60)
In Canada, the Coalition on Medication Use and the Elderly has been working
to coordinate the efforts of professional groups, drug manufacturers,
government agencies, and seniors to address the problem of inappropriate
use of prescription and non-prescription drug by many older Canadians.
of efficiency and equity are of particular concern for the older members
of the population. They include: apparent lack of coordination among various
providers, inadequate or impersonal care, the over-medicalization of social
problems, growth in waiting times for certain procedures, and use of costly
medical technologies. Quantifying the effect of either preventive or curative
approaches in order to assess their contribution to the survival and quality
of life of the elderly is extremely difficult, as are attempts to determine
the economic cost of the various approaches.
HOW CAN THE LONG-TERM
HEALTH NEEDS OF THE ELDERLY BE MET?
is an important consideration in promoting the health and well-being of
the elderly. An elderly person often enters the health or social system
as the result of an acute episode requiring admission to a hospital. A
recent survey in Saskatchewan, the Canadian province with the highest
percentage of seniors in 1991, noted that many elderly patients in Saskatchewan
hospital beds stayed there too long and would have been better off in
home-care or outpatient programs.(61)
those elderly who seek entry to health care in non-acute conditions, the
challenges can be great. Community care resources are often uncoordinated,
poorly integrated and difficult for elderly individuals or their families
to access. Providing a balance between acute care and long-term care,
between care provided by formal service providers and care provided by
informal caregivers, between care provided in institutions and care provided
in the elderly person's home is seen as the key to success.
care is different from acute care in that it requires health and social
service support over a prolonged period. For older Canadians who need
long-term care at some point in their lives, several options may be available,
depending on factors such as health status, family status, and geographic
area. Services can be received while living alone in one's own home, living
with family or friends, or living in a residential or institutional setting.
These services should be diagnostic, preventive, therapeutic, rehabilitative,
and supportive and can be delivered by formal and informal caregivers
for short-term or continuous periods.
home care is more effective and less costly than institutional care is
still open to debate.(62) Many of the existing studies
emanate from the United States, where geriatric services are less coordinated
and comprehensive. The current discussion in Canada is increasingly focused
on finding a balance between cost-effectiveness and a good quality of
life for older Canadians.(63)
are particular organizational and structural aspects of health service
delivery to the older population. If, as demographic projections indicate,
the growth will be most pronounced in the numbers of those over 80 years
of age, the sometimes frail elderly who are the heaviest users of long-term
care, greater numbers of both formal and informal caregivers will be needed
to provide long-term support. The current system of formal long-term services
is seen as inefficient, uncoordinated and sometimes inappropriate for
seniors' needs. It has been argued that expanded home care programs with
greater support for both formal and informal caregivers may be the most
effective and least costly way to provide health care to the elderly.(64)
caregivers are those who provide paid services to the elderly through
community-based or facility-based organizations. Such caregivers include
visiting homemakers, nutritionists, physicians, nurses, social workers,
physiotherapists who may go into homes or who provide services in day
hospitals, and workers in day programs, respite care programs and other
facilities based in the community.
Canada, there is no national policy on long-term care. While home long-term
care and institutional care are generally seen as a continuum, their relative
positions and the ability to integrate them to meet the changing needs
of elderly people is not yet a reality. Home care, home support and community
services are frequently considered to be discretionary programs, for which
people must often pay, while institutions, particularly hospitals, provide
most care services without charge.
health care to the elderly in their homes is considered to be the most
effective strategy and in Canada, visiting homemakers are considered to
be central to a community-based system. In addition, there have been suggestions
for increased training for physicians, nurses and social workers in preventive
approaches to primary health care and for greater provision of all services
in rural areas.
care services delivered by professionals other than physicians can result
in more appropriate use of existing acute care and long-term care services.
