75: International Perspectives in Geriatric Care

Sandra Y. Moody, MD, BSN, AGSF &Miwako Honda, MD

Japan has the highest life expectancy, at nearly 87 years, and faces the most rapidly aging society in the developed world. This likely has been achieved through a convergence of several factors, but most importantly a decline in infant mortality since the 1920s, an economy that grew rapidly over 2–3 decades beginning in the late 1950s, and the introduction of universal health insurance coverage in 1961, which allowed equal access to health care across the population. Commensurate with the growing proportion of older adults in Japan, the total fertility rate has decreased drastically, and continues to do so, leading to a crossover effect—a rapid growth in the proportion of older adults, with a declining proportion of younger people.

The proportion of adults age 65 years and older has grown substantially from 4.9% in 1950 to 22.7% in 2010. As of March 2012, Japan’s total population was estimated to be 127,650,000, with approximately 29,487,150 individuals who were age 65 or older. Furthermore, it is estimated that by 2050, a full 40% of Japan’s population will be age 65 years and older. Assuming Japan’s total population will decrease during the next 50 years, by 2060, nearly 41 million individuals (40.5% of the population) will be age 65 years or older.

In addition to having the longest life expectancy, Japan also has been noted to have the best healthy life expectancy in the world as of 2007, which is partly attributed to a national health insurance plan that encourages annual health checks and preventative care. For example, on average, Japanese men live in a healthy state for 73 years and women for 78 years. These successes put Japan in a position to serve as a model to other nations as they address similar aging-related issues, including the United States.

Challenges of an Aging Society

Japan faces several challenges given its aging society. These challenges include: (a) how to continue to support and maintain its national health insurance system, and (b) how to prepare a health care workforce that can care for a society that is aging rapidly.

Health Care Expenditure in Japan

Japan’s national health insurance is a social insurance plan to which all citizens must contribute. Broadly speaking, the health care payment structure consists of insurance premiums and state subsidies. According to the KEMPOREN (the National Federation of Health Insurance Societies), for those who are fully employed, insurance premiums are drawn from their “monthly salary, bonuses, allowances, and all other forms of compensation for work received by the insured person from the employer.” This cost, shared by the employee and employer, ranges from 3% to 12% (the proportion employees pay depends on their annual salary). The state pays the administrative costs. Because the payment structure is complex, it is not discussed in detail here.

As of 2008, health care expenditures in Japan were only 8.5% of the gross domestic product compared to approximately 16% for the United States. As fewer younger workers contribute to the coffers of the health care system, Japan will be challenged to keep health care expenditure as low as possible and still pay for its aging society. Many approaches are being considered, but one is to create a social structure that dispenses with forced retirement and encourages older adults to continue to work for as long as possible based on ability and not age.

Geriatric Medicine in Japan

The relative underdevelopment of geriatric medicine in Japan poses another challenge to overcome as the society ages. Geriatric medicine was recognized as a subspecialty in 1988 (Japan Geriatrics Society). Currently, there are 6200 members of the Japan Geriatrics Society, which is one of the main organizations that advocates for the care of older adults, but only 1494, as of December 2013 physicians are board certified in geriatrics. This translates into 1 geriatrician for every 34,500 older adults. Not all older adults are in need of a board-certified geriatrician, but because the general population of doctors has not been trained in geriatric medicine, a huge burden rests on those who are.

There are 80 medical schools in Japan and between 30 and 40 university- or hospital-based departments or divisions of geriatrics/gerontology. The care of older persons occurs from 2 perspectives—geriatrics and gerontology. Geriatrics focuses on the care of older persons through research, education, and clinical practice, but the research is the most emphasized. Gerontology focuses on health promotion by way of social welfare, psychology, environmental, and social systems.

Not only is clinical geriatrics underdeveloped, but there is also very little formal geriatrics education in medical school or postgraduate training. Furthermore, medicine in Japan is composed of mostly subspecialists. Primary care in its “purest” form is not widely practiced. For example, general internal medicine and family medicine specialties are in formative stages throughout the country. In general, subspecialists provide both primary and subspecialty care. Nevertheless, geriatrics is gradually being integrated into current practice by on-the-job training (“geriatricizing” currently practicing physicians) through seminars and the availability of an online geriatrics handbook provided by the Japan Geriatrics Society. Additionally, some of the physicians train abroad in geriatrics with the intent of expanding geriatrics practice in Japan. Change is afoot, but there are unmet opportunities to develop the field at a faster rate in response to apparent or projected need.

