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From the Editor: Geriatrics in the Middle East

A. ABYAD, MD, MPH, AGSF

This is the first issue of the Middle-East Journal of Age and Ageing. The Mission of the Journal is to promote geriatric medicine, gerontology and ageing related issues in the Middle East . As a new peer-reviewed journal, its aim is to meet the needs of scientists, practitioners, policymakers, and the patients and communities they serve in the Middle East. The Journal will begin publication, online, in January 2004. The frequency will initially be once every six months for the first year, then once every four months the second year, followed by once every two months.

The Journal will publish original, clinical and educational research of interest to geriatricians, primary care physicians , practicing clinicians, residents, and others involved in services for health related problems in older people. The Journal will also publish special articles and commentaries about the fundamental concepts of medical education, as well as book reviews and international reports. It will foster the basic and applied sciences of geriatric medicine, primary care for older people, and gerontology care practice.

The number of Supporting Organisations reflect the importance of health issues in the elderly, in the Middle East and worldwide. The journal has been endorsed by the W.H.O. aging program.

As the editor of the journal, I would like to congratulate the editorial team and all those that have assisted in having this journal come to fruition, especially medi+WORLD International, Australia.

Abstract

Middle eastern countries have certain cultural, social and economic characteristics in common with similar aspiration. The percentage of elderly in th Middle East is expected to increase with improvement of the health care delivery in the area. The region , like other developing countries, needs to define the policies and programs that will reduce the burden of aging populations on the society and its economy. There is a need to ensure the availability of health and social services for older persons and promote their continuing participation in a socially and economically productive life. The morbidity burden of the geriatric population can quickly overwhelm fragile and under financed health infrastructures which are unable to meet fully the prevention and treatment needs of a younger population with relatively low-cost, easy-to-prevent, easy-to-treat illnesses.

1. Introduction

The population of the world is aging rapidly. It is currently estimated that more than half (58%) of all people who are 65 years and older live in developing nations. The world's older population experiences a net increase of 1.2 million each month, 80 percent of which occur in Third World nations ^(1,2,3). It is projected that by the year 2025, the total elderly population will reach 976 million with 72% living in developing regions ^(2,3,4). Also, as in the west, the growth rate is fastest for the oldest old, those most likely to have chronic diseases and be in need of health services. It is apparent that the problems of the frail elderly and development of geriatric programs and understanding of geriatric principles are international problems⁽⁵⁾. The Middle East will develop rapidly aging populations within the next few decades. Many factors has resulted in increase in the elderly including improvement in living standards, the curbing of communicable disease, and the latest breakthroughs in medical science.

Health Transition

The Region is passing through the "Health Transition Phase," which is characterised by an unprecedented increase in both number and proportion of adults and elderly persons. Improvement of health care has been achieved by a combination of technical advances, social organisation, health expenditure, and health education^(6-13). Rapid urbanisation and industrialisation are occurring across the Middle-East countries. The epidemiological consequences of these changes will lead to an increased rate of death from cancer and circulatory disorders. In addition, an increase in chronic disorders of old age and the aging of the population itself, will make enormous demands on the health care system. As yet, there are no satisfactory geriatric care services available for the elderly. Different countries in the region have started different programs which tend to be rudimentary and fragmented with no national programs available on a national level.^(9-13)

Epidemiological Data

There is a lack of appropriate knowledge about the nature and extent of health problems in the region. Statistics and data about health problems within the community are scarce . For these reasons, program priorities have been based on inappropriate information. Much of our epidemiological knowledge of health problems comes from studies using hospitals or health services as data sources.

Life expectancy at age 65 years is a better reflection of the success of a nation in the aging process. Life expectancy at birth reflects factors such as infant mortality, poor control of infectious diseases in childhood and youth, violent deaths, and an increase in genetic diseases with early mortality. Table 1 shows the life expectancy for the region compared to other areas in the World. In the developed world, life expectancy is relatively increased for both genders (above 75 years for the United States and close to 80 years for Japan). The Arab countries show wide variations in their life expectancy ranging from as high as 75 years in Kuwait to 63.9 years in Egypt and as low as 50.4 years in Yemen^(9-13). (table 1).

