I am actually here representing NICE, the National Initiative for the Care of the Elderly, of which I am a member. I am a psychologist, and I work at a veterans care program in London, Ontario, at one of the large priority-access-bed facilities in Canada.
The National Initiative for the Care of the Elderly is an international network of researchers, practitioners, seniors, and students dedicated to improving the care of older adults in Canada and abroad. NICE is funded through a new initiative grant from the Networks of Centres of Excellence.
Our members represent a broad spectrum of disciplines and professions, including geriatric medicine, nursing, social work, gerontology, rehabilitation sciences, sociology, psychology, policy, and law. We promote and facilitate interdisciplinary collaboration between and among researchers and practitioners to improve the care of the aging population in Canada and elsewhere.
The overarching emphases of NICE are networking and knowledge transfer--that is, getting good research into practice.
NICE has three overarching goals. The first is to help close the gap between evidence-based research and actual practice. The second is to improve the training of existing practitioners and geriatric educational curricula, and to interest new students in specializing in geriatric care. The third is to effect positive policy changes for the care of older adults.
With that as the background of who it is I'm representing, I'd like to provide some comments from NICE for the committee.
NICE would like to compliment Veterans Affairs Canada on the thoughtful consideration of aging issues that is reflected in the work of the Gerontological Advisory Council's report, Keeping the Promise, and in the veterans health services review. To further this good work, there are three specific issues that NICE would like to bring to the committee's attention.
First, we note that several of the issues of concern to NICE--in particular, caregiving, dementia care, and end-of-life care--are easily identified in the work to date. NICE has also identified elder abuse and mental health as priority issues for improving the well-being of older adults.
Mental health is an underserved focus in health care for seniors. This is evidenced by its prioritization within the NICE thematic framework as well as by the coming together of the Canadian Coalition for Seniors' Mental Health--another organization that I am a member of and have been on the steering committee of--specifically to advocate for improvements in this aspect of care for older adults.
Mental health is a critical component in any broad-based health promotion strategy. It's well known that poor mental health has implications for the ability to access, assimilate, and derive benefit from interventions that aim to enhance, maintain, or restore independence, that aim to improve functional autonomy, and that promote quality of life.
So mental health problems and illnesses are not well served by home care programs in general. We hope that appropriate attention will be given to the promotion of mental health in any changes to the veterans independence program that result from the committee's deliberations.
Second, we applaud the committee's interest in making services under the veterans independence program available to a greater number of recipients. We agree that the services provided should be based on assessment of needs. We note that the evolution of needs across the lifespan is an important consideration. An effective and user-friendly monitoring process will be essential to ensure that the provision of services stays current and timely.
We suggest that the inclusion of older adults in the process of developing and implementing monitoring will be essential to its success. Routine monitoring that is triggered by the passage of time is important, but even more important is the realization that health status can change rapidly for seniors, especially for those with a more tenuous hold on their independence. The needs-based assessment protocols that are developed should encourage self-monitoring and user input in the face of significant change on an ongoing basis. We would suggest that expertise in knowledge transfer and networking should be accessed to develop creative, state-of-the-art approaches to shared care in this context.
Third, we agree with the goal of supporting a range of residential care options for seniors, and agree that efforts should be made to encourage and enable older adults to reside independently as long as possible.
We note, however, that there is a risk in conceptualizing long-term-care homes as the residences of last resort. This has the potential to exacerbate the stigma already associated with this residential care option. For many reasons, a substantial number of veterans and other older adults need full institutional care if they are to survive. It has been said that a society can be judged by how it cares for its most vulnerable members.
Communication and advertising about changes to the current system should not suggest that those veterans and families who do not need long-term-care placement are somehow more successful than those who do. We also note that it will be important to ensure that the new emphasis on health promotion and innovative service delivery is as valued for those who reside in long-term-care facilities as it is for those who remain in their communities.
Thank you for the opportunity to present these views to the committee.