Innovative Models of Care

One of the most innovative care models in Japan is the Public Long-term Care Insurance System (LTCI), a system that has been updated over the years. Its predecessor, the Long-term Insurance Act, was approved by parliament in 1997 and came into effect in April of 2000. The Long-term Insurance Act was created to address the increasing health care needs of the older adult population resulting from a gradual change in societal norms—mainly a breakdown in traditional family supports for older adults. Traditionally, the daughter-in-law of the eldest son became the caregiver for her parents-in-law, but more and more women are working outside the home; fewer people are getting married and when they do, they do so at an older age; and many women no longer want to be the primary caregivers. As the gap in traditional family supports has increased, the government has stepped in to fill the gap.

According to Tamiya et al, the primary focus of the LTCI is “to help older people lead more independent [lives] and to relieve the burdens of family [caregivers].” They further state that it operates on social insurance principles, in which health care benefits are provided regardless of income or family situation; coverage and benefits are substantial; only services, not cash allowances, are provided; and recipients are free to choose the type of services they will need as well as the entity that will serve as the provider of those services. The providers of care include the local government, semipublic welfare corporations, nonprofit organizations, hospitals, and others. In Japan, the average length of hospital stay is about 2 weeks, but can be prolonged for various reasons if the older person does not have a place that can provide the appropriate level of care upon discharge.

The Long-term Care Insurance System

All individuals age 40 years and older are covered under this plan. However, the primary recipients are those who are age 65 years and older. Individuals who are between the ages of 40 and 64 years receive coverage only if they have a “geriatrics-related” illness, such as dementia, stroke, or significant functional disability. To keep costs down, the services are primarily community-based, with the intent of preventing institutionalization—whether acute hospitalization or long-term nursing home care. Fifty percent of the cost derives from public funds and 50% from premiums paid by the recipients. A cap is placed on how much the individual has to pay to prevent financial catastrophe.

The appropriate level of care for each patient is determined by the patient’s answers to a 74-item questionnaire that is based on activities of daily living, which are then analyzed to determine 1 of 7 levels of care for which the person is eligible. The levels identify a person is “self-reliant,” “needs assistance” (levels 1 and 2), or needs long-term care (levels 1–5). The higher numbers indicate greater needs. Figure 75–1 gives the outline of the LTCI system. According to Tamiya et al, it has been difficult to show the efficacy of LTCI, but there is some evidence that it is effective in reducing caregiver burden.

Japan faces a rapidly aging society, possesses the oldest society in the developed world, and has the highest healthy life expectancy. It has been successful in creating one of the most innovative long-term care insurance plans worldwide. Yet, it will require a herculean effort for Japan to fully develop the practice of geriatric medicine and to train enough physicians, including more geriatrics specialists, to meet the health care needs of its aging population. Many efforts are currently underway, but how successful Japan will be in meeting its goals in a time-sensitive manner is yet to be determined.

Japan Geriatrics Society. http://www.jpn-geriat-soc.or.jp

Roster Board Certified Geriatricians Japan Geriatrics. https://www.kktcs.co.jp/jgsmember/secure/senmon/seek.aspx

Ministry of Health, Labour and Welfare; http://www.mhlw.go.jp/english/topics/elderly/care/2.html

National Institute of Population and Social Security Research in Japan. http://www.ipss.go.jp/index-e.asp

Jochanan Stessman, MD & Jeremy M. Jacobs, MBBS

Comprehensive health care is a universal right of all citizens of Israel. In 1995, the Israeli parliament passed the National Health Insurance law, which guaranteed compulsory membership to 1 of 4 existing health maintenance organizations (HMOs), all of whom are obligated by law to provide a Uniform Benefits Package, locally known as the “health basket.” This continually updating umbrella of services includes preventive, ambulatory, emergency, and hospital care of all types, as well as paramedical care. The HMOs compete among themselves for membership, based upon satisfaction of health insureds, quality of care and services provided. Comprehensive coverage is irrespective of age, and older people are of prime importance within the national health care system.