Psychiatric morbidity in the Arab world is underestimated. This is due to the fact that few epidemiological studies have been done in the field. Screening of representative samples of primary health care patients in Saudi Arabia and the United Arab Emirates (UAE) demonstrated psychiatric morbidity of 26 and 27.6 % respectively^(13,14). Unofficial data in different nursing home facilities in Lebanon revealed a 25 to 30 percent level of depression among residents and 10 to 15 percent of dementia. At Ain WaZein elderly care center, Lebanon, the prevalence of dementia is almost 20 percent of the residents and depression is currently at 25 percent. Behavioural disturbances affect around 20 to 30 percent of residents in long term stay in Lebanon.

Socioeconomic and Political Factors

The aging of the population has been called a "great triumph of civilisation," but it also presents the challenge of ensuring that older people have access to the economic, social, and health resources they need, in general, similar to those of developed nations⁽¹⁰⁾. Suffering of the elderly may be severe, mainly because of poverty. There are various systems of pensions for only a minority of the elderly in the region .

a - the relevance of the extended family
The current pressing problems of elderly persons are predominantly economic difficulties and low access to health services. There is no housing problem since the traditional family still provides protection for the old. The social and cultural patterns that still protect the elderly from isolation in society need to be encouraged and supported. Social policy should be designed to strengthen family support channels which may prove impractical. Therefore, new services will have to be instituted to supplement a decaying, informal system and personnel must be produced to provide these services. One study revealed that suicide rates are higher among elderly people living in three-generation households than among those living alone⁽¹⁶⁾. The family has always been the mainstay of the frail elderly in Lebanon and the Middle-East, but events are gradually eroding this support system. Factors such as youth migration for employment and education and divisions in families account for the erosion of the familial support system. Some writers from the developing countries challenge the belief that families can be depended on to take care of old people^(9-13,17,18).

b -the Status of the elderly in the Middle-East Culture
Middle-Eastern culture ensures respect for the elderly and values highly the natural bonds of affection between all members of the family. The eldest members are a source of spiritual blessing, religious faith, wisdom and love. Despite the general feeling among most people in the region that sending an elderly parent to a nursing home violates our sense of sacred duty towards them, many individuals and groups are faced with situations, where they have no other alternative. It is clear that the majority of elderly in nursing and psychiatric homes are there owing to circumstances where their families cannot possibly look after them. Among such groups are those whose families are abroad, unmarried women, old people whose families cannot support them financially, and those who suffer from diseases where professional care is needed. Morbidity patterns have changed and lead to prolonged states of chronic disease, dependency and loss of autonomy for growing numbers of elderly in the region ^(9-13).

Elderly people in the area receive social and economic support from the informal sources of extended kin networks, and particularly from their own children. With smaller families being the trend, this will lead to fewer potentially supportive children available. Studies from developed countries reveal that where children are in a position to help their aged parents, the majority of them do so. However, traditional patterns of family responsibility will diminish with economic development^{(9-13,
16)}. Young city dwellers may become more preoccupied with the future of their children than with the difficulties of their parents. Women, who traditionally bear the main responsibilities for providing family care, enter the labor force for reasons of personal choice and economic necessity and are no longer available to care for aged relatives^(9-13).

The urban poor manage to maintain extended families intact even though frequently under undesirable circumstances in slum housing. At the other end of the social scale, upper income persons can afford the large homes and the household help that allow them to accommodate all of the members of the extended family. It is the middle income family, living in a nuclear household, frequently with the wife in the labor force, which is most likely to institutionalise an older relative. As the family has proven to be more effective and efficient than public structures, as regards the care of the elderly, planning and social policy should encourage keeping those structures and encourage intergenerational relationships and not allow them to deteriorate. Financial, social and emotional assistance to family members who care for their elderly should be provided from governmental and nongovernmental agencies.

c - the Political Situation
Governments of the area are still assuming that families will take care of their own elderly. The changing economic and shifting migration patterns lead to the projection that the provision of long-term care will be an important part of health care planning ^(1,9-13). Government is unwilling to make major commitments to elderly health ^(9-13,16). The worldwide recession of the late 1970s and early 1980s affected the whole region. Interventions for the elderly, whether preventive or curative, are almost always far more expensive ^(9,10,17-21). There is little incentive to direct limited resources in order to add an additional few years of life. There are conflicts between the needs of large population groups and the purchasing power of a more limited elite. The role of private sector is very important. Given the fragile finances of the government, the private sector has a greater role to play in the insurance of health care.

