Archive | August 2012

New ideas on how to counter polypharmacy risks

Over- and polymedication among the elderly is a risky business that we have covered earlier, eg. in a blog post by agjessica on Polypharmacy among the elderly. As Jessica recounts studies have shown that the risk of drug interactions (with potential negative consequences) increase from 6% to 50% in patients on 2 or 4-5 medications, respectively. Nevertheless, as the digitalization of healthcare gains grounds there are a couple of really interesting ideas out there on both how to better document the side effects caused by taking various medications at a time as well as on how to use technology to help elders (and others) out with keeping track of when they need to take their medications.

Last week I had the privilege to listen in to parts of a high level summit on the Globalization of the Healthcare Market, namely the Swedish American Life Sciences Summit, where Digital Healthcare was one of the subtopics of the year. As a former Mechatronics student I took a particular liking to two innovative solutions tackling the above challenge.

The first was presented by Nicolaus Henke, McKinsey’s Director of Healthcare Practice in Europe, the Middle East and Africa, as an example of the future potential of the mix of technology and healthcare. Dr Henke explained how Proteus Digital Health (that just got FDA approval to sell their solution as a medical device a little over a month ago) has created a pill that, swallowed, together with the gastric acids of the body gets activated and the energy needed to start analyzing real-time conditions of the body, such as information related to the medication taken. This information is communicated to a wearable patch, that apart from receiving the signal from the edible sensor also records the time that the medication was taken, as well as a number of other factors related to the person’s health, such as heart beat, temperature, physical activity, position (standing, lying down) and rest patterns. The patch further communicates this information to one’s smartphone and a secure server in order to collect and analyze data in order to support medical adherence and effective monitoring of a person’s health. The person being monitored can, in turn, choose who can see this information (physicians, caregivers and/or family members, only him-/herself etc) as well as get feedback via notifications when medications are overdue.

Fascinating piece of solution in my opinion. Proteus Digital Health’s edible sensor can currently ‘only’ monitor the time, characteristics and identity of what you swallow, but the company is working on a solution that can analyze bodily measures on a more advanced scale. Since estimations have shown that as many as a third to half of the world’s patients don’t take their medications properly solutions like these apparently have a large target market. Even though development and research on biomedical telemetry from ingestible electronics has been around since the 60s Proteus D. H. have managed to put the first (and currently only) product on the market within this particular field. Looking forward to follow what the research community on related solutions is planning in the years to come.

The second solution was developed by one of the conference participants, Mr. Robert Pakter, CEO and founder of Pilljogger, a company that has created an app that helps people track their medical intakes and thanks them when they stay on track. Mr. Pakter shared that he and his company are planning on developing a feature where patients will be enabled to report side effects that they experience when taking different medicines. Given that the Pilljogger app already will keep track of the different medications the patient is taking, this will also provide for an opportunity to track different side effects that arise from the combination of different medications in certain patients on a wider scale, providing a unique material that can later be used for further research and conclusions in the field of polypharmacy.

Thus, after my brief and intense opportunity to rub shoulders with some of the Healthcare industry’s finest, I feel reassured that we can expect to see a lot of exciting things in the field of digital health in the year’s to come.

PS. I also wanted to shine a little light on an unrelated topic, namely the Not-For-Profit research organization MEND (Medicine in Need), that I also got the chance to listen in to last week, and that are doing amazing work on the formulation of vaccines, reengineering them in order to make them more easily distributed to the developing world (mainly by taking them out of the cold chain, that is often so much more difficult to maintain in the developing world). Really inspiring work! DS.

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Elderly in China

In China, the population over age 60 has reached 180 million. It is predicted that the number will be increasing every year by 5-8 million. Beijing, for example, has the number of elderly people accounting for more than 15% of the city population. In the meantime, due to birth control (one child policy) starting in 1978 – together with the fact that more and more young people are going abroad for work or studies – the number of households with only elderly people is increasing. Senior citizens living alone have become the main characteristic of the aging situation in cities such as Beijing and Shanghai.

The retirement age normally is 50 (for women) or 55 (for men) in China, which is relatively young comparing to the western countries. What do they do after they retire? Most elderly have to provide day care for their grandchildren since maternal leave is only 3-4 months, while kids could only start going to day care at the age of three. In fact, the elderly are taking care of their grandchildren day and night during working days and the kids only stay with their parents during weekends. So when the elderly are enjoying the company of grandchildren, they have to make efforts to take care of them too.