Funding for the health service is derived from health tax (26%), direct government funding (35%), supplementary optional services provided by HMOs and the private sector (38%), and donations (1%). Per capita reimbursement of health taxes to the HMOs is weighted according to certain medical indices and age, with age older than 65 years resulting in a 3.5 factor increase. In 2011, Israel’s health expenditure constituted 7.7% of GNP ($2046 per capita), as compared to 17.6% in the United States and 9.4% average in the Organisation for Economic Co-operation and Development (OECD) countries. People age 65+ years account for approximately 35% of HMO expenditure.

Average life expectancy in 2010 for Israeli males and females was 79.7 and 83.5 years, respectively, while life expectancy at age 65 years for males and females was 18.5 and 20.5 years, respectively, ranking high for longevity compared to other countries. Israel is a fairly “young” society in its demographic makeup. In 2009 people age >65 and >75 years formed 9.9% and 4.7%, respectively, of the general population. The number of people age >65 years is expected to increase by 44% from 2009 to 2020 (3.4% annual growth), and by 84% from 2009 to 2030 (3.0% annual growth), as compared to annual growth rates among the general population of 1.4% from 2009 to 2020 and 1.3% and 2009 to 2030.

Geriatric Care

Israel is considered a pioneer in health care technology, with the implementation of electronic medical records for both primary, and general and geriatric hospital care in virtually 100% of the country’s health care facilities. The increasingly innovative and efficient use, analyses and sharing of data serve to promote the continuum, quality, as well as efficiency of care. There are 3.36 doctors per 1000 people in Israel.

In 1986, the parliament passed the National Community Long-Term Care Insurance law, which entitled older people living at home to claim state-financed nursing care from the National Insurance Institute (NII), the Israeli equivalent of the U.S. Social Security Administration. According to their dependence in activities of daily living, and financial means testing, older people are entitled to receive between 9.5 and 18 hours per week of home help. In 2011, home help was provided to 16% of older people, of whom about one-fifth received the maximum level of assistance. Aimed at improving quality of life, it is an important step in keeping functionally dependent home bound older people in the community (Table 75–1). Frail older people who are unable to remain at home, mainly for social reasons, are entitled to “sheltered living.” These facilities cater to ambulatory, mentally intact, continent older people requiring some degree of assistance in instrumental and certain basic activities of daily living. Unrelated to the health basket, sheltered living is provided by the Ministry of Social Affairs and Welfare Services, and is based upon financial means testing.

Long-term (“nursing home”) care in Israel is partially financed by the Ministry of Health, and is not included in the health basket. Most long-term care departments provide a high standard of care, and are under licensing and regulatory control of the Geriatric Division of the Ministry of Health. To be eligible, subjects must be functionally dependent, no longer ambulatory, and/or doubly incontinent. Financial coverage by the Ministry of Health requires financial means testing. Specialized psychogeriatric departments cater to the specific needs of ambulatory dementia patients, who require 24-hour care because of cognitive and affective problems. These departments are also under the auspices of the Ministry of Health, with similar guidelines for licensing and financial assistance.

The continuum of long-term care includes patients with complicated medical needs, whose level of care demands greater medical and nursing supervision than is provided in the regular long-term care. Specialized departments for “complicated long-term care” cater to nursing patients who suffer from major pressure sores, end-stage heart or respiratory lung disease, or hemodialysis, as well as patients receiving end-of-life care for both nononcologic and advanced terminal cancer. Similarly, a growing number of long-term ventilated patients receive care in specialized departments. Complicated long-term care is included in the health basket.

Geriatric rehabilitation plays an important role in the spectrum of geriatric care. In keeping with national guidelines of the Ministry of Health, the health basket provides free geriatric rehabilitation for up to 3 months, either at home or in a geriatric rehabilitation department, according to the patient’s needs. Typically included are common orthopedic and neurologic disorders, as well as deconditioning.

Subacute (postacute) care is a recognized modality included within the health basket, providing an interim period following acute admission and prior to discharge back to the community. Patients transferred to these departments are typically frail older adults with a clear diagnosis and treatment plan and an expected slow recovery. Typically cheaper than treatment in a general hospital, these departments cater to patients requiring close geriatric medical care from a multidisciplinary team, whose emphasis is upon functional gain.

