But how did we get this old?

Elderly people today were caught off guard: they got old and were not expecting it. But growing old does not have to be a threat. It demands from all of us, as a society, an appropriate and innovative response, which the health professionals, above all, should be aware of. In palliative and dementia care, there is also talk of innovation. A subject that Leaping Forward of Hospital da Luz could not leave out of its debates.

 

This month, the Rolling Stones will start on yet another world tour, «14 On Fire», which includes Abu Dhabi, Japan, China, Singapore, Australia and New Zealand, after passing through Europe and the United States. Mick Jagger, as always, will be the man at the centre of attention. After all, even 50 years after starting his career, Jagger does not appear to have lost any of his artistic or mental capacities, and certainly none of his physical abilities.

Under the spotlights on stage, the vocalist of the most famous rock bank in the world that is still performing will, as usual, run, jump, kneel, and get up immediately… And no-one among those who succeed in attending a live performance of one of the concerts of this tour will think about an incontrovertible fact of the life of this musician: Mick Jagger is 71 years old.

“At that age, as is the case with everyone in the same age group, he runs serious risks of breaking his hip or having a stroke. Especially doing what he does on the stage. And if that should happen? What he will ask from his doctors is not just that they resolve that health problem. What he would want is to be back on the stage six months later! That means a lot more that doing an operation or prescribing physiotherapy for him.”

The example given by Manuel Caldas de Almeida, physician and clinical director of Hospital do Mar – the Espírito Santo Saúde unit dedicated to on-going and palliative care and to neurodegenerative diseases – and one of the directors of the symposium «Palliative and dementia care module» of Leaping Forward, at Hospital da Luz, is not just an academic one.

At 70, and although he continues to feel and act like any young vocalist of a rock band, Jagger is “an elderly person! It is just that he is not like the elderly of fifty years ago. For them, it was enough to be treated so they could walk with a cane. Not at all! The elderly today have expectations and completely different needs. This is because we today, culturally, have stopped feeling old,” says Caldas de Almeida, adding: “This means that we, as doctors, cannot continue to call people old when they don’t feel old. And we have to understand that these people come to the health professionals and services looking for answers that have nothing to do with that which most of us think about giving them.”

The idea seems simple, even obvious, says Isabel Galriça Neto, who is also responsible for the symposium on palliative and dementia care of Leaping Forward and coordinator of the Palliative and On-going Care Unit of Hospital da Luz.
But “we are still a long way from seeing things that way,” she says. “We continue to think of ageing as a threat. But the real threat is to not understand that the needs of the elderly, those who are chronically ill or have irreversible conditions cannot continue getting the answers that the health systems are giving them at the moment,” claims the doctor, adding, “Ageing is a fact. And that idea demands a change in attitude that must come, first of all, from the very health professionals themselves.”

In fact, when we speak about new needs, explains Caldas de Almeida, we are talking about more than prescribing physiotherapy to make a certain muscle work or operating on a broken hip, for example. “We must once and for all put aside this simplistic and partial concept of treatment. And the example of Mick Jagger tells us that. What people want is to regain their autonomy, which requires a lot more from health professional than simply making a diagnosis and prescribing a therapeutic,” going on to say, “And when we talk about restoring the autonomy of our patient, we’re talking about helping him or her to return to a normal life within a very broad and multi-disciplinary perspective, even in financial, legal, architectural, and environmental terms… For example, in dealing with a patient with a rheumatic disease, perhaps, while he still has money and is earning his salary, I should help him make his house more friendly, to prepare him for the day when he can’t move about easily. This will allow him to live more happily and comfortably with his disease when it gets worse.”

But the care given to the elderly has another side. Because, in the end, there comes the time when, as Isabel Neto says, ageing becomes an incontrovertible fact – because of an irreversible illness, a dementia for which there is no cure. At that point, the care needs are also more than “what we’re doing”. And it is at this point, she says, that it is the organisation of health care that is in question. “Because it is not in the context of a hospital for acute illnesses, as so many times happens, that the needs of these patients are properly dealt with.”
Here we should be talking about “maintenance and comfort”. And about the skills required of health professionals who must accompany someone who has an incurable disease and is nearing the end of life. “These skills are pharmacological, ethical, spiritual, and the making of clinical decisions,” exemplifies Caldas de Almeida, whilst Isabel Neto stresses, “And about the obligation we have as a society to rethink the organisation of health care in response to the increase in chronic and irreversible illnesses, dementias, and the fact that all these patients need palliative care.”

The numbers cited by the physician of Hospital da Luz leave no room for doubt: “In Portugal, we have more than 200 thousand persons who need palliative care (numbers that include the families of the patients), of which 120 thousand are persons with dementia. Of these, 90 thousand are patients with Alzheimer’s,” she says, and adds, “Ten to 20% of the patients who are in acute care ought to be in on-going and palliative care. Furthermore, 80% of the care given these patients is by informal carers, who represent an expense of 11 thousand euros per year for each patient.” And all too quickly they become emotionally and physically drained. “Is this what we want, as a society?” asks Isabel Neto.

Espírito Santo Saúde, an example of innovation

When innovation in Medicine is talked about, as is the case at the Leaping Forward international medical conference, being held at Hospital da Luz, in Lisbon, it seems strange to also talk about on-going, palliative and dementia care.

“Not at all. It is more than fair to say that there is innovation in this area, as well,” states Isabel Neto. “Here, in light of the reality we have been describing, innovation is thinking about the organisation of the health services in a completely different manner – in terms of organisation, efficiency and clinical governance. It is thinking about the system more in line with the needs of the chronic and irreversibly ill and less in terms of the interests of the system itself.” In the end, it is to provide the most suitable answers to this new reality, “which we stubbornly refuse to face up to,” confesses the doctor.

This is the framework in which the specialists, national and foreign, will debate innovation in palliative and dementia care at Hospital da Luz, as part of the international medical conference Leaping Forward, organised by Espírito Santo Saúde (ESS).

The moment for doing this could not be more opportune, given the increasing age of the Portuguese population. And the place is the most appropriate location. After all, “It is fair that we should say it: we are an example in this field,” states Caldas de Almeida, explaining: “At Espírito Santo Saúde, we do not just focus on meeting need A or need B. We decided to organise our health services in order to give a structured response to the needs of the elderly persons, and those who have chronic and irreversible condition. I must say that, in this area, we are very innovative in Portugal.”

The model of care functions in an integrated manner, explains the director of Hospital do Mar. “It is an efficient response, and there is no other hospital in Portugal that has organised its responses in this way,” confirms Isabel Neto. And in fact, at the ESS units it is possible to give the elderly person the answer he or she needs, whatever may be the health care needed – emergency hospital care (which has the capacity to respond to the problems of elderly people), acute care hospitalisation (which also has the skills specifically tailored for this population), the specialised geriatrics hospital and senior residences, which now includes dementia care, as well.

This example of innovation, represented by Espírito Santo Saúde, will also be talked about at Leaping Forward. “The objective is to reflect on how we should prepare ourselves for the future,” says Isabel Neto. And in this matter, as in so many others, the future has already begun here. G.R.

 

Special Report, Leaping Forward - Lisbon International Clinical Congress, Hospital da Luz, Lisbon, february, 13-19.