Tuesday 1 October 2013

S'pore lacks after-hours care for the elderly: Gan

Minister has set up committee to find ways to provide home-care support
By Salma Khalik, The Straits Times, 30 Sep 2013

THERE are gaps in Singapore's eldercare services that need to be plugged if more old people are to continue living at home after they become frail.

One of them is the need for after-hours care, said Health Minister Gan Kim Yong.

Today, support services for the elderly, such as day and rehabilitation care, are largely available only during office hours. These services need to be extended to accommodate elderly people with family members returning home late or those living alone who might need help at night.

Another is having medical care, such as a general practitioner clinic or polyclinic, located near apartments for the elderly - something Singapore can include in its development plans, said Mr Gan.

The minister was sharing with the media some ideas from his four-day study trip to Japan earlier this month that can be applied to Singapore.

He revealed that he set up a Homecare Working Committee comprising professionals in the field and service providers in April this year. The committee will draw up a masterplan on how to develop the services needed to help the elderly age in the community, and how to find and train the manpower needed.

During the trip, Mr Gan, who was accompanied by officials from the Ministry of Health, Agency for Integrated Care and the Housing Board, visited 20 eldercare providers, including hospitals, nursing homes and day rehabilitation centres in and around Tokyo.

They also visited the burgeoning "Smart City" complex, where elderly people live in rented flats. These flats and the surrounding area are being redeveloped to give them better care, social support and even work opportunities.

Seeing how Japan is coping with the needs of its ageing population reaffirms that Singapore is heading in the right direction, said Mr Gan, who also chairs the Ministerial Committee on Ageing.

In 20 years, Singapore will be facing challenges similar to the ones Japan is dealing with now.

Singapore's move to get firms to re-hire those eligible up to the age of 65 from 62 - and eventually to 67 - is something it learnt from Japan, said Mr Gan, who was the manpower minister before taking on his current portfolio.

Japan wants to keep people working for even longer. He said: "Our target is 67, but if we live longer and longer, we clearly need to adjust according to lifespan."

Japan has been preparing for its ageing population for decades, but was still caught off guard by the ballooning group of older people, and now has long waiting lists for its eldercare services.

This is because of the longer lifespan of the Japanese, said Professor Junichiro Ohgata of Tokyo University's Institute of Gerontology. Before World War II, the Japanese had an average lifespan of 50 years. Today, they have the longest lifespan in the world - women live an average of 86 years, and men, 82 years.

Singaporeans are also living longer - about 15 years more than in 1965. Said Mr Gan: "We need to build in flexibility and adapt strategies as the demographic pattern evolves."

That is why the Government wants to promote home-care services, so many elderly people can continue living at home. To do this, the minister wants to adopt Japan's "3Cs" approach.

First, providing comprehensive care - social, medical and care support - for the elderly living at home.

Second, building up capacity ahead of need, such as adding more than 20 nursing homes and several hospitals and polyclinics in the coming decade.

Third, giving caregivers more support, such as guidance on how to take care of the old and frail in the family, and respite, so they can manage in the long haul.

Said Mr Gan: "We have always taken the position that ageing can be fulfilling to the individual, who can also be an asset to society."

Rehab patients pushed to exercise
Health Minister Gan Kim Yong was in Tokyo earlier this month to see how Japan copes with its rapidly greying population. At one nursing home, he saw how it rehabilitates and sends home a higher proportion of patients.
By Salma Khalik, The Straits Times, 30 Sep 2013

FIVE months ago, Mrs Tonaka Toshiko, 76, fell and fractured her hip. After two months in hospital, she was transferred to Roken Rehabilitation, where she has spent the past three months.

Now, she spends several hours exercising every day. Due to her lack of mobility, her exercise is limited to standing up for short periods and slow walks.

This is done together with seven others in a group. Holding on to parallel bars, they take turns to practise, with the rest counting loudly to 10 to spur them on.

This encourages them to stay the course; if they were doing it alone, they might have given up after a count of five.

"I am encouraged by the others," Mrs Toshiko said in Japanese. "I feel more energetic after exercising."

Japan has 10 levels of nursing homes with a range of services, from community hospitals to old folks' homes.

The cost of nursing home stay and treatment at Roken Rehabilitation comes to 450,000 yen (S$5,800) a month, of which the patient pays a third. Long-term care insurance picks up the rest of the tab.

Mr Naoto Miyako is the head of the nursing home, which is run on a not-for-profit basis. He strongly believes that exercise raises hormone levels and increases motivation in his elderly patients.

