22 September 2007

International Symposium on Comprehensive Care of Fragility Fracture from Hospital to Community
Department of Orthopaedics and Traumatology
Chinese University of Hong Kong
Elderly Care ¡V from Policy to Practice

Dr. C. H. Leong

In October 1964, I set foot in Britain to sit for my surgical fellowship. It was an unexpectedly cold autumn and in October there was already the first sight of snow. On that same day, we were taken to Roehampton for an Orthopaedics teaching session and I was questioned by the senior consultant what I thought was the main emergency admissions the night before. Being a young man, a general surgeon coming from a place where snow was never heard of, I dare not even to venture an answer, and I was told that it was fracture of the neck of the femur in the elderlies.

Exactly one year ago while visiting South Africa, now an elderly myself being 67 year old then, I slipped and fell on level ground. No, I did not fracture my femur, no I did not sustain a Colles fracture, I was lucky. But I ended up smashing my face to the extent that lions in South Africa ran away from me, and I twisted my cervical spine resulting in some degree of paraesthesia of my thumb that persisted up to today.

These 2 incidents gave me a shocking impact. Elderlies are prone to be unstable ,and fragility fractures are common, many could result in irrecoverable disability.

To wit in the US, elderlies account for some 75% of death from falls. The injury rate of falls is highest among persons 85 year of age or above. In Hong Kong, the commonest injuries among older persons are caused by fall accident. 7.4% of those waiting for infirmary care had proximal femoral fractures.

2 years ago, I accepted the appointment to chair the Elderly Commission. For those from overseas, let me perhaps explain what this body, the Elderly Commission is all about. It is an advisory body to the HKSAR Government on issues relating to elderly care, service and welfare and to determine priorities of these services for the Government to promulgate.

There is no doubt in my mind that the seniors of today are much more healthier than they were of yesteryears and those in the future will even be healthier. How do we keep them healthy for as long as we can? How can we help them to realize that they are still very much with the society and not a burden to the society? We therefore promote the issue of ¡§Active Aging¡¨. Paradoxically, if accident falls are prone in the elders, how could we promote them to be active? 2 issues therefore come to mind.

„P What are the factors that lead to proneness to ¡§fall¡¨ in the elderly? Are these preventable?

„P Are there ways and means to improve the elderlies to prevent them from falls?

It is common to divide risk factors into:

„P Intrinsic risks, which are related to the health, behaviour of the individuals and;

„P Extrinsic risks, which are risks related to the person¡¦s environment.

These factors could furthermore be divided into 4 catergories.

1. Medical Risk Factors

With the process of natural ageing coupled with the effect of chronic health conditions, there come the unavoidable issues of physical disabilities, muscle weaknesses, vision changes and cognitive impairments.

2. Behavioural Risk Factors

With ageing there may well be the possible changes of life-style. Chronic use of certain medicines, lack of concentration or unattention „o crossing roads when it is still a red light or not aware of on coming traffic. For most elderlies, because there are no new income, they tend to be conservative in money spending. They would still be using old wornout footwears which may well be inappropriate. They might be force to strive on an inadequate diet. Many even have an intrinsic fear for falling.

3. Environmental Risk Factors

These range from hazards at home, in the community and even in the institutions they reside.

It is not uncommon to find scattered electric wires on the floor, poor lit room to reduce fuel consumption, slippery floors and lack of hand rails and grasp bars etc. All to the disadvantages of our already unstable elderlies.

Our surrounding environment could well be a danger trap for our senior citizens „o uneven pavements, uneven steps, slippery surfaces, frequent road excavations, poorly lit corridors and poor building designs.

Even those that live in institutions are not absolve from danger „o such as lack of hand rails, design of doors that could only open onto one side, lack of hand rails and very commonly poor lighting.