The neighborhood community plays a key role in daily life for the elderly, especially in urban areas. The community center is an ideal place for elderly living in the same neighborhood to gather together and play chess, exercise, etc. Recently, these communities would also be responsible for the day care services (i.e. meal delivery) for the elderly who lose self-care abilities and ensure health checkups of the elderly in the neighborhood.

Transportation is a dilemma, as it is both easy and hard for the elderly. Starting with Shanghai, several other regions such as Sichuan, Lanzhou, Hangzhou, etc. allow elderly people aged above 70 to take public transportation for free. However, if they wish to take a flight, a health certificate is required by most aviation companies.

Monthly pension is normally 1000-2000 CNY (157-315 USD). However, elderly people feel insecure due to low coverage of public medical insurance (from the government). So Chinese people generally save for retirement, meanwhile support from the family is also expected especially when they are sick in the hospital – since usually medical insurance is not enough to cover the costs. Furthermore, nursing service is normally expected from family members due to Chinese tradition and unsatisfying nursing services provided by public hospitals/nursing homes.

Nursing homes are more acceptable by the elderly now than they used to be. In the past, elderly going to nursing homes has been looked down upon, since normally only solitary aged individuals would have to go there and the service from nursing homes was poor. However, due to the trend of an oncoming inverted pyramid within the population – and the improvement of service – going to nursing homes is more acceptable by the elderly nowadays. By interviewing one private nursing home owner, it was observed that compensation on the nursing homes for the elderly requires several criteria. Non-profit nursing homes are either hard to get in or equipped with poor service – with 6-8 beds in one room and one nurse for 15-20 people, while private nursing homes would have rooms with single bed available. There are also newly built public nursing homes these years with better conditions, but it could take the elderly years in the queue system to get a spot. Another issue mentioned by the interviewee was the labor system. Running nursing homes needs employees take night shifts. However, the nursing home labor system doesn’t share the same one as the hospital’s, which has made the management of employees difficult.

The Fifth Social Welfare Institute is one of the best nursing homes in Beijing. It has 230 beds in total and the normal price is 1800 CNY per month per bed. It is equipped with designated medical care (which could be reimbursed), as well as different kinds of activity rooms for dancing, playing pingpong, calligraphy, reading, etc. The reasonable price and complete setting of the nursing home attracts lots of elderly people, however, the waiting time to get in could be years.

In short, after early retirement, the elderly in China rely on pension for the expenses on daily life. While when they get sick or more senior, support from the family will be needed. They enjoy having fun with the people at the same age in the neighborhood or in nursing homes. The number of nursing homes in China is far from enough due to the rapid aging population. Though, the bed occupancy rate might be low in private nursing homes. More affordable nursing homes with upgraded and reimbursable medical services are definitely required for the elderly population in China.

Palliative Care in Singapore

According to the WHO definition of Palliative Care:  “Palliative care is an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual” (WHO Definition of Palliative Care[1]).

In Singapore, palliative care started as a grassroots movement in the mid-1980s to meet the needs of patients dying of cancer at home. The first home care team worked out of a university lecturer’s apartment in Gillman Heights. No doctors were trained in palliative care and there were limitations on the kind of care and setting where care could be provided.

Things changed a few years later. Singapore saw its first doctor trained in palliative care in the late 1980s. The first palliative care home provider – the Hospice Care Group – was formed in 1987. In 1988 Assisi Home and Hospice was established. This was followed by Agape Home and Hospice and the Hospice Care Association in 1989, Dover Park Hospice in 1995, Metta Hospice Care in 2001 and the palliative arm of Bright Vision Hospital in 2002. In 2007, the Lien Centre for Palliative Care was established to promote research and education in palliative care in Singapore and the region.  Since 1996, the restructured hospitals have also been building up expertise to support palliative care for their patients.

Palliative care has now advanced to the point that it can help manage and stabilise patients’ symptoms, and reduce their suffering. Due to greater and more structured training opportunities for healthcare professionals (palliative care is a subspecialty of medicine now), and a steady expansion of palliative care services, even treatments such as blood transfusions and intravenous infusion can be provided to patients in hospice care.

