Veterans Affairs Committee on March 4th, 2008

[The Chair, Conservative, Rob Anders]

Welcome to yet another meeting of our glorious veterans affairs committee.

I would like to welcome our witness for this afternoon. From Simon Fraser University, we have Gloria Gutman, co-leader of the British Columbia Network for Aging Research, and former director and professor emeritus, Gerontology Research Centre and Department of Gerontology.

You're probably aware that this is pursuant to our study of the veterans health care review and the veterans independence program.

The way it generally works is that our witnesses receive either ten or twenty minutes. In this case, the clerk says it will be ten minutes. I'm sure that if you were to extend beyond that, we would not treat you harshly. Then we go to a predetermined order of questioning. The first round is generally seven minutes, and after that it's five minutes back and forth.

With that, I offer the floor to our witness and guest.

Thank you.

[Gloria Gutman, Co-Leader of B.C. Network for Aging Research, Former Director and Professor Emeritus, Gerontology Research Centre and Department of Gerontology, Simon Fraser University]

I'm pleased to be here.

I would like to begin by saying that I have long been a fan of the veterans independence program. In one of my capacities, which is that of immediate past president of the International Association of Gerontology and Geriatrics, on numerous occasions and in numerous countries I have spoken with considerable pride about our continuing care activities in this country, drawing particular attention to the VIP program, which has played a leadership role over the years.

I'm here wearing a number of hats, but in respect of my research, I'm probably best known as an environmental gerontologist. My speciality has been in seniors housing, shelter and care for persons with dementia, and in the built-environment side of things, extending as well to WHO projects on cities that are age-friendly.

Today I'd like to speak a bit about some recent research of mine on how to make hospitals more age-friendly. This is particularly important. We need to remember that the bulk of veterans are able to stay in their communities because when they are ill or have an accident they are able to go to a hospital and get the care they need. To a lesser extent, this also applies to those who look after these veterans, the older wives, daughters, and so on.

What many people don't know is that, unfortunately, sizable numbers of older people who go into hospital because of congestive heart failure, a heart attack, or a fall lose functional status and independence while they're in the hospital. The resultant condition can be far more severe than the one they were admitted for. One reason for this has to do with iatrogenic illnesses—in particular illnesses that come about because of some treatment or procedure. Often it's a medication interaction or medication misprescription. But there are also other causes. Some of them lie in outdated beliefs and stereotypes about what you can and cannot repair in older people, what treatments and procedures they can successfully survive and thrive on.

What we're learning more and more is that age per se is not a good predictor of who should qualify to be a recipient of a heart transplant or a bypass surgery. If you think back 10, 20, 30 years, many of the procedures that today are commonplace—knee replacement, hip replacement, triple and quadruple bypass surgery—were thought to be far beyond what any older person could survive. They were considered too risky for older people. We now know that in fact many of these procedures can be successfully performed and can provide a better quality of life to older people. There are still some people in the medical field, some nurses and doctors, who are not as aware as they should be of the resilience of older people. So we need to increase our supply of geriatricians, geriatric nurses, all of the allied health professionals that work with older people.

Some of the blame for the deconditioning that happens when older people go into hospital resides with the seniors themselves. They think they need to remain in bed, whereas in fact the opposite is true. The sooner they can get back on their feet and start to resume the activities of daily living, the greater the possibility that they can go home and continue to live independently.

It's also important to recognize that the physical environments of hospitals can act either as barriers or as facilitators for older people. We did some studies in British Columbia in acute care hospitals, and we looked at the design of the hospitals. We talked to staff, and they told us what they thought were the problems. Then we brought in groups of older people who were all over the age of 75 and still living at home. They weren't sick, but they were older people somewhat on the frail side.

We exposed the older people to two different rooms. One was a traditional hospital room. The second one had started out the same as the first but we adapted it, and we found that it did make a difference in terms of their ability to understand and remember post-discharge instructions and in terms of their being safely mobile as they moved about the room. They got out of the bed, walked towards the washroom, sat themselves down on the toilet, got up from the toilet, went over to the sink, and pretended to wash their hands, brush their teeth, and comb their hair--all of the things that many of us take for granted and that people who go into hospital need to resume doing as soon as they possibly can.