:
Two things come to mind in response to your question. One is that the need for institutionalization is often driven by a whole combination of factors, and many of them are caregiver-focused. So if a caregiver who has been managing someone who has a progressive dementia has a fall and ends up in hospital, then it's more likely that the veteran who had the dementia is going to have to go into a long-term-care home, because the caregiving support systems aren't there any more.
So one issue is the progression of the disorder, and the other issue is the stability of the environmental supports. There are some things that can happen in the course of dementia that make it increasingly difficult for people to be managed at home, regardless of whether the situation is stable or not, and that's when some of what they call the psychological and behavioural symptoms of dementia start to become more prominent, which happens as the dementia gets worse. This is the wandering, the aggression, the inappropriate behaviours and hallucinations--the kinds of behaviours and symptoms that can become a lot more difficult to manage in a home and community environment. So if the disease progresses so that those start to become more a part of the symptom picture, that may be what triggers the need for institutionalization, even though the family or the spouse hasn't changed.
On the other hand, the disease could be fairly stable and the caregiving situation could change, and all of a sudden that requires institutionalization.
To go back to your previous question, about what research there's been, well, I don't think there's been a lot of focus on determining whether there has been a higher incidence of dementia in veteran versus non-veteran populations. There has been quite a bit of research done, and quite a bit of this has come out of the United States, actually. They've looked at older veterans who have managed quite well through their middle-aged years--they worked, they had a good career and a good early retirement--and then they developed dementia. The combination of the dementia and what that brings in terms of the ability to cope and to reason and to function, together with the losses that come with aging, can create a pretty volatile situation that becomes quite difficult to handle. So you can get a situation whereby the normal stresses of aging are exacerbated.
:
Good afternoon, Mrs. Gibson. Thank you for coming. Your presentation was very interesting.
If I understood correctly, you're in favour of home care. You said it was important for seniors to stay in the community or at home for as long as possible. Do we have qualified people to help them, those who are called natural helpers?
In my friend Gérard Asselin's riding, for example, there's a problem issue. A certain Antonin Lévesque, an elderly veteran, has serious problems. His wife, who is nearly as old as he, is no longer physically able to care for her husband, so much so that she was forced to put him in some centre for a few weeks before bringing him back home. How do we resolve this kind of situation?
:
This is exactly why I think we have to be really careful about looking at it as a continuum of care with multiple options and about making sure we're making the decision that provides the right care for the person in their circumstances. If the person has the kinds of needs that are easily met by the services available, then they're going to be able to be kept in the home longer. But once you start to get into the mental health issues and the dementia issues and so on, there may not be readily available professional assistance in the existing home care service roster to provide the care that's needed.
The human resource issue on the health care professional side is a big problem, in terms of adequately servicing home care clients, absolutely. That's why you also have to be careful, in your assessment process, to make sure you're taking a very broad-based look at assessing need. It's not purely function—what you can do under the ideal circumstances—it's a question of what's really available to you and the kind of support you are going to need.
It's also a question of recognizing that people don't necessarily go into long-term care as a one-time thing, whereby they go in and never come out. There's a quite a revolving door for long-term care as well. People may need to be in long-term-care beds for a while and then are able to go back to the community at different stages of their life, depending on what resources are available to them.
I think we need to become much more flexible in how we think about all the different options along their care continuum and how these can intersect and work together to meet different needs at different times.
Maggie--if I may call you Maggie--thank you very much for coming out today.
We're heard testimony from other folks that there are just not enough people like you around. Obviously, if we have these great plans, and even if the government and the opposition agree that x number of dollars will go into funding, and we'll do everything that's been recommended to us, if we don't have the physical human resources to do them, it could all go by the wayside.
What recommendation can you give to federal and/or provincial governments to encourage people to take this up as a career, as an opportunity to help people, to make a decent living, as obviously you have, and to encourage them that it is a wonderful and valued career? Year in and year out we seem to have this problem of getting people to take this up as a profession. What recommendations can you give to us that we can then pass on?
