24 May 2008

Family Physician & The Elderly Community

Dr. C. H. Leong

*Based on a speech delivered to the HK College of Family Physician at its Annual Scientific Meeting on 24th May 2008

I would address the topic “The Family Physicians in the Elderly Community” in 3 capacities, -----as an elderly, myself; as chairman of the Elderly Commission; and after all I am also a physician.

It is an undeniable fact that all over the world the population is aging and HK is no exception. In fact HK’s population is aging faster than most in the world. The fact remains that our birth rate is low.

I would like therefore to go with you over 4 areas:

• Statistics and figure of our elderly population and how it would affect our community;
• The role of the Family Physicians in the provisional of health care to our elders;
• The role of the Family Physicians as an advocate for our elderly population; and
• What role should a Family Physician play when he or she becomes an elderly

Statistics & Figures

There is basically no definition of what constitutes an elderly. All civil servants are supposed to retire at the age of 60. Therefore any age over 60 could be counted as elderly. On the other hand, you are not entitled to Old Age Allowance (生果金) until after 65.

Be that as it may there are 852796 people in HK 65 and above, representing – 1 in 8 of our population. HK of course boast over 100 centurions.

But it is the rate of aging that is the area of concern. Figure show that by 2033, the number of 65 will be over 2 million----i.e. one in four of our population.

What would all these mean?

As a start, there will be less and less young people who, by all intends and purpose are income earners, to support more and more elderlies who may not have regular incomes. The elderly dependency ratio (the number of persons aged 65 or above per 1000 persons aged 15-64), which reflect this; showed that it is 170 in 2007, and will be 428 in 2033. In short, unless we maintain our elders active and income generating, the burden on our society will be exponential.

What is the impact on health care? Elderly population has a much greater health care needs. Statistics showed that persons aged 65 or above use on average 6 times more in-patient care than those below 65. To wit some 49% of the beds in the Hospital Authority are occupied by patients 65 or above. Figure have shown that public health expenditure will increase by 3.9 times between 2004 and 2033 while GDP will only grow by 1.3 times.

In real dollar terms public health expenditure will increase from $37 billion to $186 billion between 2004 to 2033.

In per capita terms, public health expenditure per capita will be 4 times increase from $5600 (2004 figures) to $2230 (2033 projections)

A large percentage is the result of our aging population.

Much of health care funding burden could be saved if our elders are kept healthy and out of harms way of sickness.

But are our elders that much of a burden? It is perhaps important to look at and to compare the status of cohorts of elders in the past, the present and the future.

As a start our elders are living longer. The life expectancy in HK for the male is 78 years and female 84. This is expected to be further lengthened. In short, our elders today are perhaps more healthy than those of our forefather and those 10 years from now would even be more healthier. In terms of education level, a recent publication on population by census 2006 by the Census and Statistics Dept of the HK SAR Government has shown that elders with no schooling and only preprimary education decreased from 43.7% in 1996 to 35.8 in 2006, whereas those with secondary and higher education increased from 16.1% in 1996 to 25% in 2006.

In the same score, it could be projected that elders 10 years from now would probably be more financially independent than those today, definitely better than those of yester year.

With such background, it would be obvious that elders should never be considered as society’s burden. Instead, encouraging them to be active, improve and maintain their health, encourage them to engage the community through their experience, elders can and will contribute to the society in just the same way as the rest of the population and more.

This is where we as Family Physician and Physician at large come in to play our role.

The role of the Family Physician in the provision of health care for our elders.

In these days of specialization and super-specialization, it may be said that our senior citizens should be best taken care of by geriatricians when they are sick. Nobody will deny that, yet there are currently over 800000---elders, only-----88 registered geriatric specialists. There is no reason why our family physicians could not and should not provide the well acclaimed primary health care service. Furthermore if our aim as we have mentioned before, is to ensure that our senior citizen do not get in harms way of acquiring diseases, our general goal should be to keep our elders healthy and to prevent than from getting ill. This is where the Family Physicians come with. This is where the Family Physicians can best perform their intended role. For it is health education, educating and preparing of the family to care for the elderlies; early detection and prevention of diseases that becomes the order of the day.

Let me cite 2 examples: Dementia and Osteoporosis
Dementia and cognitive deterioration is a known sickness associated with aging. In short, aging of the population is invariably associated with the exponential increase in the number of people with dementia. Figures are that dementia will double every 5 years after 65. According to a study reported in Lancet, the global prevalence of dementia is 24.3 million and there is 1 new case in every 7 seconds. The number is postulated to double every 20 years. In the Asia Pacific Region as reported by Access Economics 2006 there were 13.7 million in 2005 and is projected to be 64.6 million by 2050.