The design alterations we made were all done in stages. The first thing was to drop the ceiling and to add some acoustical tiles to act as sound barriers. The second thing was to put in a rubberized flooring. The third thing was to make it possible for the patient to control the lighting. Many times when an older person--or anybody, for that matter--goes into hospital and they're in a bed, to reach the light, which is way behind the bed, they have to have considerable manual dexterity to grasp and pull the string. We realized that this was beyond what people could do, and that they were falling out of bed and breaking their hips for reasons like that. But if you go into a Home Hardware, you can buy--off the shelf, for a very minimal cost--a remote control that allows you to turn lights on and off.

We also found that by making it possible for the older persons themselves to control the bed going up and down, it was much easier for them to get out of the bed and to do so without tripping and without injury.

Another kind of simple adaptation we did was to put an automatic light, a movement-activated light, in the bathroom. When the door opened and they entered the bathroom with a walker, they didn't have to take their hands off the walker in order to turn on the light.

So there are a lot of simple solutions that can be done to make hospitals much safer and to make it easier for older people to be able to be independent during the period while they are convalescing, which has a great impact on what will happen when they go home. These are small illustrations.

The study was done in a community hospital, but I draw it to your attention because I know that many veterans who become frail end up in veterans hospitals. I would bet your hospitals are no better than the community hospitals in terms of the physical design. And these things can be done. These are adaptations that need to be done.

A set of studies we have not yet done, but which needs to be done, has to do with making hospitals safer for people with dementia. The good news is that more and more people are living to be old. The bad news is that over the age of 85, the probability of having a dementing illness goes up considerably. But those people, if they get physically ill, still need to go into hospital and need to be safe.

Many of these same kinds of adaptations can be done to the homes of older people for relatively minimal cost. When you think what it costs if a person falls and has a serious injury from that fall, the adaptation is well worth the kinds of costs that might be involved. Canada Mortgage and Housing Corporation, through the various programs it has had over the years, has made it possible for some of these kinds of adaptations to be funded. Those programs need to be expanded, continued, and improved and enhanced, both for veterans and for other people.

In terms of seniors housing, we talk about the six As. Again, I know that in the veterans program many units have gone up. They tend to meet the first A, which is affordable. We think about accessibility, tend to think about it as wheelchair accessible, but with normal aging what many more people experience is sensory fading, so you need to be concerned about lighting and sound and those kinds of things. They need to be attractive. They need to be acceptable, to be the kinds of homes people want to go into. And people need to be able to age in place, which is the catchword these days, meaning that people can stay in a familiar environment for an extended period of time.

One of the things that makes that happen is the availability of some alternatives, so that if they cannot manage in the family home or in conventional housing without some help, they can move into an assisted living facility. As there is further change, those who do require it should be able to get into a care facility.

In many parts of the country, care facilities are now restricted to only those who are very, very fragile, so there is a gap between independent living and assisted living, and then the care facility over here. What happens to those people in the middle? We need to be sensitive to those kinds of challenges. Those are the primary things.

The other issue, which has to do with design, is making it possible for people to be very much a part of the community in which they live. This means being able to get out of their home and to navigate to get to the store, to get to the bank, to get to the doctor, and to be independent for as long as possible, which has implications in terms of how you design your streets—the traffic signals, traffic patterns, and so on.

The World Health Organization, in conjunction with the Public Health Agency of Canada, has just finished a project that was done in 33 cities around the world. That now has a rural and remote component in Canada, where they're looking at how to improve communities to make them more friendly and to keep our senior citizens functioning. These apply to veterans; they apply to other seniors.

I guess the unique feature for veterans is the experiences they have had in the past and how those translate in terms of current changes in behaviour. We know that some seniors are at risk because of their previous experience; some seem to have greater resilience because of their previous experience.

Certainly the message that comes through loud and clear is the heterogeneity, both of your veterans community and your general community. There is not a one-size-fits-all. Gerontologists are very much talking about options, alternatives, and a range of different kinds of living, working, and recreational spaces for our senior population.

Those were the main issues I wanted to bring to the table.