Palliative care is primarily provided by hospices (at an inpatient, home, or day-care setting).  There are four palliative care providers that offer inpatient hospice care, six providers that offer home hospice care and two that offer day hospice care.

Many restructured hospitals, as well as some community hospitals and nursing homes have also developed palliative care services, including  to meet the needs of certain specialty groups, such as children (for example, in KK Women’s and Children’s Hospital).  These services have largely evolved to meet the needs of patients admitted; the provision of palliative care services is not the main function of these institutions.

Palliative care is financed primarily by government subsidies and charity dollars.  Most home hospice services are free-of-charge for patients. Day hospice services, hospital-based services, and inpatient hospice services are offered at nominal fees, which can also be partly or fully waived depending on the patient’s financial ability.

Palliative care education is provided by a variety of organisations and institutions. For doctors, palliative care is part of the undergraduate medical curriculum. Subspecialty training is also available for some residency programmes. Palliative care is also incorporated in the formal generalist nursing curriculum for nurses and there are options for them to obtain an advance diploma in palliative care at the polytechnics. A number of different training programmes/certificates on palliative medicine/care are also run by different organisations for all health professionals (doctors, nurses, pharmacists, social workers and other health allied workers).

Public awareness and understanding of palliative care is still quite low. Many people still associate palliative care with giving up hope and treatment. The Singapore Hospice Council recently launched a new community outreach program to increase public awareness of inpatient, home and day hospice services available for end-of-life patients here.

Healthcare providers’ willingness to discuss end-of-life care and dying is also low. Research suggests that, even in hospitals, there seems to be some unwillingness of both patients and healthcare staff to talk about the potential of death.  Since 2009, health professionals have started utilising Advanced Care Planning (ACP) as a tool to start having open discussions with dying patients and their families.  ACP is currently being piloted at a few restructured hospitals, nursing homes and other end-of-life programmes.

These changes as well as some others implemented suggest that although willingness to discuss death still remains low, there has been improvement over the last few years.

In late 2011, MOH commissioned the Lien Centre for Palliative Care at Duke-NUS Graduate Medical School to formulate a National Strategy for Palliative Care in consultation with key stakeholders in the healthcare system.  The report reaffirms the important role of palliative care in the health sector as well as the importance of delivering such care in a coordinated and affordable manner. The report lists ten strategic goals and associated recommendations that address the importance of supply-side interventions such as training and ensuring adequate capacity as well as demand-side interventions such as the need for greater awareness and research. It also calls for greater leadership and governance to guide the development of palliative care services in Singapore.[2]

MOH recently accepted the report on the national strategy for palliative care. Presently, the Government has committed to expand the workforce and hospice care services to make end-of-life care more accessible to patients by committing to:

  • Incorporate a greater degree of palliative care training into courses offered in universities, polytechnics and Institutes of Technical Education.
  • Expand public education drives and awareness of the services to the terminally ill.
  • Promote specialised research and improve understanding of palliative care, by learning and adapting models used abroad.
  • Set up an implementation taskforce to put the strategies set forth by the Report on the National Strategy for Palliative Care into action in a country-wide coordinated manner.
  • Ensure that palliative care remains a key part of each regional health system.

Singapore’s ageing population and the effect it will have on epidemiological trends (increased burden of non-communicable disease, frailty and dementia, etc) and the subsequent needs required of the health system (increased demand for preventive services, long-term and end-of-life care), coupled with trends of increasing affluence, demand for more choices and declines in informal care-giving structures, suggest that the case for a greater role for palliative care, to meet the needs of patients who will face terminal illnesses, is strong.

Thus, a National Strategy for Palliative Care is welcome. To fully develop, palliative care needs more measures to promote the awareness of palliative care options, ensure that there are an adequate number of skilled healthcare professionals in the sector, introduce standards of care
across providers and settings, improve the coordination of care and ensure that there is adequate capacity to meet the demands for its care.

A greater role of palliative care will help increase the options, visibility, medical and social support for people facing end-of-life and enable decision-making based on preferences. It also allows for a more efficient use of resources for the health system.


HLC 2012. Briefing: Palliative Care in Singapore, July 26, 2012 version. Healthcare Leadership College, MOHH Holdings, Inc., Singapore.

Lien Centre for Palliative Care, Duke-NUH Graduate Medical School “Report on the National Strategy for Palliative Care,” Submitted to the Ministry of Health, Singapore, 4 Oct 2011.

