ORIGINAL ARTICLE

An Interactional Model of Mental Disability(IMMD) Based on the International
Classification of Functioning andDisability (ICIDH-2)
Hiroshi YAMANE, OTR1, Toshihiko KINOSHITA, MD2
1 Division of Occupational Therapy, College of Medical Technology, Kyoto University
2 Department of Neuropsychiatry, Kansai Medical University

Abstract: Some models based on the International Classification of Impairments,
Disabilities, and Handicaps (ICIDH) are being put forward and tested world-wide forvarious objectives. An Interactional Model of Mental Disability (IMMD) is proposed
here as a new practical rehabilitation model based on the ICIDH and the International
Classification of Functioning and Disability (ICIDH-2). The IMMD provides a basis forunderstanding the interaction of mental disabilities (impairments, disabilities andhandicaps) and other factors (environmental factors, personal factors). The other featureof the IMMD is that it provides a recording format for a practical application of themodel. From our experience with the IMMD, we conclude that it is useful forunderstanding the client's condition and disability, for setting goals and implementing ateam approach for professionals, and for helping the client understand his/her own
condition and the services provided.
Key words: ICIDH, model of disability, rehabilitation model, IMMD
(Asian J Occup Ther 1: 1–11, 2001)

Introduction
In Japan, the major shift in medical concern
from the treatment of acute diseases to chronic
diseases has highlighted the need for early medical
rehabilitation, social rehabilitation, or both tofocus on the quality of life of people with
Received: April 21, 2001, Accepted: Nov. 13, 2001
Corresponding to: Hiroshi Yamane (OTR); Division of
Occupational Therapy, College of Medical Technology,
Kyoto University
53 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto 606–8397,
Japan
phone: 81-75-751-3940 fax: 81-75-751-3965
e-mail: hirobo@itan.kyoto-u.ac.jp

disability. The functional management of dailyliving, not only the treatment for disease, has
become the goal of rehabilitation. Disability
should also be classified so that consequences
as so ciat ed with heal th cond i tions ca n be
systematically grouped.
The World Health Organization (WHO) firstissued the Internatio nal Classification of
Impairments, Disabilities, and Handicaps (ICIDH)
in 1980 for trial purposes. The ICIDH-1980(WHO, 1980) contains a classification of
disabilities that systematically groups
consequences associated with health conditions.
The ICIDH-1980 has been used to collect data forthe evaluation of health care delivery, policy and2

AN INTERACTIONAL MODEL OF MENTAL DISABILITY

financing. The educational value of the ICIDH1 9 8 0 h a s b e e n t o r a i s e aw a r e n e s s o f t h econsequences of health conditions and people’s
participatory rights. However, in daily psychiatricclinical contexts, the ICIDH-1980 is less useful asa clinical rehabilitation tool.
We have therefore developed a new practicalrehabilitation model, which we call anInteractional Model of Mental Disability (IMMD)
based on the ICIDH-2 (WHO, 1997; 1999), andwhich also includes a team conferencing work
sheet and a self-assessment sheet to facilitate
application of the IMMD to rehabilitation
practices.

Transition and Problem of a Model of
Mental Disability
In Japan, Ueda (Ueda, 1980) introduced amodel which was an adaptation of the ICIDH1980. Since, a structural model for mental
disability had long been a subject of discussion in
the Japanese psychiatric domain, the Ueda modelgave rise to a lively debate. A few models(Hachiya, 1981; Utena, 1985; Anzai et al., 1984)
have been proposed to explain and classify mental
disabilities, but there have never been enoughconsensuses to establish a common language andconcepts. After the 1988 and 1995 revisions of theJapanese Mental Health Law, heated discussions
among rehabilitation professionals about models
for mental disability have become commonplace(Yamane, 1997; Asano, 1999; Tomioka, 1999).
The 1988 and 1995 revisions of the Japanese
Mental Health Law led to rapid changes in the
rehabilitation and medical treatment of mental
patients. The new law has placed special emphasison the human rights of the mentally ill and thesocial participation of people with mental
disabilities. In order to facilitate theimplementation of these concepts, a commonly
accepted classification of disability is required fora model that enables communication about healthconditions in various disciplines.
The ICIDH is helpful for making a distinction
among impairments, disabilities and handicaps as
separate concepts and is useful for health carepractice, administration, research, education and

Disease → Impairments → Disabilities → Handicaps
or DisorderFig. 1. Disablement phenomena in ICIDH-1980 (WHO,1980)

policy. However, some problems with the 1980
model (Fig. 1) (WHO, 1980) are:
1. Impression of model
It is a medical model that incriminates disease
as disability.
2. Visual representation
The arrows linking disease or disorder,
impairments, disabilities and handicaps in
Figure 1 has been interpreted as representing a
causal model and as indicating a change overtime. This representation thus implies a
unidirectional flow from impairment todisability to handicap.
3. Effects of personal factors and environmental
factors
Personal factors such as individual abilities andenvironmental factors play an important role int h e d i s a b i l it y p r o c e s s b e c a u s e o f t h e irinteractions with all three dimensions of theclassification. Therefore, their effects should be
included in the figure.
4. Content
It is difficult to clearly differentiate between
impairments and disabilities.
5. Terminology
There is considerable disagreement concerning
the terminology of the model, particularly
words like handicaps and disabilities, which arethought to have negative connotations.
In the last decade, some studies (Polatajko,
1992; Martini et al., 1995; Fougeyrollas, 1993;
Japanese Association of Psychiatric Rehabilitation(JAPR), 1996; 1997) have concentrated on
improvement on the ICIDH-1980 or a better fit forthe occupational therapy and the psychiatricdomain. Yamane (1996, 1997) has describedsome structural models for psychiatric diseases
and disabilities in which personal factors, such asindividual abilities, environmental factors, anddetails of mental disability, are reflected.
WHO devoted an annual conference to theAsian J Occup Ther 1: 1–11, 2001

revision of the ICIDH hosted by the WHO
Collaborating Centre in Paris in 1995 (WHO,1995). Since then, the overall concept (Fig. 2) of
the current version of the ICIDH-2 (WHO, 1997;1999) has been introduced for field trials. The
following problems of this revised version havebeen pointed out (Yamane, 1999):
1. Although the ICIDH-2 is generally expressed in
non-judgemental terms without undue
negativity, it includes one negative term,
impairment. The term impairment was changed
to body functions and structure in the Beta-2
Draft (WHO, 1999).
2. It does not adequately reflect interactions
among disabilities.
3. There is some confusion about terminology
because activity and participation have been
defined differently from their commonly
accepted definitions.
4. The relationships and meanings indicated byarrows showing the effects of Environmental
Factors and Personal Factors in the ICIDH-2
Beta-1 and Beta-2 Drafts need to be made more
explicit.
The ICIDH-2 will be completed by the end of
the year 2001 following the results of the fieldtrials. Various models based on the ICIDH-1980
and the ICIDH-2 are now being put forward andtested on a world-wide basis for various objectives(e.g., Fougeyrollas, 1993; Yamane, 1996; 1997;
Arizuka, 1995; Ueda, 1996; Nakazawa, 1996;
Ohashi, 1997).

Characteristics of the Principal Models
Let us first analyze the characteristics andlimitations of the principal models based on the
ICIDH. The Canadian model (ICIDH-PR model)(Martini et al., 1995; Fougeyrollas, 1993) is an
explanatory model of the consequences of disease
and trauma. The Canadian model highlights thenature of handicaps as the situational result of aninteractive process between the characteristics of aperson's impairments, disabilities and the socialand environmental obstacles in a given situation(Fougeyrollas, 1994). The latest Canadian modelshows the interrelationships of personal factors(organic systems and capabilities), environmental

Yamane H et al.

3

Fig. 2. Current interactions of ICIDH-2 (Beta-2 Draft)factors and life habits, but not the interaction of
impairments and disabilities, and the schema itself
is complicated.
The Yamane model (Yamane, 1996;
Yamane, 1997) accounts for the interaction
between disabilities and the effects of environment
and individual ability. In the Hirosaki (Arizuka)
Model (Arizuka, 1995), individual capability
while in good health and handicaps before illness
are considered. Although this model shows theinterrelationships among disabilities and otherfactors in a manner which is useful for grasping theconcept of disability, the figure is too complicatedfor clinical use.
Characteristic of the revised Ueda model(Ueda, 1996; Ueda, & Okawa, 1998) is that it
views illness and disability as forms of experience.
In the revi sed model, Ueda explains that
disabilities influence each other (Ueda, 1996), but
the vectors in the figure are one-directional andthus made the model appear as a causal model.
The vectors showing the relationships among
mental disabilities are bi-directional and theinfluence of reverse vectors on mental disability islarger than Ueda suggests (Utena, 1985; Asano,
1999; Nakazawa, 1996).
The Nakazawa model (a spiral model)(Nakazawa, 1996) tries to depict “the difficulty ofliving” (Utena, 1985). Heated arguments were
exchanged between the proponents of the
Nakazawa model and of the Ueda model (JAPR,
1996). The former model shows how difficulties
of living are generated. The Ohashi model(Ohashi, 1997), on the other hand, attempted todescribe many different patterns of interaction ofenvironmental factors. This model is made up of

4

AN INTERACTIONAL MODEL OF MENTAL DISABILITY

nine visual representations. It is unique in that it
illustrates the situation associated with individual
disabilities, but it is difficult to execute because of
its conceptual modality.
All these models, which are revisions of themother model in the ICIDH, focus on different
aspects of disability for various objectives.
However, none of the models are clinical, only
conceptual.

Necessity for a Practical Rehabilitation
Model of Mental Disability
Some have suggested that the WHO should
publish an officially authorized “Mother Model”
of ICIDH-2, such as shown in Figure 2 andintroduce various versions based on the “Mother
Model” (Japan ICIDH-2 Field Trials Planning
Committee, 1998; Nakazawa, 1997; Sato, 1996).
In order to apply a model of disability to
psychiatric rehabilitation practices, it is necessary
to define the characteristics of mental disability.
In contrast to physical disabilities, characteristics
specific to mental disability (Utena, 1985; Anzai etal., 1984; Asano, 1999; Yamane, 1997; Nakazawa,
1996; Sato, 1996; Lin, 1991) are:
1. Disease coexists with disability. To deal withthe fact that disease coexists with disability,
both the treatment of disease and therehabilitation of disability in daily living shouldbe performed at the same time.
2. Secondary disorders may surface because oflong-term hospitalization. To avoid secondary
disorders, it is necessary to shorten a hospitaltime by early treatment and rehabilitation.
3. Disabilities are relatively distinct but alsointeractive. It is necessary to break the vicious
circle of interactive relations and use teamapproach.
4. Disabilities are influenced by environments,
especially the human environment. It ise ffecti v e t o pr omot e s o cial ac tion l ike
environmental modifications
5. There is an interaction between disability andpersonal factors. The rehabilitation model
should value individual’s talent, ability andcapability.
6. Disabilities are variable. It is necessary to allow

for both recovery and recurrence.
In addition to these:
7. The labelling of a mental disease contributes tosocial prejudice and discrimination. It isnecessary to provide accurate information about
disease and disability
These characteristics and problems of mental
disability are seen as factors that make treatment
and rehabilitation of people with mental disability
difficult (Utena, 1985). Discriminatory labellingis peculiar to mental illness. In the view of manyobservers, prejudice against those with mental
illness lies at the root of resistance to accepting
persons with mentally illness in the community(Lin, 1991).
According to the medical model, “disability”
is a problem directly caused by a disease that
requires medical treatment and care by
professionals. According to the rehabilitation
model, however, “disability” is an interaction
between personal health conditions and the social
environment to promote the quality of individual
lives. Therefore, the management of mental
disability requires comprehensive biopsychosocial
approaches. The health care services should moveaway from a focus on disease and disability to afocus on activities in daily living and social
participation of individuals.

IMMD: A Practical Rehabilitation
Model of Mental Disability
Outline of the IMMD
The IMMD was proposed as a practicalrehabilitation model (Yamane, 2000; 2001) to deal
above-mentioned characteristics to mental
disabilities and heath care. The overall schema of
the IMMD is depicted in Fig. 3. Table 1 contains
the definitions of terms for the IMMD. The IMMD
is a three-dimensional overall rehabilitation modelof mental and physical functions, activities in dailyliving and social participation and the twocontextual parameters of personal andenvironmental factors.
The IMMD is a practical rehabilitation model
designed for team conferencing amongprofessionals and interviews, and consultations
with clients. It visualizes the characteristics andAsian J Occup Ther 1: 1–11, 2001

Yamane H et al.

5

Fig. 3. An Interactional Model of Mental Disability (IMMD) based on ICIDH

Table 1. Definitions of terms
Common terms in a model
Mind and body functions
Activities in daily living
Social participation
Personal factors
Environmental factors

The physiological or psychological functions of the body
The performance by an individual in daily living
An individual’s involvement in community life
An individual’s ability and capability to facilitate social participation
The natural, human-made and socio-cultural environment.

