OUR ELDERCARE CHALLENGE
We are in the midst of a major demographic shift that will affect everything from urban planning and housing to public transit and taxation. But it’s in the area of health and social services that the greying of Quebec will have the most impact.
In 15 years, one-quarter of Quebec’s population will be over 65. Are we ready to take care of our elderly? If the province’s current track record is anything to go by, far from it. Aaron Derfel kicks off our special series, in Saturday Extra
Are we, as a society, ready to take care of our elderly?
Agathe Moses had just returned home from a game of bingo at her activity centre in St-Henri one afternoon in October and was hanging up her coat when suddenly her legs gave out and she fell to the floor in the narrow corridor of her apartment.
She wasn’t dizzy when she fell, but of late — perhaps as often as once a month — the 79-year-old grandmother loses her balance despite the aid of a walker, and she takes a tumble.
Like many elderly people in Quebec, Moses, a lifelong Côte- StPaul resident, lives alone — with the support of a CLSC home-care attendant who bathes her twice a week, and two sons and a daughter who visit. But on this recent day, when she fell and banged her head against the front door and the floor, no one was there to rush to her side.
“I tried to get up on my own, but I couldn’t reach the doorknob,” Moses recounts in her modest thirdfloor apartment.
She could have summoned help immediately by pressing the panic button on a bracelet on her right wrist, but didn’t initially think it was worth the trouble.
“I didn’t use it right away. I waited. I wanted to get up on my own. But after three hours on the floor, I couldn’t wait any longer.”
During those three long hours, Moses soiled herself as aching pain shot through her upper back and bruises swelled up on her arms. Finally, at 6 p.m., she pressed the button. Firefighters arrived within minutes, but they couldn’t push open her front door because her head was pressed against it. So they hoisted a ladder up to her balcony and came in through the side door.
After being hospitalized for a week, the ordeal hasn’t changed her mind about the merits of her living arrangement.
“I like living at home,” she says. “I can do as I please: eat when I want, watch TV when I want and go to bed when I feel like it. I want to stay at home for as long as I can.”
Agathe Moses’s predicament — wanting to live at home while struggling with limited mobility and a range of chronic illnesses (she takes 19 pills a day for everything from arthritis to heart disease) — is increasingly common as Quebec’s population ages.
But Quebec and the other provinces are now at a crossroads: for the first time in the country’s history, Statistics Canada reported this year that there are more people over age 65 than there are children under 15.
And the stark statistics don’t stop there: in five years’ time, one in five Quebecers will be of retirement age. Ten years after that, onequarter of the province’s population will be 65-plus, according to projections by the Institut de la statistique du Québec — most of whom will be over age 75 and, like Moses, be afflicted with a host of medical problems and in need of support for basic daily tasks.
This major demographic shift, experts predict, will affect everything from urban planning and housing to public transit and taxation. But it’s in the area of health and social services that the greying of Quebec will have the most impact.
Which raises a fundamental question: Are we, as a society, ready to take care of our elderly? If the province’s current track record is anything to go by, far from it.
“If we keep doing things the way we’re doing them now, we won’t be ready,” warns Amélie Quesnel-Vallée, an associate professor in the department of sociology at McGill University, who holds the Canada Research Chair in Policies and Health Inequalities.
“Right now, we’re putting a lot of the burden on informal caregivers like family members, and (elderly) patients are being ping-ponged from one institution to another.”
Judith Gagnon, president of the Association québécoise de défense des droits des personnes retraitées et préretraitées, is even more blunt in her assessment.
“It’s a tragedy,” Gagnon says. “Our health care system is incapable of providing appropriate long-term care to people. There’s also not enough home care. There are a lot of elderly who live alone and who are poor. As a society, our values have not improved.”
In her annual report made public in September, Quebec’s ombudsman notes with alarm that “the state of home support services is increasingly limited” and the “number of places in residential and long-term care centres (CHSLDs) is declining.”
“Unfortunately, we can expect a worsening of pressure on other components of the service network,” Raymonde Saint-Germain concludes in her report.
Eldercare in Quebec has evolved dramatically over the last 50 years — from a model in which the family played a predominant role (with three generations sometimes living under one roof) to largely state-funded institutional care.
Back in the mid-1960s, the elderly sat at the tiny top of the demographic pyramid. In the last two decades, however, the elderly have occupied more and more of that pyramid, as life expectancy has soared (Quebec reported an astonishing 1,813 centenarians in 2014) while the province’s birthrate has fallen. The fear is that the pyramid might one day become inverted, with fewer taxpayers at the bottom having to support costlier health and social services.
Instead of responding to this demographic shift, the Quebec government in recent years has begun to “disengage” from eldercare, observes a 2014 study by the national Institute for Research on Public Policy.
“The number of places available in public residential care facilities has continued to shrink, leaving the private sector to assume a growing role in that area,” the study’s author, Jean-Pierre Lavoie, writes. “Notwithstanding some funding increases in recent years, home care remains underfunded, with Local Community Services Centres (known as CLSCs) only able to respond to roughly eight per cent of care needs overall. Government must therefore rely on families (and the private sector) to make up the shortfall.”