"We used to be very gentle with patients who said they ache, and would stop their exercise," he said. This changed six months ago when the nursing home decided to push its exercise programme.

"It's better for them to exercise all day than to play mahjong. This way, they live to their fullest potential," he said. "Today, our facility looks like a fitness centre."

Indeed, patients at the 130-bed home, which also has 45 day rehabilitation patients, look alert. Many have smiles on their faces.

Said a senior staff member: "Now we see smiles and get 'thank yous' from patients more often. It gives them something to live for and it makes us very happy."

Since the programme was implemented, the centre has been able to send half its discharged patients home - instead of just one in three as in the past.

The rest either return to hospital because of other illnesses, or move to another long-term care home as they cannot manage on their own, or die.

However, discharged patients are encouraged to return for regular day rehabilitation.

Staff visit the patients' families before they are discharged, to discuss the care plan and see if their homes can be better equipped to help the patients in their recovery. They pay a second visit a month after discharge, to see how the patients are managing.

In spite of that, Mr Miyako said, many return as in-patients three to six months after discharge. They typically stay for three months, undergoing intensive rehabilitation before returning home. This cycle is sometimes repeated.

Patients at the home who are mobile are expected to walk at least 8,000 steps a day. This is clocked by a pedometer strapped to a shoe.

One of the mobile patients is bus driver Matsunage Masatake, 75, who goes for day rehabilitation twice a week after he broke his hip in a fall. At the centre, he does three sets each of 30 sit-ups, 20 minutes on steps and weight training - in all, two hours of exercise each day.

On the other days of the week, he continues to exercise by going for walks and lifting weights.

What works at Japan's nursing homes
By Salma Khalik, The Straits Times, 30 Sep 2013

Tapping technology

AT NAGISA Waraku En nursing home, the use of technology and the right equipment makes caring for the elderly easier.

The equipment includes simple slide boards that enable one helper to move patients from bed to wheelchair, and a hoist to move them from wheelchair to bathtub.

The shoes of dementia patients are tagged so that an alert goes off when the patients try to leave the premises.

Health Minister Gan Kim Yong said: "Every little bit helps. When you add them all together, it makes a difference. The time saved can be used in caring for patients or doing other things. They are mindful that the equipment has to be cost-effective."


NURSING homes in Japan achieve high standards of care because of the professionalism of the operators, said Mr Gan.

"It is quite obvious that the operators take great pride in their work and understand what the seniors need," he said.

They do research to find ways to improve the care of their charges.

They also train their workers, who feel that making the elderly happy "is the greatest satisfaction that they derive from their work", he added.

Keeping the elderly happy

One of the last senses to go as people age is the sense of taste. That is why Yomiuri Land Keiyu Hospital takes special care to make meals appetising and appealing. It does this not just by serving delicious food, but also by presenting the meals in an attractive way.

For example, those on soft meals might get a tray with six different spoons, each with food in different colours, such as mashed spinach or carrot, and tofu with miso and dessert.

Patients can also "borrow" accessories to doll themselves up for "formal" dinners. They take these from a cupboard with a wide array of costume jewellery.

This is especially good for dementia patients who recall their past more easily than the present.

Elderly helping the elderly

MR INAO Okada, 73, spends two hours every day giving massages to the elderly in a nursing home.

The former physiotherapist has retired, but is still active and able. The home pays him the going rate of 120,000 yen (S$1,530) a month.

"When I come here to help, I get stimulated myself," he said.

Japan feels that keeping older people in the workforce keeps them healthier.

Roping in volunteers

NAGISA Waraku En nursing home has 500 volunteers who visit to help on a regular basis.

Mr Nobuo Suzuki, its acting director, explained: "We get a lot of volunteers because we let them decide when they come."

The home also trains the volunteers, who can then do useful things to help, whether it is keeping the elderly company or cleaning their rooms. Mr Gan said having volunteers is important not only because they are an extra pair of helping hands, but also because it is a way to engage the community.

Nagisa Waraku En has students, adults and even seniors helping out.

Mr Gan noted: "It's something we can learn from them - how to include the young to be part of a nurturing society."

Separate insurance for long-term care and health-care bills
By Salma Khalik, The Straits Times, 30 Sep 2013

IN 2000, Japan separated long-term care insurance from health insurance to try to contain the rising cost.

Both forms of insurance are compulsory in Japan, the latter for people 40 years and older.