In British Columbia, a random study found that adding a health promotion
component administered by a public health nurse to the existing long-term
care assessment process reduced the need for long-term institutional services
for the frail elderly over 21 months of follow-up.(65) In New Brunswick, the extra-mural hospital
program relies on public health units and VON nurses to provide backup
care for elderly people transferred from general health care facilities
to their homes.(66)
Victoria Health Project is one of the most frequently cited examples of
how a different approach can reduce the demand on acute care services.
In this project, multidisciplinary Quick Response Teams of nurses, social
workers, physiotherapists and occupational therapists, working in conjunction
with physicians, help elderly clients to recuperate at home in health
circumstances that previously would have required hospitalization. Findings
suggest that without the Quick Response Team approach, all of the frail
elderly appearing at emergency wards would have been hospitalized; instead,
only one in ten or 10% need to be admitted to the acute care hospital.(67)
everywhere rely on the community, particularly families, friends and neighbours,
to provide for the needs of the elderly. In Canada, it has been estimated
that family members and friends provide between 75% and 85% of all care
for elderly people in the community.(68) Family and friends, while
viewed by the elderly as their most important source of emotional and
physical support, may find this task beyond their ability to cope. As
seniors get older, the need for personal care services increases greatly
and their families and friends cannot be expected to assume sole responsibility.
Canada's framework for health promotion, mutual aid is recognized as one
of three essential factors, along with self-care and a healthy environment.
In this context, mutual aid implies people helping each other to deal
with their health concerns, "supporting each other emotionally, and
sharing ideas, information and experiences."(69) Today, at the same time as
the population of elderly is growing, family structures are changing as
a result of geographic mobility, smaller families, more divorces and separation,
and an increased number of women in the labour force.
to the health needs of older Canadians may mean providing assistance with
grocery shopping and meal preparation, work in and around the house, financial
management, and personal care. According to 1985 data, up to 80% of seniors
received help in at least one of these activities, with those over 80
receiving the most help.(70) According to Statistics Canada, approximately
60% of women and 70% of men over 85 continue to live outside institutions.(71)
family members spend hours assisting older relatives, in addition to working
their regular hours at paid employment. A recent Canadian study on eldercare
found that 46% of employees surveyed had provided assistance to a relative
aged 65 or over in the previous six months.(72) Of these respondents,
26% combined eldercare with childcare responsibilities. General eldercare,
including assistance with shopping, transportation, financial arrangements
household tasks, and memory and mood difficulties, took an average commitment
of four hours per week. Personal eldercare that included bathing, dressing,
eating, medications and toileting took an average commitment of nine hours,
the equivalent of an additional work day.
has been suggested that the care of the elderly by family members must
be acknowledged in financial as well as social terms. Government committees,
employers, unions and caregivers themselves have made some effort to address
this issue with proposal for tax exemptions or offers of leave from work
for those caring for elderly family members.
Canada in 1990, the National Advisory Council on Aging, created in 1980
to advise the federal Minister of National Health and Welfare, unanimously
voted to support and enhance the role of informal caregivers.(73)
Discussed were the need to link formal and informal networks as well as
ways to accommodate the needs of caregivers, particularly the economic
implications of caring for others.
at the federal level, in 1993 a House of Commons Subcommittee on Senior
Citizens Health Issues, examining abuse of the elderly, heard that informal
caregivers, often family members, provide a wide range of daily services
to older people who might otherwise be in institutions or calling on other
services in the community. The members recommended that the federal government
consider methods of recognizing such work in economic terms by providing
payment to those who care for elderly relatives.(74)
the Nova Scotia and the Saskatchewan governments have initiated measures
to provide financial assistance to informal caregivers, while groups in
Ontario and British Columbia are seeking government support for the concept.(75)
The Family Caregivers' Network of Victoria, B.C. emphasizes the important
cost-savings achieved by informal caregivers of the elderly. They cite
research showing that hospitalization of the elderly often results from
caregiver breakdown rather than increasing pathology of the older person
employers and employee associations sometimes assist informal caregivers,
very few Canadian employers offer direct support to workers with family
responsibilities for the elderly. More common are flexible work arrangements
and family leave for illness. Unions do include issues related to family
responsibilities on their agendas; however, the issue of eldercare is
still peripheral and is secondary to concerns about childcare.(77)
paper has examined some characteristics of the elderly and how these characteristics
affect the demand for services in the present health care system. It has
also explored the way that the current organization generates demands
and has identified the need for a restructuring of the way health services
are delivered and financed.