The Presentation of these problems to health services and the role of primary and specialist care for the elderly

A - Elderly Characteristics
Diversity is a key term that describes the elderly population. While the label elderly is commonly used for the population 65 years and over, this group is remarkably heterogenous. Each age, gender and ethnic group has distinctive characteristics, and the experience of aging differs among the demographic groups. Also, rural elderly have characteristics and needs different from those of urban elderly. Some older people have significant health problems while others spend time vacationing, exercising, and participating in sports. Some stay in the paid work force until they die while many fill their leisure time with volunteer work, care for children and the frail elderly, or other personally satisfying activities. Some are bored, angry, or depressed. In short, the elderly, like other age groups, encompasses people with varied levels of needs, abilities, and resources. Accurate information on the conditions and needs of older persons is crucial for planning health service development and training of personnel. Of primary importance is determining the age distribution of older persons, since there is a marked difference between the health needs of the "young aged" and the much more vulnerable groups of the extreme aged, 80 and over.

B - Elderly Facilities
It is recognised that social, environmental and psychological factors can underline ill health among the elderly as much as biological factors. Bereavement, social isolation, loss of work roles, lack of exercise and physical activity, poor nutrition and misuse of medicines constitute major risk factors for illness, and even premature death. Therefore the pressing priority is the provision of facilities including medical, psychiatric and rehabilitative services for early diagnosis and treatment of illness, to alleviate problems that could lead to long-term debilitating conditions in old age. It is important to achieve a balance of care between community and institutional services, both for humanitarian and economic reasons. Given the growth of the aging population in the region, especially the oldest with expected multiple chronic illnesses, the need for intermittent or continuous long term care services will undoubtedly grow, including nursing facilities and home or community-based long term care.

The Development of health care and social services for the elderly in the Middle-East

When we look at the world as a whole, the elderly in the region are increasing or growing at a much faster rate, than the elderly in more developed countries. This is a fact that is often overlooked, and, it has very important implications. Health care systems in the region have ignored the needs of the elderly. There are only sporadic programs that take care of the elderly, mainly initiated by the community or within the private sector. In Egypt for example there are 34 'old people homes' for over one million elderly people and some homes have waiting lists of over 1000 persons. During the past two decades most Middle Eastern countries have placed increasing emphasis on improved health care. Delivery of health care in the region interrelates strongly with other factors, such as food and nutrition, sanitation, water supply, literacy, and income distribution. In general, the government is the main provider of health care, and social insurance is viewed as a public responsibility.

The countries in his region can be divided into the following groups:

1. Countries typified by substantial capital, rapid development, and a small indigenous population, such as Saudi Arabia, Kuwait, and most
Persian Gulf states

2. Countries with less capital, more people, a quantitatively larger medical infrastructure, and more trained medical personnel, such as Egypt,
Israel, and Algeria.

3. Countries whose extensive medical service plans have been halted or greatly decreased in scope because of civil strife or war, such as Iraq, Lebanon, and Iran ⁽¹²⁾.

Education and training aspects for all professions involved

A. Role of the Academic Institutions

The trend is toward increased specialisation and subspecialisations. There is a limited supply of primary care physicians and well-trained family physicians, in addition to major deficiencies in the number of physicians trained in geriatrics, occupational or environmental health, and preventive medicine^(9-12). Medical schools in the area generally press for strong basic science programs and sophisticated tertiary care. There is a need for schools to modify their curricula to address national or local health needs, to emphasise primary health care, preventive medicine, and public health education. Academic institutions in the region are responsible for preparing health professionals responsive to demographic changes. There is little evidence of the responsiveness of academic institutions to the problems associated with the aging population. They are fixed in a mid-twentieth-century mode, patterned after traditional schools in the developed world. The recent development of a Family Medicine Program with community orientation appropriate to the resources, cultural, material, and economics available in the community, however, is encouraging^(9-12).

B. Health Professionals

Health professionals at all levels have received little or no training in the care of the elderly, and many do not find working with them to be rewarding. Clinical training of health professionals should include participation in interdisciplinary work in order to gain knowledge and appreciation of the roles of all health and social service workers to be better able to work as a team. The needs of older adults, especially the frail or impaired, require a healthcare workforce knowledgeable about the systems and services of care with which the elderly interact, with the skills to provide care within these systems. Care of the elderly, within managed care and long term care systems, require a unique body of knowledge and practice which is necessary to be able to work cooperatively with managers. The complexity of problems common to older adults often demand the knowledge and skills beyond that of individual practitioners. Education is required to understand the principles of interdisciplinary teams and when they are appropriate to convene. One of the most important areas in caring for the elderly is to focus on the need for geriatric and gerontological education and training for a wide range of health professionals and para-professionals who provide care to elderly persons, in order to meet the future demand for quality long-term care services^(9-12).

