Silver threads among the gold

There is still much to be done to improve the health of Israel's elderly.

old people 298.88 (photo credit: Courtesy)
old people 298.88
(photo credit: Courtesy)
With the president of the state being 84 years old, the minister in charge of pensioners' affairs 81 and the health minister 80, it would seem that the elderly are getting more public attention and concern than ever. But it really isn't so. Even though these VIPs are octogenarians, the average elderly Israeli - especially those with serious health problems - is still not doing so well. Many live alone; tens of thousands don't go to the pharmacy with doctor's prescriptions or even to a medical specialist because they can't afford the copayments; considerable numbers can't buy or don't have the energy to prepare nutritious meals; and many get sub-standard geriatric nursing care or none at all. The Israel National Institute for Health Policy and Health Services Research (NIHP, whose Web site is, an independent organization set up as a result of the National Health Insurance Law in 1995, held a recent seminar on "Healthy Ageing - A Feasible Achievement" along with the two ministries. The event was attended by over 100 people at the Conrad Adenauer Convention Center in Jerusalem's Mishkenot Sha'ananim and was opened by the two elderly cabinet ministers. Prof. Shlomo Mor-Yosef, director-general of the Hadassah Medical Organization and the new chairman of the NIHP's executive, said at the outset that he hoped the symposium would provide tools for decision-makers and move geriatrics forward. The diminutive Pensioners' Affairs Minister Rafi Eitan, whose head barely peeped above the podium, told the audience that after a long career (as head of the Mossad operation that captured Adolf Eichmann, advisor on terrorism to prime minister Menachem Begin and head of the Bureau of Scientific Relations and then a businessman), he had intended to be a sculptor. But Gil Pensioners' Party activist Ya'acov Ben-Yizri, who was then 79 and eventually became health minister, persuaded Eitan to head the new party running for the Knesset. "I told my doctor that if I had lived 100 years ago, I would have been dead already; I certainly would not have reached 80. I was a heavy smoker," he said. "My mother had died at 62. At 40, I decided to kick the habit, but it took a while. I started to take care of myself. Our ministries have to increase awareness of preventing disease among young and old. Everyone should work until the end of life - if not paid work then as a volunteer - take an interest in sport, find hobbies, take care of your health and get diagnosed early. I was diagnosed with cancer in time." BEN-YIZRI said he retired 14 years ago and never intended to work again, "but here I am with a new career. I insisted during coalition negotiations that I wanted to be health minister." Ben-Yizri had worked for years as a Clalit Health Services district manager. The government, he continued, is advancing in many fields, including economics, transport, infrastructure and education. "But where is health? We are standing in place. Every time, we struggle over a few more million shekels. Payment ceilings for the elderly who need prescription medication will drop, so the elderly will have to pay less. We want to reduce copayments for pensioners who visit a specialist. But it is not enough. We must plan for the next 10, 15 or 20 years. Now is the time to stand on our hind legs and demand that the government do more for health," Ben-Yizri said. He was especially concerned about geriatric nursing care. "We have to deal with it because it isn't included in the National Health Insurance Law. My ministry has prepared the needed bills. We need geriatric nursing care to be included in the services supplied by the health funds." This was supposed to have gone into effect in 1998, but implementation was prevented by the Treasury. He disclosed that he will soon ask the cabinet for approval of a proposal to raise health taxes by 0.3 percent (above the current 4.6%), covering most of the cost of decent geriatric nursing care for those who need it. The rate of health taxes, collected monthly on a progressive scale by the National Insurance Institute, has not been hiked since the National Health Insurance Law went into effect. The increased health taxes would provide some NIS 700 million a year for geriatric nursing care, according to outgoing Health Ministry deputy director-general Gabi Bin-Nun, who is leaving for academia after almost three decades in the ministry. He said that someone earning the average gross wage of NIS 7,000 would have to pay only about NIS 10 a month for such coverage. THE YOUNG Treasury budgets division deputy chief Raviv Sobel wasn't popular with the audience when he said he and his bosses oppose transferring geriatric nursing care to the health funds and preferred "small changes to solve problems." Bin-Nun insisted that Israel's impressive economic growth allows the country to offer more and take risks. Bin-Nun, who has worked on the geriatric nursing plan for two years, said the ministry - free of the burden of financing and supplying these services - will be able to concentrate on its intended role of regulation and supervision to ensure that these services will indeed be available, equitable and of high quality. NIPH scientific director Prof. Alexander Aviram noted that 10% of the population are elderly, but they use twice as many health services as younger people. His institute - charged with conducting research on how the health insurance law is regarded and implemented, and which acts as a forum for professional and public discussions about the organization and management of health policy in Israel - has so far financed 62 studies related to the elderly. "We looked at equity and the use of services, the