policy must determine the most effective way to integrate concern for
the health of the elderly with concern for the health of the nation as
a whole; to do this there must be a commitment to research into both the
science of aging and how public policy can balance competing notions of
the responsibility of the individual, of organized health care institutions,
and of the state. There are divergent views on whether the costs of health
care for the elderly are higher than those for other parts of the population.
This points to the need for systematic information collection and consistent
interpretation of any data on the use of health care services by older
people, as well as careful analysis of how to meet demands for efficiency
has achieved near universal access to a basic, high-quality health care
service for the elderly. Health services can be preventive as well as
curative; they can be delivered on a short-term or a long-term basis,
and can involve a range of service providers. All services will require
significant investment in order to maintain current standards. Good quality
health care, however, includes more than access to treatments for disease
and disability; it should also include services to support the desire
of the elderly to live secure and independent lives and reduce the sense
of isolation and vulnerability that some older people feel as a result
of their increasing physical infirmity and reduced mobility. Providing
more resources for usefully engaging seniors in activities that could
benefit the community and for helping them to stay fit might reduce consumer-generated
demands on the health care system.
controlling health care expenditures and reforming ways of financing are
proving difficult, while technological change and the growing requirements
of older people may push up costs in the future. The varied needs of the
different groups within the older population require flexible responses
and an emphasis on the prevention, treatment and management of chronic
conditions. Public policy must balance competing interests in developing
programs to meet these challenges in an aging population.
Douglas. Review of Significant Health Care Commissions and Task Forces
in Canada since 1983-84. Canadian Hospital Association, Canadian Medical
Association and Canadian Nurses' Association, Ottawa, 1991.
Maureen. The Status of the Elderly. BP-164E, Research Branch, Library
of Parliament, Ottawa, December 1988.
Louise. L'Évaluation quantitative des résultats des programmes de longue
durée sur la santé, le bien-être et la qualité de vie des personnes âgées
en perte d'autonomie: Aspects conceptuels et méthodologiques. Ministère
de la santé et des services sociaux, Quebec, 1993.
Daniel. Alzheimer's Disease. BP-335E, Research Branch, Library
of Parliament, Ottawa, May, 1993.
Columbia Royal Commission on Health Care and Costs. Closer to Home.
Report, Volume 2, 1990.
Barbara, Katherine Cook, Faith Magwood. "A Self-Help Model for Caregiver
Education and Support Groups." Social Worker, 61, Spring,
1993, p. 41-44.
May Anne. "Implications of an Aging Society." Canadian Social
Trends, Spring 1991, p. 6-8.
Public Health Association. Ethnicity and Aging: Report of the National
Workshop. Ottawa, 1988.
Task Force on Mental Health Issues Affecting Immigrants and Refugees.
After the Door Has Been Opened. Supply and Services, Ottawa, 1988.
Neena, Laurell Strain and Audrey Blandford. Aging and Health Care,
A Social Perspective. Holt, Rinehart and Winston, Toronto, 1986.
Neena. "Society and Essentials for Well-Being: Social Policy and
the Provision of Care." In Ethics and Aging: The Right to Live,
The Right to Die. James E. Thorton and Earl R. Winkler, eds. University
of British Columbia Press, Vancouver, 1988, p. 142-154.
Neena and John Horne. Housing and Supportive Services for Elderly Persons
in Manitoba. Canada Mortgage and Housing Corporation, Ottawa, 1987.
