Dialogue between the South African Older Persons’ Forum

4. Geriatric Medicine AND exclusion of gerontological nursing science or gerontology (including geriatrics) from the National Qualification Framework
Nationally, only eight registered geriatricians are available to serve a population of 3.8 million older people. The health care system has prioritised and increased its resource allocation for maternal and child health, as well as HIV/AIDS related programmes to accommodate the health care needs of younger adults. Older health care clients have been marginalised in health service provision and delivery. Virtually no nurses and other professionals in fields allied to medicine have special training in geriatric care. In the training of nurses, geriatric training has been removed from the curriculum. The absence of postgraduate programmes, with little or no undergraduate training, trivialises the sub-discipline, and health professionals emerge from training institutions with inadequate knowledge and skills to care for elderly patients and to serve as role models. Only four of the eight medical schools in SA are registered for training in geriatric medicine. There are no dedicated geriatric services in rural areas. Health care services targeted at older adults, as well as research, education and training in geriatrics and gerontology, have received very poor attention. As part of a plan for the modernisation of tertiary services, the development of geriatric care was singled out as one of the areas needing urgent expansion (Department of Health, 2003). However, there has been no indication about the implementation of this plan, now or in the immediate future.

The requirements of the National Health Act, 2003 indicate a clear need for the training of nursing and care staff in Residential Care Facilities. The South African Nursing Council informed training colleges that new qualifications registered with the National Qualification Framework no longer include courses in gerontological nursing science or gerontology (including geriatrics); various stakeholders in the aged sector have appealed to the SA Nursing Council and have also requested the National Department of Health’s intervention in this regard. The National Department of Health has written a letter, signed by the Deputy Director-General: Strategic Health Programmes, to the SA Nursing council recommending a revision of their decision to exclude Gerontology Nursing Science as an elective for Registered Nurses to qualify as Geriatric Nurses specialists. The re-inclusion of the elective will form part of the proposal for electives to the education committee of the South African Nursing Council.

Summary of Challenges

1. 
   SA only has eight registered geriatricians available to serve a population of 3.8 million older people;
   
2. 
   Geriatrics is a specialized field;
   
3. 
   Older persons are marginalised in health service provision and delivery;
   
4. 
   Virtually no nurses and other professionals in fields allied to medicine have special training in geriatric care;
   
5. 
   Geriatrics has been removed from the nursing curriculum;
   
6. 
   The absence of postgraduate programmes, with little or no undergraduate training, trivialises the sub discipline: health professionals emerge from training institutions with inadequate knowledge and skills to care for elderly patients;
   
7. 
   Only four of the eight medical schools in SA are registered for training in geriatric medicine;
   
8. 
   No dedicated geriatric services in rural areas and very little in urban areas;
   
9. 
   Although geriatric care was singled out by DOH in 2003 as one of the areas needing urgent expansion, no indication of the implementation of this plan has been forthcoming.
   

Recommendations

1. 
   Recruitment of geriatricians from other countries in working towards reducing the marginalisation of older persons in service provision and delivery;
   
2. 
   Program to encourage nurses in training to specialize in geriatric care;
   
3. 
   Development of postgraduate programmes and undergraduate training that includes geriatrics;
   
4. 
   Partnering with the Department of Higher Education to encourage medical schools to register for training in geriatric medicine;
   
5. 
   Programmes aimed at the development of geriatric services in rural areas;
   
6. 
   To encourage geriatrics as a career path amongst students and especially amongst nurses, OT, Physiotherapists and social workers and other allied health care professionals.
   

5. attitudeS of some medical practitioners towards older persons
A countrywide survey of the attitudes of medical practitioners’ towards Geriatric Medicine and older patients conducted in 2004 showed high levels of disinterest in the sub-specialty and negativity towards aged patients. The researchers concluded that South African medical practitioners’ attitudes towards older patients are ageist and based on negative stereotypes. However it is encouraging that younger doctors are more positive about Geriatric Medicine and older patients than their older colleagues but general deprioritization of ageing issues negatively impacts on young professionals when choosing a career path.

Older persons visiting state clinics and hospitals claim that it appears as if health care professionals care less about their health than that of younger patients. Conflicting protocols prevail in many state clinics and hospitals. In the case of repeat prescriptions some doctors insist on seeing the patient before issuing the scripts, others refuse to see the patient on the grounds that they are not ill, resulting in the older person being denied chronic medication.

