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1 CHAPTER I INTRODUCTION TO AGING By: Geriatric Care Team Millenium Muda Mandiri THEORIES OF AGING • • • • Discuss theories and models

of aging process Describe the most common biological theories of aging. Describe the most common psychosocial theories of aging. Discuss the relevance of these theories to nursing practice.

Descriptions: Introduction There has been a large demographic shift in the past century. In 1880, approximately 3% of the United States population was over the age of 65. By 1900, it was about 4% of the population. Today, approximately 12% of the population is over the age of 65. The fasting growing age group is currently those 85 years of age and over. The care of the elderly is a multi-billion dollar industry including but not limited to nursing home care, home health, medications, hospitalizations, medical problems, surgical problems, vision changes, and medical changes. The 12% of the population (some 30 million people) accounts for over 20% of the “poor.” However, only 5% of the elderly are in institutions, like nursing homes. Thus, 95% are out in the community. The elderly population is expected to increase to 20% in the next 30 plus years. It is estimated that there will be over 45 million elderly people by the year 2020. In 1880, the average life expectancy was 45 years. In 1900, it was 47 years. Currently, it is over 75 years for females and somewhat less for males. At present, patients over the age of 65 consume health care dollars more per capita than any other age group. This 12% of the population use 1/3 of all hospital beds and take 1/4 of all medications prescribed. Overall, this population consumes about 30% of all health care dollars spent. So what are the problems? First, there are physiological changes. There is a decrease in the cell mass of all vital organs with resultant concomitant decease in function. Also, coupled with chronic diseases and the high incidence of psycho-socio-economic problems, there is an increased incidence of malnutrition, alcohol abuse, and depression. Significant change due to aging begins at approximately 30 years of age and slowly continues onward. However, the rate varies among different individuals. It also has different meanings for different people, like professional athletes, for example. Thus, two individuals at age 65 could look and feel very differently from one another.

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2 Definition Geriatrics is a branch of health care that deals with diseases of the elderly. However, there is no good way to draw an age line at which a person becomes “geriatric.” Some simply use the age of 65 and over to define when a person is considered to be “geriatric” or “elderly” which is how this lecture will use the term. Theories of Aging This section outlines some of the most widely accepted and major theories of the causes of aging. It is important to know the cause(s) of aging, because as with treating any disease one must first understand the problem, so that afterward the precise remedy can be applied. It is our belief that some of these theories of aging may be a result of other theories. Many of them are interlinked, in the same complex way the biological processes of the body and the many factors affecting it are linked. However, approaching any one or a combination of the following theories with a specialized treatment protocol will assist the aging problem on different levels, and help to slow down and eradicate some of the so-called Pillars of Aging. Wear and Tear Theory The Wear and Tear Theory proposes that the cumulative damage to vital irreplaceable body parts leads to the death of cells, tissues, organs, and finally the whole body. Thus, cumulative damage to DNA leads to a decline in cell function. The problem with this theory is that there are no research models that give credible support at this time. Free Radical Theory The Free Radical Theory proposes that there is a progressive accumulation of high energy oxygen species that progressively and irreversibly damages cellular components such as membranes and the genetic apparatus. The accumulated damage leads to aging. There is some research evidence to support this theory and human research with the use of antioxidants is ongoing at this time. Apoptosis or “Pre-programmed” Genetic Aging Theory This theory proposes that the cells of the body are genetically “pre-programmed” by an intrinsic pacemaker system that determines life expectancy of the cells of the body and therefore, the whole body.

Genetic Theory

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3 It is well accepted that genetic factors are important determinants of aging. However, the exact mechanism is unknown. For instance, the life expectancy of identical twins is more similar than is observed with fraternal twins or other siblings with the same two parents. Polygenic Theory This is the theory that most researchers are starting to accept as the reason for changes related to aging. In this theory, the powerful influence of both the genetic apparatus and the environment’s impact on the cells of the body “add up” to direct aging and life expectancy. This theory basically embraces all the above theories and gives credence to all these factors playing a role in the aging process. The DNA and Genetic Theories Some scientists regard this as a Planned Obsolescence Theory because it focuses upon the encoded programming within our DNA. Our DNA is the blue-print of individual life obtained from our parents. It means we are born with a unique code and a predetermined tendency to certain types of physical and mental functioning that regulate the rate at which we age. But this type of genetic clock can be greatly influenced with regard to its rate of timing. For example, DNA is easily oxidized and this damage can be accumulated from diet, lifestyle, toxins, pollution, radiation and other outside influences.Thus, we each have the ability to accelerate DNA damage or slow it down. One of the most recent theories regarding gene damage has been the Telomerase Theory of Aging. First discovered by scientists at the Geron Corporation, it is now understood that telomeres (the sequences of nucleic acids extending from the ends of chromosomes), shorten every time a cell divides. This shortening of telomeres is believed to lead to cellular damage due to the inability of the cell to duplicate itself correctly. Each time a cell divides it duplicates itself a little worse than the time before, thus this eventually leads to cellular dysfunction, aging and indeed death. Another key element in rebuilding the disappearing telomeres is the enzyme telomerase, (an enzyme so-far only found in germ and cancer cells). Telomerase appears to repair and replace telomeres helping to re-regulate the clock that controls the life-span of dividing cells. In future protocols it may be possible to introduce telomerase. But right now we know that free radicals damage DNA and so does glycosylation. Thus protocols for those two, as well as hormone replacement therapy may help prevent DNA damage. The Neuroendocrine Theory

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Dean recommends receptor resensitizers such as the bi-guanidine drug Metformin (which improves insulin sensitivity) and the eugeroic drug Modafinil (which improves noradrenaline sensitivity). Dr. One theory for the hypothalamus loss of regulation is that it is damaged by the hormone cortisol. Such an argument demands the use of cortisol adjusters (such as DHEA. leading to an ever increasing degree of cortisol production and thus more hypothalamic damage. It is known to be one of the few hormones that increases with age. But as we grow older the hypothalamus loses it precision regulatory ability and the receptors which uptake individual hormones become less sensitive to them. Gerovital-H3 ® or Phenytoin) to help slow down the cortisol accumulation. as we age the secretion of many hormones declines and their effectiveness (compared unit to unit) is also reduced due to the receptors down-grading.4 By Professor Vladimir Dilman and Ward Dean MD. Accordingly. This damage could then lead to hormonal imbalance as the hypothalamus loses its ability to control the system. then over time it becomes a vicious cycle of continued hypothalamic damage. The hypothalamus controls various chain-reactions to instruct other organs and glands to release their hormones etc. this theory elaborates on wear and tear by focusing on the neuroendocrine system. If cortisol damages the hypothalamus. Cortisol is produced from the adrenal glands (located on the kidneys) and cortisol is considered to be a dark-hormone responsible for stress. This system is a complicated network of biochemicals that govern the release of hormones which are altered by the walnut sized gland called the hypothalamus located in the brain. 4 . The hypothalamus also responds to the body hormone levels as a guide to the overall hormonal activity. control and improvement. Dean also believes that the next-generation of hormone replacement therapy are the hypothalamus hormones (expected to be commercially available in the next few years). A catch-22 situation. These are some of the reasons that Dr. These types of natural supplements could present a whole new approach and concept to endocrine balance.

Because the free radical molecule has an extra electron it creates an extra negative charge. oxygen is a potent free-radical producer. the balanced molecule becomes unbalanced and thus a free radical itself. lower energy levels and generally impede vital chemical processes.. The term free radical describes any molecule that has a free electron. Such a broad cross-section of anti-oxidants includes substances such as beta carotene. lifestyle. and vitamin E and possibly also stronger substances such as Hydergine. drugs (e. there is also natural production of free-radicals within the body. disturb DNA. otherwise higher damage free radicals may be converted into a greater number of lower damage free radicals. particularly from the mitochondria (see the Mitochondrial Theory of Aging). grape seed extract. which then create metabolic waste products (see the Membrane Theory of Aging). However. vitamin C. Particular anti-oxidants will bind to particular free radicals and help to stabilize them. are all accelerators of free radical production within the body. Melatonin and Vinpocetine. tobacco and alcohol) and radiation etc. This is the result of the production of energy. This unbalanced energy makes the free radical bind itself to another balanced molecule as it tries to steal electrons. The simple process of eating. Perhaps a bit likes bumper-cars crashing into each other at the Fair? It is known that diet.g. In so doing. Note. Free radicals are known to attack the structure of cell membranes. and this property makes it react with healthy molecules in a destructive way. Free radicals can however be transformed by free-radical scavengers (otherwise known as anti-oxidants). Such toxic accumulations interfere with cell communication. Free radicals come in a hierarchy (according to their potential for damage) with the hydroxyl-radical and the superoxide-radical at the top of the list. It is therefore necessary to take a cross-section of anti-oxidants in order for the process of elimination of the free radicals to occur. RNA and protein synthesis. as the body produces the universal energy molecule Adenosine Triphosphate (ATP). The Membrane Theory of Aging 5 .5 The Free Radical Theory This now very famous theory of aging was developed by Denham Harman MD at the University of Nebraska in 1956. drinking and breathing forms free-radicals from the energy production cycles.