Anne and David Hsu (with Stella Tsang). Canada's Health Care System:
Its Funding and Organization. Canadian Hospital Association Press,
Jake. Minister of National Health and Welfare. Achieving Health for
All: A Framework for Health Promotion. Supply and Services Canada,
S., L. Stone, and W. Tholl. Cost and Financing of Long Term Care in
Canada. Health and Welfare, Ottawa, 1986.
Mary. "Monograph Series on Aging-related Diseases: III. Stroke (Cerebrovascular
Disease)." Chronic Diseases in Canada 14(3), Summer 1993,
Michael. "Community Care for the Elderly: Is It Really Better?"
Canadian Medical Association Journal, 148(3), 1993, p. 393-396.
Carolyn. "Group Will Monitor Women's Health Studies." Medical
Post, 30 March 1993.
N., P.D. Beck, D. Johnson, et al. "Twenty-One Month Outcomes
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Daniel. "Heart Treatments for Men Not As Useful for Women."
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Affairs, Seniors, and the Status of Women. June 1993.
Susan. "Victoria Health Project." Paper prepared for the Community
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Publication. April 1991.
Thérèse. Health Issues in Rural Canada. BP-325E, Research Branch,
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Marc, Minister of National Health and Welfare. A New Perspective on
the Health of Canadians. Ottawa, 1974.
Olga. "Health Care System Must Adapt to Meet Needs of Multicultural
Society, MDs Say." Canadian Medical Association Journal 146(12),
15 June 1992, p. 2210-2212
Olga. "Cultural Awareness Part of the Health Care Agenda at Toronto
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of Seniors `At Risk,' Study Says." Toronto Star, 2 July 1992.
Pradeep and Lynn Acri. "Unions' Collective Bargaining Agenda on Women's
Issues: The Ontario Experience." Industrial Relations 47(4),
1992, p. 623-652.
Mary Beth and Jillian Oderkirk. "Surgery among Elderly People."
Canadian Social Trends, Summer 1991, p. 11-13.
Odette. Demographic Aging: The Economic Consequences. BP-261E,
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- Native Elders? Ethnic Seniors?" Aging Vignette #3, Ottawa,
Advisory Council on Aging. "A Quick Portrait of Canadian Seniors:
How Healthy? For How Long?" Aging Vignette #6, 1993.
Advisory Council on Aging. "A Quick Portrait of Canadian Seniors
- Major Causes of Death?" Aging Vignette #7, Ottawa, 1993.
Advisory Council on Aging. "A Quick Portrait of Canadian Seniors:
Consuming Health Services? At What Cost?" Aging Vignette #10,
Advisory Council on Aging. "A Quick Portrait of Canadian Seniors:
Needing Support for Daily Living? From Whom?" Aging Vignette #11,
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All. PAHO, Washington, D.C., 1992.
Judith, "Monograph Series on Aging-related Diseases: II. Parkinson's
Disease." Chronic Diseases in Canada, 14(2), Spring 1993,
Canada. Age, Sex, and Marital Status. Catalogue 93-310, Industry,
Science and Technology, Ottawa, 1992.
Canada. Selected Income Statistics. Industry, Science and Technology,
Canada. Dwellings and Households. Catalogue 93-311, Industry, Science
and Technology, Ottawa, 1992.
Canada. A Portrait of Seniors in Canada. Supply and Services, Ottawa,
Canada. Immigration and Citizenship. Industry, Science and Technology,
Leroy and Susan Fletcher. The Seniors Boom: Dramatic Increases in Longevity
and Prospects for Better Health. Supply and Services, Ottawa, 1986.
L.O. and H.Frenken. Canada's Seniors. Supply and Services, Ottawa,
Alistair. "Financing Health Care: A Discussion Paper." In Exploring
Options for Canada's Health Care System. The Health Action Lobby (HEAL),
James E. and Earl R. Winkler, eds. Ethics and Aging: The Right to Live,
The Right to Die. University of British Columbia Press, Vancouver,
Nations. Vienna International Plan of Action on Aging. United Nations,
New York, 1983.