Some doctors at state clinics / hospitals refuse older patients the prescribed two check-ups per year. Often health care personnel are blatantly rude to older persons, passing derogatory remarks about them e.g. that older persons smell of urine. Some older persons are reporting that they were refused treatment simply because they are old, being told that they will die anyway. Apart from being unprofessional, this is elder abuse.
Summary of Challenges

1. 
   General negative attitudes by medical practitioners towards aged patients prevails;
   
2. 
   General deprioritization of ageing issues negatively impacts on young professionals choosing a career in geriatrics and gerontology;
   
3. 
   General perceptions of older patients are that health care professionals care less about their health than that of younger patients;
   
4. 
   In the case of repeat prescriptions some doctors insist on seeing the patient before issuing the scripts, others refuse to see the patient on the grounds that they are not ill, resulting in the older person being denied chronic medication;
   
5. 
   Some doctors at state clinics / hospitals refuse older patients the prescribed two check-ups per year;
   
6. 
   Some health care professionals are blatantly rude to older patients;
   
7. 
   Reports of older persons being refused treatment simply because they are old, being told that they will die anyway.
   

Recommendations

1. 
   Prioritization of ageing issues by the DOH at national, provincial and district level;
   
2. 
   Programs aimed at sensitising health care professionals towards the health care needs of older patients;
   
3. 
   Conflicting protocols re prescription of medicine, consultation prerequisites and check-ups to be dealt with urgently;
   
4. 
   No older person, anywhere in SA should be refused treatment at any state clinic or hospital solely on the grounds of age.
   

6. Hospitals & clinics/ Medication shortages

Hospitals & Clinics
Primary health care centres are the point of entry to public health services for the majority. Patients may be referred from this level to either secondary or tertiary levels of care depending on individual need and systemic arrangements. The preventative, curative and rehabilitative needs of older health care clients are mainly integrated into general sessions at primary clinics. However, in practice, older patients are marginalised at the facilities, and very few are referred to secondary or tertiary levels for treatment and/or management. Quality health care at all levels is thus available to only a few older persons and the level of services available is not standardised. No specialists are available at primary level, but some work at secondary level, carrying out specialised diagnostic and treatment services. Tertiary level care is mainly provided by specialists, and offers highly specialised diagnostic and treatment services.

At public hearings conducted by the South African Human Rights Commission into the public health care system in 2007, older persons expressed extreme dissatisfaction with health personnel, their perception being that examinations are not thorough and subsequently they are incorrectly diagnosed. . Older patients are often treated sub-optimally and with disdain at public health care facilities. In a ruling handed down by the Supreme Court of Appeal in March 2011, health care providers were instructed to treat patients with dignity and challenged the attitude, widely held in the public service, that patients are receiving a favour. The judge ruled that patients be treated in the same way as private patients and should be fully informed about their treatment. In handing down his judgment, Judge Mohamed Navsa, ruled that patients in public health facilities “are entitled to be treated in the same way as patients who can afford private medical assistance.” That means they should be as involved as possible in their own treatment”. He added: “It is about a doctor communicating adequately with a patient. It is that basic sensitivity that the Constitution demands.” Older patients report of dismissive treatments by health care professionals due to ageist attitudes, they are frequently told: “What do you expect at your age?” Proper doctor-patient communication protocols are especially relevant to older patients given that they bear a high burden of non-communicable diseases which are poorly managed and/or not diagnosed at all because of a lack of screening of this high risk population.

Staff of NGO’s operating residential facilities often has to interact with health care professionals at state health care facilities when taking residents for treatment. By and large the experience of facility staff is based on past poor treatment / negative attitude of health care professionals at state facilities towards the older patients referred for treatment or admission.

Problems experienced by care/nursing staff in relation to public health care facilities include:

1. 
   Nursing staff of residential facilities claim that health care professionals at public clinics and hospitals in many instances refuse to even to read referral notes. “We would refer somebody critically ill to them and the Doctors will give an antibiotic and analgesics and return them to the facility without doing any investigation or even examining them and with no concern as to the interaction of different medication in older people.”
   
2. 
   A major complaint of staff of residential facilities is that patients are repeatedly being discharged without a discharge summary being issued. When an older person is discharged with new medication, nursing personnel of facilities are left in the dark as to whether previous medication should be continued or not. Patients are discharged without a proper diagnosis and hence facilities are ill informed as to the preferred care plan.
   

3. 
   Many instances are reported of older persons left lying on a trolley in the passage of a casualty department awaiting medical attention;
   
4. 
   Older patients being neglected during hospitalization to the extent that they develop bedsores.
   
5. 
   Huge delays in securing follow up appointments
   

As a result of the marginalization of older persons, dedicated geriatric and psychiatric clinics no longer exist. Some of the clinics are situated in very unsafe areas or are inaccessible to older persons.