Terms used for the team conferencing work sheet and self-assessment sheet
Housing and finances
Summary of treatment
Summary of assessment
Family information
Focal problem
Rehabilitation goal
Long-term goal
Short-term goal
Support Plan
Difficulties
Present hopes
Your goals

Individual’s financial status and housing
Summary of all medical treatments (e.g., psychotherapy, medicine)
Summary of physiological and psychological functions, activities in daily living,social participation and so on
Family history, structure, membership, and relations
The most important and achievable target
Goal of rehabilitation team for medical treatment and support
Goal to be achieved within six months (one year maximum)
Goal to be achieved within one month (three months maximum)
Rehabilitation program, treatment period, method, etc.
The most difficult problems for client
Expectations of client: return to school, employment, making friends, etc.
Goals of client

problems of mental disabilities, especially thedistinct and the interactive nature of the three
dimensions of disability. It makes it clear that twocont ext ual factors interact w ith all t hreedimensions of classifications. The model also
shows that disability is not a consequence ofdisease, and that the labelling of a disease
contributes to social prejudice and discrimination.
For example, the prejudice against mental illness
has m ade the p rovision of housing in thecommunity extremely difficult.
The following explanations are meant tocorrect the definitions of the ICIDH-2 Beta-1 andBeta-2 Drafts. The term Mind and Body Functions
indicates the body structure or physiological andpsychological functions. The negative aspect ofMind and Body Functions, which was formerly
impairment, indicates a loss or abnormality ofbody structure or physiological and psychological
function at the level of body (biological organs
and functions, including the brain). What is
generally called symptom is synonymous with
impairment. In addition, secondary dysfunctions,abnormalities, or both (e.g., side effects, decline inphysical strength due to long-term hospitalization)
should be included.

6

AN INTERACTIONAL MODEL OF MENTAL DISABILITY

The term Activities in Daily Living, orfunctions at the personal level, is used in the
broadest sense to capture every physical andmental activity that a person engages in at various
levels of his/her daily living, such as grasping,walking, seeing, communicating, remembering,interacting with others and so on. The negative
aspect of Activities in Daily Living, formerly
disability, is represented by Activity Limitations,which are caused by disability and handicaps.
Difficulties in any domain of an individual’s
activities in daily living, and also lack ofexperience in life because of the disease should be
included. Lack of experience includes: difficulties
in daily social skills, family roles, occupational
performance, and in utilizing social resources,interpersonal skills, or both.
The term S ocia l Pa rticip atio n, o ne ’ sinvolvement in society, means the interaction
between impairments and limitations in dailyliving activities and contextual factors(environmental factors, personal factors). The
negative aspect of Social Participation, formerly
handicap, is represented by Participation
Restrictions, which are caused by impairments,
disabilities and negative associations of thedisease, serious deviant behavior of the person in
the community arising from the interaction of
impairments and environmental factors, or both.
Participation Restrictions includes income
limitations, restrictions on fundamental humanrights and difficulties in seeking employment andpublic housing.
In the IMMD, the term Disability is used as aco m p r e h e n s i v e t er m f o r a l l t h e n e g a t i v edimensions of Mind and Body Functions,
Activities in Daily Living and Social Participation.
Environmental Factors represent external
influences on a person’s functions and arecomposed of components of the naturalenvironment (e.g., weather), the human-madee n v i r o n m e n t ( e . g . , c o m m u n it y f a c il it ie s ,transportation), socio-cultural environment (e.g.,rules and regulations, laws, attitudes, customs,
institutions) and human environment (e.g., otherindividuals). P ersonal Factors representinternally influences on functions and comprise
individual features, such as age, educational

background, life experience, aptitudes, character,preferences, special abilities. In other words, thepositive side of Personal Factors can be describedas individual abilities including capabilities.
These two contextual factors can be either
participatory facilitators and inhibitors, andinteract with one another.

Conferencing work sheet and self-assessment
sheet
Conferencing work sheet (Fig. 4) and Selfassessment sheet (Fig. 5) have been designed forpractical application of the IMMD. Both sheets
have almost the same design to compare therecognition of the client with the assessment of theprofessionals. In the self-assessment sheet, someterms are changed to understand what the client is
expecting and the problem perplexed him or her(e.g., difficulty, present hopes, your goal). In the
top portion, there is a chronological table, where
the events in the individual’s life (e.g., growth
history, educational background, job career,present illness, hospitalization, and medical
treatment) are entered. The chronological table
helps the client to recollect his/her own life andexperiences.
The conferencing work sheet is filled in byprofessionals and is used for team conferencesamong professionals. That helps to consider how
and who to support the client in the professionalteam approach. The self-assessment sheet is filled
in by clients. That shows how clients arer e c o g n iz in g th e m s e l v e s , r el ati o n s h ip s toenvironmental factors, and what the client is
expecting. The self-assessment sheet is used tohave a common goal with the client.

Practical Application of the Immd
Subjects and methods
During a three-year period, we used the
IMMD, conferencing work sheets and selfassessment sheets in three day-care facilities, twomental hospitals, one vocational aid center and one
cooperative work place. We also surveyed
professionals and patients about the utility of the
IMMD.
Ap p e n d ix 1 sh o ws th e ou t lin e o f th e

Asian J Occup Ther 1: 1–11, 2001

Yamane H et al.

7

Fig. 4. Outline of team conferencing work sheet

Fig. 5. Outline of self-assessment sheetquestionnaire. The purpose of question 1 was todetermine whether the IMMD is useful forunderstanding a client’s mind and body functions
and disabilities. Question 1 was rated on a fivepoint scale, and the Wilcoxon signed-ranks test

was used to compare differences in the level ofunderstanding of the client’s mind and bodyfunctions and disabilities before and after using the
IMMD. Other questions were answered with yesor no, and the Chi-square test was applied to the8

AN INTERACTIONAL MODEL OF MENTAL DISABILITY

test. The results showed significant differences forthe team approach (p<0.05), for consensus amongprofessionals (p<0.01), and for sharing goals withthe client (p<0.01). However, no significant effectwas seen in terms of shortening conferencing time.
Table 4 shows the results of the questionnaire
for patients and analysis using the Chi-square test.
The Chi-square test showed significant effects ofconsultation with professionals for both theinpatient and outpatient groups (p<0.01). In termsof setting their own goals, however, no significant
effects were found on either the inpatient or
outpatient group. Answers to the usefulness ofanswers.

Results
We received answers to the questionnairefrom 43 professionals and 64 patients (30inpatients and 34 outpatients). Table 2 shows thecomparisons of the levels of understanding before
and after using the IMMD and the results of the
Wilcoxon signed-ranks test, showing significant
differences for the professionals group (p<0.01)
and the outpatients group (p<0.01).
Table 3 shows the results of the questionnaire
for professionals and analysis using the Chi-square

Table 2. Comparisons of levels of understanding before and after using the IMMD
Professionals (N=43) Inpatients (N=30) Outpatients (N=34)
Level of understanding before using the IMMD (Mean ± SD) 2.326 ± 0.808
Level of understanding after using the IMMD (Mean ± SD)
4.070 ± 0.704
Corrected p-value
1.78707E-08
Wilcoxon signed-ranks**

1.700 ± 0.702
2.167 ± 0.913
0.00815NS

2.000 ± 0.696
3.529 ± 1.051
1.02854E-06***, p<0.05; **, p<0.01; NS, not significant.

Table 3. Results of questionnaire for professionals (N=43)

Shortening of conferencing time
Usefulness for team approach
Usefulness for establishing consensus among professionals
Usefulness for having a common goal with a client (patient)

Yes

No

Chi-square

26
28
30
33

17
15
13
10

1.8837 NS
3.9302*6.7209**12.3023***, p<0.05; **, p<0.01; NS, not significant.

Table 4. Results of questionnaire for patients

Usefulness for setting own goal
Usefulness for understanding services provided
Usefulness for consultation with professionals*, p<0.05; **, p<0.01; NS, not significant.

Inpatients (N=30)
Yes
No
Chi-square

Outpatients (N=34)
Yes
No
Chi-square

10
19
21

21
23
25

20
11
9

(3.3333) NS
2.1333 NS
4.8000**13
11
91.8824 NS
4.2353*7.5294**

Asian J Occup Ther 1: 1–11, 2001

understanding the provided services weresignificantly more positive only in outpatientgroup (p<0.05).

Discussion
From our experience with the IMMD and theresults of the questionnaire for professionals andpatients, we found that the practical usefulness ofthe concept of IMMD to build a concrete base forteam approach. The significant improvement ofprofessionals’ reported level of clients’
understanding suggested the unique contributionof the IMMD to facilitate an overall and organizedperspective of the client’s mind and bodyfunctions and disabilities. We assume that an
overall shared understanding of a client became afactor to identify roles in team approach, to reach aconsensus, and to establish shared goals with aclient. Although the utilization of the conference
sheets did not shorten a conferencing time byitself, it was expected that team members needed
to become accustomed to using the work sheets asa shared communication frame.
The results of patients' survey evoked somequestions to be studied in a future. Both inpatientand outpatient groups answered significantly
positive for the usefulness of the IMMD work
sheets for consultation with professionals, and not
significantly negative nor positive for theusefulness for setting their own goals. Thissuggests that the IMMD may help clients tounderstand the different roles of professionals interms of their practical needs but may not help toorganize their own goals if professional help is not
being provided based on their self-reported IMMD
work sheet. This points out the importance ofusing the IMMD not only as an informationgathering tool but also as a communication processwith a client. The result of outpatients showing
positive usefulness of self-reported better
understanding of their own conditions encouraged
the future utilization of the IMMD to share acommon goal with a client.
The non-significant changes of self-reported
understanding level of self conditions among
inpatients and the tendency of more negative
answers to usefulness for setting their own goals

Yamane H et al.

9should be studied more thoroughly in relation totherapeutic structures and milieu of long-term
hospitalization.
The IMMD expresses the characteristics
specific to mental disability and is a functional anduser-friendly model. The IMMD and work sheets
apply the concept of the ICIDH and ICIDH-2 toclinical in the psychiatric domain. Consequently,
using the IMMD and work sheets may change theparadigm from seeing a person with mental
disability as being a subject for medical treatment,
to a person whom we live together with in thecommunity.
Acknowledgment: Expressions of thanks are due
to Dr. Hiroshi Utena of Sakamoto Hospital, Dr.
M a s a h ik o M a ts u m ot o , Dir e c t o r of K yo t oPrefectural Rakunan Hospital and Ms Norma Joan
Johnson of Hiroshima University for reading themanuscript in its original form.

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towards normalization. Journal of Japanese
Association of Occupational Therapists, 19(suppl.), 123 (in Japanese).
Yamane, H. (2001). The concept and practical use of
an interactional model of mental disability(IMMD). Journal of Japanese Association of
Occupational Therapists, 20, 145–153 (inJapanese).

Asian J Occup Ther 1: 1–11, 2001

Yamane H et al.

Appendix 1. Outline of questionnaire
For professionals
1. Do you have sufficient understanding of the client’s mind and body functions and disabilities?
Level of understanding before using the IMMD
Insufficient 1-2-3-4-5 SufficientLevel of understanding after using the IMMD
Insufficient 1-2-3-4-5 Sufficient
2. Has conferencing time been shortened?
Yes
No
3. Is the IMMD useful for the team approach?
Yes
No
4. Is the IMMD useful for establishing consensus among professionals?
YesNo
5. Is the IMMD useful for establishing a shared goal with a client?
Yes
No
For patients
1. Do you have sufficient understanding of your own mind and body conditions and disabilities?
Level of understanding before using the IMMD
Insufficient 1-2-3-4-5 SufficientLevel of understanding after using the IMMD
Insufficient 1-2-3-4-5 Sufficient
2. Is the IMMD useful for setting your goal?
Yes
No
3. Is the IMMD useful for understanding the services provided for you?
Yes
No
4. Is the IMMD useful for consultations with professionals?
Yes
No

11

WFOT SAPPORO SYMPOSIUM ON REHABILITATION FOR THE ELDERLY

Rehabilitation Challenges of Health Carefor the Elderly in Japan
Kumiko TERAYAMA Ph.D, OTR1,2
1 Former President, Japanese Association of Occupational Therapists
2 Occupational Therapy Division, Tokyo Metropolitan University of Health Sciences

Abstract: Japan has become an ultra-aging society as people over 65 years of age
increase to 17% of the population. The Law of Public Care Insurance for the Elderly
system commenced in April of the year 2000. As a result, the payment system for elderly
care services was transferred from taxes to national health insurance. Community-based
rehabilitation, which includes occupational therapy, will make even greater contributions
to the ultra-aging society in Japan.
Key words: ultra-aging society, Law of Public Care Insurance for the Elderly,
community-based rehabilitation(Asian J Occup Ther 1: 12–14, 2001)

Ultra-Aging Society and Changing
Values of Japanese Society Toward
Aging and the Aged
From the view point of health, the mostimportant characteristic of Japan is to recognizethat the nation is an ultra-aging society where thepercent of people over 65 years of age has
increased to more than 17.2% of the populations.
The current Japanese average life span is 77.2
years for males and 84 years for females. In 1984,
Japan had the highest average life span in theworld. An equally significant shift is that the
number of physically feeble elderly, senile
dementia and bed bound elderly cases are
Corresponding to: Kumiko Terayama (Ph.D, OTR); Tokyo
Metropolitan University of Health Sciences, 7–10–2
Higashiogu, Arakawa-ku, Tokyo 116–8551, Japan
phone: 81-3-3819-1211 fax: 81-3-3819-1406
e-mail: terayama@post.metro-hs.ac.jp

projected to increase to 5.3 million in 2025. This
would amount to 4% of the total Japanese
population if we do not take steps to alleviate thissituation. In particular the number of the bedbound will markedly increase for those over 85
years old (Hattori, 2000). This signifies that the
aging problem of Japan is primarily a problem
centered on Japanese over 75 years old which
worsens with greater longevity. This remarkable
trend of ultra-aging has forced the Japanese tochange their attitudes toward aging and theelderly. Specific trends have been:
1. A shift to more westernized thinking where
every person including the elderly and disabledshould be treated as self-reliant individuals
versus the traditional Japanese Jukyo religiousinfluenced values where persons retired from
active life are treated with warmth, respected
and protected by the younger generation.
2. A shift to a more active attitude that individuals

Asian J Occup Ther 1: 12–14, 2001s h o u l d m a in ta in t h e ir o w n h e a l t h w i t hoccasional support from medical doctors andother professionals versus more passive
attitudes where the family members, medical
doctors and other professionals without any
informed consent take care of the physical andmental needs of the elderly.
These changing views and attitudes havebeen described in the publication, National
Strategy “Healthy Japan 21st Century”. The
policies now in effect will be detailed later in thispaper.

