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    • PROPOSAL PRESENTATION ON CGHS. LONG TERM CARE IN SENIOR CITIZEN REHABILITATION Goutam Chowdhary Ex-Post Grad. Trainee National Institute of Social Defence Ministry of Social Justice and Empowerment (Govt. of India) Introduction :- Old age is often viewed as a gradual loss of physical and mental abilities With an increasing difficult to maintain mobility & independence. Age related factors influencing rehabilitation. Biological Psychologic Homeostenosis Decreased In all system learning Capacity. Personal and religious beliefs Social Ageism by society, physician & self. Financial reason. Distribution of Chronic disability condition by age group. 45-64 Yrs 65 -74 Yrs >75 Yrs Arthritis 253 229 383 Hypertension 27 239 360 Hearing Loss 118 231 353 Cataract 16 107 234 Vision Loss 45 69 101 Heart Disease 118 231 353 Source : National Health Interviews Survey 1989, Vital & Health Statistics, 10,176.1990
    • Disease related factors affecting rehabilitation. Biologic Psychologic Comorbility Cognitive deficits Deconditioning Depression Poly pharmacy Homeostenosis Social Ageism Lack of facility, financial problems Process of Rehabilitation :- As seen in Figures 1 & 2, there are many barriers for older people In the Rehabilitation process. Nevertheless, the steps of rehabilitation are the same for people of all ages, even through the process may differ slightly. POLY PHARMACY :- It is a common problem in older patient because they are likely to have multiple medical problems and to be taking multiple medications.This predisposes them to having adverse drug-drug interactions. These drug-drug interactions can make the difference in the older patients health. Factors Responsible : The major disabilities in elderly person which need long term Care those are closely interrelated. Those are 5 – I’s *INCOMPETENCE (DEMENTIA) *INCONTINENCE *IMMOBILITY *IMPAIRMENT *IATROGENIC PROBLEM.
    • The concept of geriatric rehabilitation began when physicians were faced with many elderly immobile patients. They realized that it was crucial for these patients to maximize The functional activities of daily living (ADLs) such as personal hygiene, eating, toileting and Dressing. It was believed that exercises and activities to maintain various functions can retard deterioration of Physical and psychological processes. Table 1 Demographic Data [ Total Elderly population Approx 70 million (7%)] Age Group 60 – 69 80% (Years ) 70 – 79 18% Socioeconomic status (Urban / Rural) Chronic Diseases 45/45 Economically Independent 34/29 Employed 40/27 Living Alone 8/6 Source : Ageing : S.L. Yadav & K.K. Singh Here Table 1. shows that 2/3rd of disabled population are Over 60 years of age. Elderly people usually do not expect their independent To their life style but only improve and maintain their active daily livings. GERIATRIC REHABILITATION Geriatric rehabilitation may be defined as the restoration of the disabled older person to maximum capacity – physical and emotional. Improvements in medical and scientific technology and in public health have dramatically increased life expectancy in our country.
    • Table 2 Degenerative Disease in the Elderly that lead to need for rehabilitation Disease Possible Problems 1. Stroke Paralysis,dysphagia,dysarthia 2. Peripheral Vascular disease Amputation 3. Impaired homeostasis (Vestibular, Sensory) Falls and Fracture 4. Orthostatic hypotension Falls and Fracture 5. Arthritis Immobility, Contractures 6. Osteoporosis Fracture, Immobility 7. Nervous System Incontinence, Immobility 8. Dementia Inability to perform activities of daily living Ageing :- S.L. Yadav & K.K. Singh. There are three major focus areas: 1. The obviously handicapped patients ( those with hemiplegia, arthritis, amputation And neuromuscular diseases). 2. The chronically ill patients without signs of a manifest disability ( those with chronic cardiac Disease, chronic pulmonary disease etc.) 3. The elderly persons who are not obviously ill but whose physical fitness is impaired. Preventive Rehabilitation: Restoration of maximal functions is the ultimate goal, sufficient for demand of daily living and for psychological adjustments. The elderly may be said to have been rehabilitated if one becomes self sufficient at least in ambulation, washing, eating , dressing and toilet activities.