Eventually (after 50-odd times of division) there is simply not enough DNA information available to complete any sort of division? We also know that calorie restriction in animals significantly increases their life-span. The Hayflick Limit Theory The Hayflick Limit Theory of Aging (so called after its discoverer Dr. This cellular toxin is referred to as lipofuscin and as we grow older lipofuscin deposits become more present in the brain. Dr. Moorehead in 1961.-Nagy of Debrechen University. As we grow older the cell membrane becomes fewer lipids (less watery and more solid). This impedes its efficiency to conduct normal function and in particular there is a toxic accumulation. He showed that nutrition has an effect on cells. heart and lungs and also in the skin. Maybe each time a cell divides it loses some blue-print information. According to this theory it is the age-related changes of the cells ability to transfer chemicals. Hayflick theorized that the human cells ability to divide is limited to approximately 50-times. It is known that Alzheimer Disease patients have much higher levels of lipofuscin deposits than compared to their healthy controls. As cells divide to help repair and regenerate them we may consider that the DNA & Genetic Theory of Aging may play a role here. thus reducing communication. Professor Zs-Navy himself became involved in research to find substances that could aid in the removal of lipofuscin deposits and improve cellular lipidity and communication. (interestingly. Other substances that have shown an ability to remove lipofuscin include DMAE and the amino-acids Acetyl-L-Carnitine and Carnosine. In essence less fed animals live longer. Leonard Hayflick) suggests that the human cell is limited in the number of times it can divide. The cells declining efficiency also means that the essential and regular transfer of sodium and potassium is impaired. after which they simply stop dividing (and hence die). Hungary. heat and electrical processes that impair it.6 The membrane theory of aging was first described by Professor Imre Zs. Indeed some of the skin age-pigments referred to as liver or age-spots are composed of lipofuscin. Part of this theory may be affected by cell waste accumulation (which is described in the Membrane Theory of Aging). Professor Zs-Navy is currently working on an analogue). It is also believed that electrical and heat transfer is also impaired. Is this because they are subject to less free radical 6 . The development was Centrophenoxine (Lucidril ®) which is perhaps the most efficient substance currently available. with overfed cells dividing much faster than underfed cells. Working with Dr.

man needs to generate an average of 80-90 lbs. Chemically speaking.1 lbs. The use of ribonucleic acids (RNAs. then Carnosine will be another potent Hayflick Limit extender. ATP production declines. Cell division can be slowed down by diet and lifestyle etc. the efficiency of each organ mitochondria are essential to that particular organs repair processes and functions. but it is also surmised that cell-division can be improved with many of the protocols of the other aging theories described herein. As organs cannot borrow energy from one another. Human clinical studies with RNA supplements such as NeyGeront ®and RN13 ® indicate that there are a number of biological. 7 . of ATP daily! Under strenuous exercise the use of ATP may rise to as much as 1. ATP is literally the life giving chemical because every movement. improve cell repair processes. CoQ10 (Idebenone). so as we age the mitochondria become less efficient. physiological and practical improvements for geriatric patients.7 activity and therefore less cellular damage? Or is it that insulin and glucose damage is less prevalent in them than in overfed animals? The Hayflick Limit indicates the need to slow down the rate of cell division if we want to live long lives. Yet very little ATP can be stored in the body. the building-blocks of DNA). thought and action we make is generated from it. Their primary job is to create Adenosine Triphosphate (ATP) and they do so in the various energy cycles that involve nutrients such as Acetyl-L-Carnitine. If a particular organs mitochondria fail. NADH and some B vitamins etc. Accordingly. enhance cellular capabilities and increase the maximum number of cell divisions in animals and vitro tests. in order to produce a continuous supply of essential ATP for the necessary repair and regenerative process to occur. fewer in number and larger. under normal conditions the mitochondria are fiery furnaces and subject themselves to a lot of free radical damage.. per minute! But reserves of ATP are considered to be no more than 3-5 ounces. thus under those same strenuous exercise conditions that's approximately 8-seconds worth! Thus it becomes apparent that the mitochondria have to be very efficient and healthy. If laboratory results prove true also for the individual. then so does that organ (which of course can lead to death). The Mitochondrial Decline Theory The mitochondria are the power producing organelles found in every cell of every organ. It is estimated that a 180 lb.They also lack most of the defenses found in other parts of the body.

Cross linked proteins have also been implicated in renal disorders. One obvious example to reduce the risk of crosslinking is to reduce sugar (and also simple carbohydrates) in ones diet. as well as substances such as Idebenone and Pregnenolone. Simply cut an apple in half and watch the oxygen in the air react with the glucose in the apple as it turns yellow and brown and eventually becomes tough. In fact. leathery and yellow skin. The cross-linking of proteins may also be responsible for cardiac enlargement and the hardening of collagen. It is also theorized that sugars binding to DNA may cause damage that leads to malformed cells and thus cancer. these have been called Syndrome X. Enhancement can be achieved with the above mention nutrients. In this theory it is the binding of glucose (simple sugars) to protein. you can see cross-linking in action now. which may then lead to the increased susceptibility of a cardiac arrest. Living a longer life is going to lead to the increased possibility of oxygen meeting glucose and protein and known cross-linking disorders include senile cataract and the appearance of tough. The Cross-Linking Theory The Cross-Linking Theory of Aging is also referred to as the Glycosylation Theory of Aging. The modern diet is of course a very sweet one and we are bombarded with simple sugars from soft drinks and processed foods etc. (a process that occurs under the presence of oxygen) that causes various problems. Of particular use may be Acetyl-L-Carnitine and Hydergine. Once this binding has occurred the protein becomes impaired and is unable to perform as efficiently. as well as ATP supplements them. both of which have been proven in experiments to greatly improve the mitochondria condition of aged animals. Indeed. Some pharmacological interventions that could help reduce the carbohydrate/ starch/ glucose intake and affect. Protection may be afforded by a broad spectrum of anti-oxidants substances. 8 . include Acarbose and Metformin. Diabetes is often viewed as a form of accelerated aging and the age related imbalance of insulin and glucose tolerance leads to numerous problems. diabetics have 2-3 times the numbers of cross-linked proteins when compared to their healthy counterparts.8 Enhancement and protection of the mitochondria is an essential part of preventing and slowing aging.

The effects of this process may be similar to elevated glucose levels & shorter life spans of diabetics. Glycation Theory 1. Two of the most important at present are Aminoguanidine and the amino-acid Carnosine Biological Theories of Aging Biologic theories classify aging as genetic (heredity) & non-genetic (wear & tear). How does this theory apply to aging? Normally. death. then there will probably be an alteration in a genetic sequence. we constantly or faithfully produce cells throughout our bodies using our same correct DNA map (or proteins) to do so time & time again. Somatic Mutation Theory This theory holds that Mutations are those inheritable changes that occur in the cellular DNA. Studies conclude that glycation may have profound cumulative effect during a person's life. 2. What this theory is saying is that over time an error or mistake occurs in our DNA map (or proteins) and it begins to produce cells that are not correct … it's like going from producing a high quality product to producing a lesser quality product. Ok. we all know an Error is a mistake and Fidelity refers to being faithful… so knowing that we can discuss this theory. If there is extensive damage to DNA and it is not repaired.9 But other supplements are also appearing that show great promise in the battle to prevent. Glycation is the nonenzymic reaction between glucose & tissue protein. Also remember that this occurs over a lifetime. This deterioration results in aging and eventually over a lifetime. slow and even break existing cross-links. 4. There has been some suggestion related to background radiation of various types. Genetic Theories Error & Fidelity Theory 1. Suggests that glucose acts a mediator of aging. The negative effects of this process on proteins may be a major contributor to age changes. 2. 9 . Genetic theories are the most promising in relation to finding answers about aging. 3.