Health Care System and Description of
Rehabilitation for the Elderly in JapanThe following four areas will be discussed:
1. Health insurance system related to rehabilitationand occupational therapy
2. Medical insurance system related torehabilitation and occupational therapy for theelderly
3. Public care insurance system for the elderly
related to rehabilitation and occupational
therapy
4. Social service system supported by welfare
taxes related to rehabilitation and occupational
therapy
Total expenses of both pension and medical
services have rapidly increased while social
welfare services have stayed at low stable levels
for the past thirty years. A 5: 4: 1 ratio of pension
to medical to social welfare currently exists(Hattori, 2000). Greater medical expenses are
directly attributed to increased size of the elderly
population. The Japanese Government hasenacted policies to reduce the total cost of medical
services by appropriating gradual portions tosocial services as the years progress. The Ministryof Health and Labor announced that the ratio
between pension, medical and social services
should change from the present 5: 4: 1 to 5: 3: 2 in
the future. Medical costs have markedly increased
over the past years as Japanese have aged. In 1998
a slight decrease of the total medical costs wasseen for the first time. The Japanese Government
has strongly pushed Japanese people to maintaintheir health and prevent various diseases caused by

Terayama K

13

unhealthy life styles. This policy is called“Healthy Japan toward 21st century”.
In order to coordinate health and careproblems of the elderly, Japanese Government
passed the “Law of public care insurance for theelderly” in April, 2000. Citizens over 65 years
who have care service needs through public careinsurance are required to apply for benefits in theirown local distr icts. Districts, then, send
investigators to their homes to assess physical,
psychological abilities and other basic needs.
When this data is collected and analyzed by thegovernment computer, the applicant is temporarily
assigned one of six levels of care status whichsignifies heavy to light levels of public care.
Later, Judgment Committees are organized by the
district composed of medical, health and social
authorities to decide the applicant’s final carelevel. The next step involves case managers who
prepare care plans for each individual applicant
before actual services begin. The percent ofexpense burden assumed by national healthinsurance users is about 10%. Fifteen percent iscovered by health care insurance system and thebalance is covered by public tax revenues.
Eligibility depends on two factors: age 65 years orolder and those who fall in the 40 to 64 years age
range. Users must also pay a specified amount of
insurance to their own district. The rate varies
according to each district. The public care services
coverage includes home visiting by nursing,rehabilitation for the elderly, day care service,technical aids, house adaptation and physical andmental care services are provided under the Publiccare insurance. Despite the umbrella of various
legislated health services, there is a lack of both
quality and quantity of hospitalized medical
rehabilitation and community-based rehabilitation
services in practice.

Expected Developments in CommunityBased Rehabilitation and Occupational
TherapyI n the y ear 2000 ,To kyo Metrop olitan
Government has published a proposal report
entitled “Toward the structure of support systems
for independent living of the disabled in the 21st

14

REHABILITATION CHALLENGES OF HEALTH CARE FOR THE ELDERLY IN JAPANcentury.” This report emphasized that both theelderly and the disabled desire to live in their own
communities, to use various care and rehabilitative
services tailored to individualized needs andcarried out by care management providers.
Because community-based rehabilitation andoccupational therapy pl ace their pr imary
rehabilitative thrust on self- independence within
the home and community, there is great urgency
for substantial development of these healthprofessions in Japan for the upcoming decades.
Kin-san, the elder of the oldest and most
famous twin sisters in Japan who died at a ripe ageof 107 and her younger sister Gin-san who passed
at 108 are endearing symbols and ideal models for
the Japanese. They lived long productive lives

who graced us with their beautiful smiles. This
was achieved in great part, because Kin-san and
Gin-san received sustained support from family
members, community volunteers and rehabilitation
services until the very end of their lives. Each oneof us hopes for the same.
Acknowledgments: I wish to express my special
thanks to Dale Ann Sato for her careful revisions
and corrections.

References
Hattori, M. (2000). Structure of public care insurance
system for the elderly. Tokyo: Japan Jitsugyo
Pub., 12–23.

WFOT SAPPORO SYMPOSIUM ON REHABILITATION FOR THE ELDERLY

Aging Through Occupation
Anne SPENCER, MA, OTR, FAOTA1,2
1 1st Vice President

World Federation of Occupational Therapists
2 Occupational Therapy Consultation and Direct Service toCalais Regional Hospital, Calais, Maine, USA
Brooksville Elementary School, Brooksville, Maine, USA
Adams School, Castine, Maine, USA

Abstract: The quality of life of the older person is formed by all life experience. The
health of a person throughout the growth process from birth to death is greatly influenced
by the daily occupation of the individual. Occupational development may be delayed,hindered, thwarted or changed by debilitating congenital or acquired illness or injury at
any age and may be temporary or permanent. The individual depends on the knowledge
and experience of past years to help with recuperation; future developmental stages will
be positively or adversly affected by disability. Retirement from years of work at a job
may provide freedom to explore new interests and occupations; or isolation from routine
and community and poor self-motivation for activity, often resulting in declining healthand quality of life, lacking daily achievement and satisfaction. In the United States
increasing programs are available for rehabilitation of the older person both within andoutside of the medical environment. With shorter hospital stays, emphasis is on homecare, assistive living, and long term care with a homelike atmosphere. The rehabilitation,home care, and long term care teams focus on engaging the older person in newoccupations to provide health and quality in the remaining years. With longer life,
increased attention to quality is essential in the health care environment, be it in an
institutional or community or home setting. Occupational therapists play a key role ineducating staff and families in the importance of optimum self-care and self-directed daily
activity to enable elders to engage in a life of achievement and satisfaction within
individual limits and potentials.
Key words: occupation, quality of life, control, independence, achievement, satisfaction,
aging through occupation(Asian J Occup Ther 1: 15–21, 2001)

Corresponding to: Anne Spencer (MA, OTR, FAOTA);
RR2, Box 988
Cape Jellison Road
Stockton Springs, Maine 04981, USA
phone: l-207-567-3856 fax: 1-207-567-3914
e-mail: easpence@mint.net

Introduction
The purpose of this paper is to emphasize theimportance of occupation or involvement in self
directed independent activity in all aspects of daily
life within the individual’s capabilities and16

AGING THROUGH OCCUPATION

appropriate to his or her physical, social,environmental, and cultural context throughout thedevelopmental continuum from birth to death.
Occupation is th e lif e for ce of bein g andbecoming. Health care options begin withadequate care of oneself during the developmental
periods to enable optimum daily health in the later
years of life. Quality in one’s life is affected bycontrol in decision making and activity. Injury,
illness, and retirement can be enhanced orhindered by the quality and appropriateness ofhealth care programs and practices.
T h e e x t e n t t o w h i c h s a t i s f a ct i o n s i n
employment are carried over to retirement affectattitudes toward employment. Some, reluctant toretire to a daily pattern without the structure ofwork at a job, a consistent paycheck, and the desire
to continue work may continue to pursue work
such as teaching, doctoring, or consulting inbusiness to name just a few. Other older adults
may find that retirement is a welcome change fromstructured occupation and provides freedom toenable them to pursue long-awaited activities ofchoice such as recreational or leisure interests,
reading, the arts, socializing, tending personal
gardens, taking college courses, working on home
improvements, or spending more time withchildren and grandchildren.
The ideal is to be able to do these things,
perhaps with the aid of glasses, hearing aids,
canes, crutches, walkers, wheelchairs or otherassistive devices. Successful adaptation tochanges enables the retiree to maintain and to gain
a sense of usefulness to himself and to society andpromotes continued and optimum health.
There is increased longevity for persons witha spinal cord injury and increased survival frombrain injury. Patients are helped by earlyin te r v e n t i o n o f d i a g n o s i s a n d t r e at m e n t ,so phistocated r ehabilitation devices, newpsychiatric medications to control problem
behavior, exercise programs and adaptive
equipment to aid in active participation in
productive activity in the home, the workplace, orthe community. More comfortable and usefulprosthetic devices are enhanced by new socket
designs, and improvements in wound healing
techniques are available for persons with diabetes.

These improvements in medical, health, andrehabilitative care are necessary to meet the needsin the rise in life expectancy in persons over 65
years, with increasing numbers living functional
and independent lives in their eighties andnineties.

Meaning of Occupation to Life
The quality of life of the older person isformed by all life experience. Major areas include:
personal self-care,
individual and social play,school, work in the family and in the home,
work in paid employment,
retirement from formal work,
adaptation to retirement, rehabilitation, assisted
living, and long term care.
Throughout the growth process personal
health is greatly influenced by the daily occupationof the individual. Involvement or occupation inphysical and social independence through selfdirected activities found in work, play, leisure, andrest helps to develop and integrate mental,
physical, and functional skills needed to pursue
interests in education, recreation, manual ability,
career planning and training, and employment.
Satisfying development in these areas is enhancedby healthy family and community participation.
Nelson (1992) states that a lack of meaning leads
to lack of purpose.

Control in Our Lives
We all want to be in control of our lives:a lack of meaning leads to lack of purpose,
there may be a tendency of the older person toslow down,changes may cause disuse of abilities,
loss of control of self and decisions may occur;
health care may result in
impingement on individual autonomy.
Occupatio nal th erapists facilitate theoccupational potential inherent in an individual
through assisting a person to maximize successful
activity function from infancy to adulthood,regardless of ability or disability. Occupational
development may be delayed, hindered, thwarted

Asian J Occup Ther 1: 15–21, 2001

or changed by debilitating congenital or acquired
illness or injury at any age. Disability may be
temporary or permanent.

Developmental Life Stages
Activity experiences develop and varysignificantly through the growth stages ofchildhood, adolescence, through adulthood. At theage of occurence of debilitating illness or injury,
the individual is dependent on the resources
developed to that point of development (Spencer,
1998). From then on, the individual must integrate
the experience of the trauma and develop
maximum independence in functional physical,
sensory, cognitive, and psychosocial ability. The
stage of development and the age of the person canbe both advantageous and disadvantageous tonecessary adjustments.

Ability to Disability to Ability
Functional restoration following debilitating
trauma or disease requires transition from the premorbid ability status, through a disability stage, toa new stage of ability (Spencer, 1988) Timely andeffective rehabilitation is essential as the older
patient is vulnerable to the development of further
disease or disability processes. The need to
improve the health of the elderly impacts not only
prolonging independent self-care but also thefinancial consequences of the nation to provide
adequate and appropriate health care services.
Development of many new community healthprograms for the elderly evidence the move toward
optimum use of the body and the mind to avoid
falling into a pattern of unnecessary physical,
psychological, functional and social disuse causedb y a s e d e n t a r y n o n - p r o d u c t i v e li f es ty l e ,particularly after retirement. In her introduction to
her book, A Natural History of the Senses, Diane
Ackerman (1990) warns that “there is no way inwhich to understand the world without firstdetecting it through the radar-net of our senses”.
Initial experiences of smell, touch, taste, hearing
and vision in infancy enhance and condition our
movements in response to a multisensory andfunctionally demanding world.