[The Chair, Conservative, Rob Anders]

Fair enough. Thank you very much.

To let you know, according to my time clock, you went thirteen minutes, and I didn't start the clock until you were two minutes in. We let you have a good run at that.

Now we're over to the Liberal Party of Canada and Mr. Valley, for the first seven minutes.

[Roger Valley, Liberal, Kenora, ON]

Thank you, Mr. Chairman.

I can guarantee he won't be near as kind to me.

Thank you very much for your presentation today. I come from northern Ontario--Kenora riding. A lot of my questions are going to be around the professionals we use to help protect the older generation.

I was amazed at what I learned from your comments just on my own home. I'm the oldest guy in it, but I'm not quite as old as some of my colleagues. You just cleared up a problem in my own home. I have a mother-in-law who's older than 75, and her older brother. The biggest complaint she has when she visits is that she's not in familiar surroundings and she could easily fall. I could alleviate that through the comments you made about remote control. I had never thought of that; I thought it was just my mother-in-law complaining. It's amazing how we can do something in our own homes.

I want to ask a lot of questions about age-friendly cities. We have just started hearing these kinds of comments, so I'll be looking into that.

You said we need more geriatric nurses--I think that was the term you used.

[Gloria Gutman]

Yes.

[Roger Valley, Liberal, Kenora, ON]

Do they come from the existing nurses who decide to specialize, or do they become trained to deal with older people right from the first part of their career?

[Gloria Gutman]

They do generic training in regular nursing and then some specialization.

We would argue that in today's population we need to have every nurse who is trained in a module on geriatrics. After all, who are in hospitals? It's basically the older population. Many of the younger people are now being treated as outpatients.

[Roger Valley, Liberal, Kenora, ON]

That's true. So you're not saying a specific geriatric nurse qualification, but everyone who is there....

[Gloria Gutman]

It's a specialization.

[Roger Valley, Liberal, Kenora, ON]

Do they do it right out of university? I have mentioned before that my daughter is a psychiatric nurse, but she came out of university like that. She wasn't a nurse first and then specialized.

[Gloria Gutman]

There are training programs that give them the credential to call themselves geriatric nurses.

[Roger Valley, Liberal, Kenora, ON]

Okay.

We just finished touring some military bases, and we heard about the services being provided, or that are trying to be provided, for the serving men and women in the forces. We know there's a break when they leave the forces and become veterans. They're not receiving any kind of transition, and it makes it difficult for them.

The thing we heard about the people who are serving is that there are not enough professionals in any of the fields. How do we deal with that?

As I mentioned, I'm from one of the areas in Canada with not much population, large distances between communities, and very few services for the general public, let alone the aging public. How do we try to get more professionals into this field?

[Gloria Gutman]

It's interesting. When the question is asked why they don't have a problem in Britain recruiting into geriatrics, it's because the geriatricians are paid at the same rate as surgeons or urologists or psychiatrists. In this country there appear to be some differences. First of all, it often takes more time to work with the older patient. You have to talk a little slower; you have to give them a little more time. There is not the same incentive. They don't make as much money. The surgeons can perform a lot of surgery and get higher fees than the individuals who specialize in geriatrics.

We also need to make it clear to the young doctors that this a very challenging field. We need to put in some incentives--scholarships, prizes, reasons for them to be attracted to the field and to see the potential.

[Roger Valley, Liberal, Kenora, ON]

Thank you.

You classified yourself as an environmental gerontologist. Are there many people in your field who provide advice?

I know I'll be cut off shortly, but again to that, you just mentioned Britain. Where does Canada stand in the world, then? What's our approach toward geriatrics? Are we doing well? Do we have a long way to go to get to where Britain is?

[Gloria Gutman]

We have been blessed in this country by a number of Brits who came over here and who have played leadership roles. The people who have come into the field have been excellent, both the imports and the local people who have been attracted to the field. We've been lucky that the geriatricians are very good, as good as you'll find anywhere; there just aren't enough of them. We have tended to use them as resources to deal with the more difficult problems, because there never will be enough. Again, you have to insert into the generic training of virtually all the specialties and subspecialities the idea that they're going to see more and more older people, and that they should think about prevention in particular.