M.C., G. Rowe, J.F. Gentlemen and M. Tomiak. Career Earnings and Death:
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for Advanced Research, Toronto, PHPWP.12, 1991.
Work and Eldercare Research Group. Work and Family: The Survey.
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(1) Health and Welfare Canada, The
Active Health Report on Seniors, Supply and Services Canada, Ottawa,
1989, p. 5.
(2) Jake Epp, Minister of National Health and
Welfare, Achieving Health for All: A Framework for Health Promotion,
Supply and Services Canada, Ottawa, 1986, p. 10.
(3) Marc Lalonde, Minister of National Health
and Welfare, A New Perspective on the Health of Canadians, Ottawa,
1974, p. 66-72.
(4) Epp (1986).
(5) Douglas Angus, Review of Significant
Health Care Commissions and Task Forces in Canada since 1983-84, Canadian
Hospital Association, Canadian Medical Association and Canadian Nurses
(6) United Nations, Vienna International
Plan of Action on Aging, United Nations, New York, 1983.
(7) Statistics Canada, Age, Sex and Marital
Status, Catalogue 93-310, Industry, Science and Technology, Ottawa,
1992, p. 1.
(8) Ibid., p. 1.
(9) National Advisory Council on Aging, "A
Quick Portrait of Canadian Seniors - Major Causes of Death?" Aging
Vignette #7, Ottawa, 1993.
(10) Daniel Brassard, Alzheimer's Disease,
BP-335E, Research Branch, Library of Parliament, Ottawa,
May 1993, p. 3.
(11) Ibid., p. 14-15.
(12) Lalonde (1974), p. 59.
(13) National Advisory Council on Aging, "A
Quick Portrait of Canadian Seniors: How Healthy? For How Long?" Aging
Vignette #6, 1993.
(15) Statistics Canada, Selected Income
Statistics, Industry, Science and Technology, Ottawa, 1993, p. 2 and
(16) Leroy Stone and Susan Fletcher, The
Seniors Boom: Dramatic Increases in Longevity and Prospects for Better
Health, Supply and Services, Ottawa, 1986, section 4.9.
(17) Health and Welfare Canada, The Active
Health Report on Seniors, Supply and Services, Ottawa, 1988, p. 18-19.
(18) Health and Welfare Canada, Active Health
Report on Seniors, p. 20.
(19) M.C. Wolfson, G. Rowe, J.F. Gentlemen
and M. Tomiak, Career Earnings and Death: A Longitudinal Analysis of
Older Canadian Men, Canadian Institute for Advanced Research, Toronto,
(20) Cited in Maureen Baker, The Status
of the Elderly, BP-164E, Research Branch, Library of Parliament, Ottawa,
December, 1988, p. 8.
(21) National Advisory Council on Aging, "...
How Healthy? For How Long?" Aging Vignette #6, Ottawa, 1993.
(22) Statistics Canada, Age, Sex, and Marital
Status (1992), p. 2.
(23) Statistics Canada, Dwellings and Households,
Catalogue 93-311, Industry, Science and Technology, Ottawa, 1992, p. 1.
(24) Health and Welfare Canada, The Active
Health Report on Seniors (1989), p. 17.
(25) Statistics Canada, Dwellings and Households
(1992), p. 13.
(26) Statistics Canada, A Portrait of Seniors
in Canada, Supply and Services, Ottawa, 1990.
(27) Daniel Haney, "Heart Treatments for
Men Not as Useful for Women," The Ottawa Citizen, 18 March
1993, p. A6.
(28) Carolyn Green, "Group Will Monitor
Women's Health Studies," Medical Post, 30 March 1993, p. 19.
(29) Mary Gordon, "Monograph Series on
Aging-related Diseases: III. Stroke (Cerebrovascular Disease)," Chronic
Diseases in Canada 14(3), Summer 1993, p. 68.