Spencer A

17

During the first contact with a patient
following trauma or disease, the the therapist must
learn the pre-morbid or previous lifestyle
experience of the individual including likes anddislikes, abilities and deficits, accomplishments
and failures, and challenges. Optimum
occupational therapy intervention enables thepatient to develop a future lifestyle of ability; fromdisability to ability. The fortunate healthy older
adult, with or without a significant residual
disability may maintain the ability to live safely
alone at home or with spouse or family until theage of 70 or 80 or 90. Indeed, many adults may
start new occupations enabling them to work atvoluntary or remunerative jobs during these
decades.

Retirement: A Major Change in
Occupation
Some effects of retirement on health are:loss of routine daily structure,change from direction by others to selfdirection,change in occupational areas and motivation,
refocusing of work orientation into productive
and satisfying self-directed activity,
adaptation to change,
deterioration of physical, mental and social(work) skills, anddiminishing employment opportunity (choice).

Community services: prevention
In the United States, increasing attention is
given to the health needs of the older adult.
“Wellness” programs in the community are
directed toward providing structured exercise,
activity, social, and educational programs toprevent illness and to promote continued health.
“A group for whom there is little social andeconomic demand will necessarily lose selfesteem.” (Butler, 1983).
Positive community involvement combats
dependency from conditions such as stroke,
diabetes, multiple sclerosis, post-polio,
amputations, cancer, psychological disorders,social isolation, physical dysfunction, fractures,and hearing or visual deficits. Hospitals,

18

AGING THROUGH OCCUPATION

rehabilitation centers, outpatient programs,
nursing homes and other health facilities assist in
patient and family education by providing written
information, books, video tapes, lectures, andconsultation to individuals and groups on
prevention of disease and injury. People need to
be kept out of hospitals and nursing homes and intheir own homes as long as possible.
To meet the needs of the increasing numberof older adults, prevention programs in hospitaland community must be augmented by resources
provided by federal and state funding, private
insurance programs, community agencies, andlocal volunteers. For example, Medicare is aFederal program of the Department of Human
Services designed to fund hospital andrehabilitative care of the person 65 years and older.
This may be in a hospital inpatient or outpatient
program, or a home care program: many hospitals
have all three as well as an Education Department
and a Retirement Community within their healthcare services. Adults receive Social Security fromthe government following retirement from work at
62–65 years of age. A new law is in effect toencourage older adults to continue working past
the age of 65 with full Social Security benefits, as
the worker contributes to Social Security whileworking.

according to diagnosis, and expected length oftreatment time based on medical need andreimbursement restrictions. Many hospitals are
p r o v i d i n g n o n - tr a d i ti o n a l o u tp a t ie n t a n dcommunity services and developing free-standing
retirement community complexes which provide
home health, assisted living, long term care, andhealth education programs.

Home health or health at home
There is a general surge to enable older adults
to return home following temporary stay at
hospital, assisted living, or nursing home to thefamiliar domain of family and memories to insure
continuity of safety and quality of life.
It has been found that elders:find comfort at home,recover from acute illness more quickly,
receive support of family and friends and,find ease in adjusting to the difficulties ofp e r m a n e n t d i sa bi li ty , l on g - t er m h e a l th
problems, and terminal disease.
With shorter hospital stays, independentfunctions are emphasized so that patients can gohome with needed assistive devices for self-care,plans for home modifications for safety andaccessibility, and maximum functional
independence.

Hospital services

Assisted living

Advances in emergency medical care have
served to increase the number of people with longterm di sab ili ties . Use o f co m preh en siv erehabilitation teams, improved and expanded
rehabilitative approaches and techniques, researchin assistive technology, and public awarenessregarding universal accessibility have provided
resources to assist the elderly in achieving andmaintaining maximum independence.
Psychosocial counselling aids the patient andfam ily to plan for activ e p articipation in
productive activity toward positive adjustment todisability and changes in daily living in the home,
the workplace, and the community. An increasing
number of elders are living functional andindependent lives over 65 and into their 80s and90s. Hospital stays and rehabilitation services aretime-limited in the United States, usually

Assisted Living apartments allow elders tolive in an environment where they can live alone
but benefit from some services such as meals,
nurse on call, and an aide available to assist withdaily needs. Assisted Living programs may also
be attached to or within a nursing home. With apositive prognosis for improved function andindividual and staff efforts toward independence,
the resident may be able to go home rather thanhave institutional long term care.

Nursing homes and long term care
Services in long-term care facilities areavailable to the elder as funded by the Federal
Medicare program and the State Medicaid
program or welfare program. Programs include
Home Care, Congregate Housing, Adult Day
Services, Assisted Living and HomemakerAsian J Occup Ther 1: 15–21, 2001

programs. Federal and State benefits may be
augmented or substituted by private insurance.
The nursing home or long term care facility may
be a temporary or long stay, depending on thehealth status, medical needs, functional ability ofthe patient, financial resources, and options forstaying staying at home or returning homefollowing institutional medical care. Residents
may have physical, sensory, psychological or
cognitive deficits affecting functional
independence, and/or intellectual functions such as
memory, judgment, orientation, problem solving.
Residents are encouraged to perform self-care
activities with maximum independence, toparticipate in occupations such as constructive
activity and socializing, and to participate inindividual and group social and manual activity
programs. The facility may provide entertainment
as well as special events, visits, and outings.
Nelson (1992) notes that “individual meaning andpurposeful occupation frequently creates conflicts
in the orderly and medically oriented institutions”
where the “individual’s inherent need forautonomy and a sense of control overenvironment” may clash with the values of theinstitution associated with promoting docility andpassivity in residents.” These words may
stimulate thoughts of the too often institutional
priorities given to scheduled times of services
needed by residents, stereotyped group andindividual programs expected to please or enhance
the involvement of all residents in activity.
Assumed inability of the resident on the part ofcaretakers may impose further mental restrictions.
Lack of appropriate respect and courtesy for theindividuality of the resident with regard topreferred times, for example, to get up, to get
dressed, to eat, to engage in activity, to socialize or
to rest prevents the attitude of consulting with theresident to work out a meaningful therapeutic andhealthy program to truly enhance the daily living
quality for the resident as seen by both thecaretaker and the resident, even though possibly
different.

Healthy Options
Many regional and local community services

Spencer A

19

are available for the elderly. Community centersprovide a variety of activities such as exercise andactivity programs, meals, discussion groups,
reading groups, and group travel to museums andconcerts. Transportation needs are provided bycommunity services, and meals are taken to thehomes of elders who have disabilities and are notable to get out to shop; homemakers provide
laundry, cleaning, and cooking services in thehome to enable an older adult or “senior citizen” tostay at home where it is familiar and comfortable.
Safety is enhanced by visits from family andfriends to one who is alone. To encourage theseniors (elders) to participate in cultural events,
discounts are often available in theatres, stores,
insurances, fuel and other needed commodities.
The American Association of Retired Persons(AARP) provides various types of insurance
policies reduced rates on prescriptions, car rentals
and hotel rates. This organization publishes amagazine and a news bulletin on changes in healthcare through government resources and provides alobby group in the national government for
improvements in health policies for the older
adult. In community centers, free assistance isprovided for legal and tax needs.
Participation in community programs often
provides the life-giving social and physicalactivity with others that gives joy and satisfaction
in one’s life. The following list names some
programs available in the USA:
Meals on wheels/Meals for Me (taken to thehome daily),
Community Companion (voluntary or paid),
Support groups: ie. post-polio, spinal cord
injury, multiple sclerosis,
AA/Alanon, Arthritis (no cost),
Social groups: ie. book discussions, trips,
concerts, museums (usually freeMembership, some participation costs),
Elderhostel or Senior College education courses(50 or over, low cost),
Seniors Day: ie. shopping the mall, activity
programs at hospitals or schools, voluntering at
health care facilities (no cost),
Seniors Sports: ie country club, competitive,
community center, and more...and more...andmore. (usually discount or low cost).

20

AGING THROUGH OCCUPATION

Wanting control over our lives coincides withthe requirement in long term care facilities (in theUSA) that organized activity programs must beo f f e r e d b u t c a n b e at t e n d e d v o l u n t ar i l y .
Unfortunately this resident choice may thwart thetherapeutic advantages of the program OR theresident may be wheeled into a program without
being given a choice. Gradually the interior andexterior design and architecture in long term carefacilities provide a more homelike atmosphere,m o r e c o l o r , n e ed e d f u n c ti o n s w i t h i n t h eenvironment such as laundry machines, kitchens,
and gardens for residents to use. New meanings
derive from new activities, sensations, andexperiences over time. These occur with staff
recognition of individual resident needs andlifestyle preferences. Priorities focus on theresident, encouraging choices to increase the senseof individual control in getting to know and use the
new homelike environment.
Initiation of activity on the part of theindividual is motivated or thwarted by past
personal developmental effects of stimulation to
the sensorimotor, cognitive, and social systems.
Participation in group activity relates to thepersonal p erceiv ed need , an d an inherent
confidence in a pleasurable outcome of theinvolvement. Acknowledgment of the importanceof the “sensory map” of the individual and its rolein his/her day to day living is crucial to encourage
the elder to engage in life-giving occupations in
the long term environment or assisted living...aswell as the hospital or home environment.
An activity which was presented effectively
to residents in a nursing home was described by
Kenneth Koch (1977) in his eloquent andheartwarming book entitled I Never Told Anybody.
These words he suggested to his students in thenursing home to use in starting a poem. He
developed a stimulating program of a weekly classin writing poetry. It was found that through theprocess of looking, listening, touching, smelling,and hearing that the residents gradually became
interested in expressing their own ideas in poetry
and listening to those of other residents. They
found new enjoyment in the effort to put together
lines of thought in single poem or in collaboration
with others. When the instructor suggested topics

such as: “talk to the moon, the seasons...think of aflower...think of a memory...think of a joyous day
or event...” (Koch ) he f ound h is students
expressing ideas relating to where they foundcolor, how they felt about nature, about a memoryof family or an event. The published book reveals
the possibilities of finding joy in an art form whichperhaps had previously been thought unreachable
by the resident. The same effort can be used withart and other creative media.
Another common activity in an active nursing
home is dancing, often encouraged by a visiting
group of dancers to the facility. Music is acommon way of stimulating one to want to move;with encouragement and assistance, it can be donewith the help of a brace, a crutch, a walker, or awheelchair. Where there is life there is apossibility of awareness, stimulated by thefunctions of sensation, movement, andaccomplishment through occupation in life-giving
activity. The student, the patient, the client or the
resident can be encouraged to find the joy andsatisfaction of youth in daily living when there is
the opportunity for choice, new learning, andcontrol of the daily satisfactions within the limits
and the potentials of the individual’s capacity toparticipate.

Main Ideas⋅ Quality of life of the older person is formed by
all life experience.
⋅ The health of a person is greatly influenced by
the daily occupation of the individual.
⋅ Occupational performance is the voluntary
doing of the individual in the physical andcultural environmental context that elicits
individual function.
⋅ Independence in self-directed activity enhances
satisfying development.
⋅ A lack of meaning leads to a lack of purpose or
motivation.
⋅ We all want to be in control of our lives.
⋅ Health care may impinge on autonomy.
⋅ Stage and age of development affects
adjustment to trauma.
⋅ Retirement from a job is a major change inoccupation.

Asian J Occup Ther 1: 15–21, 2001

⋅ Retirement can be advantageous ordisadvantageous to health.
⋅ The move from ability to disability to ability
requires transitions through rehabilitation.
⋅ Health care options are available in the home,
hospital, and community.
⋅ People need to be kept out of hospitals andnursing homes and in their own homes.
⋅ People can live alone and benefit fromservices; home health and assisted living.
⋅ Individual meaning and control may clash withinstitutional and professional objectives; selfexpression enables independent activity.
⋅ Funding may come from federal, state, private,
and community resources.
⋅ “It takes a long time TO GROWYOUNG”.......Pablo Picasso⋅ “I never told anybody...how beautiful theocean was...”Spencer A

21

References
Ackerman, D. (1990). A natural history of the senses.
p xv. New York: Random House.
Butler, R. N. (1983). Ageism. In H. Cox (Ed.),
Annual editions: Aging, p 67. Guilford, CT: The
Dushkin Publishing Group, Inc.
Koch, K. (1977). I never told anybody: Teaching
poetry writing in a nursing home. New York:
Vintage Books, Random House.
Nelson, D. L., & Stucky, C. (1992). The roles ofoccupational therapy in preventing further
disability of elderly persons in long-term carefacilities. In J. Rothman, R. Levine (Eds.),
Prevention practice: Strategies for physicalt he r a p y a n d o c c u p a t i o n a l t he r a p y , p 2 0.
Philadelphia: W.B. Saunders Co.
Sp en ce r, A . (1 98 8). Fu nctio n al resto ratio n:preliminary Concepts and Planning. In H.L.
H opkins , H.D. Smith (Eds.), Willa rd andSpackman’s occupational therapy, p 437, p 438.
Philadelphia: J.B. Lippincott Company.