World Health Organization (WHO). WHO Definition of Palliative Care .Accessed April 27 2012

Dementiabots: The movie, Robot & Frank

I went Friday night to see a movie just released here, Robot & Frank.  I knew I would love it just based on the premise, but it may just be my favorite movie in the last couple years.

Set in the “near future”, it tells the story of Frank, an older man suffering from early dementia, who is given a robot by his children to help take care of him.  The man, bored and isolated in a country town, gradually comes to enjoy the company and stimulation the robot provides.  The story gets moving when you learn that before his retirement he was a professional jewelry thief and now, with the encouragement the robot provides to be active, he realizes he can get back in the game and teach the robot to help him steal.  It’s a movie, so inevitably they get into trouble.

I am a sucker for movies about dementia because it is complex and a hard topic to do sensitively and well.  But Robot & Frank is about more than the vanishing mind.  It is about the person Frank was, is and always will be, and how dementia is just a part of that.  The movie and the actor, Frank Langella, make him shine as a character.  It is also about the stress that an aging and vulnerable parent puts on children, especially in the US, who live far away and have their own families or geographically distant careers.  In this way it touches on the way Americans in particular are dealing with dementia.

But it went from good to great because it got how we treat dementia right (Sadly, in the near future we still don’t have better medication to treat dementia it seems).  Now we largely treat dementia with lifestyle changes and support via caregivers and adult day programs.  The robot is basically a lifestyle manager– he gets Frank on a routine; he makes sure he sleeps enough; he keeps the house clean and orderly; he cooks and serves him well-balanced meals at regular times.   He endlessly proposes activites: let’s garden, let’s go for a walk, let’s play a game.  He knows that to keep Frank well he needs to keep him as physically and mentally as active as possible and keep a routine.  And then when Frank gets upset or angry, naturally he does not take it personally and can continue to work with Frank.  He does not get upset or burnt out — an unfortunate reality for many human caregivers.  By the end I was intrigued on how robots could be the perfect treatment to help people with dementia have the best functioning possible.

I would even suggest that Frank gets the idea to have the robot help him with burglaries because his brain is working better at this point, after the robot’s interventions have made him sharper.  This is not unusual.  When someone with dementia starts getting good care, they start doing better in many ways– mentally, socially and physically.

No matter, it’s all a movie anyway and such sophisticated technologies, while present in small ways– eg.  alerts installed at home to help family monitor their loved ones from afar, small fuzzy robots to help demented patients with behavior issues (see this prior post)— are a long way from being fully autonomous beings that can live with otherwise independent elders.  But I was impressed with how the screenplay and the movie treated the tangled issues of dementia, aging, and family tension and made it fun and funny.  Like anyone with dementia, Frank never stops surprising everyone, even the robot, who he reminds that “the human brain, it’s a lovely piece of hardware.”  Indeed.

See other reviews:

The Philippine Telegeriatric Pilot Project: How did it Start?

Access Health Philippines promotes innovations for the healthcare delivery system so that “all people wherever they are, have access to quality and affordable healthcare”. In partnership with Asian Institute of Management – Dr. Stephen Zuellig Center for Asian Business Transformation (AIM-ZCABT), a Telemedicine Project was formed with an ultimate goal of filling the gaps of widening problems in health access and shortage in the number of health specialists.

Elderly in the Philippines comprises 6.8% of the total population (NSCB, 2010), which means 1 out of 5 households have senior citizens. Older people have special needs and challenges in accessing healthcare services. The physical and cognitive disabilities limit their capacity to travel and access healthcare. They need specialist care providers for the aged. With the lack of access or difficulty to access health care, distance medication can be of great help to this sector of the society. This brought the telemedicine team to propose a start up project for the elderly population which is known as the “Telegeria”.

A Telemedicine team was formed which composed of members from different sectors which have stakes in providing better healthcare for the elderly. They are the Ayala Technology Business IncubationACCESS Health Philippines, AIM SRF/AIM ZCABT, ClickMedix, Total Transcription Solution Inc., Coalition of Services of the Elderly, Inc. (COSE) and Alliance of Young Nurse Leaders & Advocates International Inc. (AYNLA).