The bulk of community geriatrics exists within primary care practice and is provided by family physicians. Most of the HMOs are working to determine nationwide standards-of-care and quality-of-care indices for geriatric patients. Community-based home-care units provide multidisciplinary care to home-bound older people.

In 1990, the first Home Hospital in Israel was established in Jerusalem by the Clalit HMO, with the explicit goal of providing high-quality physician-led multidisciplinary care at home, as an alternative to in-patient care. The service offers a home-based alternative to a wide spectrum of in-patient geriatric care: acute, subacute, long-term complicated medical care, rehabilitation, and chronic home ventilation, as well as palliative end-of-life care. The model of care has been adopted throughout the country, and in addition to high patient and family satisfaction, has proven itself to be cost-effective.

Comprehensive geriatric assessment is recognized as an important tool, and is thus also included in the health basket. Efforts are being made to introduce routine comprehensive geriatric assessment on a national scale. In addition, social care for older people in Israel is well developed, with formal, informal and volunteer services spanning numerous areas of care.

Challenges

Many challenges face geriatric care in Israel. The growing demand for alternatives to in-patient care is expected to further stimulate the establishment of home care and home hospital units. The contribution of geriatricians is likely to undergo subtle changes, with increased role as educators, planners, and consultants. Family physicians and medical internists will most likely become increasingly empowered as first-line providers of geriatric care. Geriatric medicine is a recognized medical specialty, and geriatric medicine is already a compulsory part of the medical school syllabus. It may also become part of general medical residencies.

The fact that numerous bodies are involved in providing care for the older adult population is often perceived as an obstacle, causing fragmentation rather than continuum of care. An attempt at creating a single unified body responsible for providing the full spectrum of geriatric social, medical, and nursing care has yet to be completed. Recently, it has been suggested that the health basket be widened, to include full financial responsibility of the HMOs for long-term nursing care. Protagonists claim that this step would serve as a stimulus to invest in early identification and treatment of vulnerable older adults, and a far greater interest in preventing functional decline.

Inequalities in health care exist, closely linked to socioeconomic status. The fact that 38% of funding for health care is generated from private or supplementary health packages (outside of the health basket) is cited as a leading cause, and is a subject of public debate.

Despite numerous challenges, the current state of geriatric care in Israel is both comprehensive and universal. The wide spectrum of available treatment options and care settings ensures that among older people, no one is left behind.

Shuang Wang, MD & Joseph H. Flaherty, MD

Four societal factors in China are colliding, creating dramatic challenges never before seen in a country’s aging population: (a) a previously high fertility rate followed by a rapid decline to a very low fertility rate; (b) migration of young people away from rural areas, where the majority of older Chinese still live; (c) an inordinate burden of family obligations on the adult population (of would be caregivers) that will make traditional filial piety difficult to sustain; and (d) an increase in life expectancy with an associated increase in functional disabilities and chronic diseases.

Although most discussions about the aging demographics in China point to the 1 child per couple policy as the main cause (instituted in 1979, and strongly enforced in the mid 1980s), the increase that is predicted to occur is the result of a once-high fertility rate (as high as 7.5 in the early 1960s) followed by a rapid decline within 1–2 generations (1.7 in 2003). According to the 2010 national census data, China had more than 119 million older adults (defined as older than 65 years of age), who accounted for 8.87% of the population, with 21 million older than 80 years of age. The annual growth of the older population in China has been increasing at a rate of 3.3% since 2001, and is expected to reach 437 million by 2051.

An understanding of the changing demographics of the aging population in China requires an understanding of the shifting demographics of the population as a whole. First, the majority of China’s population, including older adults, still live in rural areas, where the provision of care to aging residents poses far more challenges than those witnessed in urban areas. Second, migration of the young from rural areas to large cities, which previously included “developed” regions of the country (mostly on the northeast and southern coast), such as Beijing, Shanghai or Guangzhou, is now occurring at a rapid rate in areas considered “underdeveloped,” such as Chongqing municipality and Sichuan province (in the southwest). This outmigration from underdeveloped regions might have more negative consequences compared to developed regions.