:
I can speak to the area of psychology. If you go to the website of the American Psychological Association in the States, you'll see that they have all sorts of informational, promotional materials directed at encouraging people, and especially students, who are interested in the mental health field to take up a career in care of the elderly or in geropsychology.
The Canadian Psychological Association is doing more in that direction now, and I'm involved in some of that. I really think that the focus has to be on the education system, and we need to make people more aware of the interest, the potential and the value of careers in the care of older adults earlier in their careers before they've selected their focus, before they're in graduate school and have already decided what they're going to do, and have started down a track that it's hard to turn from.
It's not just the mental health professions that are facing difficulties. Certainly geriatrics is facing difficulties as well in terms of recruiting enough people who want to specialize in this area.
People specialize through the education system, so we have to be working with the colleges and universities to create more interest and have more educational offerings early on that will steer people in those directions.
:
Unfortunately, I'm not going to be able to answer that question to your satisfaction, because I actually work in the geriatric component, the long-term-care component, at Parkwood Hospital in the veterans care program. I don't work in the operational stress injury program. Certainly there would be people well able to describe that program in detail to you. My focus is geriatrics.
But in terms of your question about how veterans are different, one of the things in long-term care that I think is particularly important is that the long-term-care veterans population is mostly male, and the long-term-care population from the community is predominantly female.
That's going to change for a couple of reasons, partly because the demographics in the mortality rates are changing—men are living longer—and partly because family structures are changing. The given scenario where you have the younger spouse who cares for the older man who is then able to live out his whole life at home is going to change as well, because the family structure is changing.
What we have in the veterans care population is a real opportunity to understand what the needs of aging men are that then can be extrapolated to what the needs of aging men in the community are going to be over the next few decades when the numbers start to balance out and we will have more equal numbers of men and women surviving to older ages.
:
Yes. I think most of us know that.
I want to follow up on something that I know my colleague Peter brought up too. It has to do with professional care, just to expand a little bit on that.
One of the things that is always a concern is where do we get the professional care? That was one of the questions.
In every town in Ontario—and I suspect it's pretty much the same across the country—when we're looking for doctors, or we're looking for specialists in some areas but always doctors, each town is struggling to meet the medical needs they find within their community. When we have the same issues in our long-term-care facilities, how do we supply those facilities in terms of the professional needs we have?
Do you have any recommendations on how we can share, how we can work with the communities, work with the general public, on being able to get the care that is needed?
Good afternoon, Ms. Gibson. We're glad to have you here as well as, certainly, your presentation in raising the whole issue of mental health and its importance in terms of this particular study.
I just have a question. I was struck when Health Canada appeared before us and they listed a couple of statistics. I don't know exactly what they were now—I don't have the paper in front of me—but they said that the vast majority of the elderly in a certain category said they were in good health when they were asked. Then there was another statistic that said, basically, in the same group there was a high percentage with at least four chronic diseases they were managing and a higher percentage dealing with at least one chronic disease, but still when asked how they would view their overall health, they said it was very good.
So I asked them that question, and they said that was a state of mind. I still feel a statement such as “I'm in a good state, even though I have four chronic diseases” is quite interesting. Could you speak to that at all?
My second question would be this. Because we're talking about veterans and we're targeting programs around veterans, we know there are going to be certain similarities between elderly or seniors or the aged and veterans as a subgroup. But if we're talking about veterans specifically and we're talking about programs targeted towards veterans, we know some of them are going to be similar to what you would do for similar types of populations. Is there anything specific that we should be addressing for elderly veterans, which make up the vast majority, so that our resources, time, and efforts are more targeted?
Those would be my two questions.
:
I think with respect to the second question, it's really more a matter of being able to target veteran populations with programs that are.... It's a contained population, so you can target veterans populations with ideal programs, with model programs that are focused on different issues. We don't know because we aren't targeting the elderly who need assistance with ideal and model programs in general, but we can at least think about targeting the veterans population, which is a defined group, with what we think are really ideal programs. Then when they work and when we figure out what works about them, why they help, and which pieces of how they help are really because it's focused on men or on long-standing relationships between spouses or on something about having that camaraderie of the veterans' identity, we'll be in a good position to learn from those programs and figure out how they could be translated to the broader community.