WFOT SAPPORO SYMPOSIUM ON REHABILITATION FOR THE ELDERLY

The Validation Therapy Approach to theManagement of Dementia
Rosemary B CROUCH, MScOT (Witwatersrand)1,2
1 2nd Vice President, World Federation of Occupational Therapists
2 Medical University of South Africa (MEDUNSA)

Abstract: This paper will describe a program of intervention which is specific to
Dementia. Anne-Marie Kidd, an occupational therapist in Cape Town, South Africa, has
had success in implimenting the Validation Therapy Approach to the management of theelderly person with Dementia. She is ackowledged for her major contribution to thisarticle. At the outset, the concept of the Validation Therapy Approach will be describedin detail. Concepts such as creating a sense of importance in the elderly person, allowing
them to feel they have something to contribute, structuring activities so that the personwith Dementia feels useful and optimising assets, are key issues in this type of therapy.
An example of a unit that employs this type of therapy will be described in detail and abrief discussion will bring the article to conclusion.
Key words: geriatric management, dementia, occupational therapy, validation therapy
approach(Asian J Occup Ther 1: 22–25, 2001)

Introduction
It is true to say that most Western societies
support the philosophy that unless you remember
something, it is not worthwhile doing. However inthe person with Dementia, the feeling or ambienceof the event will linger long after the memory has
faded. Dementia may be a terminal disease, but it
is not the end. (Alzheimer’s Association 1999).
Anne-Marie Kidd, an occupational therapist,
working in a home for the elderly in CapeTown,
Corresponding to: Rosemary B Crouch (MScOT); Medical
University of South Africa (MEDUNSA), PO Box 95657,
Grantpark 2051, Johannesburg, South Africa
phone: 27 11 728 2852 fax: 27 11 728 4575
e-mail: rcrouch@intekom.co.za

South Africa, has been part of a team who has
implemented a very different approach to the
management of the elderly, with specific emphasison the residents with Dementia. This approach iscalled The Validation Theory. The essence of thistheory is to communicate with the dementing
person by validating and respecting their feelings
in whatever time or place is real to them, thereby
reducing the stress factors in the client and in theoccupational therapist. The occupational therapist
or family member, should avoid communicating
failure such as “that is wrong”, and in its place say“try another way”.
Creating a sense of importance in the elderlyis the aim of therapy. Structured activities that
all ow the e lderly pers on t o feel they arecontributing to society, are important. It isAsian J Occup Ther 1: 22–25, 2001

Crouch RB

23

important also to optimise assets and avoid using
childish motivators such as sweets. Compliments
are more effective and should be given
immediately.
Over 10,000 Agencies who are involved in
the management of Dementia, use the Validation
Approach and over 80,000 books have been soldon the subject. Naomi Feil, who has been
instrumental in developing the approach, has given
over 50 television interviews about Validation.

rooms with spare clothing, incontinence products
etc. should the residents require this assistance.
There are approximately 50 residents at thehome between the ages of 65 and 100 years.
There is a team of health workers including
nurses, occupational therapists, a social worker
and consulting doctors. There is a strong teamapproach, which helps to create a therapeutic
milieu in which the Validation Approach can be
implemented.

Definition of Concepts

The Program

Dementia

The residents spend the whole day in group
activities. Those that are very disruptive remain in
the wards.
Each resident is assessed and placed into
groups depending on their functional performance.
The COPM (Canadian Occupational Performance
Model, 199 4) is successf ully used b y theoccupational therapist for this purpose. This
assessment can be repeated on a yearly basis, aswell as with new admissions to the home. This
assessment records their task behaviour on a 10point scale and their general behaviour on a 5point scale.
The program is structured and varied andactivities are adapted for the needs and capabilitiesof the residents. Examples of activities are table
games such as cards, dominoes, scrabble andbingo. The residents also take part in appropriate
sport and exercise groups such as carpet bowls andalso in crafts.
Music reminiscence groups form an
important part of the program and volunteers
provide exercises, music and dancing, art classes
and outings in the nearby vicinity.
Cultural activities form an important part ofthe program and residents take part in celebrating
various religious holidays.
Sensory stimulation is used by theoccupational therapists with residents who are in asevere stage of Dementia. These residents cannot
take part in task-orientated groups. Sensory
techniques such as, eye contact to name calling,
response to touch, smell and music are used todevelop an alertness to the surroundings. Aromatherapy is also used.

An acquired global deterioration of memory,
intellect and personality (Alzheimer’s Association
1999).

Validation therapy
Va lid atio n Th erapy is th e pr o cess ofcommunicating with a disorientated, elderly
person by validating and respecting their feelings
in whatever time or place is real to them, at thetime, even though this may not correspond with
our “here and now” reality. (Day 1997).
Validation Therapy (VT) was developed
between 1963 and 1980 by a gerontologist, social
worker, Naomi Feil, during her work with theelderly, in Cleveland, Ohio, U S A.

Description of A Residential Home
Where the Validation Therapy Approachis Employed
An old home for the elderly in Cape Town
was reconstructed and decorated in July 1997. The
new decorations were done in accordance with
1940/1950 Western European cultural style.
There were heavy, gold curtains, chandeliers andart deco furnishings. The premise for this type offurnishing was that it should be decorated in a styleof an era that the residents remember well andshould help put them at their ease. The rooms
decorated in this fashion are called “reminiscencerooms”. Other rooms, where residents can rest if
they are agitated or tired are called quiet rooms.
These are painted in dark green for a calming
effect, and have a sleeper. There are also change

24

THE VALIDATION THERAPY APPROACH TO THE MANAGEMENT OF DEMENTIAManagement of the Residents Using the
Validation Therapy Approach
In contrast to R O (Reality Orientation), andapproach previously used in the past with theelderly, VT is based on the belief that there is logic
behind all behaviour. Understanding the meaning
underlying the individual's behaviour, rather than
the awareness of reality, is the goal behind VT.
The definition of VT tells us that the processof communicating with a disorientated, elderly
person, by validating and respecting his or her
feelings, in whatever time or place is real at thetime, even though this may not correspond with
our own “here and now”, reduces anxiety andsupports self-esteem.
Residents are allowed to live in the past andreminisce. It is part of the program.
A sense of importance is also created byusing structured activities and responsibilities. In
this way residents feel they have something useful
to contribute. No childish motivators are usedsuch as sweets and staff avoid communicating
failure. Instead of saying “that’s wrong”, they say“try another way” and demonstrate if appropriate.
(Brodaty, 1999).
It is important to note that in the early stagesof treatment for Dementia, R O is used in an
informal way in order to orientate residents to theirsurroundings, date and time. Sometimes there isrepetitive questioning and extreme agitation.
Diversion through the use of activities works wellto contain mildly agitated behaviour.

Restraints
Residents who display wandering and pacing
behaviour, are allowed to do this freely. No
physical restraints are used unless there are
doctor’s orders for safety reasons.
In the Western world there is a tendency tooveruse medication (sedatives and psychotrophic
drugs) in the management of the person sufferingfrom Dementia in order to calm aggression,
restlessness and agitation.
As little medication is given as possible. It isf ou n d th a t s ti m ul a tio n , s oc i a lis a ti on a ndinteraction with others maintains, and in somecases improve, cognitive, physical and functional
performance, as well as provide a good quality oflife throughout the progression of the disease.
Medication is needed but it needs to bestrictly monitored and reduced when behaviours
are more under control. It must never be used as aquick and easy way to manage difficult behaviour.

Support Groups for the Staff
There is a severe risk of burnout amongst
staff in this kind of program. Regular groups areheld for staff to discuss issues that affect them andcase presentations stimulate interest in theapproach to treatment.

Conclusions
The benefits of the Validation Approach to
the treatment of Dementia have been clearlymeasured and stated by Naomi Feil (1997):⋅ Residents sit more erect and keep eyes open
more often.
⋅ They display more social controls and decrease
crying, pacing and pounding.
⋅ Aggression is decreased and as a result there isless need for chemical and physical restraints.
⋅ There is increased verbal and non-verbal
communication and gait is improved.
Effects that are more difficult to measureinclude:⋅ There is less anxiety⋅ Life tasks are resolved⋅ There is an improved sense of self-worth andthey tend to withdraw less
⋅ Residents may assume familiar social roles in
the groups and develop an improved awarenessof concensual reality.
⋅ A sense of humour is often restored⋅ Deterioration is slowed down
⋅ There is increased staff morale and a decrease inburn-out.
All of these assets add up to a different andsuccessful new approach to the elderly,
particularly in the treatment of Dementia.
Acknowledgements: The writing of this article
has been made possible through the contribution

Asian J Occup Ther 1: 22–25, 2001

by Anne-Marie Kidd, Occupational Therapist, andRae Labuschagne, Occupational Therapist andGerontologist.

References
Brogarty, H. (1999). Help-notes. The Alzheimer’s
Association. NSW PO Box 42 North Ryde. NSW
2113 Australia.
CAOT (1994). Canadian Occupational Performance
Measure. (COPM). (2nd Ed.) Ontario: CAOT

Crouch RB

25

Publications ACE.
Day, C. R. (1997). Validation therapy. A review ofthe literature. Journal of Gerontology Nursing,
April: 29.
Feil, N. (1984). Communicating with the confused
elderly patient. Geriatrics, 39 (3), 131–132.
Feil, N. (1993). The Validation Breakthrough.
Baltimore, MD: Health Professions Press. The
Validation Training Institute.
(http://www.vfvalidation.org/article1.html)

WFOT SAPPORO SYMPOSIUM ON REHABILITATION FOR THE ELDERLY

Care of the Elderly in the 21st Century:
A UK Perspective
Clephane HUME, SROT1,2
1 Honorary Secretary, World Federation of Occupational Therapists
2 Independent Practitioner

Abstract: This article is based on a paper presented at JAOT International Conferencein Yokohama, 2000. It outlines care provision for elderly people in the United Kingdom,with specific reference to Scotland. It describes some of the problems that people may
experience, the range of services available, and some of the challenges and dilemmas
influencing the general provision of care. Examples of particular physical andpsychological problems and the ways in which the community has responded to the needsof patients and carers, provide an illustration of the difficulties encountered. Reference
is made to some of the principal non-governmental / voluntary organizations (NGOs)
which provide advice or care. Two brief case histories are included as an appendix.
Key words: elderly, voluntary organizations, carers services(Asian J Occup Ther 1: 26–34, 2001)

Introduction
In considering the provision of healthcare,and the associated problems, it is important toremember that the majority of old people are welland leading active lives. We have special
magazines for the elderly, packed with ideas andsome very active groups making full use of varied
post retirement opportunities, such as the
University of the Third Age. Health promotion
campaigns focus on healthy ageing and 70 year
old s h a ve a majo r i np ut in ou r v o lun taryorganizations.
There are ‘silver surfers’ (white haired users
Corresponding to: Clephane Hume (SROT); 30 Findhorn
Place, Edinburgh, EH9 2W, United Kingdom.
phone/fax: 44 1 31 668 3568
e-mail: Clephanehume@compuserve.comof the internet) and students - one of my fellow
graduates from the Open University was aged 84.
My neighbour purchased new furniture when she
was aged 97! She is now 103 and lives in a nursing
home for elderly people but when she was 100 she
was living at home, alone. It is not uncommon tofind people of that age, but when they reach it, theyreceive a telegram of congratulations from the
Queen.

Life in the UK - Some of the Problems
Facing Elderly People.
Social isolation
Three generation family homes are not thenorm in the UK and in fact 35% of elderly people
live alone in the community. 40% live with aspouse, but are often geographically separated
from their children and grandchildren.

Asian J Occup Ther 1: 26–34, 2001

C o ns e q u e n tl y , p e t a ni m a ls a r e im p o r tan t
companions.
Loneliness also results from health problems,
not necessarily major ones - I have always taught
students that, simple though it may seem, sore feet
are a major source of isolation. Reduced energy
and tiredness are obviously also a factor.

Population
Scotland is a multicultural society, with many
Polish and Eastern European immigrants as well as
people from the Indian sub continent, Hong Kongand South East Asia. Thus some people findthemselves growing old in an unfamiliar culture another matter for consideration in relation toproviding suitable care facilities. Refugees, anincreasing number of whom are coming to
Scotland, have additional problems. These
problems are made worse by lack of knowledge ofEnglish. It is important to work with community
groups, many of which provide excellent support
for their aged members.

Financial difficulties
Pensioners have various benefits, such as freeprescriptions, extra state Pensions at 80+,subsidised transport and price reductions invarious public services. Attendance allowance isavailable for those who cannot manage daily living
tasks without assistance. However, poverty iscommon and homelessness is not unknown inelderly people. One organization recently
produced a poster entitled “Heating or eating?”
For some people that is a real choice, even in thewelfare state, though there are special heatingallowances in the winter.