(30) Judith Seidman-Ripley, "Monograph
Series on Aging-Related Diseases: II. Parkinson's Disease," Chronic
Diseases in Canada, 14(2), Spring, 1993, p. 40 and Gordon (1993),
(31) Canadian Public Health Association, Ethnicity
and Aging: Report of the National Workshop, Ottawa, 1988.
(32) Statistics Canada, Immigration and
Citizenship, Industry, Science and Technology, Ottawa, 1992, p. 66.
(33) Canadian Task Force on Mental Health Issues
Affecting Immigrants and Refugees, After the Door Has Been Opened,
Supply and Services, Ottawa, 1988, p. 79.
(34) Ibid., p. 82.
(35) Olga Lechky, "Health Care System
Must Adapt to Meet Needs of Multicultural Society, MDs Say," Canadian
Medical Association Journal, 146(12), 15 June 1992, p. 2210-2212 and
Olga Lechky, "Cultural Awareness Part of the Health Care Agenda at
Toronto Hospital," Canadian Medical Association Journal, 146(12),
15 June 1992, p. 2212-2214.
(36) National Advisory Council on Aging, "A
Quick Portrait of Canadian Seniors - Native Elders? Ethnic Seniors?"
Aging Vignette #3, Ottawa, 1993.
(37) Health and Welfare Canada, Medical Services,
Aboriginal Health in Canada, Supply and Services, Ottawa, 1992.
(38) Ibid., p. 33.
(39) Organisation for Economic Co-operation
and Development, The Future of Social Protection, OECD, Paris,
1988, p. 47.
(40) National Advisory Council on Aging, "A
Quick Portrait of Canadian Seniors: How Many? Men vs Women? How Old? All
Married?" Aging Vignette #1, Ottawa, 1993.
(41) Edward Ng, "Children and Elderly
People: Sharing Public Income Resources," Canadian Social Trends,
Summer, 1992, p. 12.
(42) Pan American Health Organization, Health
of the Elderly: A Concern for All, PAHO, Washington, D.C., 1992, p.
(43) Thérèse Jennissen, Health Issues in
Rural Canada, BP-325E, Research Branch, Library of Parliament, Ottawa,
(44) Neena Chappell and John Horne, Housing
and Supportive Services for Elderly Persons in Manitoba, Canada Mortgage
and Housing Corporation, Ottawa, 1987, p. 62.
(45) Organisation for Economic Co-operation
and Development, Ageing Populations: The Social Policy Implications,
OECD, Paris 1988, p. 27.
(46) National Advisory Council on Aging, Intergovernmental
Relations and the Aging of the Population: Challenges Facing Canada,
Supply and Services, Ottawa, 1991, p. 9.
(47) Neena Chappell, "Society and Essentials
for Well-Being: Social Policy and the Provision of Care," in Ethics
and Aging: The Right to Live, The Right to Die, James E. Thorton and
Earl R. Winkler, eds., University of British Columbia Press, Vancouver,
1988, p. 147.
(48) Mary Anne Burke, "Implications of
an Aging Society," Canadian Social Trends, Spring 1991, p.
(49) Alistair Thomson, "Financing Health
Care: A Discussion Paper," in Exploring Options for Canada's Health
Care System, The Health Action Lobby (HEAL), Ottawa, 1992.
(50) S. Fletcher, L. Stone, and W. Tholl, Cost
and Financing of Long Term Care in Canada, Health and Welfare, Ottawa,
1986, p. 8.
(51) Neena Chappell, Laurell Strain and Audrey
Blandford, Aging and Health Care, A Social Perspective, Holt, Rinehart
and Winston, Toronto, 1986.
(52) Organisation for Economic Co-operation
and Development, Ageing Populations: The Social Policy Implications,
OECD, Paris, 1988, p. 66.
(53) Cited in National Advisory Council on
Aging, "The Canadian Health Care System: Myths and Realities,"
Expression, 8(2), Spring 1992, p. 5.