    •  Primary Prevention: Some of the steps enumerated below : - use of hand rails while negotianting stairs. - Standing up with support of chair arm of mattress. - Tidy house keeping to create safe living conditions. - Prevention of the metabolic disturbances which cause osteoporosis. - Conditioning exercises to improve cardio – vascular conditions. - Postural guidance to make positive changes in their posture. - Adequate pain management. - Care of skin to avoid the risk of dermal wounds. - Patients education depending upon physical condition level of motivation - and support systems.  Secondary prevention: The prevention of a secondary disability is a major responsibility of the Rehabilitation team before the era of surgical reduction of hip fracture, the mortality of hip fracture patients was high because prolonged immobilization resulted in the development of venous thrombosis, hypostatic pneumonia and decubitus ulcer.When immobilization or prolonged bed rest is imposed, the process of demineralization gets accelerated. Contracture is another frequently observed secondary disability. Another preventable but sometimes fatal secondary disability is decubitus ulcer. The long term care in Geriatric Rehabilitation means not only support elderly by physically also by Socially, mentally environmentally and spiritually. This care can be defined as health, Social and Personal services provided to the chronically ill and disabled of any age over an extended period of time in variety of settings. Goals of Long Term Care. (a). Restoring & maintaining Function (b). Maximising quality of life ©. Preserving Autonomy. (d). Maintaining safety & providing comfort ; (e). Dignity in dying. Goal achieve- even with the most devoted, caring & intelligent Animator and funding.
    • Lack of care facilities:- The two equally important dimensions of care of a patient having dementia are the Quality of the patient and the burden of his/her family. Multi – model inputs are essential to optimise the quality of life the patient and to alleviate the family’s burden of caring for the patient. The 6 – tier care model for the demented elderly:- Long Term Care Respite Care Counselling Day Care. Counselling Community Care By Trained Personal Counselling Information and Guidance in Care. Counselling Information only : Formation of Care Giver’s Groups. For the comprehensive care of the demented elderly and their families, we propose A 6 – tier care model taking into consideration the different degrees of care Requirements. 1. Information only During the initial stages of dementia, the care needs of the patient will be often Minimal. With some supervisions by the care – giver the patient will be competent To care for himself/herself. What the family requires at this initial stage is mainly Information about the nature and course of the illness and the potential disability and psychiatric and behavioural problems the patient may develop in future. These information may be conveyed to the care – givers during group meetings.
    • 2. Information and guidance in care With the progression of the disease, various disabilities in self care may begin to Manifest in the patient. Along with this, several psychiatric and behavioural problems May also make their appearance in the patient. At this stage the care giver may be provided With information and guidance in the specific care giving techniques. Also the primary care Givers often require counselling to alleviate their burden of care-giving. Periodic meetings of care – giving. Periodic meetings of care-givers group are essentioal. 3. Community Care The disability of many patients may become very severe. So the care – givers often Find the care – giving process difficult which creates significant physical and Psychological strain in them. In such families, trained personnel need to share the Burden of care – giving with the family. This should be supported by regular Counselling of the primary care – giver. Institutional Care Institutional care may be at different levels namely day care, respite care and long termCare. In a rural agrarian community, the cultural milieu and the family structure are competent to adequately care for the patient to a great extent. But in the urban setting, due to the nuclearisation of families and the different cultural milieu. The family of patients find the care – giving process extremely burdensome.So in the urban context, institutional care should form n integral part of the total care- giving process. This will ensure the quality of life the patients and will alleviate the burden of the families. Facilities which provide such comprehensives care are virtually absent in our community. Necessary measures need to be taken to tackle this issue at the earliest. 4. Care-giver’s issues. As many chronic care patients, the patients having dementia cannot be considered in isolation From his/her family. Both the patient and the family are victims of this devastating ailment in Their separate ways.
    •  TRAINING OF ELDERLY ABOUT EXERCISE Exercise can be used to prevent or reverse the effects of disuse of muscle or Body part caused by injuring or inactivity. The Preventive measure of Geriatric patients by remembering the “USE IT OR LOSE IT” principle. 1. Touch top of head by both hand; 2. Touch waist in back by hand; 3. Grip strength; 4. Place palm on hip; 5. Sitting on chair and lean forward to touch great toe by finger. 6. Stand unassisted; 7. Step over a 6” block (wooden) to improve muscle power of Lower extremities. Types of Long Term Care 1. Institutional Long Term Care: - (a). Chronic Care Hospital (b). Sub- acute Care Unit ©. Inpatient Rehab. Unit (d). Skilled Nursing facilities (e). Geriatric Care – giver facilities (Geriatric Animator Facilities) Under Non- Skilled Nursing Facilities. Long Term Care in Community Setting: - (a). Home Health Care (b). Skilled Home Care. ©. Day Geriatric Hospital (d). PACE (Program for All – inclusive Care of the Elderly) Continuing Care Retirement Centre – in one campus. (a). Congregate Living (b). Assisted Living Facilities (ALF) ©. Adult Foster Care (d). Hospice Services (e). Respite Care Services. STAFFING FOR LONG TERM CARE. Geriatric Physician – Nursing – Pharmacist – Therapist – Dieticians – Geriatric Cover – Social Worker – Psychologist – psychiatric – Dentist – Ophthalmologist.