effects of the national health insurance law, nutrition and disease prevention, mental health, quality of life, satisfaction and views, the use of drugs and rehabilitation." Aviram presented the good news that since 1995, the health system has become more equitable and accessible to disadvantaged sectors, but there is "still a gap between the Arab and the Jewish sector. Low socioeconomic groups are still disadvantaged in all fields," said Aviram, "but discrimination against the elderly because of age has disappeared. Satisfaction with health-fund services has increased, even though the feeling of inequality has also increased." THE BAD NEWS is that nutrition, heath education and disease prevention get low priority among family doctors, especially in their dealings with the elderly. Family doctors rarely intervene to identify patients who get inadequate nutrition or have sensory problems (such as poor vision or hearing) or a decline in cognition. "Doctors feel they lack the knowledge and time for health promotion," Aviram said. "It's easy to hide behind this as an excuse, but many doctors don't know how to do it because they weren't taught to speak to healthy people." Many Israelis over 65 suffer from malnutrition and chronic illness, use a lot of medications and rarely get supportive care. They should get intensive consultation from a clinical dietitian. Men who reach 65 usually have wives who cook for them, but elderly women who are widowed often feel it isn't worthwhile cooking only for themselves." The institute's scientific adviser also complained that only 15% of heart attack victims get rehabilitation paid for by the health fund, even though they are entitled to it from the health services basket. Cardiac rehabilitation has been proven very effective in preventing another heart attack, improving the quality of life and reducing medical costs. But most, especially the elderly, rarely get it. Another problem of the ageing is that they take a wide variety of medications, some of which conflict with each other and cause harm. Sometimes they can be seen with plastic bags full of drugs, and often there are the same drugs with different commercial names. At older ages, dosages have to be different than at younger ones. DR.SHAI BRILL, director of Clalit Health Services' Beit Rivka geriatric hospital in Petah Tikva, told the audience there are various levels of disability among the elderly. Some 645,000 over 67 can take care of themselves. Some 35,000 are frail but do not get outside help, while 80,000 cannot perform basic tasks, and 40,000 need round-the-clock nursing care. Responsibility for such care is fragmented and includes the families, the Health Ministry, the health funds, the National Insurance Institute (NII) and other agencies. "Even at 85, it is worth doing comprehensive geriatric assessment, treatment and disease management," Brill said. "Everyone should have a case manager for his or her health functioning. A comprehensive geriatric assessment can improve an individual's physical, cognitive, emotional and other functioning." But Brill, who is a "Baby Boomer," worries that there won't be enough qualified geriatric professionals to assess and assist his generation. "We have fewer rehabilitation hospital beds than we had in 1993," he added. These are meant for people who suffer a stroke, heart attack, hip fracture or other serious condition that would respond to the right therapy. The NII, he said, could save a lot by having nurses assess injury and disability and prevent people from being hurt again and becoming more disabled. "We mistakenly used to think that old people can't exercise because their bones would break and they would have heart attacks. But numerous studies have shown that physical activity of the right kind results in fewer falls and bone fractures, improved health and even a reversal in sarcopenia [muscle loss]," Brill said "We should aim at helping people age with dignity," said Prof. Mordechai Shani, chairman of the Gertner Institute and former director-general of the Health Ministry and Sheba Medical Center. "Today we know that mental exercise and intellectual stimulation can boost cognitive functioning. Additional neurons can apparently be created in certain parts of the brain even at these ages. The elderly need physical exercise as well; only 30 minutes a day can be enough." Sixty-five or 67 years of age should no longer be regarded as the onset of old age, said Prof. Jiska Cohen-Mansfield of the Tel Aviv School of Public Health and Jerusalem's Herzog Hospital. "It should start at 75." Almost half of the elderly say they don't have enough income. Health Ministry statistics show that 48% have a monthly income of less than NIS 2,275. About 88% of those over 75 have at least one chronic disease, and 79% take more than one drug. About 30% have vision problems, 36% hearing problems - but only about 8% of these have hearing aids - and 63% suffer from pain. Even though many get effective pain killers from their doctors, the quantity is often insufficient, as physicians are afraid to prescribe them for fear of addiction. She added that many elderly, even those with dementia, can usefully undergo rehabilitation. But when nothing can help, palliative care to reduce suffering is needed. "More must be done to treat depression in the elderly. And those who want to should be helped to talk about death, which is a part of life." As many pensioners live alone, Cohen-Mansfield said, efforts must be made to expand their social networks so they are not cooped up at home. "The environment can encourage social contacts through neighborhood cafés, synagogues and Jewish studies, organized trips, walking groups in shopping malls and elder co-housing. Many elderly don't feel 'old enough' to go to golden-agers clubs. There should be other activities to link them socially."