However, these changes — underfunding in the public sector amid evolving demographics — have come at a terrible social cost. Many caregivers are in despair and burned out, so heavy is the burden of tending to loved ones suffering from dementia and other disorders. And the proliferation of private residences — which critics argue are poorly regulated — has sometimes led to horrific consequences, with cases of neglect, mistreatment and outright abuse of the elderly.
Gagnon, of the seniors’ rights association, criticized the fact that private residences are certified only once every two years by public authorities who must follow what she described as lenient criteria, while public-sector institutions must abide by more stringent standards.
Jean-Pierre Ménard, a medical malpractice lawyer, says many private residences furnish the “bare minimum of care,” with few staff and visiting physicians who can’t possibly examine patients indepth. He deplores the practice of some private residences charging as much as $6,000 a month to care for individuals with complex medical and cognitive problems who should really be placed in a government-run nursing home.
“The public system is turning a blind eye to what’s going on in
the private sector,” says Ménard, whose own mother-in-law’s death at a private residence was “accelerated by the poor decisions that were made by the staff.”
Geriatricians (of which there are a meagre 248 for all of Canada) advocate for what they describe as the “continuum of care” — ensuring that the elderly get the right care at each stage. It starts with home care: having doctors and nurses visit a senior’s house for checkups and an attendant to help with administering medication and with personal hygiene, among other basic needs.
As an individual’s health declines and short-term memory problems arise, the next stage might be “assisted living” in a private facility, or among the few governmentsubsidized seniors’ residences — a lighter version of long-term care — that are available in Quebec. For those who might eventually require 24-hour care — for example, someone with Alzheimer’s — the public institution tailored for this late stage is the CHSLD, or Centre d’hébergement et de soins de longue durée.
The problem, Gagnon points out, is that the average wait time to be placed in a CHSLD is one year, and sometimes as long as three years. Some literally die at home before they can be placed, while those with the financial means choose a private facility, Gagnon said. Nearly everyone agrees that a combination of comprehensive home care and support for “proches aidants” — informal caregivers — is the most cost-effective and dignified solution to the crisis in eldercare.
Yet after years of boosting funding for home care (at levels that were still not nearly enough, critics charged), Quebec is now beginning to cut back as Premier Philippe Couillard pursues an austerity agenda and as the federal government tapers its health transfers to the provinces. Hospitals and other public institutions across the province are under orders to chop a total of more than $500 million from their operating budgets this year and more the next year.
(Spending on home care for seniors rose to $714 million in 2013-14 from $656 million the year before. A Health Department spokesperson told the Montreal Gazette that figures for 2014-15 will only be available this winter.)
In the field, homecare workers are concerned by the cuts.
“The hours of service that we give to new clients is being reduced,” says Mohammed Rhallad, a highly dedicated CLSC Côte-des-Neiges homecare worker who emigrated from Morocco to Quebec.
For Quesnel-Vallée, who advocated for her ailing mother until her death last year, Quebec has it backward when it comes to home care. She recommends that the province follow the lead of Denmark in investing 75 per cent of long-term care dollars in home care and 25 per cent in institutional care.
“For us, it’s the opposite, with most of the money being spent on institutional care,” she says. “There’s no two ways about it: more money needs to be put into care for the elderly, but not just thrown at the system. There needs to be a very clear action plan, a major overhaul. It’s not just about eldercare in the medical sense. It’s about social care, as well.”
There are some signs of hope in the midst of the bleak warnings, however.
At the Jewish General Hospital, located in Montreal’s ethnically diverse Côte-des-Neiges district, medical teams had to face a decade ago what the rest of Quebec is only now grappling with: a high proportion of elderly patients. Today, 40 per cent of hospitalized patients at the Jewish General are 75 or older, compared with 25 per cent for the rest of Quebec.
The hospital has established a geriatric assessment unit, a memory clinic, a geriatric oncology clinic and a rapid-response team that springs into action whenever an elderly person is admitted into the emergency room. The Jewish General is also pioneering new protocols for staff to flag potential problems with delirium, mobility and nutrition — problems that if detected early can be treated before a person’s health deteriorates quickly.
“We want to help health professionals connect the dots and realize that a small amount of prevention will go a long way,” says Dr. Ruby Friedman, associate director of the Jewish General’s division of geriatric medicine.
Georgia Papadopoulos, a nurse in geriatrics, says the Jewish General works closely with family physicians in the community to “make sure that the elderly can stay at home for as long as they can. If we can prevent an emergency room visit, then we’ve done a great job.”
Ultimately, though, Quebec’s political leaders will have no choice but to confront the crisis in eldercare as more and more baby boomers — who belonged to the generation that influenced much of Canadian society in the 20th century — reach advanced age themselves, Gagnon suggests. In 2011, the oldest baby boomers turned 65.
“In the United States, there is already a powerful, organized lobby for the elderly,” she says. “That’s going to happen in Quebec, too. It’s called grey power. And as more baby boomers become elderly, there will be a paradigm shift. The baby boomers will demand better home care, better social housing and better public transit.
“And why not? Why can’t we have an aging population that can still have a good quality of life?”
The public system is turning a blind eye to what’s going on in the private sector.
JEAN-PIERRE MÉNARD