Veterans Affairs Committee on Feb. 7th, 2008

[The Chair, Conservative, Rob Anders]

Good afternoon, committee members. This is yet another meeting of our Standing Committee on Veterans Affairs. We are continuing with our study of the veterans health care review and the veterans independence program.

Today our witness is Maggie Gibson, a psychologist with the veterans care program.

Just so you're aware, I think the clerk has informed you that you have ten minutes, but if you want to go a little bit longer than ten minutes, that's probably acceptable. Usually our witnesses as a group testify for twenty minutes. After that we'll go to questions from our committee members.

The floor is yours.

[Dr. Maggie Gibson, Psychologist, Veterans Care Program; Member, National Initiative for the Care of the Elderly]

Thank you very much.

I am actually here representing NICE, the National Initiative for the Care of the Elderly, of which I am a member. I am a psychologist, and I work at a veterans care program in London, Ontario, at one of the large priority-access-bed facilities in Canada.

The National Initiative for the Care of the Elderly is an international network of researchers, practitioners, seniors, and students dedicated to improving the care of older adults in Canada and abroad. NICE is funded through a new initiative grant from the Networks of Centres of Excellence.

Our members represent a broad spectrum of disciplines and professions, including geriatric medicine, nursing, social work, gerontology, rehabilitation sciences, sociology, psychology, policy, and law. We promote and facilitate interdisciplinary collaboration between and among researchers and practitioners to improve the care of the aging population in Canada and elsewhere.

The overarching emphases of NICE are networking and knowledge transfer--that is, getting good research into practice.

NICE has three overarching goals. The first is to help close the gap between evidence-based research and actual practice. The second is to improve the training of existing practitioners and geriatric educational curricula, and to interest new students in specializing in geriatric care. The third is to effect positive policy changes for the care of older adults.

With that as the background of who it is I'm representing, I'd like to provide some comments from NICE for the committee.

NICE would like to compliment Veterans Affairs Canada on the thoughtful consideration of aging issues that is reflected in the work of the Gerontological Advisory Council's report, Keeping the Promise, and in the veterans health services review. To further this good work, there are three specific issues that NICE would like to bring to the committee's attention.

First, we note that several of the issues of concern to NICE--in particular, caregiving, dementia care, and end-of-life care--are easily identified in the work to date. NICE has also identified elder abuse and mental health as priority issues for improving the well-being of older adults.

Mental health is an underserved focus in health care for seniors. This is evidenced by its prioritization within the NICE thematic framework as well as by the coming together of the Canadian Coalition for Seniors' Mental Health--another organization that I am a member of and have been on the steering committee of--specifically to advocate for improvements in this aspect of care for older adults.

Mental health is a critical component in any broad-based health promotion strategy. It's well known that poor mental health has implications for the ability to access, assimilate, and derive benefit from interventions that aim to enhance, maintain, or restore independence, that aim to improve functional autonomy, and that promote quality of life.

So mental health problems and illnesses are not well served by home care programs in general. We hope that appropriate attention will be given to the promotion of mental health in any changes to the veterans independence program that result from the committee's deliberations.

Second, we applaud the committee's interest in making services under the veterans independence program available to a greater number of recipients. We agree that the services provided should be based on assessment of needs. We note that the evolution of needs across the lifespan is an important consideration. An effective and user-friendly monitoring process will be essential to ensure that the provision of services stays current and timely.

We suggest that the inclusion of older adults in the process of developing and implementing monitoring will be essential to its success. Routine monitoring that is triggered by the passage of time is important, but even more important is the realization that health status can change rapidly for seniors, especially for those with a more tenuous hold on their independence. The needs-based assessment protocols that are developed should encourage self-monitoring and user input in the face of significant change on an ongoing basis. We would suggest that expertise in knowledge transfer and networking should be accessed to develop creative, state-of-the-art approaches to shared care in this context.

Third, we agree with the goal of supporting a range of residential care options for seniors, and agree that efforts should be made to encourage and enable older adults to reside independently as long as possible.

We note, however, that there is a risk in conceptualizing long-term-care homes as the residences of last resort. This has the potential to exacerbate the stigma already associated with this residential care option. For many reasons, a substantial number of veterans and other older adults need full institutional care if they are to survive. It has been said that a society can be judged by how it cares for its most vulnerable members.