One of the strongest attributes in Chinese culture that many people are depending on to alleviate some of the challenges of the aging population is the Confucian philosophy and Chinese traditional value of filial piety, a respect for one’s parents. Currently, less than 1% of older adults in China live in nursing homes and most older Chinese prefer to stay with families rather than in retirement or nursing facilities. However, the looming question is whether the strong value of filial piety (which is based on having many children) can withstand the pressures of a family structure of 2 working adults in their 40s or 50s taking care of up to 4 aging parents in their 70s and 80s? It is too early to tell how this will turn out, as the first generation of “1-child” children (ie, the future caregivers) will not reach their 40s until around 2025.

With life expectancy in China at 74 years (77.1 for women, 72.8 for men), it is not surprising that functional disabilities and chronic diseases such as atherosclerotic vascular disease, cancer, dementia, depression, fall-related injuries, osteoporosis, and incontinence in the older adult population has increased dramatically. In 2009, there were 9.4 million disabled older persons (1.9 million in urban areas and 7.5 million in rural areas). There were also 18.9 million older persons with partial disability.

Long-term Care in China Today

The next 20 years will be an exciting yet anxious time for all involved in long term care (LTC) in China. The first major challenge is that currently older persons can receive “institutional” LTC under 2 different systems, which have separate funding mechanisms and policies: the social welfare system (run by departments of Civil Affairs at national and regional levels) and the medical care system (run by local Departments of Health).

The social welfare system has traditionally been responsible for institutional LTC in rural areas (but institutions under this system do exist in urban areas). Patients must meet certain eligibility requirements for the social welfare system, the most important of which is not having any children or other people with a legal responsibility for support or care. Based on just this system, LTC in China is not as well established as it is in developed parts of the world, such as the United States, Europe, and Japan. A late 2010 report published by the Chinese Ministry of Civil Affairs noted that there were nearly 40,000 National Senior Welfare Agencies in China with approximately 2.66 million beds. Comparing China and the United States, there are far fewer beds per capita for older Chinese (Table 75–2). However, this report may not include private facilities, and does not include “beds” in the medical system (see below).

Although there are reports that claim China needs more LTC facilities now, the need may be overestimated based on current disability rates in the social welfare system. Among residents in social welfare facilities, only 17% are totally disabled (defined as dependence in 5–6 activities of daily living [ADLs]), compared to 51% in the United States.

A limitation of social welfare institutions is the level of medical care. Only approximately 40% of facilities have medical services within the facilities, and most facilities (especially in rural areas) do not have physicians who visit, and physicians who do make visits are not geriatricians.

In most urban areas, the medical care system, in the form of hospitals and rehabilitation wards, has evolved as a major provider of institutional care for older persons. This has happened for 2 reasons. First, hospitals (a typical hospital includes inpatient and outpatient services) have become a common location where many older people go for their routine health care, not just acute care. Thus, as the number of older people with chronic conditions has increased over the past couple of decades, the number of people with chronic conditions who visit hospitals and subsequently are admitted to hospitals, has increased.

Second, because many of these patients are retired military and government officials, they have good health care benefits for acute care but not for LTC. As a result, although social welfare institutions and for-profit LTC institutions exist in urban areas, many older hospitalized patients with chronic diseases, especially dementia, often stay in the medical system (ie, hospitals) for prolonged periods. Transferring patients from acute care to postacute care facilities or LTC facilities has not become common practice.

Third, because the aim of the treatment has traditionally been disease-oriented rather than function-oriented, ADLs are typically done by a privately hired untrained caregiver. This probably perpetuates long stays because patients become more dependent over time and the emphasis in not on functional recovery. However, this situation is changing. One example is West China Hospital, which has more than 200 inpatient beds in the Department of Geriatrics. In the past, almost all inpatients were retired military and government officials for whom comprehensive geriatric assessment (CGA) or interdisciplinary rehabilitation processes were not very useful because they were either younger (young-old) or very disabled. Now, more and more older persons from the general population (nongovernmental workers) are admitted with acute medical problems, which has made geriatric clinical practice (CGA, interdisciplinary teams) as well as geriatric clinical research useful and possible.