These altered abilities result in increased susceptibility to disease & to abnormalities that result form autoimmune responses. 3. Suggests that one cell. 2. Suggests that aging may be a result of an impairment of the cell in translating necessary RNAs as a result of increased turnoffs of DNA. 2. interferes with cell proliferation. 3. In other words. and each life experience and each change in a person's environment has an effect on that person. 2. The neurologic & endocrine systems are major controllers of body activity. Some suggest the Thymus as the 'pacemaker' or 'biologic clock. thereby initiating the process of senescence throughout the body. Sociologic changes refer to changes that relate to the environmental influences that contribute to and affect aging people. Each older person is an individual. or one type of tissue. the transcription of these messages into functional proteins may be restricted in older people. 2. As the body ages the immune system is less able to deal with foreign organisms & increasingly make mistakes by identifying ones own tissues as foreign (thus attacking them). During the human life span there is a 10% decrease in the weight of the brain due to both loss of cells & fluids in the cerebrum. Neuroendocrine Control Theory 1. Psychological aging is characterized primarily by behavioral changes.' Theories of the Organ System Autoimmune Theory 1. Aging Pacemaker Theory 1. 10 . 2. Some segments of DNA become depleted with advancing age. Psychological Theories of Aging 1.10 Theories of cellular aging Programmed Cellular Aging Theory 1. 3. It is suggested the age related changes in response to hormones may be the result of changes in the receptors for hormones rather than changes in the activity of the endocrine hormones themselves. or selected cellular structures seem to change with age so that DNA transcription is restricted.

a change in the ability to adapt due environmental variables. random wear & tear. Psychosocial aging can be described as a result of the disuse of previously acquired skills. 7. The four Psychosocial Theories we will discuss here are: 1. Some suggest that this theory does not consider the large number of older people who do not withdraw from society. As people age they experience greater distance from society & they develop new types of relationships with society. Aging is defined here as the transformation of the human organism after the age of physical maturity so that the probability of survival decreases & it is accompanied by regular transformations in appearance. Refers to an inevitable process in which many of the relationships between a person and other members of society are severed & those remaining are altered in quality. and may be partial or total. 5. genetic influences over the life span. 2. 4. and the activities in which they engage change. 11 . their behavior changes. 3. experience & social roles. 6. Activity theory emphasizes the importance of ongoing social activity. Withdrawal may be initiated by the aging person or by society. Disengagement theory Activity theory Life-course theories Continuity theory Disengagement Theory 1. The bottom line of Psychosocial Theory: As people grow older. Social scientists agree that genetics (heredity) is a major factor in determining the length of human life.11 Psychosocial Perspectives on Aging 1. 3. This theory is recognized as the 1st formal theory that attempted to explain the process of growing older. 4. behavior. 2. 2. 3. their social interactions change. 4. loss of internal & external resources. Is another theory that describes the psychosocial aging process. although environment plays an important role in modifying the expected life span. It was observed that older people are less involved with life than they were as younger adults. Activity Theory 1. 2. In America there is evidence that society forces withdrawal on older people whether or not they want it.

just as it does with younger people. 12 .e. Continuity Theory 1. 4. Life-Course Theories One theory we are all very familiar with is Erikson's developmental stages. which here approaches maturity as a process. Adjust to living arrangements different from what they are accustomed. Within each stage the person faces a crisis or dilemma that the person must resolve to move forward to the next stage. Aging occurs from birth to death. The process of aging leaves people alone & cut-off. Hanighurst stated that for older people to progress they must meet the following tasks: 1. Meaning that older people may seek to use familiar strategies in familiar areas of life. psychologic & sociologic processes. Adjust to pleasures of aging i. States that older adults try to preserve & maintain internal & external structures by using strategies that maintain continuity. 5. Adjust to retirement & reduced income. 2. Aging involves biologic. Standards & expectations of middle age should be projected to older age. People should be encouraged to remain active & develop own-age friends. This theory suggests that a person's self-concept is related to the roles held by that person i. recreational roles. retiring may not be so harmful if the person actively maintains other roles.12 3. 5. or not resolve which results in incomplete development. 3. such as familial roles. 2. 4. 2. Experiences during aging are shaped by historical factors. A more recent framework used in conducting research following these assumptions: 1. There is an abrupt beginning of old age. To maintain a positive sense of self the person must substitute new roles for those that are lost because of age. The Activity Theory makes the following certain assumptions: 1.e. Adjust to the death of a spouse or family members. volunteer & community roles. 3. 3. increased leisure & playing with grandchildren. Adjust to declining health & physical strength. And studies show that the type of activity does matter. Aging persons should be encouraged to expand & be involved. 4.

Describe methods that are effective in preventing elder abuse 17. & Weidenbach. Describe the housing options that are available to older adults. Descriptions: While there have been specialized pediatric courses for many years. In later life. Describe the subjective and objective ways that aging is defined. Discuss the myths that exist with regard to aging. 6. 14. 15. and functional status (including activities of daily living and instrumental activities of daily living). 12. Examine the role of nurses in dealing with an aging family. Identify the major economic concerns of older adults. James. 7. 10. 3. In order for theories to be useful in a practice discipline such as nursing. Discuss assistive technology for elderly clients. 11. Relevance of these theories to nursing practice Based on biopsychosocial theories of aging. only recently have we begun to recognize important issues with our geriatric patients. 4. Describe the changes in family dynamics that occur as family members become older. Describe the effects of recent legislation on the economic status of older adults. 3. geriatric depression. The Adult Assessment Tool can facilitate comprehensive. 16. Identify the political interest groups that work as advocates for older adults. Recognize the most common signs of abuse. 5. 1968). Discuss the health care implications of an increase in the population of older adults. Continuity theory has excellent potential for explaining how people adapt to their own aging. A decision for nursing care evolves from the nurse's assessment. Identify recent demographic trends and their impact on society. Discuss screening examinations for mental status. best-practice decisions in caring for hospitalized middle-aged and older adults. rancho los amigos. Identify the forms of elder abuse.13 2. Discuss basic gerontological nursing practice 2. 8. which includes not only what the nurse observes but also the nurse's ability to perceive what might be actually "going on" TRENDS AND ISSUES OF GERIATRIC CARE 1. Identify personal and societal attitudes toward aging. These patients account for a 13 . adults tend to use continuity as an adaptive strategy to deal with changes that occur during normal aging. Changes come about as a result of the aging person's reflecting upon past experience & setting goals for the future. 13. a tool was developed to assist nurses in conducting holistic adult admission assessments. a direct application is needed to guide the nurse in caring for a specific population in a given setting (Dickoff. 9.

Systems that were once efficient are no longer so. Even falls from a standing height are associated with significant morbidity and mortality in the elderly. Ninety percent of hip fractures result from falls. This is referred to as polypharmacy. diuresis and depression. also increase the risk of falls. Compliance with medications is also an issue when elderly patients are easily confused or forgetful. osteoporosis) and poor balance. It is not unusual for some patients to have many. Bodies change with age Bodies gradually change through adulthood and into the geriatric years. External factors. if not all. decreased lung elasticity and increased chest wall stiffness will cause shortness of breath with a lower level of exertion than in a younger patient. In the geriatric population age 75 and older. taking morning meds four times per day for almost two days. Table II on page 130 describes some of the changes that commonly occur in the elderly patient. inappropriate footwear and throw rugs. Finally. drowsiness or confusion. Polypharmacy may result in problems caused by interactions between medications prescribed by different physicians. medications can cause dizziness. such as poor lighting.) 14 . Polypharmacy Many geriatric patients take multiple medications. eyesight). For example. (This is another opportunity to help with prevention strategies. Instead of taking medications out of the container from top to bottom. This article highlights some of these issues as they pertain to our day-to-day care of geriatric patients in the field. of these risk factors. She had taken dangerously high doses of medications for hypertension. Falls occur for a number of reasons. Some are due to changes associated with aging. further increasing the risk of falls.14 large percentage of our runs and pose some important challenges in patient care. Fall Prevention Falls are a leading cause of injury-related emergency department visits across all age groups. The term may also imply that the combination of medications may not be ideal or could cause harm to a patient. These inefficiencies result in signs and symptoms of injury and illness earlier and more frequently than seen in younger patients. the patient went across the top. It is not uncommon for an elderly patient to have hypertension. type II diabetes. One of the authors recently treated an elderly patient with an altered mental status whose daughter came in several times per week and placed her mother's medications in a container with four compartments for each day of the week. arthritis and prostatic hypertrophy-all requiring medications. including reduced senses (hearing. physical conditions (arthritis. falls account for 75% of accidental deaths.