Are the health professions in the region equipped to meet the present and future health care needs of the elderly? Are the health profession's faculties prepared to teach geriatrics and gerontology? Do curricula of basic and graduate level education include aging content? Is discipline-specific aging research being conducted? And do health care professionals in Lebanon choose to care for the elderly? Are rewards, professional or financial, being given to those who care for the elderly?

These obstacles will have far-reaching effects in the near future, when it is anticipated that much of a health care professional's time may be devoted to care for the elderly. A health workforce, prepared with the knowledge base and technical skills of geriatrics and gerontology, can respond more effectively and efficiently to the needs that arise from the challenges faced with advancing age. There is no doubt that, through research, education and training, a skilled workforce can help reduce disability and functional limitations, improve the quality of life for both the aged and their family members, and can be an effective means of providing appropriate health care to an aging society.

One of the most important areas in caring for the elderly is to focus on the need for geriatric and gerontological education and training for a wide range of health professionals and para-professionals who provide care to elderly persons, in order to meet the future demand for quality long-term care services. There is substantial overlap between geriatrics and long-term care, but the two terms are not synonymous. Geriatrics is a medical and health care specialty which is practiced in most long-term care settings, but long-term care involves more than the practice of geriatric medicine. It is a broader concept, incorporating quality of life, environmental appropriateness, family involvement, and other aspects of daily living. While geriatric education focuses on diseases of aging, we must take a broader perspective, addressing care needed as a result of a range of functional and other changes related to aging, and this is where gerontology comes into play.

It also is important to understand the distinction between geriatrics and gerontology . Geriatrics refers to the clinical practice by physicians and other health care professionals involved with treating elderly patients. On the other hand, gerontology is the inter-disciplinary study of older persons, including disciplines such as economics, psychology, sociology, political science, and many other academic and applied fields . It is critical that health care providers, both professionals and para-professionals , understand both geriatric care and gerontology . That is, in addition to knowing about the diseases and conditions being treated, they also need to know about older people, as people, and as patients . They need to know how to effectively communicate with older persons, how to be supportive , and respond to their complex array of concerns and problems.

The increasing need for geriatric education and training in the region, similar to other countries, will be driven by the changing demographic face of the area. A rising geriatric population, with increasingly unmet health care needs, strongly suggests the necessity for better educational preparation of those health professions actually or potentially serving them. The absence of sufficient numbers of trained geriatricians and gerontologists, among health professionals, seriously undermines the ability of the country's health care system to adequately assess, treat, and rehabilitate the growing aging population. This shortage leads to inappropriate care, higher costs, and poorer patient outcomes. Education is key to more informed health care services, without which, fertile soil exists for the emergence of negative attitudes and stereotypes toward aging and older people. This may lead to avoidance of older people and their problems.

C. Implications for Nursing

As this century progresses nurses in the Middle-East will be increasingly concerned with the aging population. Nursing must focus upon the entire spectrum of health and develop interventions geared, not only toward the individual patient, but also toward the family and community. It is a prime responsibility of nursing to encourage elderly people to optimise their physical, social, and psychological function during changes in their state
of health.

The keys to enable the nursing profession to effectively cope with the challenge of caring for the elderly lie in specialised training that equips nurses with the knowledge needed.
There are no gerontological nurses in the Region. The concept of nurse practitioner is not acceptable in the area, although nurse practitioners are increasingly popular in the USA. There is a need for nurses to stress emphasis on health rather than illness⁽²³⁾ in addition to stressing the holistic aspect of nursing practice with older adults⁽²⁴⁾. There is a need to incorporate gerontological nursing preparation into basic nursing education ⁽²⁵⁾. The teaching of a Nursing Home Program is of vital importance. It will help nursing homes gain access to the research and educational resources of universities with student access to actual clinical nursing situations in real life. An attempt to create a close relationship between facilities and private institutes providing health care services to the elderly and institutions responsible for education and research should be made.

In the area of nursing, it was not until 1970 that the American Nurses Association developed and published the Standards of Geriatric Nursing Practice. These nurses are primary care and front line providers. They are most appropriate for coordinating and managing the care of the aged. Nursing is largely focused on health promotion, disease prevention, and long term management of chronic disorders and their exacerbations which require prompt and intensive interventions. The role of the geriatric nurse, in primary and managed care, can best be described as that of the health care provider who assesses the clients' needs and strengths on an ongoing basis, who provides continuity of care, and referrals to appropriate health professionals and agencies, as well as coordination of the clients' total care.