StigmaThere are some other less positive social
issues, one of which is ageism. Pullen (1994)
writes about negative attitudes, noting that these
may relate to younger people’s fears of becoming
old and incapable themselves. There is a new
campaign in the UK focusing on the problems of
those seeking employment, but having an
incurable condition - they are over age 45. That isage discrimination.
As suggested by the above, elderly people are

Hume C27

not necessarily venerated for their wisdom andexperience. They may be criticized and resented
and in a minority of extreme cases, family
members physically abuse their elderly relatives(referred to as ‘Granny bashing’) or refuse to takethem home from hospital (Granny dumping). The
strain of caring has become excessive and thefamily can’t cope. Many citizens have been
shocked and disturbed by recent publicity posters
targeted at these areas.

Integration
To counterbalance the issues describedabove, it is important to recognize a few of themany positive Initiatives which exist. Many
communities have introduced reminiscenceprojects, in which elderly people tell the younger
generation about their experiences, thus ensuringthat information is documented for the future
instead of being lost. Young people’s groups visit
homes for the elderly and several volunteer
projects provide transport to social occasions, suchas tea parties in someone’s home.

Summary
Although the focus of this section has beensome of the problems which occur, it is importantto remember that for the majority of elderly
citizens, old age is not a time of illness andinactivity. There are however, as elsewhere, close
links between social deprivation and ill health, anddisparities in provision between urban and ruralcommunities.

Provision of Services
There have recently been many changes in
the provision of health care within the UK, and thegovernment is constantly criticized for notproviding adequate care. This is not unique to the
UK! There is a rapid increase in the number of
elderly people, a population which will continue togrow during the next few years and it can be
confidently predicted that further changes will be
required in order to meet their needs effectively.
Health care in the UK is administered in threesystems - by different Government departments,
voluntary organizations (NGOs) and private care

28

CARE OF THE ELDERLY IN THE 21ST CENTURY: A UK PERSPECTIVE

schemes. Care of the elderly comes within allthese systems and occupational therapists are
employed in all the contexts.
As stated above, there are differences inservice provision between rural and urban
communities and smaller population in some of
the more geographically distant and isolated areas
are less well provided for.

The National Health Service
The state run National Health Service
provides comprehensive free health care to all
citizens and is funded by contributions (known asnational insurance) from people's salaries. It
includes general hospitals, specialist units andcommunity based primary care delivered bygeneral medical practitioners, nurses and other
health workers. The emphasis is on short term
admissions; day care and care in the community,
both for follow up and as an alternative toadmission. Many of the original psychiatrichospitals have been closed and mental health careis also community based, or within general
hospitals.
For medical purposes, people are classified aselderly at age 70. Care of the elderly may be
within separate geriatric hospitals or integrated
into general hospitals. In reality, the highproportion of elderly people receiving in-patientcare means that most units will have elderly
patients. The need for terminal care in specialized
units is becoming more widely recognized.
Geriatric hospitals provide care within
psychiatric and physical wards and day hospitals.
This will usually mean separate wards for people
with neurological and cardiac or respiratory
problems and GORUs - Geriatric orthopaedic
rehabilitation units. There are also wards
providing long term care.
In the field of geriatric psychiatry, there are
separate sections for functional and organic illness
to divide people with problems such as depression
from those who are elderly and confused. Again
these include wards and day hospitals, and longterm care. In addition, adult psychiatry hospitals
may have separate geriatric units.
Inevitably, due to the multifactorial aetiology
of difficulties in old age, people require assessment

for different problems, which cannot be dealt within one location. Often acute care is in a general
hospital, followed by continuing care in arehabilitation unit in a geriatric hospital.
Thus there are several patterns of careprovision within the NHS.

Social work services
The second major area of state provision isthrough Local Authority community based Social
Work Departments which administer care inpeople’s own homes. Now that there is rapid
discharge, and also a policy to maintain people
outwith hospital, this sector of care has anincreasing role to play.
There are day centers, with a social rather
than medical focus and people are provided a wide
range of services for example home helps who
undertake domestic tasks, and ‘meals on wheels’ school meals delivered to the housebound by
volunteers.
Occupational therapists play an essential andaccepted part in all this and are responsible forassessing requirements for gadgets and housing
modifications required for people to cope athome. A recent study by Walker et al (1999)
demonstrated that people not admitted to hospital
after having a stroke, who received occupational
therapy in the community, were more independent
in daily living tasks after 6 months than those who
had not had occupational therapy input.
Understanding all the benefits andentitlements is complex and needless to say thereis never enough money to provide all the things
that people would like.

Private care
Lack of state provision encourages thedevelopment of private resources, another major
source of care, which links closely to thedevelopment of insurance related work. Private
sector initiatives include hospitals and nursing
homes which provide long term care; community
home based care services; housing and holidays
for the elderly; and manufacturers of equipment
such as stair lifts and gadgets for disabled people.
Private enterprise also includes service providers
such as the Gas Board, which will arrange adaptedAsian J Occup Ther 1: 26–34, 2001

equipment for those who need it and carry out
safety checks on heating and cooking appliances.
Such service may in reality be free to users.
Waiting lists for hospital admission forelective surgery such as hip replacement, have led
to the development of private insurance policies tocover the cost of treatment and as acute care.
Policies are now available for provision fordisability and long term care. Some of these may
be corporate policies which continue from theworkplace into retirement but many are paid for byindividuals and this is becoming big business inthe more wealthy social groups, away from theethos of the original NHS. Private but unregulated
hospitals are developing to provide care and staff
work between the state and private sectors.

Voluntary organizations - NGOs
The final significant source of care is fromvoluntary organizations, of which there are many,
providing a wide range of expertise. These
commo nly f ocu s on the need s of specificdiagnostic groups such as people with dementia or
stroke and provide social activities, day care andsupport. Research into treatment methods andillness processes is also undertaken.
There are housing associations which provide
accommodation for the elderly and action groups
e.g. Age Concern, which focus on the rights ofelderly people. Charitable bodies may assist withwelfare issues including specific grants of money.
It is essential for occupational therapists to work inliaison with these organizations and some are
employed within the voluntary sector.

Lay sector care
It would be wrong to omit the amount of care
undertaken by the lay sector, in other words
neighbours, friends and family. This burden ofcare, now ackno wledged by W HO, pos es
difficulties for some people, who may have to giveup a job in order to care for an elderly relative.
The consequent financial strain may beconsiderable. Equally, the physical demands ofcaring may be impossible for an equally or
disabled elderly relative. Without this input ofcare, it would however be impossible to cater forthe needs of elderly people.

Hume C29

Summary
It can be seen that health care provision iscomplex for everyone, not least the consumer.
There is joint work between agencies andincreasingly, elderly people requiring long termcare are being referred to private resources,
receiving economic assistance from the state.

Social / Political Issues to be Considered
for the Future
Looking ahead, as indicated above, there willcontinue to be a rapid increase in both the numberof elderly people and the ratio of elderly toyounger people within the population. As people
live longer, the proportion of frail and more
seriously disabled individuals will multiply.
Consequently, the demand for care will increase.
It is a fact that the more care is provided, the more
expectations for care provision are raised. There
are dilemmas for private agencies and competitionin the market system.

Cost
The cost of state services is met throughworking people paying national insurance pension contributions- and it is likely that in futurecontributions will increase and there may be
reduced access to free care. As the population
distribution alters, it may even be difficult to findpeople to provide care.
To reduce state outlay, the age of receipt ofstate pension has been increased to 65 for both
men and women. (Previously women received it
at 60). This means a longer working life, andhence longer contributions, which may enhance
expectations. This change is being implemented
over a period of years, so that those at present intheir 50s are not affected.
A Royal commission on the elderly was set
up to examine care provision and its report entitled‘With Respect to old Age’ concluded that the costsof long term care should be divided between living
costs, housing costs and personal care. Personal
health care should be available after assessment,
according to need and paid for from generaltaxation. The rest (living and housing) will be paidby the person, according to means. Thus there is

30

CARE OF THE ELDERLY IN THE 21ST CENTURY: A UK PERSPECTIVE

joint work between agencies and increasingly,
elderly people requiring long term care are beingreferred to private resources, receiving economic
assistance from the state.
However, these recommendations are not yet
fully implemented and the financial strain may
therefore be considerable, with some people
selling their homes in order to pay for care.
Anyone who has savings over 15,000 pounds(2001) does not receive free care.
T h e S c o t t i s h E x ec u t i v e h as r e c e n t l yannounced a financial package to help carers,
meaning the family. This extra provision issomething that occupational therapists must
consider in setting up treatment packages, in orderto ensure that those who need such help receive it.

Regulation of residential care provision
In relation to long term care, residential
homes require careful regulation and local / city
councils have established registration procedures
and monitoring systems in order to ensure thatstrict standards are met. Similarly, nursing homes
are monitored by Health Boards. This has resulted
in several small facilities being closed, with theconsequent loss of more homely environments.

Legal issues
Nations within the UK have always had
centrally funded, tax based care, but separate
financial allocation and organization. The new
separate parliamentary bodies in Scotland andWales are independent of the English system andthis has enabled separate legislation to be enacted,
for example the Adults with Incapacity (Scotland)
Act 2000, which gives rights to people affected bychronic illness, notably dementia.
This provides safeguards to protect theinterests of vulnerable people in relation tofinancial and welfare matters. People are able toappoint a Power of Attorney - a trusted person who
will m ak e decisions on their behalf Su chappointments are supervised by the Public
Guardian, and in the case of someone who isconfused, must be signed by a doctor or solicitor.
Advocacy services for those in long term care haverecently been established to complement the above
provisions.

Ethical issues
Some current aspects of treatment pose
ethical issues for staff including occupational
therapists whose Code of ethics requires them totreat everyone equally. Medical developments
lead to costly treatment procedures and prolonging
of life. Expectations for cure are high. How do
staff chose who gets what form of care? There are
criticisms that elderly people are overlooked infavour of those who are younger. In order tocombat such problems the National Institute forClinical Excellence was set up by the government
to audit services and new treatments and toprovide guidelines for prescription of drugs.
People do not want to live in a state ofprofound handicap and wish to make ‘living wills’
to prevent this. These are documents signed by a
medical practitioner known to the individual, andare a legal statement of the person’s wish not tohave prolonged treatment in the presence of severe
disability. Some opt for euthanasia, which is notlegal.

Policy planning
Another reality that provision of services
often relates to political issues. At election timecare of the elderly does not always lead to votes
and thus becomes a low priority in policy
planning.

Specific Health Issues and Medical
Problems
Physical disability
Considering physical disability / medical
problems affecting the old and the very old, there
are problems common to all countries with anelderly population: fractures - especially of thefemur, falls, trauma, arthritis, sensory
impairments; long term severe disability, and thevulnerability of general frailty. Palliative care in
the community is now commonplace.
Hospital admission is usually for as short atime as possible and people are returned to theirown homes in the community, where both medical
and social services have responsibility forcontinued treatment and care. Despite the rise in
the number of old people, recent policy has been toAsian J Occup Ther 1: 26–34, 2001

reduce beds and this situation needs to be reversed.
Although day hospital places have increased, there
are demands on family carers and there is a needfor respite facilities for those with long term
conditions and the multifactorial problems of oldage. During recent flu epidemics it has become
apparent that convalescence beds are lacking for
those requiring less intensive hospital care.
Health promotion focuses on diet andexercise, there are programs related to preventionof falls. The value of short term rehabilitation inprevention of long term problems gains new
significance.
An organization which contributes much for
those affected by specific disabilities is Chest
Heart Stroke Scotland. This was founded over 100
years ago to help people with TB and its work has
grown. It provides. a telephone helpline andadvice on welfare and resources, research grants,(including one looking at community based
occupational therapy), health promotion material
and training for health professionals and thegeneral public.
One of its special services is the provision of‘stroke clubs’. These are social clubs, staffed byspeech and language therapists working withvolunteers, where people with speech problems
can meet others with similar difficulties and also
be encouraged to use any residual speech.
Physical exercise and getting to the club areimportant aspects and the psychological benefit ofa social outing cannot be ignored.