Communication and advertising about changes to the current system should not suggest that those veterans and families who do not need long-term-care placement are somehow more successful than those who do. We also note that it will be important to ensure that the new emphasis on health promotion and innovative service delivery is as valued for those who reside in long-term-care facilities as it is for those who remain in their communities.

Thank you for the opportunity to present these views to the committee.

[The Chair, Conservative, Rob Anders]

That was incredibly succinct. You were actually under six minutes. All right. Fair enough.

[Gilles-A. Perron, Bloc, Rivière-des-Mille-Îles, QC]

It's quality.

[The Chair, Conservative, Rob Anders]

It's quality. That's right, Mr. Perron.

We will now go to the rotation. We have the Liberal Party of Canada, represented by Mr. St. Denis, for seven minutes.

[Brent St. Denis, Liberal, Algoma—Manitoulin—Kapuskasing, ON]

Thank you, Mr. Chair, and thank you, Ms. Gibson, for being here and helping us out with our study.

There are a couple of things.

Have there been any studies answering the question of whether things like Alzheimer's are less or more prevalent among veterans as compared to the general population? Is there any correlation between military experiences, whether they were wars long ago or more recent peacekeeping conflicts, and the onset of Alzheimer's, or is it accepted that dementia--and these are almost the same thing--is strictly genetic or an environmentally driven condition?

[Maggie Gibson]

I'm not aware of any studies that have specifically set out to determine whether the incidence is different in a same-age, same-circumstance elderly male population who aren't veterans versus those who are. I'm not aware of any studies that have taken that actual approach.

Based on what we do know about Alzheimer's, I think your second point, that there really is more in the genetic and the environmental area, would explain the incidence. I don't think there have been any studies that have specifically addressed whether trauma-based combat situations contribute to a higher incidence of Alzheimer's. I would be surprised to find that the incidence was different in that population, but I don't think the research is being done.

[Brent St. Denis, Liberal, Algoma—Manitoulin—Kapuskasing, ON]

I'm just thinking of a couple of veterans who come to mind in my own riding, for whom Alzheimer's has become a serious issue. One was getting VIP help, and he is at a point where the family is trying to decide on the best course going forward. He is physically capable of staying at home, but due to his wandering and so on, it might be unsafe for him to be at home.

Are there any standards that help professionals and families decide? VIP is designed to help people transition in their older years, allow them to stay at home, and provide help through a transition until such time comes, should it come, that they need to be put into a domicile. Are there any standards or metrics that are used, like a checklist of questions, to allow the professional and the family to say “Here's the point in time. The VIP has been great. The grass is being cut, but now it's time to move Dad to the regional home”?

[Maggie Gibson]

Two things come to mind in response to your question. One is that the need for institutionalization is often driven by a whole combination of factors, and many of them are caregiver-focused. So if a caregiver who has been managing someone who has a progressive dementia has a fall and ends up in hospital, then it's more likely that the veteran who had the dementia is going to have to go into a long-term-care home, because the caregiving support systems aren't there any more.

So one issue is the progression of the disorder, and the other issue is the stability of the environmental supports. There are some things that can happen in the course of dementia that make it increasingly difficult for people to be managed at home, regardless of whether the situation is stable or not, and that's when some of what they call the psychological and behavioural symptoms of dementia start to become more prominent, which happens as the dementia gets worse. This is the wandering, the aggression, the inappropriate behaviours and hallucinations--the kinds of behaviours and symptoms that can become a lot more difficult to manage in a home and community environment. So if the disease progresses so that those start to become more a part of the symptom picture, that may be what triggers the need for institutionalization, even though the family or the spouse hasn't changed.

On the other hand, the disease could be fairly stable and the caregiving situation could change, and all of a sudden that requires institutionalization.

To go back to your previous question, about what research there's been, well, I don't think there's been a lot of focus on determining whether there has been a higher incidence of dementia in veteran versus non-veteran populations. There has been quite a bit of research done, and quite a bit of this has come out of the United States, actually. They've looked at older veterans who have managed quite well through their middle-aged years--they worked, they had a good career and a good early retirement--and then they developed dementia. The combination of the dementia and what that brings in terms of the ability to cope and to reason and to function, together with the losses that come with aging, can create a pretty volatile situation that becomes quite difficult to handle. So you can get a situation whereby the normal stresses of aging are exacerbated.