The literature on Second World War veterans internationally really seems to show that one of the things that has been very protective for veterans in many countries is the camaraderie. It is the fact that their services were acknowledged and continue to be acknowledged through remembrance kinds of activities. That sense of appreciation and of being cared for is actually correlated with good mental health in the face of many aging challenges.
It's really worth looking at the studies that go across the Finnish, Russian, British, and American veteran populations to see where some of those commonalities come out. One of them seems to be that if you have been through a really traumatic event like a war, the remembrance component and the acknowledgement component carried out through your life is a protective factor. That's different from the rank and file community person who may have various traumas occur to them but not in any kind of systematic, organized, acknowledged way.
So there are some advantages to the veterans group that I think we can capitalize on, in terms of developing health care programs for an aging population that will be really quite model programs. I think that's what Veterans Affairs has tried to do in many ways.
I apologize; I have completely forgotten your first question. What was it?
:
Good afternoon, Mrs. Gibson. I very much enjoyed your presentation, despite the lack of time that was allotted to you, and I want to congratulate you on it. Perhaps we could have given you a few more minutes, in view of the interest your presentation raised among committee members.
We know today that a boy or a girl who decides to join the Armed Forces is under the responsibility of the Department of National Defence. When he or she leaves National Defence, that responsibility is transferred to the Department of Veterans Affairs.
As Mr. Perron said earlier, there is little training or information on the consequences or the mental health problems that may arise.
In one article, for example, we learned that, in the United States, at least 6,256 persons who had served in the Armed Forces committed suicide in 2005, an average of 17 persons a day. The average in the general population is 8.9 per 100,000 inhabitants, and the average for veterans in the United States is 18.7 to 20.8, twice that figure.
Veterans in my riding are lacking information. First, they spent time in the Canadian Armed Forces. They went into combat. They have a file number as veterans, but today those individuals are elderly, often disabled and have lost quality of life. They are therefore left to their own devices because they don't know that there is a health program for veterans. They don't know that they could be receiving some kind of financial compensation or that various programs are there. Unfortunately, veterans are left to their own devices from the moment they leave National Defence.
This happens at the expense of their health and families. A number of them become discouraged and commit suicide. I think veterans should at least be informed about federal government financial assistance from the moment they join the Armed Forces. Veterans should also be constantly monitored to eliminate health problems or at least to provide them with the services to which they're entitled as veterans.
If a veteran from my riding came to see me in my office and asked me whether I could tell him where in Quebec he could get the relevant information for veterans, I would be at a bit of a loss and I would have to turn to Mr. Perron—somewhat as I did this morning—in order to be able to communicate with the Department of Veterans Affairs.
I think there is a considerable lack of information on health, follow-up, programs and financial assistance to which people are entitled. People often can't stand it and decide to commit suicide. There are cases of suicide, but there are also cases of murder.
I would like you to tell me how the government could improve the federal system in order to help veterans and to reassure them about health programs.
:
I can offer some experience.
I don't know that I have the answer to what the government should do, but one of the things that's really dramatic that's happening with younger populations is the reliance on the Internet. Not our elderly population so much, but younger populations go to the Internet to get information. And I think an informed public is a good thing. I think one of the best things we can do is get the information out there in user-friendly websites so that anything that is public information and anybody who wants to learn about it can learn about it. Because you or I or anyone else is not able to retain all the information about all the services, programs, and different aspects of things, and veterans' care is only one of the things you need to have on your plate.
I can't tell you about a clinic I'm not involved with, but it would be easy enough to find the information. I agree with you, I think more information is better, and the way of the future is Internet access, so good websites that put everything available to the public out there in easily accessible ways is the way to go. If there's information that people should be able to access and that you should be able to direct people to, figure out ways to get it on the web.
:
I do. I think that loneliness is a huge problem for older adults, and I think it's one that's not easily solved, because in part it's a result of circumstances.