Mental healthIn the field of mental health, obviously there
are all the problems of younger age groups such as
depression, substance abuse and psychoses andnow there are older learning disabled people(mental handicap), living in the community, theirneeds require consideration.
The greatest need for care and development isin the field of dementia- ‘the quiet epidemic’. The
future number of people with dementia cannot beignored. In global terms, the number oft hoseaffected in 2000 was 18 million, 2/3 of whom live
in developing countries. 61,000 live in Scotland,of whom one third have moderate to severe

Hume C31

dementia. Globally, 34 million sufferers are
predicted by 2025. This represents a challenge forthose providing assessment and care.
But,‘Expertise is emerging which is helping to
make the experience of dementia, for both theperson with the dementia and the people whocare for them a less devastating experience’.
( P r o f e s s or M a r y M a r s h a l l, D em e n t i aServices Development Centre, Stirling
University).
This multidisciplinary centre has a researchand educational focus and produces reports andpractice guides on numerous topics - architecturalplanning, furnishings such as chairs, taps, alarms,
assessment and special aspects of care, e.g.
spirituality, sexuality and challenging behaviour.
Occupational therapists are fully involved in thiswork.
Reporting on one research study focused on
people’s subjective experience of dementia,
Goldsmith (1995) writes on advocacy - ‘Hearing
the voice of people with dementia’ and stresses thevalue of reminiscence, and life story. He alsomentions the value of non verbal communication,
all of which are recognized as integral tooccupational therapy.
A vo lun tar y or gan ization with wh ich
occupational therapists work closely is
Alzheimer’s Scotland - Action on Dementia. This
tackles education, publicity and awarenesscampaigns, research into the efficacy of new drugs
e.g. aricept and dilemmas such as should someone
with dementia be told his or her diagnosis?
ASAD provide identity cards for dementia
sufferers, a 24 hour telephone helpline, day care,long term care, respite, and holidays. Carers
support groups help to reduce the physical andemotional strain, though assessment of need may
be difficult, as often relatives hide problems.
Outreach workers for minority ethnic groups areavailable to provide specialized support.

Summary
Essentially, there is mixed responsibility care- state, family and volunteers.

32

CARE OF THE ELDERLY IN THE 21ST CENTURY: A UK PERSPECTIVE

Occupational Therapy
What are the implications for occupational
therapy? There are over 21,000 registeredoccupational therapists, (June 2000) of whomroughly three quarters are members of BAOT.
Some work in private practice, including insurance
related work, but the majority work in the health orsocial services. This division of practice is one
which sometimes creates difficulties in continuityof treatment from hospital to community.
The more I see of occupational therapy inother countries, the more similarities I see, rather
than differences. Services in the UK are notgreatly different from those described by Tamaru(1999).
Using a client centered assessment, thetherapist will devise a plan of treatment which canbe evaluated and revised. The aim will be tomaintain and wherever possible regain abilities
and skills, be it to be independent in personal
living skills, use a bus, or enjoy community
resources. In the same way as in other places,
therapists have preferred theoretical approaches,frames of reference and therapeutic media, but theclient's priorities will be acknowledged.
Review of assessments has been undertaken
by Tullis and Nicol, (1999) and Thom and Blair(1998) have considered risk in relation todementia. More attention is given to research andMountain (1998) has published information onevidence based practice relating to the elderly.
Co - o per a ti on wit h o th e r or g a n iz a tio n s i simportant, such as the development of practiceguidelines for stroke with the Royal College ofPhysicians.
Hagedom (1995) has described therapists as‘discharge technicians’ - a bit extreme perhaps,
though fast track programmes and rapid discharge
are of economic importance. Outcome measures
are now well established, as are audit and quality.
My ultimate quality question is - would you likeyou mother to be treated like this?
Information Technology is not, it is to be
hoped, going to lead to virtual treatment, but
Information management and effective use of theinternet is vital. The elderly use it!
Some other aspects of practice are gaining

importance. Evening and weekend work are now
commonplace and new areas of work are being
established, for example, advocacy services;which although not solely for the elderly, haverecently been established for those in long termcare. A parallel is the work of the Mental Welfare
Commission which monitors psychiatric services
and investigates complaints relating to care. For
some years an occupational therapists has been
appointed as one of the commissioners.
Another important aspect is education fortherapists, beyond the level of first degree
qualification and Masters. Evidence of continuing
professional development is now a requirement forregistration and employment. Masters
programmes related specifically to gerontology
are being developed and membership of the COT
specialist section for practitioners working withelderly people is expanding rapidly.

Personal Conclusion
Within all this, we have to remember ourroots, and the value of activity. Creek (1997)
writes about creative activities and a personal
example will endorse this. One man told me
recently that his wife had ‘run out of sewing’, (oneactivity which she can still carry out
independently), with consequent agitation andstress for them both as she wandered without
purpose. Small, but it’s the base of our profession.
Occupational deprivation is recognized within thedeveloping sphere of occupational science and ishighly relevant to the elderly with diminishingabilities.
In conclusion, the only thing I can confidently
predict is change. However, I believe our future iswith the elderly. They are the last source of ourhistory. We should appreciate them and value
them, which means doing all that we can to ensurethat satisfactory care is provided.

Appendix - Two Case Histories
James, aged 90, married, living with his wife
Susan (91). 3 children living in other cities in
Scotland and several grandchildren and great
grandchildren. They own their house which isAsian J Occup Ther 1: 26–34, 2001

situated near to shops and public transport andbuilt with two floors.
James had a history of falling, probably due
to insufficient cerebral blood supply, although thishas had no effect on his mental health. His
m em o r y i s g e n e r a l l y g o o d , t h o u g h s o m edeterioration has been noted by Susan.
One day he fell heavily, and sustained afractured neck of femur. Initially he was taken to
the general hospital receiving emergency cases,
and from there to the orthopaedic hospital where
he received a replacement hip joint. He was againtransferred to a geriatric unit at a rehabilitation
hospital, where he is receiving physiotherapy andoccupational therapy.
He is very keen to go home and is rather
unrealistic about how well he will be able to cope.
Like an increasing number of people, healready has a privately owned motorized scooter
which he uses for getting around in theneighbourhood. His wife is worried about how she
will cope with his more restricted level ofmobility, particularly as there is no downstairs
bedroom or bathroom.
The social services therapist has previously
visited to organize the provision of bathing / toilet
aids and is now advising on suitable furniture,
alterations to convert one room to a bedroom andto install a shower room and toilet. The couple
will contribute towards payment for thesealterations.
These alterations are being made and Jameshopes to go home soon. The couple have a home
help each day, to assist with cleaning, shoppingand cooking and they pay for this service.
It can be predicted that there will be someproblems, and Susan will find caring for him
tiring. Nevertheless, they have been married for
60 years and it is desirable (and also economic)that he should return home.
In contrast, Mary lives with her husband
Kenneth in a small flat which they rent from thecouncil. He retired early with respiratory
problems and the couple receive financial benefits
and some social service help with cleaning andshopping.
They have no family, but good neighbours.

Hume C

33

Mary has become increasingly forgetful andtakes less care over her appearance. She getsagitated easily and can be quite irritable. Kenneth
has to watch what she does when she is preparing
meals because she recently failed to light the gas
cooker after she had turned it on. He is becoming
worried about her ability to cope. Last week she
went out alone and a neighbour had to bring her
home.
Mary was referred to the local geriatrichospital by her general practitioner. The
psychiatrist examined her and suggested that she
might attend the day hospital two days each week,
to provide a break from caring for Kenneth. Here
she receives supervision for her personal care andtakes part in occupational therapy, including
domestic skills and reminiscence groups.
In future, as she deteriorates, it is likely that
services such as the home help, incontinence
laundry service and respite care will be necessary.
Her attendance at the day hospital may be
increased and staff here will liaise with her generalpractitioner and social service staff.
Kenneth has information about support
groups for carers of people with dementia, and oneof the volunteer helpers will provide transport toenable him to attend a group every month.
It is important to make every effort to ensurethat his state of health is maintained in order for
him to care for Mary for as long as possible.
Kenneth does not like the idea of long term carefor her, but this may eventually be required.

References / Sources of Information
Alzheimer’s Scotland, Action on Dementia (2001).
Newsletter Issue No. 34, June.
(http://www.alzscot.org)
Chest, Heart & Stroke Scotland. Annual report(2000). (http://www.chss.co.uk)
Creek, J. (1997). Occupational therapy and mental
health (2nd ed.). Edinburgh: Churchill,
Livingstone, Chapter 7.
Dementia Services Development Centre, Universityof Stirling, Scotland. (http://www.stir.ac.uk/dsdc)
Recent Reports include: A practice guide forcommunity nursing: Supporting people withdementia and their carers in rural communities.
Taps.

34

CARE OF THE ELDERLY IN THE 21ST CENTURY: A UK PERSPECTIVE

Goldsmith, M. (1996). Hearing the voice of people
with dementia. London: Jessica Kingsley,
Chapters 8 & 10.
Hag edom, R. (1995 ). Occu patio nal therapy.
Perspectives and processes. Edinburgh: Churchill
Livingstone, Chapter 1.
Mountain, G. (1988). Rehabilitation of vulnerable
older people. Nature of the evidence base andimplications for occupational therapists. Collegeof Occupational Therapists, UK. Summary
available from COT. (http://www.cot.co.uk)
National Clinical Guidelines for Stroke. RoyalC ol lege of Physi ci ans Publi cati ons Unit.
(www.rcplondon.ac.uklceeu_stroke_home.htm)
Pullen, I. (1994). Old Age. In C. Hume & I. Pullen(Eds.), Rehabilitation for mental health problems,

Edinburgh: Churchill Livingstone, Chapter 11.
Tamaru, A. (1999). Occupational therapy in theJapanese community—relating to the ageing
society. WFOT Bulletin 40, 12–20.
Thorn, K. & Blair, S. (1998). Risk in dementia assessment and management: a literature review.
British J Occup Ther 61 (10), 441.
Tullis, A. & Nicol, M. (1999). A systematic reviewof the evidence for the value of functional
assessment of older people with dementia. British
J Occup Ther BJOT 62 (12), 154.
Walker, M. F., Gladman, J. R. F., Lincoln, N. B.,
Siemonsma, F. & Whiteley, T. (1999).
Occupational therapy for stroke patients not
admitted to hospital: a randomized controlled trial.
The Lancet 345 (9175), 278–280.

WFOT SAPPORO SYMPOSIUM ON REHABILITATION FOR THE ELDERLYCHOICE: Innovation in Community Carefor the Elderly #E. Sharon BRINTNELL, OT(c)MSc1,2
1 Honorary Treasurer, World Federation of Occupational Therapists
2 Department of Occupational Therapy, Faculty of Rehabilitation Medicine, University ofAlberta

Abstract: Identifying effective preventive interventions which can preserve theautonomy and the maintain health of elderly persons living in the community isparamount. Health service restructuring in Alberta, Canada provided the impetus to
implement an integrated community-based program to address the fragmentation and lackof coordinated services for the frail seniors. The program content and approach taken by
two organizations in partnership with the Capital Health Authority (CHA) in Edmonton,
Alberta is described The outcomes study results of a recent evaluation of the CHOICE
program is reviewed.
Key words: elderly, community, innovation(Asian J Occup Ther 1: 35–40, 2001)

The graying of North American society andthose of other developed countries in the worldsuch as Japan is bringing increased attention to theneeds, services and resources required by theelderly. Particularly, identifying effective
preventive interventions which can preserve theautonomy and maintain the health of elderly
persons living in the community is paramount (vanHaastregt, 2000). Of concern though, are thesocietal barriers to the empowerment of theCorresponding to: Professor E. Sharon Brintnell (OT(C));
Department of Occupational Th erapy, Faculty of
Rehabilitation Medicine, University of Alberta, 2–64
Corbett Hall, Edmonton, Canada, T6G 2G4phone: 1-780-492-2499 fax: 1-780-492-4628
e-mail: Sharon.Brintnell@ualberta.ca# Adapted on behalf of the Program Staff of CHOICE,
Capital Health Authority, Edmonton, Alberta, Canada

elderly, specifically the frail elderly and theburden of care on families (Ikegami, 1998; Capital
Health Authority, 2000a).
Health service restructuring in Alberta,
Canada provided the impetus to implement a
program to address the fragmentation and lack of
coordinated services for the frail elderly. This
paper describes the program content and approachtaken by two organizations in partnership with theCapital Health Authority (CHA) in Edmonton, oneof 17 regional health authorities in the province(Capital Health Authority, 2000b). The content of
the rest of this paper is taken from the two
references of the Capital Health Authority with
their permission and on their behalf.
Based on the Program for All Inclusive Care
(PACE) (Richardson, 1998). The Edmonton
program, Comprehensive Home Options ofIntegrated Care for the Elderly (CHOICE) was

36

CHOICE: INNOVATION IN COMMUNITY CARE FOR THE ELDERLY

Table 1. Selected outcomes studies results clinical
Improved
Self Reported health status
Perceived quality of life

Deteriorated

Within 3 month admission
Within 10 weeks of enrollment

High level of satisfaction

initiated in 1996 first as a pilot project and then as
continuing program within the CHA It is one of avariety of programs within the Home Care andRegional Continuing Care system of the province(Capital Health Authority, 2000a & 2000b).