Health insurance covers hospital treatments, screening and some outpatient treatments, while long-term care insurance is for people 65 years and above who need such care, and for those 40 years and older who have severe disabilities.

After the two types of insurance were separated, the cost of board and lodging was removed from long-term care insurance to lower the insurance payouts.

So nursing homes have to provide two sets of bills - one for living costs which patients have to pay in entirety, and the other for nursing costs for which long-term care insurance pays 90 per cent.

There is now discussion on whether the wealthier elderly should co-pay 20 per cent.

Even though board and lodging is no longer covered, long-term care premiums have almost doubled since 2000 - from 34,932 yen (S$446) a year to 59,644 yen today as people age and more require help.

Premiums for health insurance are paid by the head of the household and are based on both the income earned and the number of people in the family. They are capped at 500,000 yen a year.

All hospitals covered by national health insurance have to ensure that at least half their beds carry no extra cost - usually several beds to a room with shared facilities, sometimes outside the room. People who want perks such as private rooms with en suite facilities have to pay extra on their own, as they are not covered.

The government also fixes the cost of medical treatments that hospitals can charge, as well as the hourly charges for homecare.

Japan's ageing woes are exacerbated by fewer births and an overall shrinking population: from 128 million in 2005 to 90 million by 2055, when it should stabilise.

Meanwhile, as people continue to live longer, more are suffering from the ravages of old age.

The number of people with dementia, for example, is expected to go up from 1.5 million in 2002 to 3.3 million by 2025 - a rise from 6 per cent to 9 per cent of those aged 65 years and older.

Because of their long lives - the Japanese are living 34 years longer today than they were 70 years ago - the demand for nursing homes, day-care facilities and eldercare homes is high, resulting in long waiting lists for a place.

Lessons from Japan on an ageing population
By Salma Khalik, The Straits Times, 8 Oct 2013

IN 20 years, Singapore will have the same demographic profile as Japan has today. In other words, about one in four people will be over the age of 65.

And in Japan, the picture is not pretty. Unless the right steps are taken and changes are made early, Singapore will face the same problems that Japan is trying to handle now.

Japan has more than 50,000 people aged 100 years and older, with the vast majority living in nursing homes. These homes also have many patients who are in their late 70s and early 80s, and who could remain in nursing care for two or three decades more.

At one home in Tokyo that Health Minister Gan Kim Yong visited last month, the oldest resident was 116 years old.

Over the past 70 years, the lives of the Japanese have lengthened by about 35 years. In itself, this is good, since it means people are living longer.

But unless they remain healthy for the bulk of their lives, the number of people who will need care in their later years will go up.

Between 2000 and 2012, the number of elderly needing home care and care in institutions in Japan tripled - from 1.49 million to 4.45 million.

As there is nothing so far to indicate that the Japanese have reached their ultimate lifespan - currently an average of 86 years for women and 82 for men - the number of people requiring help in their old age will likely continue to grow as the young-old join the ranks of the old-old.

But despite their longer lives, more Japanese are dying each year than are being born. Japan's population last year declined by 212,000, the biggest drop on record.

Projections by the Japanese government indicate that if the current trend continues, the population will decline from its current 127.5 million to 116.6 million by 2030, and 97 million by 2050.

This could badly impact the country's economic growth as it means there will be a smaller working population. Unlike Singapore, Japan does not have a large pool of foreign workers to bolster its flagging workforce. Language is one of the barriers.

Japan's woes don't end there. Not only is the population shrinking, but it is also moving away from the "ideal" pyramid shape where there are many young people supporting relatively fewer older people.

It is now apple-shaped, with a big number of middle-aged people. By 2060, this will change to become top-heavy - many older people supported by relatively fewer younger adults, with even fewer young people in the pipeline.

Japan and Singapore are responding by trying to keep people's disability years, or years lived with severe ailments, to a minimum by assisting the elderly to remain healthy and independent for as long as possible.

That way, longer lives would be more meaningful as the elderly enjoy a better quality of life. It would also reduce their need for care services - except perhaps for the last handful of years, rather than for a decade or two, as some people now require.

Professor Junichiro Ohgata of Tokyo University's Institute of Gerontology has also suggested redefining the working age group.

If people continue to work beyond the age of 65, it will increase the group of workers while shrinking the group of elderly people being supported. Instead of retiring at 65, as they now do, they should be encouraged to continue working till they are 75, he said.

Keeping people in the workforce for a longer time has an additional benefit, he said. It will not only boost the work pool, but also give older people the motivation to carry on, and to keep themselves healthy.