15 Geriatric patients may have reduced hepatic function. depression). syncope). Commonly prescribed medications can cause side effects in the elderly patient. There are many other confounding factors like the following example: You are called for an elderly patient complaining of altered mental status. Multiple medical conditions pose diagnostic challenges We have heard much about the different presentation of myocardial infarction in elderly patients. cardiac. constipation/impaction). who may not feel the classic pain patterns. caution should be used in the emergent field setting when administering medications such as lidocaine to the elderly. OTC sympathomimetics (urinary retention). as such. a sudden change in eyesight or in the field of vision may indicate a more acute condition. None of these factors have anything to do with the patient's current problem. It is common for providers to uncover myriad diagnostic information. even a standing fall that would be a mere annoyance to a younger person can be truly life-threatening. and he also takes medications for hypertension and angina (which lower his pulse and blood pressure) and has benign prostatic hypertrophy causing slight incontinence. such as stroke. His current complaint of altered mental status is caused by sepsis-brought on by pneumonia and worsened by the fact that his lungs no longer expand well. Falls consistently rank in the top 10 leading 15 . loop diuretics (incontinence). Age-related changes progress slowly in most cases. One clue to differentiating expected changes of aging from a pathology is by determining the onset. digitalis preparations (toxicity. which slows clearance of medications. benzodiazepine sedatives (falls) and narcotic analgesics (altered mental status. Medical conditions generally present more acutely. In this case. blood pressure of 102/58 and pulse of 56. his blood sugar will need to be regulated and his pulse may be bradycardic. (Remember that many elderly patients with infection will not present with fever. While liver function and drug clearance can vary even in younger patients. however. These include: aspirin (gastrointestinal bleeding). Trauma of the elderly Trauma isn't fun at any age. Lidocaine is metabolized primarily in the liver and. antidepressant medications (altered mental status. medications for hypertension (dizziness. Eyesight will deteriorate with age. but these aren't the problems today. who has become incontinent of urine.) Yes. should be administered in reduced doses to those with reduced hepatic function. On assessment you find an afebrile patient with a blood sugar of 202. seizures). but to the elderly patient with decreased bone density and paper-thin skin that tears easily. he has been (unknowingly) experiencing elevated blood glucose. The challenge is to place the relevance appropriately to the patient's acute complaint.

2. Orthostatic hypotension secondary to a recent change in blood pressure medications may have caused a fall. A careful history will elicit the relatively sudden change and a traumatic event that will distinguish SDH from chronic conditions of aging. resulting in pneumonia. especially in the cervical spine. side effects of certain medications can cause depression or the appearance of depression (digitalis preparations. which can cause secondary medical issues. loss of mobility and/or serious illness) and loss of cognitive function. decreased quality of life (dependence on others. gait and mentation. Elderly patients may experience a subdural hematoma after an apparently minor head injury. Bony changes in the spine make spinal injury and fracture during trauma more likely. as well as intentional noncompliance with medications to avoid the unpleasant side effectsfurther worsening the depression. Trauma to the chest has the potential to be more severe. Even minor injuries may cause pain and prevent full lung expansion. some medications used to treat depression (tricyclic antidepressants) can have significant side effects. Medications play a role in depression in two ways. These subdural hematomas are often chronic (rather than acute) and develop over time. Other considerations when treating trauma in the elderly patient: 1. narcotics. but may include alterations in speech. A medical condition may be the cause of the trauma you are treating. 3.16 causes of death in the elderly and are first in accidental causes. Elderly patients may also present with anxiety and somatic complaints (general weakness. malaise and more specific physical complaints) that are caused by depression. Signs and symptoms will depend on the extent of the hematoma. Patients who are depressed commonly present with flat affect and other typical "depressed" behaviors. the more rigid chest cavity may result in fracture and severe pulmonary contusions. Fractures to the hip and other bones are more common because of decreasing bone density. Aspirin and anticoagulant therapy will worsen the problem. 2. 1. As mentioned previously. First. Syncope may have caused a motor vehicle collision. The gradual onset (generally 3-20 days) may be mistaken for anything from dementia to normal aging. benzodiazepines). causing stretching of veins between the cortex and the dura within the skull that may tear and bleed with much less force than in a younger patient. Second. The brain atrophies with age. 16 . Depression in the elderly Some factors linked to depression include death of a spouse or close friend.

She says hello but seems wary. Regardless of the elderly patient's condition-and whether active or resident in a skilled nursing facility-all patients deserve our respect and best clinical care. there are millions of active. Elder Abuse Every year. while aging brings changes to the body. She says goodbye quickly and returns to the house. Oh. depression is disproportionately high among the elderly. who are five times more likely to commit suicide than the national average (per the National Institute of Mental Health). But there’s something else — something isn’t right. we'll all be elderly some day. You ask her about a nasty bruise on her forearm. By learning the signs and symptoms of elder abuse and how to act on behalf of an elderly person who is being abused. her skittish behavior. you slow down and greet her at the mailbox. she’s getting pretty old. she explains. Comprising 13% of the population. You may suspect that an elderly person you know is being harmed physically or emotionally by a neglectful or overwhelmed caregiver or being preyed upon financially. A corollary to this rule is to make no assumptions. 75% of the elderly who committed suicide had seen their physician within the past 30 days. Extrapolating this to EMS and the likelihood that an acute illness or exacerbation of an existing serious condition caused contact with EMS personnel provides another opportunity for screening and prevention. Often fueled by the sequelae that cause depression (loss of quality of life. tens of thousands of elderly Americans are abused in their own homes. Never assume a patient can't hear or think clearly. The greatest increase is seen in males 85 years of age and older. and even in facilities responsible for their care. loss of cognitive function). As a prevention note. those over 65 years of age account for 18% of suicides. alert and vibrant older people. the car door closed on it. You think about the bruise. in relatives’ homes.17 Suicide in the elderly population is surprisingly high. Elderly patients deserve respect No article would be complete without mentioning that. Well. Definition: elder abuse There’s an elderly neighbor you’ve chatted with at civic meetings and block parties for years. maybe her mind is getting fuzzy. bereavement. If we are lucky. Something isn’t quite right about her. as if she doesn’t quite recognize you. Start every call with an attempt to communicate and reassure the patient. you think. When you see her coming to get her mail as you walk up the street. 17 . you’ll not only be helping someone else but strengthening your own defenses against elder abuse in the future. just an accident.

or confinement. or spouses/partners of elders. Where does elder abuse take place? Elder abuse tends to take place where the senior lives: most often in the home where abusers are apt to be adult children.18 As elders become more physically frail. The most common are defined below. Emotional abuse In emotional or psychological senior abuse. ignoring the elderly person 2. and millions more cases go unreported. and others involving financial chicanery. Types of elder abuse Abuse of elderly takes many different forms. They may not see or hear as well or think as clearly as they used to. Mental or physical ailments may make them more trying companions for the people who live with them. they’re less able to stand up to bullying and or fight back if attacked. other family members such as grandchildren. habitual blaming or scapegoating Nonverbal psychological elder abuse can take the form of 1. terrorizing or menacing the elderly person 18 . Such abuse includes not only physical assaults such as hitting or shoving but the inappropriate use of drugs. leaving openings for unscrupulous people to take advantage of them. some involving neglect. isolating an elder from friends or activities 3. injury. restraints. humiliation and ridicule 3. some involving intimidation or threats against the elderly. Institutional settings especially long-term care facilities can also be sources of elder abuse. or impairment. Verbal forms of emotional elder abuse include 1. Physical abuse Physical elder abuse is non-accidental use of force against an elderly person that results in physical pain. people speak to or treat elderly persons in ways that cause emotional pain or distress. intimidation through yelling or threats 2. Tens of thousands of seniors across the United States are being abused: harmed in some substantial way often people who are directly responsible for their care More than half a million reports of abuse against elderly Americans reach authorities every year.