4. Social & Economic Risk Factors

Data have shown that people with lower income, lower education, lack of support, lack of networking, lack of welfare, lack of access to appropriate health or social services are all at a greater risk for chronic health conditions that are into risk factors for falls. In Hong Kong, while the Social Welfare Department is making great effort to provide both district base community centres to provide networks for senior citizens and outreach home help, there are still many, yet to be determined numbers, of ¡§hidden elderlies¡¨ „o those who perhaps have not realized the availability of social support or those who shun from assistance. These ¡§hidden elders¡¨ could well be within the category that are prone to fall. Worst they might not be detected after any injuries until too late for satisfactory remedy.

Many of these factors so mentioned are correctable and dare I say easy to manage. Yet it take efforts to have them put into practice.

It has been gratifying to see that the Buildings Department of the Hong Kong Government has in 2005 commissioned a consultancy study to Barrier Free Design with the purpose to update the requirements of building designing with references to change in the building technology, the quality of life of the public and to address specific needs of the elderly in order to provide a comfortable, safe, elderly friendly living environment. This consultancy report is going through a wide public consultation and appropriate legislative amendments to the relevant building regulations will then be pursued. In the draft manual, much suggested effort was made on areas that concerns improvement on the environmental risk factors that could lead to higher chances of elderlies to fall.

To bring these and others improvement that will prevent or minimize elder falls, it is imperative that the following principles be taken on board:

As a start, our Government must be convinced that it is necessary to include elderly needs into every policy direction and implementation

Secondly, elderly care necessitates that coordination of the different bureau and departments of the government. It has to be realized that elderly care involve the efforts of the whole spectrum of government services „o health, welfare, social service, housing, transportation etc.

Finally, the care of our senior citizens should not be government¡¦s responsibility alone. In fact, it should be everyone¡¦s responsibility.

Are there ways by which we could improve our elderlies to enable them to be more stable?

While there are no scientific statistics to depend on, it is perceived that any regular, persistent exercise to strive to sustain an active and healthy life style will help our seniors to have more self confidence to minimize falls. It has been claim that exercises like regular Tai Chi do help to improve balance and promote physical stability.

At the beginning of my talk, I stress that the policy of the Elderly Commission is to promote ¡§Active Aging¡¨. This is aim at bringing forward with 3 basic concepts.

„P To restore the positive image of our seniors which is due to them,
„P To promote health and healthy life style amongst them, and
„P To provide intergeneration harmony and interdependence

Through education, we hope to ensure that our policy is being practised.

As of today, the Elderly Commission has engaged 32 schools as means of elderly learning platforms. These schools will provide the necessary premises and other physical facilities after regular school hours. The students of these schools will act as ¡§teachers¡¨. Each school will partner with one or two elderly community centres which will provide the elders who will students. The syllabus will consist of compulsory health and rehabilitation lectures and exercises and care programmes. Other programmes will vary from school to school depending on the interests and needs of the ¡§students¡¨ who with their teachers with determining the final syllabus according to interest.

Going back to school, learning new practical subjects like the use of computers will restore their confidence. The health and healthy life style programmes will ensure their continuous well being physically and mentally. Finally the student teacher relationship so cultivated will enhance intergeneration harmony and interdependence. We are working towards expanding this project and formalize it to become a regular issue. The success so far is the result of putting policy into practice through the cooperation of the schools, the non-governmental welfare organizations, various government bureau, business commercial were combination part of the future.

The whole movement may not be directly related to decrease in the proneness and rid of injuries of the elderlies. Yet it hammers the conception home that to achieve any benefit for the society which is ageing needs the cooperation of the relevant Government bureau, the NGOs, the educationists, the business sectors, and further, it needs to empower the elderlies to realize that they themselves will have to contribute to their well being and their future positive image.

Ladies and gentlemen, the world is ageing and ageing fast. Hong Kong is no exception and perhaps ageing even faster. Today 1 out of 7 is over 65, in 2030, 25% of our population will be over 65. They will be maintained their function and usefulness in the society, they will be maintained healthy physical and mentally. We need proper policy for our elderlies, but we need action even more!
Finally, ladies and gentlemen, I said these with passion. Yet I have to make a confession. I have to declare my interest. For as an elderly of 68, I will be a benefactor of all these positive actions! Thank you!
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