(54) Mary Beth Maclean and Jillian Oderkirk,
"Surgery Among Elderly People," Canadian Social Trends,
Summer 1991, p. 12.
(55) National Advisory Council on Aging, "A
Quick Portrait of Canadian Seniors: Consuming Health Services? At What
Cost?" Aging Vignette #10, 1993.
(56) Organisation for Economic Co-operation
and Development, The Future of Social Protection, OECD, Paris,
1988, p. 47.
(57) Organisation for Economic Co-ordination
and Development, Ageing Populations: The Social Policy Implications,
OECD, Paris, 1988, p. 67.
(58) Chappell, "Society and Essentials
for Well-Being: Social Policy and the Provision of Care" (1988),
(59) "Lives of Seniors `At Risk,' Study
Says," Toronto Star, 2 July 1992, referring to a report by
the Senior Citizens' Consumer Alliance for Long-Term Care Reform.
(60) "Ills and Pills: An Overview for
Leaders," Live It Up!: A Guide to Healthy Active Living in the
Senior Years, ParticiPACTION, Toronto, n.d.
(61) "Hospitals Overused, Provincial Study
Finds," Globe and Mail (Toronto), 1 June 1993, p. A6.
(62) Michael Gordon, "Community Care for
the Elderly: Is It Really Better?" Canadian Medical Association
Journal, 148(3), 1993, p. 393-396.
(63) A recent study in Quebec focused the issue
on quantitative evaluations for quality of life. Louise Barnard, L'Évaluation
quantitative des résultats des programmes de longue durée sur la santé,
le bien-être et la qualité de vie des personnes âgées en perte d'autonomie:
Aspects conceptuels et méthodologiques, Ministère de la santé et des
services sociaux, Quebec, 1993.
(64) British Columbia Royal Commission on Health
Care and Costs, Closer to Home, Report, Volume 2, 1990, p. B-101.
(65) N. Hall, P.D. Beck, D. Johnson, et
al., "Twenty-One Month Outcomes of a Health Promotion Program
for Frail Elders," Paper presented at the 14th International Congress
of Gerontology, Acapulco, Mexico, June 1989.
(66) Anne Crichton and David Hsu (with Stella
Tsang), Canada's Health Care System: Its Funding and Organization,
Canadian Hospital Association Press, Ottawa, 1990, p. 88.
(67) Susan Iles, "Victoria Health Project,"
Paper prepared for the Community and Institutional Relations Chapter of
the "Canadian Health Care Management" Publication, April 1991.
(68) National Advisory Council on Aging, "A
Quick Portrait of Canadian Seniors: Needing Support for Daily Living?
From Whom?" Aging Vignette #11, 1993.
(69) Epp (1986), p. 7.
(70) National Advisory Council on Aging, "...
Needing Support for Daily Living? From Whom?" Aging Vignette #11,
(71) L.O.Stone and H.Frenken, Canada's Seniors,
Supply and Services, Ottawa, 1988.
(72) The Work and Eldercare Research Group,
Work and Family: The Survey, Gerontology Research Centre, University
of Guelph, Guelph, 1993.
(73) The NACA Position on Informal Caregiving:
Support and Enhancement (1990).
(74) House of Commons, Breaking the Silence
on the Abuse of Older Canadians: Everyone's Concern, Report of the
Standing Committee on Health and Welfare, Social Affairs, Seniors, and
the Status of Women, June 1993, p. 36-37.
(75) National Advisory Council on Aging, The
NACA Position on Informal Caregiving: Support and Enhancement, Supply
and Services, Ottawa, 1990, p. 22.
(76) Barbara Brown, Katherine Cook, Faith Magwood,
"A Self-Help Model for Caregiver Education and Support Groups,"
Social Worker, 61, Spring 1993, p. 41-44.
(77) Pradeep Kumar and Lynn Acri, "Unions'
Collective Bargaining Agenda on Women's Issues: The Ontario Experience,"
Industrial Relations, 47(4), 1992, p. 623-652.