hospital personnel. or accounts 2. but activities such as showing an elderly person pornographic material. credit cards. or forcing the elder to undress are also considered sexual elder abuse. failure to fulfill a caretaking obligation. Financial exploitation This involves unauthorized use of an elderly person’s funds or property. Getting kickbacks for referrals to other providers or for prescribing certain drugs 4. misuse an elder’s personal checks. Investment fraud Healthcare fraud and abuse Carried out by unethical doctors. engage in identity theft Typical rackets that target elders include 1. forcing the person to watch sex acts. Not providing healthcare. nurses. but charging for it 2. An unscrupulous caregiver might 1. Recommending fraudulent remedies for illnesses or other medical conditions 6. Announcements of a “prize” that the elderly person has won but must pay money to claim 2. Such contact can involve physical sex acts. income checks. Phony charities 3. constitutes more than half of all reported cases of elder abuse. Overcharging or double-billing for medical care or services 3. or household goods 3. Neglect or abandonment by caregivers Elder neglect. based on factors such as ignorance or denial that an elderly charge needs as much care as he or she does). Medicaid fraud 19 . Overmedicating or under medicating 5. examples of healthcare fraud and abuse regarding elders include 1. and other professional care providers. It can be active (intentional) or passive (unintentional. either by a caregiver or an outside scam artist. forge the elder’s signature 4.19 Sexual abuse Sexual elder abuse is contact with an elderly person without the elder’s consent. steal cash.

Broken bones. look for clusters of the following physical and behavioral signs.20 Signs and symptoms of elder abuse At first. sucking. or mumbling to oneself Sexual abuse 1. Frequent arguments or tension between the caregiver and the elderly person 2. Bruises around breasts or genitals 2. Unexplained signs of injury such as bruises. belittling. Changes in personality or behavior in the elder If you suspect elderly abuse. Unexplained vaginal or anal bleeding 20 . but aren't sure. Unexplained venereal disease or genital infections 3. Broken eyeglasses or frames 5. In fact. such as rope marks on wrists 6. such as rocking. General signs of abuse The following are warning signs of some kind of elder abuse: 1. Signs of being restrained. Threatening. Behavior from the elder that mimics dementia. Report of drug overdose or apparent failure to take medication regularly (a prescription has more remaining than it should) 4. or controlling caregiver behavior that you witness 2. indications of emotional elder abuse include 1. especially if they appear symmetrically on two side of the body 2. They may appear to be symptoms of dementia or signs of the elderly person’s frailty — or caregivers may explain them to you that way. you might not recognize or take seriously signs of elder abuse. or dislocations 3. Caregiver’s refusal to allow you to see the elder alone Emotional abuse In addition to the general signs above. Signs and symptoms of specific types of abuse Physical abuse 1. sprains. welts. many of the signs and symptoms of elder abuse do overlap with symptoms of mental deterioration. or scars. but that doesn’t mean you should dismiss them on the caregiver’s say-so.

soiled bedding and clothes 4. Being left dirty or unbathed 5. goods. Unnecessary services. titles. Desertion of the elder at a public place Financial exploitation 1. poorly paid. Unsafe living conditions (no heat or running water. stained. such as an ATM withdrawal when the account holder is bedridden 8. Poorly trained. Significant withdrawals from the elder’s accounts 2. Inadequate responses to questions about care. or insufficient staff 2. Crowding 3. power of attorney. Unsanitary living conditions: dirt. malnutrition. Duplicate billings for the same medical service or device 2. such as bed sores 3. bugs. Suspicious changes in wills. Sudden changes in the elder’s financial condition 3. or bloody underclothing Neglect by caregivers or self-neglect 1. other fire hazards) 7. faulty electrical wiring. Addition of names to the senior’s signature card 6. Risk factors for elder abuse It’s difficult to take care of a senior when he or she has many different needs. or subscriptions Healthcare fraud and abuse 1. Financial activity the senior couldn’t have done. Unusual weight loss. Unsuitable clothing or covering for the weather 6. although the elder has enough money to pay for them 7. Unpaid bills or lack of medical care. Torn. Untreated physical problems.21 4. and policies 5. Both the demands 21 . Evidence of overmedication or under medication 3. dehydration 2. and it’s difficult to be elderly when age brings with it infirmities and dependence. Evidence of inadequate care when bills are paid in full Problems with the care facility: 1. Items or cash missing from the senior’s household 4.

substance abuse Even caregivers in institutional settings can experience stress at levels that lead to elder abuse. 22 . at an earlier time. is unintentional. Social isolation. inability to cope with stress (lack of resilience) 2. adult children. have too many responsibilities. The elder’s condition and history Several factors concerning elders themselves. Among caregivers. The elder’s role. can also be extremely stressful. Nursing home staff may be prone to elder abuse if they lack training. which is common among caregivers 3. which escalate as the elder’s condition deteriorates. or ignore the needs of the elders in their care. or work under poor conditions. Risk factors among caregivers Many nonprofessional caregivers — spouses. significant risk factors for elder abuse are 1. other relatives and friends — find taking care of an elder to be satisfying and enriching. The elder’s own tendency toward verbal or physical aggression In many cases. Caregivers pushed beyond their capabilities or psychological resources may not mean to yell at. i. impatient. strike. and unable to keep from lashing out against elders in their care. influence whether they are at greater risk for abuse: 1. are unsuited to caregiving. the elder and caregiver are alone together almost all the time 3. The stress of elder care can lead to mental and physical health problems that make caregivers burned out. the caregiver’s perception that taking care of the elder is burdensome and without psychological reward 5. as an abusive parent or spouse 4. lack of support from other potential caregivers 4. while they don’t excuse abuse.22 of caregiving and the needs of the elder can create situations in which abuse is more likely to occur.. elder abuse.e. But the responsibilities and demands of elder caregiving. depression. though real. The intensity of an elderly person’s illness or dementia 2. A history of domestic violence in the home 5.

public officials. and financial abuses targeting elders that violate laws against assault. another 12 or 13 are not. When the caregivers are their children. Preventing elder abuse means doing three things: 1. many seniors don't report the abuse they face even if they’re able. How do I report suspected elder abuse? The 500. physical. nursing home workers. peace officers. medical personnel.000 reports of elder abuse recorded by authorities every year (the vast majority of which are proven to be true) are only the tip of the iceberg. Other people care and can help you.000. they may be ashamed that their children are behaving abusively or blame themselves: “If I’d been a better parent when they were younger. according to data from different states. Eastern Time. Accordingly there’s a great need for people to report suspected abuse. tell at least one person. In every state. Many fear retaliation from the abuser. though the categories of mandatory reporters are expanding. sexual. for every case of elder abuse reported. The person who answers the phone will refer you to a local agency that can help. while others believe that if they turn in their abusers. counselors. Preventing elder abuse and neglect We can help reduce the incidence of elder abuse. With some variation among states. depending on the perpetrators' conduct and intent and the consequences for the victim. rape.23 Reporting elder abuse If you are an elder who is being abused. neglected. theft. 9 am to 8 pm. and other offenses are punishable as crimes. Typically. or exploited.” Or they just may not want children they love to get into trouble with the law. a friend. either by calling a local agency or telling a doctor or trusted friend. and clergy are listed as mandatory reporters. Tell your doctor.000 to 1. but it’ll take more effort than we’re making now. While it’s important for elders to seek refuge from abuse. no one else will take care of them. Listening to seniors and their caregivers 2. or a family member whom you trust. this wouldn’t be happening. Intervening when you suspect elder abuse 23 . certain types of emotional elder abuse and elder neglect are subject to criminal prosecution. emergency personnel. The Eldercare Locator answers the phone Monday through Friday. and that responsibility is spreading to financial institutions and other entities that work with seniors. social workers. States differ on who is required to report suspected elder abuse (there’s no federal standard).