D. Social Work

Similar to the above-mentioned professions, the demand for social work services in the field of aging will be increasing through the next few decades. Major factors affecting demand for social workers include the rapidly increasing numbers of persons 60 years of age and older, particularly the rapidly growing population of older adults at high risk for social, psychological and environmental problems. There will be increased need for social, emotional and environmental support services for the elderly. Concomitantly, there will be even greater need for geriatric social work education.

Geriatric social work is built on a bio-psycho-social theoretical foundation. The definition of social work includes emphasis on the person-in-a-socio-cultural-contest, a context which includes the person as a member of kinship group, a family system, and an informal system which includes neighbours and friends. Coping with illness and disability are viewed within this system's context, which also includes the formal service delivery system and its interaction with informal supports. From the early beginnings of the social work profession, the definition of this profession has always included responsibility for what is now called case management, that is, the responsibility to secure the resources older adults need in a timely and appropriate fashion, and for facilitating the linkages among agencies and a system in order to ensure continuity of services. Today, case management is an essential component of the provision of care to older people, partly because of the fragmentation and discontinuities in the service delivery system, and partly because of the emphasis on cost efficiency and effectiveness. Although other professions are engaged in the provision of case management, the expertise of geriatric social workers continues to be a strong justification for the centrality of their role as case managers, and for this being part of their assignments on geriatric interdisciplinary teams.

The inter-relationship of social, psychological, biological, and economic factors, in determining the situations of older people, and the nature of their need for help, makes a team approach to professional practice and service delivery essential. Educational needs of those preparing for careers as geriatric social workers include an emphasis on the skills, knowledge, and values required for effective team work.

Social workers are key members of the interdisciplinary team required to deal with complex problems of older persons. The teamwork recognises that such problems necessitate a comprehensive and planned approach to their resolution.

Interdisciplinary teamwork benefits the elderly person in teams of coordinated service, more skilled services, avoidance of duplication of services, the introduction of preventive services, and convenience, not burdening the client with integrating needed services.

A recent survey in the USA concluded that geriatric social work is among the fastest growing specialisation within the profession, and further that regardless of the specialisation or the setting in which the social worker is practicing, 62% of social workers report the geriatric knowledge is required in their position. A number of significant issues in geriatric education for social workers must be considered. These issues must be confronted by the profession, in the context of the extraordinary changes, which are occurring in the health and social service system, and in these settings in which geriatric social workers practice. Emphasis should be made on managed care strategies, designed to contain health care costs, and rationalise the system, and the key role that social workers are being called upon to play as case managers. Also, increasing emphasis should be made on community based geriatric services, outside the walls of hospitals and long-term facilities, an emphasis which underscores the importance of the preparation of geriatric social workers for work with families, for linkage and advocacy roles, among others.

The need for social services for the elderly will be increasing in the next few decades. There will be increased need for social, emotional and environmental support services for the elderly. Concomitantly, there will be even greater need for geriatric social work education. Social workers are key members of the interdisciplinary team required to deal with the complex problems of older persons. The teamwork recognises that such problems necessitate a comprehensive and planned approach to their resolution.

E. Special Training programs in the Region

In Egypt an increasing number of the elderly either live alone, with elderly spouses, and/or with only one or two family members. The Care With Love program which is a training program for Home Health Care Providers was established. The purpose of the program is to create a sustainable well trained cadre of Home Health Care Providers in Egypt in order to staff units for Home Health Care Services. It was developed at the Center for Geriatric Services in partnership with the Coptic Evangelical Organisation for Social Services and Asalam Hospital, Mohandessin . The first training course was run in 1996 and 115 trainees joined the program taking various courses between1996 and 1999 of whom 99 had graduated⁽²⁶⁾. Ain Shamas University in Cairo started a series of courses on old age psychiatry. Additionally Malta Institute on Ageing had one course in Egypt on Ageing. Undergraduate medical schools have slowly started to introduce a few lectures on Ageing.

In an attempt to cover the gap, a number of professors and experts in the ageing field started the Middle-East Academy for Medicine of Ageing MEAMA in year 2002. The structure of the academy was inspired from the European Academy for Medicine of Ageing.

The aim of the Middle-East Academy for Medicine of Ageing:

* To improve knowledge and skills of professionals, physicians, nurses and health care officers, in health related problems in older people, starting with a special interest in community care in the Middle-East area.

* To harmonise the attitudes and goals of future opinion leaders in approaching the health related problems of older people in the Middle-East area.