It is suggested that many challenges may be overcome if Residential Care Facilities and Community-based services for older persons, could be utilized as bases where State medical services are offered to older persons at the preventative and early intervention levels.
Elderly patients in need of hip replacements, for example, on average, have to wait 7 years for an operation unless they are able to pay approximately R 25 000.00 to buy the prosthesis. Older patients (60+) are denied renal dialysis at state facilities; age per se is not a medically relevant factor and hence denying those 60 years and over (50 years if a diabetic) renal dialysis in simply not justifiable nor is this in line with the Constitution.
Medication Shortages

The distribution system of the medication provided by the State in rural areas is often not reliable. This causes older persons to go without their chronic medication for extended periods of time; incorrectly distributed medication is also a problem. The availability of medication for the treatment of psychiatric conditions is also a major challenge, especially in the Northern Cape. Another major concern, particularly for facilities is the substantial danger posed by unused medications that are not accepted back by the DOH; a clear policy for this is needed. Residential facilities find it extremely hard to adequately manage chronic conditions due to the irregular supply of pharmaceuticals resulting in patients foregoing medical therapy for chronic conditions. Medications and basic medical supplies made available in terms of the currently approved list, leads to gaps regarding early intervention and treatment. Over –the-counter medicines, for example cough mixtures, as well as cardex cards are no longer made available to Residential Care Facilities. The spectrum and the availability of listed medications and supplies thus need to be improved and extended to cover all of the Provinces. When collecting their medication older persons are sometimes told to return the following day or week as the dispensary does not have sufficient stock.

Appointment systems for older persons / dedicated days / preferential treatment for older persons at public health care facilities.

There are no preferential services for older patients at the primary level; older patients must compete for services with all other age groups. Although the DOH advocates fast queues for older patients, this is practiced at some state facilities but not all and at many public clinics and hospitals older patients queue from as early as 04:00 in the hope of being attended to that day. In the queue, younger people often push in telling the older person that they need to get back to work. Many older patients have to return to a hospital up to as many as three times before seeing a doctor.

The unreasonable delays for older patients needing treatment at causality units is of particular concern. Very often, some of the patients are expected to wait for hours without being attended to.
Ambulance services that are currently available do not appropriately meet the needs of older patients. Older patients appear to be discriminated against when requiring an ambulance. Some older persons face major challenges in regard to transport to and from state health care facilities.
Access to health services for the poor, especially in rural areas, is severely constrained by expensive, inadequate or non-existent transport and serious shortages in regard to emergency transport.
There are not enough step-down facilities and those that do exist are unaffordable to older persons on state grants or with very limited means.


Respite care

Affordable respite care for older persons is generally in short supply; those caring for older relatives / patient at home might need a break from their duties due to illness and/or stress. The availability of affordable respite care can be the difference between an older person being abused or care for appropriately.

Summary of Challenges

1. 
   Quality health care is available to only a few older persons who are given the opportunity for management at higher levels of care as the curative and rehabilitative needs of older patients are mainly integrated into general sessions at primary clinics- very few are referred to secondary or tertiary levels for investigation and management;
   
2. 
   Older persons by and large express extreme dissatisfaction with health personnel their perception being that examinations are not thorough and subsequently they are incorrectly diagnosed.
   
3. 
   Older patients are often treated sub-optimally and with disdain at public health care facilities;
   
4. 
   A Supreme Court judge ruled in March 2011 that patients at state facilities should be treated in the same way as private patients and should be as fully informed about their treatment- ; as per their rights in the Constitution. NGO’s operating residential facilities experience poor treatment / negative attitudes of health care professionals at state facilities, their main concerns being:
   
5. 
   health care professionals at public clinics and hospitals as a rule refuse to read referral notes;
   
6. 
   Older patients are repeatedly being discharged without a discharge summary being issued, Many instances of older patients left lying on a trolley in the passage of a casualty department awaiting medical attention;
   
7. 
   Neglect during hospitalization to the extent that the older patient develops bedsores;
   
8. 
   Huge delays in securing follow up appointments;
   
9. 
   As a result of marginalization dedicated geriatric and psychiatric clinics no longer exists;
   
10. 
    Elderly patients in need of hip replacements, for example, on average have to wait 7 years for an operation;
    
11. 
    Older patients (60+) are denied renal dialysis at state facilities;
    
12. 
    Older persons have to go without their chronic medication for extended periods of time because the state distribution system, especially in rural areas, is often not reliable;
    