against elder abuse 1. If you suspect abuse. 4. If you are unhappy with the care you’re receiving. or local respite care agencies. and you can lobby to strengthen 24 . 6. 5. Offer to stay with the elder so the caregiver can have a break — on a regular basis. with the assistance of a trusted friend or relative if necessary. Stay healthy and get medical care for yourself when necessary. Find a support group for caregivers of the elderly. Keep in touch with family and friends and avoid becoming isolated. Adopt stress reduction practices. or substandard care to your state’s elder abuse helpline or long term care ombudsman. How you can protect yourself. Tell someone you trust and ask that person to report the abuse. If you’re having problems with drug or alcohol abuse. if you aren’t in a position to help an elder personally. What you can do as a concerned friend or family member 1. from friends. And remember. Watch for warning signs that might indicate elder abuse. Make sure your financial and legal affairs are in order. 2. as an elder. 3. elder abuse helplines offer help for caregivers as well. Educating others about how to recognize and report elder abuse What you can do as a caregiver to prevent elder abuse If you’re overwhelmed by the demands of caring for an elder. Finally. Call a helpline if you think there’s a possibility you might cross the line into elder abuse. Find an adult day care program. Seek counseling for depression. 4. Call and visit as often as you can.24 3. 3. whether it’s in your own home or in a care facility. 5. relatives. if only for a couple of hours. speak up. Ask the elder if you may scan bank accounts and credit card statements for unauthorized transactions. If they aren’t. get help. enlist professional help to get them in order. which increases your vulnerability to elder abuse. 7. 2. Does the amount in the vial jive with the date of the prescription? 3. 2. if you can. Request help. Watch for possible financial abuse. Take a look at the elder’s medications. Help the elder consider you a trusted confidante. which can lead to elder abuse. report it. do the following: 1. so you can take a break. you can volunteer or donate money to the cause of educating people about elder abuse. or make the call yourself. neglect.

Assistive Technology for Elderly 1. The life you save down the line may be your own. Workstations 8. Mobility 4. Hearing 3. Learning 6. Vision 2. Switches 7. Communication 5.25 state laws and policing so that elder abuse can be investigated and prosecuted more readily. Keyboards & Mice 9. Manufacturers 25 . Environmental Control 10. Ergonomics 11.

Aside from medical schools or universities. might be 26 . Descriptions: History of Gerontology in Japan In 1959. Japan established the world’s longest life span. In 1978. I will comment on a brief history of Japanese geriatrics and conditions for Japanese older people. The 1lth World Congress of Gerontology was held in Tokyo which promoted research and medical practice. It takes about 5 years to elongate life expectancy by 1 year (2). Japanese have seen succeeding principles of longevity written by him from generation to generation. But I found little description about Japan. two institutes on aging. the number of disabled older people in Japan is much less than half of that in the United States (3). Medical costs are 7% of the Gross National Product in Japan. Finally. Since then. which is about half of that in theUnitedStates. and appreciate the efforts of people to establish gerontology. I understand why geriatrics is one of the most interesting subjects since the ancient era. and enjoying a family-mediated society with a young generation. The average life expectancy of Japanese people is approximately 5 years longer than that of American people. the Japan Gerontological Society was founded by Japan Geriatrics Society and Japan Socio-gerontological Society. Furthermore. basic and social gerontology Geriatrics and Older People in Japan I enjoyed reading ‘‘A Brief History of Geriatrics’’ (1). In 1713. hearing.000 members in clinical. and institutes of aging or geriatrics have been established in several universities as well.26 GERONTOLOGY IN JAPAN AND ELDERLY IN JAPAN • • • • Discuss elderly people in Japan Describe history of gerontology in Japan Identify cultural and economical backgrounds of Elderly Care in Japan. Now the Japan Gerontological Society has 8. Oriental food may be another potential element for longevity. The Tokyo Metropolitan Institute of Gerontology (TMIG) and The National Institute for Longevity Sciences (NILS) have been growing in their activities. Describe Caring for Japan’s elderly clients. a department of geriatric medicine has been established in many medical schools. Since then. provided by their family in their remaining life. He described many principles such as not eating to a full stomach. and now have become two major centers for geriatrics in Japan. Therefore. EkkenKaibara published a book Yohjoh Kun (a bible for longevity) when he was 84 years old. which suggests a superb Japanese culture. Life expectancy is a final goal of human culture. Mr. but daily stimulation such as talking.

Japanese Society of Gerondontology. Japanese Psychogeriatric Society.27 important for living longer. Tohoku University School of Medicine. 1-1 Seiryo-Machi. 85 in Sweden. Since life is limited. It is expected to reach 25% in 2. A growing older population would not disturb Japanese productivity in the future (5). Revised public long-term care insurance began in 2000 in Japan. Medical expenses are completely covered by public medical insurance with little to no payment by patients. and Japan Society of Care Management. this new insurance may produce similar results in the proportion of disabled older people in Japan being close to that of the United States in the near future. The Japan Gerontological Society started in 1959.025 in Japan. Japan Socio-Gerontological Society. Japan Society for Biomedical Gerontology. Japan has published the second largest number of papers on aging research in the world. consisting of the Japanese Geriatric Society and the Japan SocioGerontological Society. therefore. geriatrics itself is limited in establishing longevity (7). Sendai. no one should ever suffer from inability to receive medical services because of 27 . The National Institute of Longevity Science. The science of care for older people should also focus on establishing further longevity and quality of life for older people in Japan. historically Japan has developed an ideal social system for older people. in particular the oldest son’s wife.59 years for females and 77. Japan has long enjoyed a reputation for its ideal health insurance system. from generations of strong Confucianinduced chains. Aoba-ku.01 years for males. The time span for the increase in the percentage of elderly (beyond 65 years) to the whole population from 7% (1968) to 14% (1992) was only 24 years for Japan. It has become the country with the longest life expectancy in the world with an average life span of 83. 50 in England and 45 years in Germany. However. Therefore. Twenty medical universities have departments of geriatric medicine out of 80 medical universities in Japan. More people are interested in gerontology every year. Medical costs for older people have increased year by year and show a much higher rate of increase than the medical costs for people aged younger than 64 years. 980-8574 Japan. Address correspondence to Hidetada Sasaki. whereas it took 130 years in France. Longevity may decrease medical costs (4). started in March 2004. This new system has been thought to be a type of epoch-making revolution for Japanese women in that it can release family caregivers.940 members and consists of six societies: Japanese Geriatric Society. is the final and sixth national Institute of Medicine in Japan. according to the 1996 statistics by the Ministry of Health and Welfare. Geriatrics and Longevity Sciences in Japan The average life span of Japanese people has been expanding with tremendous rapidity. Department of Geriatric and Respiratory Medicine. faster than a developed country has ever experienced. following the United States (6). Now the Japan Gerontological Society has 13.

promotion of education and training of nurses. Medical expenses for elderly people have increased rapidly in the last decade. Department of Bio functional Research. 5. it is extremely urgent for Japan to establish a new society where elderly people engage in productive activity in cooperation with the younger generation. and proposed various policies in the society with the aged from medical. geriatric medicine. housing. Department of Dementia Research. and retirement from job is determined by a traditional rule of economical societies. a special agency for longevity sciences (Choju Kagaku Shinko Zaidan) was established. Department of Epidemiology. published a special committee report on "Quality of life and purpose of living for the aged from medical and social aspects" in 1997.Gold Plan" was proposed by the Japanese Government in commemoration of 60 years of reign of Emperor Showa. and is below 60 years of age in most instances. most businessman work at only one company or its affiliated institution. psychological and 28 . the NILS was established in affiliation with National Chub Hospital. In Japan. development of support. The research fields of longevity sciences of this agency are categorized into six: 1. and labor power is expected to decrease in the first half of the 21st century. The increase in population of elderly subjects. this project consisted of establishment of geriatric hospitals and nursing homes. home helpers and coordinators for medical and social cares for the aged. For the promotion of the national project. 2. rehabilitation. In 1997. In thefield of medicine. social welfare. The Science Council of Japan. Department of Geriatric Research. Furthermore. medical insurances. The institute has been growing rapidly in its activity with sixty research scientists (permanent and temporary working staff) and sufficient funds mainly from the government. The decrease in child birth over the last decade was very marked. pension and other economical problems have all been included in this study covered by this national plan. Department of Molecular Genetic Research. 4. social sciences. For these reasons. which functions as an advisory organization for the Prime Minister of Japan for national science projects. nursing and care. The institute consists of eight departments: Department of Basic Gerontology. and Department for Development of Supporting Equipment. Oriental medicine (2). 5. "The National Strategy for the Decade for the Aged . 4. Now Japan faces a turning point in national policies on medical and welfare services because of the following conditions: 3. It is expected to become one of the major National Institutes of Medicine in Japan in the near future.28 economical reasons. basic research on aging.and substitution instruments. and 6. Government Projects in Gerontology In 1986. 3. Department for the Care of the Aged.