[Brent St. Denis, Liberal, Algoma—Manitoulin—Kapuskasing, ON]

Thank you.

It occurred to me that an operational stress injury, or post-traumatic stress disorder, I would say, simply anecdotally, is more common among veterans than in the general population. So I was just wondering if there are any complications. As difficult as the operational stress disorder might be in the working-life period of a veteran, does it complicate an Alzheimer's situation further? Is that part of a cocktail that makes late-life care more difficult? Or does one sort of get shoved out of the mind as Alzheimer's takes over?

[Maggie Gibson]

I think it can shape the symptoms. For example, in a long-term-care facility what you can have is someone who was in a prisoner of war camp who experienced all the things that go along with that and then functioned very well. And now they're in a long-term-care home because of their Alzheimer's disease, and when the nurses come in the middle of the night to wake them up for some reason or another, it can trigger reactions that are based on previous experiences. That can happen to anyone with Alzheimer's. They can have in their demented state previous experiences triggered, but the nature of the kinds of experiences the veterans might have available to be triggered may be connected to their previous experience.

[The Chair, Conservative, Rob Anders]

Mr. Perron, from the Bloc québécois, you have seven minutes.

[Gilles-A. Perron, Bloc, Rivière-des-Mille-Îles, QC]

Are you giving me Madam's four minutes?

[The Chair, Conservative, Rob Anders]

I don't know if the other committee members would approve of that, Mr. Perron.

[Gilles-A. Perron, Bloc, Rivière-des-Mille-Îles, QC]

Good afternoon, Mrs. Gibson. Thank you for coming. Your presentation was very interesting.

If I understood correctly, you're in favour of home care. You said it was important for seniors to stay in the community or at home for as long as possible. Do we have qualified people to help them, those who are called natural helpers?

In my friend Gérard Asselin's riding, for example, there's a problem issue. A certain Antonin Lévesque, an elderly veteran, has serious problems. His wife, who is nearly as old as he, is no longer physically able to care for her husband, so much so that she was forced to put him in some centre for a few weeks before bringing him back home. How do we resolve this kind of situation?

[Maggie Gibson]

This is exactly why I think we have to be really careful about looking at it as a continuum of care with multiple options and about making sure we're making the decision that provides the right care for the person in their circumstances. If the person has the kinds of needs that are easily met by the services available, then they're going to be able to be kept in the home longer. But once you start to get into the mental health issues and the dementia issues and so on, there may not be readily available professional assistance in the existing home care service roster to provide the care that's needed.

The human resource issue on the health care professional side is a big problem, in terms of adequately servicing home care clients, absolutely. That's why you also have to be careful, in your assessment process, to make sure you're taking a very broad-based look at assessing need. It's not purely function—what you can do under the ideal circumstances—it's a question of what's really available to you and the kind of support you are going to need.

It's also a question of recognizing that people don't necessarily go into long-term care as a one-time thing, whereby they go in and never come out. There's a quite a revolving door for long-term care as well. People may need to be in long-term-care beds for a while and then are able to go back to the community at different stages of their life, depending on what resources are available to them.

I think we need to become much more flexible in how we think about all the different options along their care continuum and how these can intersect and work together to meet different needs at different times.

[Gilles-A. Perron, Bloc, Rivière-des-Mille-Îles, QC]

I'm going to show my colours. I'm stubborn, or obsessed by post-traumatic stress syndrome among our young soldiers. I prefer to call that a psychological injury, a psychological war injury, than post-traumatic stress syndrome. That's my thing.

We had a chance to hear from a number of psychologists, who explained the matter to us. I have a question and I can't answer it because I don't have the necessary qualifications. If we increased awareness among soldiers, if we made them more aware that they might suffer psychological shocks in a situation or theatre of operations, would that be beneficial to them? Would they suffer less from psychological injuries? Last time, my friends from Valcartier had two and half hours of training and were told a little about post-traumatic stress syndrome. Should they be told more about it, should more be said about it to the families who stay at home and to the children of those soldiers who stay at home when their father is out perhaps being killed? I'd like to know your opinion, your point of view on that in general.