    • PLANNING AND RECOMMENDATIONS Planning health care for the elderly should involve long term care with an involvement Of the family, institutions and the doctor playing a major role in not only providing Health services, but integrating then with other professional and multidisciplinary Services. Integrated planning for comprehensive health care in CGHS for the elderly should aim at : - Health planning with a moral orientation; - Public involvement should be encouraged at every level of planning and Management by NISD trainees (OLD AGE CARE DIVISION.) - There should be efficient cost effectively use of resources; - Health manpower research is necessary t o provide a sound basis Of a decision-making. - Health services should not be done in isolation, but in cooperation and coordination With other services connected with health. - Health care should include domiciliary care, mobile geriatric clinic Intensive health education, programming information and advise on nutritional Needs and promotion of self care for physical activity and recreation (Kumaraswami, 1991) Planning for related services to assist health care and making them accessible should Involve recommendation as given below;- 1. Primary health Care schemes should be strengthen by Central Govt. Polypathy scheme and a multidisciplinary team. 2. Every old age centre, Day care centres attached with primary schools for Psychologically upliftment. 3. Every day care centre in every village with drug stores (Polypathy) and diagnostic centre. 4. Old age home, day care centre are also run as private concern for the welfare of the inmates To create fund through direct share market basis, as iquity and debenture made and make Geriatric Care Employment Services. I, at last suggest that in every rural care centre must have multidisciplinary team of police, Geriatrician Care – giver, psychologist, Social worker and engineer. I think that team will appropriate to develop the Geriatric Care facilities in the
    • Particular area of every block of District. Then Govt. will get relief from the Heavy task for welfare o elderly. So for our today to be beautiful that our Elderly sacrificed their yesterdays, now it is our duty to build their tomorrows. CARE STUDIES In my short practice as a physiotherapist in the team of Calcutta Metropolitan Institute of Gerontology along with Dr. Kaushik Mazumder (Geriatrician), Social Worker and Psychologist from 1998 till join this geriatric care Post Graduate Diploma Course by NISD, Delhi. Here I met several patients who need long term Care in (CMIG, CALCUTTA). CARE - 1. A male patient aged about – 77 Yrs. suffering from stroke lived in City Who needs Physiotherapy, Speech – Therapy along with medical care. After knowing all facts from his wife our team from CMIG went there and Managed the patient and him family also. Then after 8th month from the Day of attack, I found the good response from the elderly patient due to Long term care in Geriatric Rehabilitation. CARE – 2. A female patient aged about 82 yrs, suffering from back pain and Osteoarthritis of knee, she was fatty in figure. One day she fell down in her Bedroom. Our CMIG multidisplinary team attended that case and that Patient got recovered after one-year. Here also we found the long term Care in Geriatric Rehabilitation. I have seen more than 317 cases in my short practice life. CARE – 3. This case from rural area of North 24 PGs District place Rajarhat In West Bengal. A male patient aged about 71 yrs with stroke (Cerebral) Was also found to be in urgent needs of medical care specially physiotherapy But they were living under poverty. After knowing all our team went There and found the patient laid down on the high bed and make him feel easy. Then we met with family carers and gave them moral support and arranged Medicines. After 6 months patient make good response after regularly Attending him every week. CARE – 4 A female patient aged about 68 yrs lived at Kalikapur Village, in 24 Pos (South) Near CMIG campus suffering from Kyphosis. i.e. front bend Of Spine. I talked to that patient to care on her posture and advise her to
    • Took help of a stick to travel here and there for mobility. I also advised Her to do some easy exercises, which help her more. Now she is improved In health and a bit straight spine. She attend to CMIG Care Centre herself For exercise to keep fit. So, all above inspired me to take long-term care in Geriatric Rehabilitation. I will do this care service as my level best for development of elderly care. CMIG started 4 tiers Geriatric Care Services for elderly in Calcutta under Supervision Dr. K.Mazumder, Geriatrician followed by :- (1). Elderly Clinic Care (2). Elderly Care outreached (3). Day Hospital (4). Short stay Respite care References :- i) Life in twilight years – Dr. Indrani Chakraborty President, Calcutta Metropolitan Institute of Gerontoloy. ii) Ageing Dr. Vinod Kumar, AIIMS Delhi. iii) Bradomm’s physical Medecine. iv) Primary on Geriatric Care, Rosenblatt & Natarajan. v) Geriatric Care – Dr. K. Mazumder, CMIG. Calcutta. vi) Dr. A.K. Mukherjee. NRS Hospital – Calcutta.