The economics of LTC in China is another challenge, not just for the government, but for older individuals and their families. At least in the near future, the quality of a LTC institution one enters will likely depend on personal finances instead of insurance. China first made “old age insurance” available to some rural areas in 1991. Although by 2000, the availability of old age insurance had reached 76% of the nation’s towns and townships, only approximately 11% of the rural population had opted to invest in this new program. One reason was the high cost of buying into the insurance plan. Use of retirement insurance for urban residents may be somewhat higher than rural, but still is quite low.

One area of opportunity for innovation and for preventing institutionalization is based on the current architecture and living arrangements of most people in urban areas. Most people (families as well as older persons) still live in apartment-like housing, from short 4–6-story buildings to highrise 20–30-story buildings. This concentration of older populations opens up the possibility of developing community-based programs on a large scale (eg, home care, community-based clinics, preventive health programs, such as falls prevention, and health promotion, such as exercise programs). These types of programs are difficult and costly in places like the United States and Europe, where travel (for patients and health care providers), is often burdensome and not time- or cost-efficient.

Geriatric Education

One of the greatest opportunities to meet the challenges of the aging population in China is in the area of geriatric education. In a cross-sectional survey of 500 physicians who care for older persons in West China (>70% of their patients were older), 77% of the respondents felt that they lacked geriatric knowledge. Only 16% of the respondents had geriatric curriculum before graduation and 26% had received geriatric training after graduation. Most physicians felt that “language barrier” and “insufficient geriatric education in undergraduate medical school and postgraduate education” were the main challenges in practicing geriatric medicine. A government report showed that no more than 30% of nurses who currently work in LTC welfare institutions had geriatric training and only one-third had nursing licenses.

Currently, only a few medical schools in China offer gerontology and geriatrics in their curricula and medical textbooks seldom cover geriatric syndromes and CGA. In Beijing, where the geriatric education resources are relatively sufficient compared to other cities in mainland China, geriatrics was not a part of the interns’ rotations at most university-affiliated hospitals, and although postgraduate (research) education has been initiated, it has not been standardized and integrated into the health education system.

Examples of growth and opportunities for large scale impact exist. A collaboration between Peking Union Medical College (PUMC) and John Hopkins University School of Medicine (JHU) has resulted in faculty member exchange between JHU and PUMC, training of physicians and nurses from the Division of Geriatric Medicine and Gerontology of PUMC at JHU, and the establishment of a geriatric inpatient ward at PUMC. Two continuing medical education geriatrics conferences in 2011 occurred as a result of a collaboration between the International Association of Gerontology and Geriatrics (IAGG) with the Sichuan Association of Geriatrics and the IAGG with the Hong Kong Geriatrics Association.

Gunnar Akner, MD, PhD

Sweden has a long tradition in geriatrics and gerontology. During the 1970s and 1980s, geriatric medicine in Sweden had a leading international role because of its developing hospital care, nursing home care, day care/night care, home health care, health monitoring, and prevention. Professor Alvar Svanborg (1921–2009) in Göteborg was the architect and international pioneer for this development. He initiated, and for many years headed, the well-known longitudinal population study of aging called H70 (Health for 70 year olds), by including cohorts of 70-year-old people from the Göteborg area and following them prospectively in 5-year intervals. This pioneering work laid the foundation for the approach to geriatrics in Sweden today.

In December 2011, the Swedish total population was 9,482,855, of which 18.8% was age 65 years and older. According to Statistics Sweden, this part of the population will increase by 50% between the years 2011 and 2040, while the age group 90 years and older is estimated to increase by 125%.

Organization of Health Care for the Elderly

In Sweden, health care is socialized and financed by taxes derived principally from 21 county councils and 290 municipalities, and, to a smaller extent, from the state. The public health care system is complemented by a small private sector with a few private hospitals and a small and declining number of private physician clinics.

Two pieces of legislation regulate care of the elderly in Sweden: the Health and Medical Services Act (Hälso-och sjukvårdslagen) of 1982 and the Social Service Act (Socialtjänstlagen) of 2001. Health care for elderly people is divided by these 2 laws into 2 financial and organizational systems: medical health care through the county councils and social and nursing health care through the municipalities. In 1992, a major political reform (“ÄDEL reform”) transferred about 40,000 beds and 55,000 staff, including the formal responsibility for long-term care patients, from the county councils to the municipalities. Physicians could also no longer be employed by the municipalities, but would be contracted on commission by the county councils instead. As a result, physicians have no formal role in the organization, team-building work, or staff education in the municipalities, which are responsible for long-term, social, and nursing health care needs of many older Swedes.