molecular genetics of Alzheimer's disease. and increase in the budget for science research was doubled in 1997 compared to that of the previous year. epidemiology of 29 . drastic changes after World War II in social structure resulted in the increase in one generation families rather than the traditional two generation families with many family members. primarily because of the influence of traditional Confucianism.541 million yen for advanced research fields in Health and Welfare Research were newly expanded. As the above conditions have lasted for more than fifty years. First. epidemiology. Accordingly. to the parliament in 1996.29 sociological aspects in the coming decade. the housing problem really does not allow a big family of three generations to live together. In 1997. Special pathological conditions relating to aging. pathophysiology and treatment of dementia of various etiology. Together with other socio-economical reasons. it had been regarded as a natural and respective way for every member of a family to respect and to take care of the older generation. there has been a traditional custom of taking care of the old people at individual homes. osteoporosis and rheumatoid arthritis are three other major topics which the government focuses studies. as the generations that really should be cared for are in their eighth decade. Dementia has been a major topic and studies include etiology. the government proposed "the science promotion act". the next generations which are expected to support the former are already older than 60 years of age and are already in retirement and can not support their parents from the viewpoint of both physical and economical conditions. prevention and treatment of senile osteoporosis. It has to be done with primary responsibility of the society itself rather than of individuals. Atherosclerosis. Geriatrics in Japan Research in geriatrics in Japan is neither outstandingly unique nor exceptional in the world. These include neuromuscular functions of the elderly. The agency for longevity sciences has conducted a series of silver science research since 1988 with researchers from all over Japan and annual reports have been published. paying very high respect to the old. establishment of a new society is urgently needed where old populations live with social responsibilities and engage in productive works and live in harmony with younger populations. Topics of studies were partly modified for the last ten years and they are as follows. This strong financial support is expected to promote research in medicine and care for the elderly in Japan Cultural and Economical Backgrounds of Elderly Care in Japan In Japan.500 million for brain science research. we are now facing a totally new social situation where taking care of the elderly is beyond the capability of each individual or the family members because of two reasons. 833 million yen (15 million US dollars) and 9. 1. With the declaration of the decade of brain research in Japan. Researches in these fields are mandatory. including 1. the basic research fund for comprehensive longevity sciences from the Ministry of Health and Welfare amounted to 1. However. Second.

Development for health and strength maintenance and their promotion system for the aged. Ed Longevity Science Promotion Agency. engineering. a. 1991 (in Japanese) 3) Whitepapers on Health and Welfare Ministry of Health and Welfare. economy and related fields. 1994. Development of personal health document recording system for health control of the aged. Prediction of needs of the aged in the future society. These research projects have been carried out with project teams composed of researchers in medicine. 30 . Sixteen research projects are underway for information acquisition.000. c. nursing and rehabilitation. medical technology. Effects of growth hormones on aging. Resources will be from the government. a. living in healthy condition with high quality of life for the elderly people in health or disease. 10. prevention and treatment of dental disease of the aged. Health evaluation in order to promote health of the aged. Development of the silver health care support system. It will cover medical treatment and care. 6. indication of surgery for the aged. building of nursing homes and supply of beds for this system are mandatory. b. d. 8. References 1) Special issue Recent progress in gerontology research in Japan Arch Geront Genat 19: 89. Nutrition control plan throughout life in relation to research on aging protection effects of food components. Comprehensive research on drug therapies for the aged. local governments and individual recipients. development of instruments for functional recovery or substitution. Tokyo. environment maintenance for the aged or handicapped-aged. Studies on mechanisms of aging. statistics.30 senile cataract. 2. 9. b. 3. Promotion of health and epidemiology research. and the local governments will be in charge of operation. Home health care. and others. Nursing and rehabilitation research for home health care from the viewpoint of disease conditions of the aged. Glycolipids changes in metabolism by aging and expression of age-related gene. 2) Life Style of the Elderly Person and Longevity Sciences Sobue I. Education and training of staff in various functions. c. A completely new comprehensive medico-social insurance system for the aged over 65 years is planned to start in the year 2. Atherosclerosis inducing substances in the environment and their mechanisms of action. 7.

In addition. Wu’s primary interest lies in what constitutes quality of life for elderly residents. The purpose of the article is to describe the current situation of home care clients and home care nursing in Japan.31 Long-term Care and Nursing Home (Homecare) in Japan • • • • • Discuss Basic concept of Long-term care Discuss Basic concept of homecare Discuss Elderly Nursing and healthcare System in Japan. high-tech home care. and how institutional old-age care is experienced and evaluated by different subgroups. Yet her secondary aims of understanding what brings elderly people. and an assessment of the impact of policy changes on life and work in the home. four issues of home care in Japan are described related to home care for older persons. By drawing on six months’ participant observation as a care volunteer and in-depth interviews with residents. the experiences of residents before and after entry. visitors’ evaluations of the home and their reasons for visiting or volunteering. workplace. terminal care. In the future. staff members and visitors to the home. Currently. sources of conflict in the institution. staff members’ perspectives on work. The number of nurses working as clinical nurse specialists will increase consistently with the rapid increase of master's programs. Caring for Japan’s elderly The Care of the Elderly in Japan is a fascinating ethnographic study of life in an institution for elderly people in suburban Tokyo. Yongmei Wu constructs a detailed picture of institutional care. nurses work as high-tech and personal care providers and are developing a new role in health care enterprises. nurses should take a lead in developing health policy. and old-age care. while the actual practice of welfare provision is radically changing following the introduction in 2000 31 . Descriptions: Homecare in Japan Home care in Japan has developed over the past 30 years. The roles of Japanese nurses in the field of home care are presented in the context of the historical perspective and view for the future. and home care for psychiatric patients. Discuss Japanese Government Projects in Gerontology Describe Implementation of Home Care Nursing in Japan. Ideas about welfare and responsibility for old-age care are being renegotiated. Home care nurses have performed care management for their community as well as for individual older clients living in their community. occupy most of the book and yield many of its most interesting insights. Nurses have taken leadership in promoting home care and at the same time have expanded their roles. The core chapters describe the home. The study takes place at a key juncture in Japanese welfare history. which combines ‘assisted living’ with a nursing care section. staff and visitors.

this woman actively sought admission to the residential home and thrives on its leisure activities and services.. In the empirical chapters. yet eschewing institutional solutions for their own parents. which refers to a person’s ability to presume upon another person’s care and indulgence. Wu shows that normative consensus exists most readily where severely frail or impaired elderly people are concerned.. more recent works are not considered. The elderly in the study experience the tension between the ideal of co-residential familybased care and the reality of their lives. Optimism among many older residents is not easily reconciled with the pity with which some staff and visitors view them. the notion of amae. first suffered from the tensions her presence was creating in her son’s marital household and then found the non-normative solution of living with a married daughter embarrassing and constraining. traditionally considered acts of government benevolence. husband and children. even in the topical area of quality of life. links to theory are brief and chiefly confined to footnotes.. Their negative views are epitomized by the head matron. Despite expressing disappointment. is central to intergenerational family relations and has been invoked to explain Japanese 32 . This is their fate’ (p.32 of the new Long Term Care Insurance system (LTCI). aren’t most of them unfortunate people? . even humiliation. For example. I think many elderly here will pass away in misery. With it. claiming to prefer it for themselves over ‘becoming a burden’ on children. Residents. and at times contradictory views different cohorts and players have about non-family care in Japan. Wu’s analysis of Japanese cultural constructs surrounding family relationships and their applicability to institutional care is fascinating. The discussion of the empirical material remains too close to the case studies which form its core. their capacity for adaptation and positive reinterpretation of their situations is remarkable. institutionalization and formal old-age care. greater abstraction and critical commentary by the author would have been desirable. 102-3). It is only the youngest cohorts – young care staff and students on placements – who seem to have embraced the view of welfare as entitlement. who tells the author: ‘Look at the residents . economic vulnerability or severe care needs. many of whom are elderly women themselves. Considering they belong to cohorts in which institutional care was associated with abandonment and the stigma of charity.. while the burden of such care on family caregivers. One elderly woman. Some of the theories dealt with. This redefinition is not taking place smoothly or uniformly. is considered unacceptably high. are outdated. That said. staff and visitors agree that the quality of care the home can offer such patients far surpasses what families could provide. often characterized by a lack of family or family conflict. at not receiving the customary care she feels she earned by serving her parents.. ambivalent. are redefined as the right of every elderly person. Most middle. One of the great contributions of the book is the way in which the author captures and juxtaposes the disparate. The book’s drawbacks lie in its weak theoretical underpinnings and discussion.aged care staff and visitors have ambivalent feelings about institutional care. like disengagement theory. for example.