If you think of the statistics, 2,000 veterans are passing on per month--I think that was the statistic that came out of the Gerontological Advisory Council's report. Many older veterans become lonely because their associates pass on. One of the advantages to communal living environments for older people is that if the environments are designed and programmed properly, they can combat loneliness. So the problem of keeping people in the community can be that their circumstances in terms of friends and families change such that through no fault of their own they become socially isolated and lonely. Communal living environments, be they assisted living or long-term care or whatever, that have good programming can give people a new lease on life and a new opportunity to participate in things and to become engaged in things and to really enjoy their last years in a way they wouldn't have if they were still living independently in the community.
So you have to be careful, in terms of promoting independence and community living, to make sure that people don't outlive the supportive network that's available to them and, through no fault of their own, come to require the development and the assistance to develop another supportive network, if they are going to have social connectedness and friendship and all the rest of it in their latter years. Loneliness is a huge problem.
:
Yes, I'll just be about another minute.
The reason is I have a 94-year-old mother and she is in one of these facilities. I go to visit her as often as I can, but unfortunately she's some eight hours away from where I live, so it's not that often. But I go there and I observe.
I observe that one of the biggest psychological problems that she and her friends there experience, I think, is that transition from being useful and helpful to others and giving, to being on the receiving end, to needing help, instead of being able to give help. Generally, when I talk to especially the old men in that place, they feel so useless. They want to fix something, they want to do something, they want to build something. They're doers, and suddenly they don't have that opportunity there.
I often think that some of these seniors places should have some activity that is actually useful in the community, maybe something they could build, making lampposts that can be spread throughout the town. Then these guys can say, “Look, we built those”. It gives them something. Is there anything like that generally? Again, just give a general response.
:
The large veterans care facilities across the country, like Parkwood, and there are 12 or 14 of them, are extremely well equipped. They have all sorts of activity options. Parkwood, for example, has a woodworking studio, a clay studio, a textile studio, bowling alley, pub, and a putting green. There are lots of leisure and recreation activities. It's viewed as “This is your life. You live here.”
Your quality of life is important. You need to have recreational activities that are appealing to you, so that means a range of activities, and you need to have an opportunity, if you so choose, to be involved in things that are more work-like, such as building things, being involved with the intergenerational programming and so on.
The concept that residential care facilities need to be communities in which there is a range of activities people can engage in so they experience both pleasure and meaning as they live out the end of their lives is well accepted in the gerontological literature and well studied in terms of how important that is for people's well-being and health. Does it always get into practice? Not always. Not everywhere.
:
I doubt very much that I will take five minutes.
I would like to begin by thanking you for appearing today, Ms. Gibson.
I apologize profusely for my late arrival. I take the veterans affairs issues very, very seriously.
I was delayed because I had the pleasure of meeting a gentleman named Guy Gruwez, who is a special visitor from Belgium, and his wife. Mr. Gruwez is visiting from Ypres, Belgium. He is the honorary chair of the Last Post Association in that country, and he has chaired that position for 40 years. He had an opportunity to meet with the Prime Minister, and I was privileged to be there with him.
So I do apologize for being late. I give you my word that I will read your testimony from cover to cover. I appreciate that I have capable colleagues who stood in my place.
I did get back in time to hear a comment from Mr. Asselin, who is also a visitor to this committee today. He talked with great passion regarding veterans, which I do appreciate.
One concern I have is that you made a statement that 70 veterans commit suicide each day. I asked the clerk where that came from, and apparently it is a newspaper. I would like you to table that. That number sounds absolutely obscene, and I would appreciate very much if we could get to the bottom of that.
Earlier we had talked about the aspect of where we would find the future psychologists to help our aged and our veterans. You had mentioned war-torn experiences and the military aura that is around it, I think you succinctly stated, because of the remembrance, things such as veterans week and everything else, and the pride they have in their medals and people thanking them.