The institute is involved in several projects concerning the elderly, including the "Smart City", a custom-built estate some 40km away from metropolitan Tokyo for about 400,000 older people. It has all the necessary support services, such as medical care, home help, social support group and accessible, barrier-free transport, so they can continue to live a good life in the community despite their increasing frailty.

The institute also has a project which finds work for people in their 70s - called second-life careers - such as running a cafe or growing vegetables in a climate-controlled container.

But the project is still in the pilot phase, so it is not known if such jobs can be profitable or even self-sustaining.

But so far, the university has found that people who continue working are generally healthier than those who don't.

Although the jobs they are doing may not be contributing much to the economy, Prof Ohgata said working keeps them away from nursing homes, which is a major benefit.

With more older people expected to need considerable help in their daily lives, the Japanese government recently announced that the sales tax will go up from the current 5 per cent to 8 per cent, to help the country cope with its mounting debt.

Meanwhile, Japan needs to divert people from its shrinking workforce to look after the dependent elderly - either in nursing homes or to provide home-care services for them.

Even with the use of technology to make caring for the dependent elderly less onerous, the staff-to-patient ratio remains high: one staff member to two to three patients when looking after the more able patients; and one staff to one patient for the more dependent ones, as well as the wealthier patients willing and able to pay for the service.

This is what awaits Singapore - unless things change.

What needs to be done is easy to identify: People here need to have more children, everyone needs to remain in good health, and the working age needs to be extended.

What's tougher is getting the desired results.

But it is obvious that it is not something the Government can do alone. Singaporeans themselves must realise the consequences of inaction.

Most nations 'not ready for fast-ageing world'
Many still lack basic social support, protection for seniors: Study
The Straits Times, 2 Oct 2013

WASHINGTON - The world is ageing so fast that most countries are not prepared to support their swelling numbers of elderly people, says a new global study by the United Nations and an elder rights group.
The Global AgeWatch index published yesterday ranks the social and economic well-being of 89 per cent of the world's seniors in 91 countries, with Sweden coming out on top as the best country for older people and Afghanistan at the bottom as the worst.

Singapore was not part of the study.

The index, which will be compiled regularly, comes amid a major demographic shift: By 2050, for the first time in history, seniors older than 60 will outnumber children younger than 15 and comprise more than a fifth of the world's population.

The report fits into an increasingly complex picture of ageing and what it means to the world.

On the one hand, the fact that people are living longer is a testament to advances in health care and nutrition, and advocates emphasise that the elderly should be seen not as a burden but a resource. On the other hand, many countries still lack a basic social protection floor that provides income, health care and housing for their senior citizens.

Afghanistan, for example, offers no pension to those not in the government. Life expectancy is 59 years for men and 61 for women, compared to a global average of 68 for men and 72 for women, according to UN data.

Although government hospitals are free, toothbrush seller Abdul Wasay, 75, said they offer little treatment and medicine. The former cook and blacksmith, who makes US$6 (S$7.50) a day, said many older people cannot find work and some resort to begging.

"You have to keep working no matter how old you are - no one is rich enough to stop," he said.

Many governments resist tackling the issue partly because it is viewed as hugely complicated, negative and costly - which is not necessarily true, said chief executive Silvia Stefanoni of elder advocacy group HelpAge International, which worked with the UN Population Fund to create the index.

Japan and Germany, she said, have among the highest proportions of seniors in the world but boast steady economies. They ranked 10th and third. "There's no evidence that an ageing population is a population that is economically damaged," she said.

Prosperity in itself does not guarantee protection for the old.

The world's rising economic powers - the so-called Brics grouping of Brazil, Russia, India, China and South Africa - rank lower at 31, 78, 73, 35 and 65 than some poorer countries such as Uruguay at 23 and Panama at 30.

Uruguay's rank is linked to its pension system which covers 86 per cent of its older population, said the report, while Panama's life expectancy at 60 is 23 years, the longest in Latin America.

However, the report found, wealthy nations are in general better prepared than poorer ones. Sweden, where the pension system is 100 years old, tops the list because of its social support, education and health coverage. The United States came in eighth.

The index addresses a lack of international data on the extent and impact of global ageing. It analyses income, health, education, employment and age-friendly environment in each country.

Elder rights advocates say a lack of data has thwarted their attempts to raise the issue on government agendas. "Unless you measure something, it doesn't really exist in the minds of decision-makers," said the World Health Organisation's director of ageing and life course John Beard.


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