Dementia is, by far, among the most disabling of all chronic diseases. There is progressive loss of memory, loss of cognitive functions, loss of judgement and daily functioning. The victims may not be aware of it but it is the whole family that suffers. Many call dementia as a family disease.

In HK according to figures from a study by the Dept of Health and the CUHK there are some 70000 case of dementia after the age of 70 (9.3%). Though most are mild condition (over 8.4%), the prevalence is projected to reach 240000 by 2036.

With such an enormous prevalence and producing such devastating effects, a lot need to be done in relation to:

Early detection;
Prevention of rapid progress;
Education of the family;
Training the carers;

Much falls actually on the ambit and responsibility of the family Physicians

Let us look at another example—Osteoporosis. Like the disaster in Sichuan where without warning concrete structures within minutes becomes rubbles; town defaced from the map; tens of thousand loss their life unnecessary and many are injured with permanent disabilities, Osteoporosis lead to fracture of our bone even with the slighted trauma. In the western world it is estimated that 50% of women over 50 will invariable have for a fracture during their lifetime due to low bone density. Osteoporosis has always been considered by many to occur mainly in women especially after menopause. This is not always necessarily the case. Hip fractures are just as common in the elderly male after the age of 50 from Osteoporosis. Worse the mortality rate in male is higher than in female.

Do we need to wait for fractures to occur before we move in to call in the orthopedics surgeons? The fact revealed that while there is no cure for osteoporosis, it could be treated or at least prevented from progressing. We know some of the etiological factors: -aging, gender, race (more common amongst Asians and Caucasians), and small body frame. We also know how to treat and slow down its progress---high calcium intake, hormonal supplements, do not over slim, and regular exercises.

The key point is education, early detection, replacement and prevention---a primary care issue which the family physician is the best specialty to deal with.

The role of the Family Physician as an Elderly advocate

For decades physicians have always pride themselves to be hard working, concentrates on our patients by burying their head in their work in the hospital, in the clinics and in the laboratories. Today this is not good enough. If we want our work to be more effective, if we want our efforts to benefit more people, then we have to use our expertise and our knowledge to act as the society’s advocate. Furthermore if we believe that the society and the environmental is the cause of many illnesses, we as physician have to remove the cause by dealing with the society at large. A revered Chinese philosopher has once said: “上醫醫國, 中醫醫人, 下醫醫病” How true! It has always been believed that the medical professional is best equipped to work for the society good. We see patients from all ranks, sectors and race of the community. If they can place their life in our hands, they will entrust us with everything that they believe the society is unfair to them. It is these knowledge that will make us good advocates of the society.

What about as advocates for the elderly?

What does our senior citizen want that we as physicians can advocate for them? I would venture only use a few examples that perhaps are dear to our hearts.
Perhaps our senior citizen hopes foremost which we would also like to promulgate, is regular body check ups as a means of early detection and prevention of diseases.
Government in its wisdom has answered to this call of the elders by providing 5 vouchers of $ 50 each as a pilot project for those 70 years old and over, where by elderlies could use these to co pay for health check up and other health and medical related uses. I believe this is a good beginning. I believe that we as physicians should ensure that this pilot scheme become a success, ride on it by pushing government to do more both by given a bigger sum and to extend it to a younger age, so that the concept of healthy aging could be truly realized.
In his recent Policy Address, the Chief Executive Mr. Donald Tsang mentioned the aim to set up a Neuroscience Centre in HK. Is this to answer the mounting prevalence or problems of Dementia and Alzheimer’s diseases? I have no idea. Be that as it may we as Physician or Family Physicians should take this opportunity to drive home to government that much needs to be done to alleviate the suffering of this devastating disease that affects the whole family. Putting dementia into the health care policy agenda must be government primary health care priority.

What should a Physician do when he/she becomes an Elderly?

I believe this is a very personal issue as it involve when each individual is prepared to retire? What does retirement means----giving up your trained professional move into a second career? What preparation would you be doing for yourself and your family before that date comes along and what preparation do you have for your patients and legal the ramification there of.
As for the time being, I would only hope that each one of you, whether you are young, or old, or soon to be old to remain.
Active,
Participatory, and
Healthy.