The nice thing in Canada over the last bunch of years is that there has been a new, growing awareness of our veterans. I think one of the reasons for that is probably because so many World War II and Korean veterans are getting older and the fact that we lose an awful lot of them every day because of old age or sickness.
For people training to be psychologists, especially when it comes to veterans and their families, would you recommend that they have not necessarily military experience, but an embedded experience with the military when they go not just to Afghanistan, but to Haiti, to Bosnia, or wherever they go in the world, so that they themselves can experience at a younger age some of the concerns these men and women will face 20 or 40 years down the road?
The reason I say that is in the study of PTSD we found that PTSD can strike you right away or it can afflict you years down the road. When they're going to people at OSI centres and such and talking to them, we've found that the people who were talking back should have a clear understanding of what it was like for them in that regard.
Would you make that recommendation, if the government were to fund that type of activity, to assist people training to be psychologists for specifically the military, veterans and their families, that they have an embedded experience in that regard?
At this stage, unless there are any other committee members who wish to add in at this point, I think we've exhausted questions.
Before we depart, we do have some things with regard to our logistics officer and the upcoming trip. There are some packages that will be handed around, and she'll be available to answer any questions.
So at this stage now, thank you very much to our witness for your presentation and for answering our questions. I know Mr. Epp, particularly, is appreciative of the time you took to answer his questions. You were very accommodating. Thank you very much.
If you don't mind, I'm sure some committee members will come by to thank you. We appreciate your visit.
Before everybody leaves, though, I just want to address some of the things about the itinerary and the upcoming trip.
Just so that Mr. Stoffer and others are aware of how this works, our person at the back, Kate, who's delivered these packages to us, is not able to appear as a witness, so if you do have questions, officially the way it's supposed to work is that you direct them through the chair.
Could everybody please open their packages and itineraries? As you can see, there's a cheque for per diems and what have you. I'm just flipping through here. We have some calculations of the per diems, both in English and French, the people who will be accompanying us. Now we see Kate's full name, Kate Bourke. We have the itinerary here. I'm just flipping through. I'm sure you're doing the same. There are maps.
Just bear with me one second, Mr. Epp, I'm just making sure I'm familiar with the document before we start referring to it.
Now, as recognized, we'll hear from Mr. St. Denis and then it's Mr. Epp on deck.
Mr. St. Denis.
:
I'm sorry, there is a bit of a logistical issue here.
From what I understand, we had initially wanted to stay on Comox, the base itself. I understand the base commander is somewhat resistant on that issue. I understand it's a rare thing, and they may feel their accommodations are not up to snuff.
Are the accommodations for the members of Parliament up in the air, then?
Okay, we've reserved at the Crown Isle. It's up to the committee to decide. They're reserved.
Sir, I'm sure, if you lobby your colleagues, you'll get your way. I don't doubt this.
Are there any other questions, comments, or thoughts?
Now we go to Mrs. Hinton.
:
Thanks very much, Mr. Chairman.
I mentioned earlier Guy Gruwez. We have new members on this committee and we have some substitutes. If you'd just indulge me for a minute, I can give you a bit of background on this gentleman.
Mr. Gruwez is the honorary chair of the Last Post Association in Belgium, and he served as the chair for 40 years.
For almost 80 years, members of the Last Post Association have been responsible for what I would have to call a remarkable ceremony that honours those Canadians who fought and died in Belgium in the First World War. Every night at sunset, without fail, before hundreds of local citizens and tourists, members of the association play the Last Post at the Menin Gate Memorial.
Listed on the memorial are the names of 7,000 Canadians who gave their lives in the Great War and who have no known grave. That's what this is all about.
If you're not familiar with the Menin Gate and ever have an opportunity as an individual or a member of a committee to visit it, I would strongly suggest that you do. The time I was there.... There's a huge open dome at the top of this facility, and literally thousands of poppies floated down during the Last Post. I'm just talking about it now and every hair on the back of my neck is standing up.
So if you ever get an opportunity and you want to see how grateful other countries are for Canadians, the brave men and women who served in the war, that's something you'll never forget.
Thank you for that indulgence.