In a market-based environment. ‘a loving heart’ among the criteria by which employees were hired) are sadly no longer assets. The picture that emerges is far from rosy. There is still prejudice towards institutions’. and the ambivalences surrounding the question of how best to manage care for frail elderly people. (This fact actually renders the book’s title misleading). In reading about one elderly resident’s earlier neglect of his family when he was successful. while staffs are increasingly hired on a part-time basis. less than 2% of people aged over 65 in Japan resided in some kind of old-age institution. Linking fees to the degree of elders’ dependency has also led to the home accepting more care-intensive patients. This prejudice is doubtless waning. or another man’s involuntary confinement to a mental institution by his mother when he was young. The trainee apologized: ‘to her. With the exception of physically dependent elderly people who have succeeded in forging close bonds with a particular matron over a long period of time. who remain ‘strangers’. and the perspectives on Japanese society that are opened up through the actions and statements of people associated with the home. consider the following statistic and anecdote. none of the residents feel entitled to make demands or presume on the indulgence of staff. excellent food.33 elders’ more willing dependence on others compared with elders in the West. The author’s perceptive description of the institution and its elderly and non-elderly members avoids judgment and thereby does justice to the sensitivity and complexity of intimate care at the end of a person’s life. In one of the best chapters of the book. Wu is able to challenge the view that amae is also found among unrelated ‘patient-caregiver’ relations by pointing to the powerful sense of indebtedness that elderly people feel towards state support and home staff. Wu reports on attitudes to the new law before its implementation and assesses its implications soon after its introduction. aspects which contributed most to residents’ quality of life (leisure activities. 33 . with the result that participation is declining. took some for her grandmother to taste. impressed with the quality of food in the home. the food in a home for elderly is dirty. but she flatly refused. partly due to the introduction of the entitlement-based care insurance system. leaving less time and resources for maintaining the autonomy and well-being of more independent residents. an emphasis on Japanese traditions. in such a way that the reader doesn’t – and can’t – come away with his or her mind made up. In 1995. we are reminded that even in the past Japanese family solidarity could not be taken for granted. The home’s renowned dietary section is under threat. And lest we rush to the conclusion that whole-sale institutionalization of elderly people is likely in the near future. not family. The book’s strengths lie in the detailed descriptions of life in the home. Cuts in government fees and the exclusion of ‘non-essentials’ have meant that food quality has dropped and leisure activities now have to be paid for by residents themselves. Wu has succeeded in portraying both institutional old-age care. One young trainee caregiver.

the active elderly (roughly 55 to 75 years old) provide care for the frail elderly (generally 75 and older) in the care receiver's own home through the cooperative's home-helper dispatch centers. One of the effects of the introduction of kaigo hoken has been a dramatic increase in demand for care services. home-visit care is the service people complain most about. Koreikyo is run democratically: members elect a board of directors and officers. which includes a newsletter subscription. this expense can be reimbursed by national long-term nursing care insurance (kaigo hoken) under defined conditions. which are not. according to the judgment of a trained care plan manager.000 members over the past decade. What makes Koreikyo an unusual co-operative is the elegant way it combines features of consumer cooperatives. Since 2000. This insurance provides them the varying degrees and types of care they require to continuing to live at home. The root causes of the problem are related to inadequate training of home-helpers. developing training programs for professional long-term care specialists to provide care together with family members. The different prices of the co-op's services are published. which are responsible for administering kaigo hoken. As a result Koreikyo is also becoming a major educational institution. In 2000 Koreikyo members started programs to train and certify themselves. as might be expected. the nation at the forefront of the elder explosion. The complaints are mostly about the quality of the services and attitudes of the care workers. and 34 . They pay an annual $30 membership fee. In the Koreikyo model. which are common in Japan. especially home care attendants. have grown rapidly to more than 100. In Japan. more and more innovative solutions will appear in the effort to provide seniors with the many sorts of care they deserve and to which they are entitled. And. all Koreikyo members make a one-time purchase of a capital share in the co-op when they join (about $50 US. by and for seniors. As a co-operative. The central focus of this long-term care insurance plan is to help seniors to live in their own homes as long as possible. day care and brief stays at nursing facilities as needed. with worker co-operatives.34 Koreikyo: A Japanese Home Care Co-op Run For and By Seniors As the baby boom ages into the elder explosion in the world's industrial nations. These two different kinds of co-operatives are combined by the simple method of a 'pay-asyou-go' ticket system. and each functioning group within the local chapter sends a member to their board. The training of home-helpers and the operation of home-helper dispatch stations have become major parts of Koreikyo activities. People 65 and over are entitled to home-helper services and visiting nurse care. 'Senior Co-operatives'--Koreikyo. a hybrid form of cooperation combining aspects of consumer and worker co-operatives of. which is returned to members when they leave the coop). opening these programs to the general public with the support of municipal governments.

and finance continuing expansion. Members buy books of tickets and as they use co-op services.35 generally kept slightly below market prices. Koreikyo provides a variety of other activities to its members. many Koreikyo activities for members are not actual business services but social activities and community services such as touring and hobby groups (e.g. "She lost over 10 kilos. All of the residents and staff just beamed when they saw her again.. among them clothing re-tailoring and home environment repair and renovation services. Koreikyo's central mission is to find ways to help seniors remain in their own homes as long as they possibly can. and transportation for dialysis and other kinds of therapy. 35 . Ito." said Mrs. In addition to their home helper service. Others do volunteer work or participate is social clubs. While working at the Kawasaki City Koreikyo in 2004. and day-care centers for seniors. Koreikyo even operates three assisted living centers. reading and discussion circles. 76. At age seventy-six. knitting." Mrs. doll-making). Tanaka and many others have already done. as Mrs. "but I couldn't keep her away. Members create community when they provide services and when they receive them. Through Koreikyo. Tanaka was not yet fully recovered from her stomach surgery six weeks earlier and might be returning to work too soon for her own good. recover at home with Koreikyo home helper services. Some chapters provide lunch and dinner cooking and home delivery. Mrs. and it approaches the problem from both ends: how to get frail seniors the help they need to stay independent. and just lights up any room she enters. Tanaka is the original Energizer Bunny. organizations to raise funds for Koreikyo and other charitable institutions. and how to help able seniors find worthwhile work that pays. One morning she came in "to just help" the Koreikyo linen changing crew change sheets at New Green Nursing Home. In Japan it is important for seniors to stay active to maintain a sense of self-worth. I met Tanaka Michiko. and she had something amusing to say to each person she met. Ito Hana. Consequently. take off time for surgery. all because she is a member of Koreikyo. Service providers--themselves all co-op members as well--in turn redeem the tickets they've collected at the co-op office for their money. Many seniors continue to work after formal retirement. Tanaka could find suitable work. and return to work more or less at her own admittedly rapid pace. The Koreikyo retains a small amount from each transaction to pay local and national professional staff. worried that Mrs. and newsletter publishing. nursing home assistance. they turn over the appropriate number of tickets to the co-op member providing the service. social service group volunteer opportunities. chief of the crew. seniors stay active and add value to their lives through service to others.