13. 
    Substantial danger posed for residential facilities and older patients by unused medications that are not accepted back by the DOH;
    
14. 
    NGOs find it hard to manage chronic conditions, because of irregular pharmaceutical supplies;
    
15. 
    OTC medicines, for example cough mixtures, as well as cardex cards are no longer made available to residential facilities;
    
16. 
    No preferential services for older patients at primary health care level, older patients must compete for services with all other age groups;
    
17. 
    Fast queues for older patients advocated by DOH but not practised at all state facilities – at many public clinics and hospitals older patients queue from as early as 04:00 in the hope of obtaining treatment;
    
18. 
    older patients in some cases have to return to hospital up to three times before seeing the doctor;
    
19. 
    Ambulance services currently do not meet the needs of older patients appropriately –claims of discrimination by this service prevail;
    
20. 
    Access to health services for the poor, especially in rural areas, is severely constrained by expensive, inadequate or non-existent transport and there are serious shortages with regards to emergency transport;
    
21. 
    There are not enough step-down facilities and those that do exist are unaffordable to the majority of older persons.
    
22. 
    Currently an older person can spend a very long day waiting at an Out-patients’ Clinic/Day Hospital without receiving the required medical attention;
    
23. 
    Unit standards do not include geriatrics and geriatric mental health;
    
24. 
    Not enough wards & specialist units for the treatment of older adults with dementia (including Alzheimer's Disease with BPSD)
    

Recommendations

1. 
   Protocols for optimal treatment of older patients at primary health care facilities
   
2. 
   Overall strategy needed aimed at improving access to quality health care at secondary or tertiary levels for older persons;
   
3. 
   Development of simple brief screening protocols to be used at primary health care level for common syndromes affecting older persons.
   
4. 
   Protocols needed to ensure health personnel make thorough diagnoses of older patients;
   
5. 
   More assistance to NGO’s providing services to the elderly. Establishment of more day care centres for the cognitively impaired especially in previously underserved areas with a high ageing population;
   
6. 
   Programs aimed at improving the relationship of state facilities with residential care care/nursing staff that includes:
   

 Consideration of referral notes by residential nursing/care staff;

 Discharge summaries being issued to nursing/care staff of residential facilities without exception;

 Better communication with older patients and nursing/care staff of residential facilities when their patients are admitted to casualty units;

 disciplinary procedures followed for nursing staff neglecting older patients;

 Improved follow up appointments system.

7. 
   Consider reintroduction of Geriatric clinics that integrate disease management, rehabilitation and disease prevention (Senior Day Centres could be possible sites for this). This will enhance the provision of comprehensive and holistic care with the knowledge that mental and physical health are closely linked in the older person;
   
8. 
   Program aimed at reducing the backlog of older patients requiring hip replacements;
   
9. 
   Reconsideration of the age cap placed on renal dialysis at state facilities;
   
10. 
    Improved state distribution system for especially chronic medication;
    
11. 
    Clear policy on unused medication;
    
12. 
    Availability of OTC medication to residential facilities;
    
13. 
    Preferential services for older patients and/or dedicated days for the treatment and collection of medication exclusively for older patients at primary level at all state facilities;
    
14. 
    Eradication of discrimination against older patients re ambulance services;
    
15. 
    Programs aimed at providing transport for older persons’ to state facilities;
    
16. 
    Increase in state step-down facilities;
    
17. 
    Expanding the unit standards to include geriatrics and geriatric mental health
    
18. 
    More financial support of research units at tertiary institutions;
    
19. 
    Government backing for more wards & specialist units for the treatment of older adults with dementia (including Alzheimer's disease with BPSD) and more posts for specialists.
    
20. 
    Raise awareness of the profile of our ageing population and promote active ageing with emphasis on the value of healthy lifestyle choices – no smoking, moderate liquor consumption, healthy eating, control of other health care risks – diabetes (including Type II diabetes, hypertension, blood pressure, heart and stroke indicators etc.).
    

7. Older patients with mental disorders

(Including Alzheimer’s AND Dementia)
7.1 Mental Disorders

The treatment and long term care of older persons with psychiatric and degenerative mental conditions pose major challenges. There is a severe lack of resources such as psychiatric services and long term care facilities. State facilities pass off such patients to Residential Care Facilities merely on the basis of chronological age, while these facilities do not have appropriately trained staff to deal with such conditions. It also has detrimental effects on other residents, especially where behaviour problems are experienced that manifest, for example in aggression and violence.