Hospitals

Since 1992, more than 95% of all geriatric hospital beds in Sweden have been closed and geriatric medicine is now only present in hospitals in larger cities, particularly in the Stockholm area, with a strong focus on acute geriatric medicine. There is also a small number of geriatric rehabilitation centers.

A study of the organization, staffing, and care production in geriatric medicine in Sweden showed, on average, 1 geriatric bed for every 799 individuals age 65 years and older, with a 10-fold variation between the counties. There were 41 independent Departments of Geriatric Medicine with 85 beds per clinic on average, again with a 10-fold variation between the counties. The report concluded that “there is no overall structural plan for the role of geriatric medicine in Swedish health care, with the desired close connection between content and dimensioning of geriatric specialist training and the practical organization of the activities.” Since then, the closing of geriatric units has continued, but no current detailed national data on the number of geriatric beds are available. This closing process has been driven by the independent county councils without any strategic national planning or broader discussion about the role of geriatric medicine in Sweden.

This development should be viewed against the fact that 75% of all hospitals open in 1980 in Sweden have since been closed. According to the OECD, Sweden had 2.8 hospital beds per 1000 population in 2009 (compared to the U.S. rate of 3.1 and the OECD average of 4.9), which was the lowest number of hospital beds in Europe. As a consequence, the average inpatient length of stay has been cut in half and many older patients are discharged too early to home care or municipality care.

Primary Care

A previous version of the Health and Medical Services Act stated that physicians serving as “stable physician contacts” in primary care must be specialists in general medicine. In the last revision of 2009, this rule was changed to allow patients to choose any specialist working in primary care as their stable physician contact. However, a number of county councils still require that all physicians serving in primary care must be specialists in general medicine. There are only occasional geriatric medicine units in primary care in Sweden, and these focus on “elderly care,” not geriatric medicine.

Medical Specialties

The medical specialty in long-term care medicine was instituted in 1969 and renamed geriatric medicine in 1992. In 2006, the Swedish government made geriatric medicine a “basal medical specialty”; that is, it is possible for physicians to specialize only in geriatric medicine. The medical specialties in Sweden were reorganized in 2012. Geriatric medicine in Sweden has no formal subspecialties, but geropsychiatry became an “additional specialty” to both geriatric medicine and psychiatry. However, on the other side of the age spectrum, there are 3 pediatric basal specialties: pediatric surgery, pediatric psychiatry, and pediatric medicine, and the latter has 5 defined additional specialties: allergology, cardiology, neonatology, neurology/habilitation, and oncology.

Physicians’ choice of medical specialty is controlled by the local county councils in how they advertise “specialty training positions,” and is not regulated by the Swedish National Board of Health and Welfare (Socialstyrelsen). This lack of national planning has led to a longstanding lack of geriatricians, general physicians, and psychiatrists, and a disproportional increase in, for example, cardiologists. According to statistics from the Swedish Medical Association, in October 2012, there were only 628 (63% female) active specialists in geriatric medicine in Sweden, many of whom have other medical specialties as well, and who frequently work part-time in their role as geriatricians (Table 75–3).

Very few geriatricians serve in primary care in Sweden and there are very few care units designated for older adult care in the primary care setting. Thus, geriatricians in Sweden serve almost entirely in hospitals, mostly in acute geriatric medicine wards or in units specializing in certain “geriatric giants,” usually falls/fractures/osteoporosis, stroke, and dementia.

Education

During the 5.5 years of medical school, medical students get 1–2 weeks of formal education and training in geriatric medicine; that is, less than 1% of the total time in medical school. Different aspects of diagnostics, treatment/care, and evaluation of older adults are taught during many other courses, but not presented as a coherent geriatric theme or curriculum during medical school.

Regarding specialist training, only physicians specializing in geriatric medicine are required to train and serve in geriatric medicine. For all other specialists, including primary care specialists (general physicians) and internists, such education is optional and based on individual interest.