* To establish a network among physicians, nurses and health care officers, responsible for the health care of older people and those responsible for medical and nurse students instruction, as well as general physicians caring for aged people.

* To stimulate scientific interest in the health related problems in older people.

The first course commenced in 2003/2005 to stimulate the development of health care services for older people in the Middle- East area. The course has been built up with 4 sessions, each of 4 days, that will cover important topics of the health-related problems in older people. The first session took place between October 2-5, 2003 . The participants came from six Middle-East countries. The members of this small enthusiastic group were all very much engaged in the problems they will face with older people in the nearby future. During the course the participants presented lectures about the situation in their own countries. The teachers' state of the art lectures focused on demographic aspects in the Middle-East area. Differences were observed between the countries. The MEAMA seems to be an excellent forum for the exchange between countries and discussions on developments. Other subjects discussed were heart failure, diabetes mellitus, osteoporosis, dementia, depression and
behavioural disturbances.

It was an advantage to have the speakers from the Middle East and from the European countries participating. This contributed to the high quality level of the discussions. The evaluation by the participants was excellent, with correct critical and constructive remarks. After these discussions topics were changed for the next sessions. At the end a comparison was made between the Middle-East area and the European Union. The patient related problems in the two parts of the world were found to be the same. A great difference exists however between the national and international structures for the development and the stimulation of care for health related problems in older people. The European Union has a well developed system of organisations which contribute to the control and improvement of the quality of services, education and training. In the Middle-East area this has to be started and needs the support of the international organisations.

The second session took place in Tripoli between April 8-11, 2004. The third session is
planned to take place in Bahrain in Oct 2004.

Solutions and Future Directions

Two expert committees from the World Health Organization^(27,28) recognise that the sophisticated and specialised services for the elderly found in the developed world are irrelevant for the immediate future and may not even be appropriate as long term objectives for developing countries. The World Health Organization^(28,29) developed a tentative model for a realistic approach to meeting the needs of the elderly citizens in developing nations. In this model, the needs of elderly people should, as far as possible, be met within the system of care developed for the population as a whole. Patterns of care should be based on functional assessment of the elderly. It envisages a system of care built up from the primary care resources of the community. Special emphasis should be given to programs that assist the family in its traditional role of supporting the elderly. Institutional long-term care services should be made available only when other alternatives are exhausted.

The severely impaired and dependent aged will need a wide range of professional care as will their families. In the process of creating adequate services, it is important to realise that home care and institutional services are complementary and multidirectional. Care of such patients needs the shared responsibility of both families and professional service providers. Services can be alternately provided in the home, the community, or the institution. Health promotion and prevention should be a key factor in any program. Environmental planning should take into consideration the needs of the elderly. The role of those concerned with aging in Lebanon or the Middle East is to provide communities and concerned professionals with the knowledge and skills to solve their problems, not to import solutions from developed countries after other alternatives have been explored. Health promotion and prevention should be key factor in any program. Geriatric and gerontological information should be a part of the education of all health professionals. Environmental design of hospitals and clinics should take into consideration the needs of the elderly.

Public Awareness

Aging is a biological process. It is not a disease. In order to increase the population's awareness of it, it is important to provide ready and correct information on the needs and abilities of old people. Bringing gerontological content to the school curriculum of children as preparation for adult life is one alternative to improve the public image of elderly patients. Many youngsters show signs of prejudice against old persons, bordering on what is now called ageism^(30-31).

Research

Despite the fact that 93% of potential years of life lost are in developing countries, only 5% of research dollars are spent on health problems of developing countries⁽¹⁾. Research is needed to optimise the strength potential of older persons and to improve their opportunities to perform rewarding roles in society. Efforts should be made to develop a population survey instrument that measures the levels of physical and mental function.

Conclusion

The demographic changes and social and economic developments in Lebanon have created new realities in an unprecedented growth of the elderly population. Trends, such as rapid urbanisation, a move from extended families to nuclear families, and technological developments make the problem of aging in Lebanon an acute one. Inappropriate application of costly technology could easily result, accompanied by diversion of resources from existing primary-care services in deterioration of the existing health care system. Many of the most effective measures promoting independence and autonomy promise to result from environmental changes and community organisation, e.g., transportation and physical adaptations for those with impaired mobility, provision of appropriate technology for the hearing or visually impaired, encouragement of mutual help groups. What is essential is to ensure the best possible quality of life for the greatest possible number of our aged.

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Table 1: Life Expectancy at birth for selected countries,
Human Development Report, 1996