[Roger Valley, Liberal, Kenora, ON]

Prevention will go along with being an environmental gerontologist. That's what you do. That's how you explained yourself. Do you get resistance when you're trying to explain what we need to do inside our home environments to actually make a difference”? Is enough attention put on that? You just said there probably isn't.

[Gloria Gutman]

Well, there are not a lot of us. The Simon Fraser University Gerontology Research Centre is one of those places in the country that does specialize in this area, but there are people around the world who belong to several of the subgroups dealing with issues of housing for seniors and environmental gerontology. Yes, we are consulted--not as much as we would like, but we are consulted.

[Roger Valley, Liberal, Kenora, ON]

Thank you.

[Gloria Gutman]

Part of my role in life seems to be that I get the developers who come across from south of the border. You can see the saliva dripping. They think that there's all this older population and that they're going to bring their products from the U.S.A. and they're going to work in Canada. What they don't realize is that we have a very different health care system, in the sense that many of our people will stay at home for as long as they possibly can. They will access home care; they will take advantage of the services available; and they will, if somebody tells them where they can access some funding, in fact make adaptations.

[Roger Valley, Liberal, Kenora, ON]

Thank you.

[The Chair, Conservative, Rob Anders]

All right. Now we'll go over to the Bloc Québécois and Monsieur Perron. Vous avez sept minutes.

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

Good afternoon and welcome, Madam. I thank you for coming today.

In answer to the last part of my friend Roger's question, you said that the tendency that is emerging today is to keep older persons at home as long as possible. Even though these older people need care, we try to care for them at home.

I believe that the problem is whether we have the qualified personnel necessary to keep these people at home. Are there family members present and are they qualified to take care of these older people in their home? Generally, family members are taking up the task. You talked about the adaptations that must be made to the house, which I greatly appreciated, but I would like you to tell us more particularly about how we can make older people comfortable at home, before they reach the point where they must be hospitalized. You talked mostly about the situation at home. I would like to hear your views on this subject.

[Gloria Gutman]

Many people are able to stay at home if they can get some.... It's what we used to call homemaker services, but they now call them home support workers, who can come in and do some of the housekeeping, make some meals, and assist them with bathing, assist them if they need to go to an appointment.

What has happened in a number of our provinces, my own included, is that we had many of these services that were available at relatively low cost for those--it was means-tested--who could not afford to pay for it themselves, but many of those have been cut back. That's the prevention side of things.

If you want to keep people staying in their own homes, then those kinds of services need to be available. That was one of the areas in which the veterans independence program played a leadership role--making some of those kinds of home support services available.

There are often arguments about whether we can afford, with our aging population, to provide some of these preventive services. I would argue that we cannot afford not to provide prevention, because if people are needing those kinds of services and they can't get them, then they will end up occupying much more expensive services at a premature time in their lives.

As far as family being able to provide support is concerned, the vast majority of families who are doing these services, particularly for your veterans, are their spouses, who are not much younger than they are, and sometimes more frail.

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

There is another element to be considered: distances can be long in Canada. The more I know about the subject at hand, the more I realize that the majority of services are designed for major centres. In a small village such as my home village of Évain, in Abitibi, which is in Northern Quebec, there are no services. Services are provided informally and we do our best to cope.

How can we solve this problem? I do not believe that an older person should be uprooted from his or her small community and be moved to a major centre in Ottawa, in Toronto or in Montreal. How could we better adapt our services to the needs of older people?

[Gloria Gutman]

Well, some of the ways that are being explored are in terms of application of new technologies. You know, many old people watch television. There's a lot of health information that you can give over television. There are systems being developed that allow a physician or a medical person who is remote from that older person to be able to do diagnosis.

There are various kinds of technologies you can use to do cardiovascular readings, check for diabetes. There are all kinds of things that are possible that companies like Intel, in their demonstrations, tell us can be adapted and used by older persons.

The problem is they are not mass producing many of those technologies at a price that is affordable for the average person. If you can put a man on the moon and you can monitor all of his functions, it should be relatively simple to be able to do some of that in our rural and remote communities. But we have not put our attention to it to the extent that we should.