For all other health/nursing care staff groups, there is very limited education and training in geriatric medicine during basal educational programs, and what exists is usually not called geriatric medicine, but rather “care of the elderly.” A small number of nurses and physiotherapists have 1 year of formal training in geriatrics/gerontology or “care for the elderly.” A recent investigation from the Swedish National Board of Health and Welfare found that only 1.6 % of all 12,316 nurses employed in municipality elderly care in Sweden have formal education in “care for the elderly.”

In several medical faculties, there are a limited number of shorter courses in geriatric medicine for different health care staff groups, but there are small incentives for employers to allow members of the staff to attend such courses during working hours.

Patients in the Health/Nursing Care System

In Sweden, older patients (age 65+ years), who often have multiple morbidities requiring multiple treatment methods, dominate in all parts of the health care system. In primary care, these patients represent approximately 50% of physician working time. In hospital departments such as internal medicine and its subspecialties, they account for 60% to 70% of all inpatients. In municipality care dedicated to older adults, 100% of all resources is given to older residents. Thus, there is a significant mismatch between the number of older patients with multimorbidities and the competence in geriatric medicine among physicians and health/nursing care staff across all groups.

Research

All medical faculties have university professors in geriatric medicine and there are units for geriatric medicine in all 7 Swedish medical faculties, except for Örebro. The professors in 3 of the faculties are focused on dementia (Stockholm, Uppsala, Linköping) and 1 is focused on osteoporosis (Göteborg). There are about 10 other professors in geriatric medicine in these faculties with different research focuses. Only a few are devoted to the study of multimorbidity in older adults, with a focus on clinical management in primary care/municipality care.

Sweden is facing a number of future challenges regarding care for the elderly:

1. Knowledge area—Geriatric medicine must be widely accepted as the knowledge area that deals with multiple risk factors, multiple manifest health problems and multiple treatments during the whole span of aging.

2. Focus—The focus of health care for older persons must switch from the present single-disease management to multiple domain management; from national guidelines and standardized care plans to individual, personalized health analysis and management; and from a reactive to a proactive approach focusing on prevention.

3. Organization—The health care organization must be much better suited for and adapted to older persons with multiple morbidities and treatments based on geriatric principles. The present hospital in-patient perspective must be completed by a primary care/municipality perspective.

4. Medical records—The most important tool to steer the analysis, evaluation, and management of care for older persons is the medical record. Presently, medical records serve as retroactive diaries and constitute a strong risk factor for multimorbid older people. To enable better care, the electronic medical record should be developed into a prospective “interactive health analysis system” focusing on providing physicians with an overview of the whole health situation, both cross-sectionally and longitudinally. It should stimulate analysis of relations between risk factors, symptoms, manifest diagnoses and various treatments in close cooperation with patients.

5. Empowerment—Older patients and their relatives must be empowered to act as codrivers who share responsibility for monitoring their health over time. This includes increased participation in decisions regarding health analysis and treatment towards end of life. In Swedish nursing homes, patient’s average 10 medical drug prescriptions per day and it is important that such intensive drug treatment is prescribed in accordance with the patients’ wishes and is properly monitored over time.

6. Education/training—The basic and continued education and training of physicians and other health care staff groups must have required curricula in geriatric medicine with several separate courses, while also being present in most other courses. There must be incentives to encourage physicians and other health care staff groups to specialize in geriatric medicine. The designation “care for the elderly” should have a firm base in geriatric medicine.

7. Living—There is a strong need to develop a wide range of different types of housing adapted to elderly peoples’ needs, particularly intermediate service facilities.

8. Research—An extensive study from the Swedish Council on Health Technology Assessment 2003 reported the strong lack of controlled treatment studies in patients age 65 years and older. For patients age 75 years and older, there are only very few such treatment studies, even though this age group, in particular, is prescribed much treatment, usually multiple treatments. This lack of appropriately targeted research has not been addressed in recent years, suggesting the pressing need for treatment trials in older patients, particularly for those with multimorbidity.

The present method of choice for treatment studies, the randomized controlled trial, is not suited to study multiple treatment effect(s) in heterogeneous populations. Thus, a new research methodology for treatment studies must be developed and integrated with routine care for the elderly. Research focusing on primary and secondary prevention for older adults using individual multiple risk factor profiles is also needed.

Further reading for a more complete understanding of problems in the present Swedish system of care for the elderly and related challenges for the future is listed below.