[Maggie Gibson]

You give me a very nice opening, because as I said, I sit as a member of both NICE and the Canadian Coalition for Seniors Mental Health. I definitely think we should be as willing to talk, to educate, to communicate about mental health disorders—the risk factors, the potential solutions to them—to make it as open a conversation around mental health issues, be they PTSD, depression, anxiety, substance abuse, or other conditions, as we are to talk about the potential for your getting diabetes or heart disease or any of the other much more acceptable medical diagnoses.

Many of us in the mental health community are hoping there will be an opening up of the dialogue through the new mental health commission, for example, and that people will start to feel as comfortable in any professional context, be it soldiering or nursing or whatever it happens to be, talking about mental health issues as they are talking about any other health issues.

[Gilles-A. Perron, Bloc, Rivière-des-Mille-Îles, QC]

Could that be a kind of assistance? I imagine myself in an armed vehicle driven by a co-worker: if I've been trained or if I have certain knowledge, I may realize that my co-worker is having problems related to post-traumatic stress syndrome, that he's endangering my life and that of all the soldiers in that vehicle.

Even though I don't have any proof of this, I believe that we're not giving enough information to these young soldiers, who could say that they're having problems, that they don't feel right and that they have to consult someone. They could also say that their co-worker is having problems or that he isn't feeling right. Am I right?

[Dr. Maggie Gibson]

I think you're absolutely right that there should be much more open information about mental health issues, and that health promotion in the mental health area can only be a good thing. For example, you see commercials on television asking you if you would recognize the symptoms of a stroke or of diabetes. There shouldn't be any big secret about what the symptoms of mental health disorders are, so that they can become de-stigmatized. People could be better able to recognize them, better able to support their colleagues and peers, and better able to direct individuals to appropriate professional care.

[Gilles-A. Perron, Bloc, Rivière-des-Mille-Îles, QC]

Merci.

[The Chair, Conservative, Rob Anders]

Fair enough.

Now over to the New Democratic Party's Mr. Stoffer for five minutes.

[Peter Stoffer, NDP, Sackville—Eastern Shore, NS]

Thank you, Mr. Chair.

Maggie--if I may call you Maggie--thank you very much for coming out today.

We're heard testimony from other folks that there are just not enough people like you around. Obviously, if we have these great plans, and even if the government and the opposition agree that x number of dollars will go into funding, and we'll do everything that's been recommended to us, if we don't have the physical human resources to do them, it could all go by the wayside.

What recommendation can you give to federal and/or provincial governments to encourage people to take this up as a career, as an opportunity to help people, to make a decent living, as obviously you have, and to encourage them that it is a wonderful and valued career? Year in and year out we seem to have this problem of getting people to take this up as a profession. What recommendations can you give to us that we can then pass on?

[Dr. Maggie Gibson]

I can speak to the area of psychology. If you go to the website of the American Psychological Association in the States, you'll see that they have all sorts of informational, promotional materials directed at encouraging people, and especially students, who are interested in the mental health field to take up a career in care of the elderly or in geropsychology.

The Canadian Psychological Association is doing more in that direction now, and I'm involved in some of that. I really think that the focus has to be on the education system, and we need to make people more aware of the interest, the potential and the value of careers in the care of older adults earlier in their careers before they've selected their focus, before they're in graduate school and have already decided what they're going to do, and have started down a track that it's hard to turn from.

It's not just the mental health professions that are facing difficulties. Certainly geriatrics is facing difficulties as well in terms of recruiting enough people who want to specialize in this area.

People specialize through the education system, so we have to be working with the colleges and universities to create more interest and have more educational offerings early on that will steer people in those directions.

[Peter Stoffer, NDP, Sackville—Eastern Shore, NS]

As you know, we've been told repeatedly that mental health issues are provincial responsibilities, except in some cases in which Veterans Affairs Canada applies for veterans or their families. What role do you see for the federal government in doing that, in assisting the provinces and getting the word out that because of our aging society--not just in the military aspect, but our overall society's becoming older and older--the problems of dementia or Alzheimer's and other concerns will be coming up to us rather rapidly? The perfect storm is coming in this regard. We see it, but we don't actually know how to handle it, in terms of encouraging....

What role do you see the federal government taking in assisting the provinces in doing this?