Program Objectives and Outcomes
CHOICE focuses on meeting the health andsocial needs of older persons through a systematicand integrated approach that is community-based.
Its objectives are to reduce acute care utilization,
avoid premature institutionalization in long termcare facilities and to maintain very frail elderly
people in the community Based on the Program for
All inclusive Care (PACE) (Richardson, 1998).
The Edmonton program, Comprehensive Home
Options of Integrated Care for the Elderly(CHOICE) was initiated in 1996 first as a pilot
project and then as continuing program within the
CHA I t is one of a variety of programs within the
Home Care and Regional Continuing Care systemof the province (Capital Health Authority, 2000a& 2000b). An evaluation of CHOICE in 1998
used five major components: program description,organizational review, program evaluation,
outcome study and cost analysis1. A brief reviewof the outcome studies result follows.
The inpatient and ambulatory care visits to
CHA acute care facilities were tracked for theperiod of January 1, 1995 to January 31, 1998. At
the time of the study cut-off date, 214 of 354
clients admitted to the CHOICE program were still
enrolled. The results were adjusted to reflect thelikelihood of accessing hospital prior to CHOICE
1For information on the findings of the full evaluation pleasecontact the CHA directly: alemire@cha.ab.ca

admission.
Quality of life rating showed a statisticallysignificant difference between entry and 10 week
post- enrollment (Table 1). Satisfaction with theprogram was at the 95th percentile while 91% were
either satisfied or very satisfied with attending the
day health centre (Table 2 & 3).
From these data, the costs savings of the
program are apparent (Table 4).
Overall the evaluation documented the costeffectiveness of the CHOICE program model. The
savings in the ambulance claims. Were around
10.6% and the pharmaceuticals claims werereduced by 86%. A third party insurer, Alberta

Table 2. Selected outcomes studies results inpatientutilization
Reduction
Overall costs
Admissions
Hospital stays

50%
30%
55%

Anticipated cost per client
Annualized cost of census$ 11.38$ 1,121,499.00

Increase

Table 3. Selected outcomes studies results ambulatory careutilization
Reduction
VisitsCosts per client per year
Annualized cost of census

25%$ 138.00$ 37,260.00

Increase

Asian J Occup Ther 1: 35–40, 2001

Brintnell ES

Table 4. Utilization cost analysis
Per diem costs

Reduction

Inpatient
Ambulatory
Ambulance
Pharmaceuticals
Provider visits & services$ 11.38$ 0.37$ 0.07$ 2.87

Total per diem$ 14.13

Increase$ .0.56

37

accessed through consulting or referralarrangements. These include: audiology, dental
care, diagnostic imaging, laboratory, medical
specialties, nutrition, optometry, ophthalmology,
podiatry, psychology, respiratory therapy andspeech-language pathology.

Home support

Blue Cross, saved approximately 87% in payouts
for the study period.

Most participants require assistance within
their homes in order to maintain their
independence. They also require help in getting
ready to attend the day centre. Services provided
in the home include meal delivery service,personal care, adaptation of the home environment
and provision of aids, home-making services.

Core Program Elements

Transportation

The program provides full 24-hour carethrough a multi-disciplinary team of professionals;
these include a physician, a registered nurse, asocial worker, rehabilitation therapists,
pharmacist, dietician and other health workers.
The multi-disciplinary team uses a casemanagement approach to supervise each program
participant’s care.

Day health centerAll participants attend the day health centre
located at a CHOICE site. The centre is open fivedays per week, with participants attending
between 9:30 a.m. and 4:00 p.m. The number ofdays that participants attend the centre each week
depends on their needs as assessed by the team.
Day centre services include personal care andgrooming, individual and family support,
recreational and social activities, rehabilitation,
health promotion activities and a meal service.

Health clinic
Each participant’s m ed ical n eed s are
addressed at a health clinic located within thecentre. Each participant is assigned to one of theclinic physicians who coordinate his/her services
with the clinic nurse and a pharmacist. Whenadmission to an acute care facility is needed, theclinic physician is the admitting physician.
Services not routinely available on-site are

The program contracts transportation services
involving wheelchair accessible vans. Drivers
take participants to and from the day centre andwill provide transportation to other appointments.

Sub-acute care
Each site maintains a small number ofdesignated beds (usually three per site) toaccommodate participants with sub-acute needs
who can be managed outside an acute care hospitalwith the capabilities and resources of the CHOICE
program. The beds are used for four purposes:
Treatment—for direct admission fromemergency, early discharge from acute care, shortterm acute illness or short-term intensive
rehabilitation;
Respite—for emergency or scheduled respiteneeds;
Night care—for when participant’s caregiver
requires night respite;
Holding bed—for when participant isawaiting placement in a long-term care facility.
The designated beds are located within the
program and are staffed by CHOICE personnel on
a 24-hour basis. The CHOICE clinic nurse andphysician during clinic hours, or the on-call nurse
and physician outside of clinic hours determine theAlberta for use of the beds.

Mental health
The recognition that a number of persons

38

CHOICE: INNOVATION IN COMMUNITY CARE FOR THE ELDERLY

with a severe and persistent mental illness wereunable to function in the mainstream CHOICE
program led to a collaboration of CHA with theAlberta Mental Health Board on a special one year
pilot CHOICE program to meet their needs.
(February 1999). No further information wasavailable at the time of writing.

been tried and do not meet the candidate’s
needs⋅ Candidate’s needs appear to be within
CHOICE resources⋅ Candidate needs assistance with activities ofdaily living⋅ Candidate has a support network committed tothe candidate staying at home.

Emergency response
An on-call nurse is available to respond toissues arising during the health centre's off hours,
nights and weekends.

Service Processes
Referral and intake
Referrals to the program are made throughthe Capital Health Authority’s single-point-ofentry system. Home care coordinators complete
an Intake Request form and forward it to the
CHOICE© intake coordinator. After notifying thefamily physician of the referral, the intake
coordinator meets with the potential candidate andfamily representatives to provide information
about the program and to determine thecandidate’s interest in and eligibility for the
program.
If, after this intake assessment, the decision ismade to proceed with the referral, the candidate is
assigned to the CHOICE site closest to where they
live or to the site, which offers a specialized
program. A team conference is held at the referralsite where the intake coordinator presents theinformation available about the participant. The
decision to accept a candidate for trial admission ism a d e b y th e t e a m m e m b e r s b a s e d o n th e
information presented.

CHOICE Eligibility Criteria⋅ Candidate is at risk for placement in long-termcare⋅ Candidate’s history includes frequent incidents
of hospital or health centre usage⋅ Candidate’s physician is in agreement with thereferral⋅ Alternate, less comprehensive services have

Trial Admission and Assessment
If the team decides the individual is a suitable
candidate for the program, a trial admission of fiveconsecutive days is scheduled. This trial allows
the candidates and their caregivers to see whether
the program will serve their needs and enables theteam to determine, from their perspective, whether
and how the program can meet the candidate’s
needs. Assessments are conducted in the coreservice areas: social work, medical, physicaltherapy, occupational therapy, nutrition, home
support, recreation therapy and pharmacy.
At the end of the five-day trial period, theinterdisciplinary team meets to discuss theassessment results and make the admission
decision. The candidate’s home care coordinatoris invited to participate in this conference.

CHOICE© Admission Criteria⋅ The needs of the candidate cannot be met byless comprehensive programs in thecommunity⋅ Interdisciplinary team assessments indicate theindividual has potential to benefit frominterdisciplinary interventions and regularmonitoring.
⋅ The program has the resource capacity to meetthe individual’s care and medical requirements⋅ Anticipated length of stay at CHOICE must be
minimum of three or more months⋅ The individual and family are committed tohaving the individual remain in their own
home⋅The individual and family are committed toscheduled regular attendance at the HealthAsian J Occup Ther 1: 35–40, 2001

Centre and compliance with services cocoordinated by the team⋅ Care can be managed within the individual’s
home environment⋅ Behavior of the individual is not problematic tothe safety of other participants or staff⋅ The individual is able to use the transportation
provided

Additional criteria are available forindividuals who are candidates for the special
program units.

Service Planning, Implementation andMonitoring
After the interdisciplinary assessment has
been completed, the team jointly develops aservice plan, identifying health care needs, goals
and team interventions in areas such as physicalhealth, functional status, nutrition, continence,social issues, socialization, recreation, pain
management, mental and emotional health,
medication, home support needs, participant andcaregiver compliance and safety. All teammembers are responsible for implementing theservice and contributing to the achievement of theestablished goals.
Every morning before participants arrive at
the centre, team members meet to identify andproblem-solve any issues that may have arisen
about the program participants. Each individual's
service plan is formally reviewed and updated
every four months.
If a participant requires services beyond thoseoffered directly through the program, staff would
organize access to these services. This may
involve arranging for specialists to come to the day
health centre or for the participant to be taken to an
external clinic.

Discharge
One of the objectives of this program is tomaintain individuals in the program for as long as
possible by changing, adapting and increasing
services, as participant needs change. For thisBrintnell ES

39

reason, discharges to other continuing careprograms are minimized.

Program Participants
Types of participants
The individuals attending the CHOICE
program may generally be described as fallingunder one of the following four categories:
Functionally frail—These individuals have ahigh need for personal care and are high users ofhome support services. They generally attend the
day health centre between two and three days per
week and have the longest length of stay with theprogram.
Medically frail—These individuals
demonstrate a high number of medical conditions
and are high users of the program’s medical andafter hours on-call services. They attend the centre
the least often of the four groups.
Chronic mental illness—These individuals
often have special day program needs. They arehigh users of social work, medical and on-callservices. Compliance with program policies isfrequently an issue for these individuals.
Dementia—Because of the high stress levels
for caregivers committed to maintaining theirfamily members at home, care of these individuals
generally involves high use of family support andrespite services. They are the lowest users of
medical and rehabilitation services. Generally,
they attend the day centre five days per week andmay be placed in the program’s secured unit. This
group of individuals demonstrates the shortest
length of stay with the program.

Success Factors
In reviewing the evaluation findings, themain contributing factors to CHOICE meeting its
program objectives include:⋅ Integrated team-case- management approach⋅ Primary care physicians as team members⋅ Preventative and early intervention focus
The combination of well-qualified
professional and support staff provides thefoundation of the program. Some staff get to know
the clients well. They are able, through their

40

CHOICE: INNOVATION IN COMMUNITY CARE FOR THE ELDERLY

contacts with clients in the day program and thehome, to observe function and detect changes
early. Physicians are active team members
attending family and team conferences, admittingclients as needed, acting as liaisons with referring
and admitting physicians in acute care andproviding for early discharge to designated
CHOICE beds in the continuing care system.
They also contribute to the education of medical
students and family medicine residents.
Site staffing is made up of 6.8 full timeequivalents (FTE’s) for therapy professionals(physical therapy, occupational therapy, social
work recreation, and dietetics) and 19.3 personnel
support personnel. For the Day Centre: 1:0 FTE
physician, 3.0 FTE’s nurses for the clinic and 3.1
for the treatment beds. Administration has a
combined 6.8 FTE’s in management and clericalroles.

Conclusion
Empowering the frail elderly needs carefulinterpretation and sensitive programming, as it has
attendant risks and different interpretation in thecontext of health, social service delivery andhousing options. It also requires time, energy,
money and a commitment to the goal and vision(Heuman, McCall, & Boldy, 2000). The Alberta
g o v e r n m e n t’ s v is i o n o n h e a l th y a g in g i scompatible with these views and is captured inrecent health related publication on future policy
and action (Alberta Health & Wellness, 2000).
CHOICE is an example of a positive undertaking.
The CHOICE program in Edmonton, Alberta,
successfully demonstrates the ability of program
planners to take a model developed elsewhere andto adapt it to a local context and situation. The
Capital Care Group (public) and the Good
Samaritan Society (voluntary non governmentalorganization) worked collaboratively with theCapital Health Care Regional Health Authority todevelop and implement the CHOICE programs.
CHOICE offers a cost-effective integrated service
to manage in the community very frail people who
cannot manage with just Alberta Home Care andother programs.

References
Alberta Health & Wellness (April 2000). Strategic
Developments and Future Actions: Health Aging
and Continuing Care in Alberta. (Retrieved
January. 2001 from www.health.gov.ab.ca/public/
documents)
Capital Health Authority (2000a). Comprehensive
Home Options of Integrated Care for the Elderly(CHOICE). Program description. Edmonton: AB.
Capital Health Authority (200 0b ). CHOICE
Comprehensive Home Options of Integrated Carefor the Elderly (CHOICE). A power point
presentation. Edmonton: AB.
Heuman, L. F., McCall, M. E., & Boldy, D. (2000).
Empowering Frail Elderly People: Opportunities
and Impediments in Housing, Health, and Support
Service Delivery. Westport, Conn: Praeger
Publishers.
Ikegami, N. (1998). Growing old in Japan. Age andAging. May. (Retrieved June 26, 2001 fromwww.findarticles.com/cf_0/m0999/7237_320/
61522839/print.jhtml)
Richardson, S. K. (1998). Medicaid Directive.
Washington: Health Care Financing
Administration, US Department of Health andHuman Services, Centre for Medicaid & State
Operations.
Van Haastregt, J. C. M. (2000). Effects of preventive
home visits to elderly people living in thecommunity. British Medical Journal. March 18.
(Retrieved June 26, 2001 fromwww.findarticles.com/cf_0.../
article.jhtml?term=%2Baged+%2Bcare+%2B+
community)