The Team initially chose to pilot the project in one of the major cities in Metro Manila. However, with a show of hesitation and delayed response from the involved staff, the Team prompted to look for another entity that was willing to adopt the concept and pilot the Telegeria. This is the Home Health Care (HHC) in Quezon City.

HHC specializes in delivering wellness programs and services to seniors and persons with disability in the comfort of their homes. It has a multidisciplinary expert team of physicians, registered nurses, physical therapists, nutritionists/dieticians, medical technologists and trained caregivers. They have been cited as a community resource providing quality home care for seniors across all settings.

HHC agreed to participate in the project seeing the opportunity for a potential innovation that could improve their management system in providing better and more cost-effective health services towards their clients.  A virtual clinic from ClickMedix system was given to HHC for a free trial of one full month. This was applied in their four senior residential facilities.

Check out for the continuation of this project in the coming blogs. This pilot project is being documented by the Program Coordinator and Program Associate of AIM-ZCABT, Davidson Teh and Jayson Soriano, respectively.

Iron in Old Age

Iron deficiency among adolescent girls and women of child bearing age has been an oft discussed topic. There have been pan-country programmes to provide supplements to these groups of girls and women. Role of iron in helping young children remain physically active and concentrate in classes etc. have been well established too. But how about iron requirements of the elderly? Does the declining physical and mental activity with age mean that they no longer need as much iron?

Nutritionists say, elderly may in fact be in need of iron supplementation. In a study conducted in Pennsylvania actually found a large percentage of women they tested on to be iron deficient. What effects does this deficiency of iron among the elderly lead to?

  1. Declining ability for physical activity-Iron, embedded in hemoglobin, helps transport oxygen to various parts in our body. Hemoglobin content in blood declines with declining iron intake. Deficiency of this carrier of oxygen in our bodies reduces the capacity of our muscles to act swiftly. This causes tiredness, short breath-in general an overall ability to strain the body physically.
  2. Declining ability to engage in meaningful mental exercises-Like our muscles need oxygen to move, our brain needs oxygen to think and concentrate. The deficiency of iron leads to the same effects it has on our physical muscles. This may reduce an elderly person’s ability to think clearly and concentrate as well as balance the body. This may lead to memory losses or at times physical injuries due to falls.
  3. Declining ability to fight infection-studies have shown that the response to infection among the iron deficient people is much more than the ones who have adequate iron. This also translates to longer healing. Increased chances of infection and longer healing processes further deplete an elderly body.

Iron supplements may be needed in some cases but eating right can help prevent iron deficiencies or the need for supplementation. The foods that are rich in iron are meats, sea food, green leafy vegetables, beans and lentils. Even when people consume good amounts of these foods, they may suffer from iron deficiency. This may happen due to poor absorption. Ability to absorb iron may decline with age. How do we overcome this problem of absorption? There are two simple steps:

  1. Have vitamin C rich foods such as citrus fruit, guava, gooseberry, papaya etc. with the iron rich food
  2. Avoid intake of tannin rich food such as tea and coffee for an hour before and after food consumption

References Sources

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Centrally planned communities, “new towns,” have been around in Japan since the 60s. However unlike the 60s many of these “new towns” are increasingly becoming more integrated, age-friendly. They are increasingly also built with the goal of ensuring sustainability and with helping communities successfully manage the rising social challenges, in mind.

An example of one such community is Yukarigaoka. Yukarigaoka was extensively planned back in the 1970s by Yamaman, a private company. It is located in the north-central Chiba city of Sakura. However unlike some other “new towns” that were also built around the 1970s (for example, Tama New Town, which is composed of mostly elderly persons), Yukarigaoka is specifically designed to allow for the elderly to live close to their families and friends in their communities with the hope that such integration will foster opportunities for younger generations to benefit from the old and vice versa (Yukarigaoka has a balanced population aged structure, which means that it provides a living environment for residents at all stages of life).

To date, Yukarigaoka has a total land area of 245 ha. and a population of 17,000. The distance to the nearest train station is no longer than 10 minutes by foot. Doctor’s offices and child care centres are also easily accessible and close to public transport. Electric bus transportation is available for the elderly in residential areas, so the aged have direct access to residential areas and can stop where they want to. Also, Yamaman directly intervenes to help maintain the relatively balanced population structure between the young and the old. Yamaman handles the sale of both new and older housing units in Yukarigaoka so that that the transition to new accommodation can occur seamlessly within the community and the value of property does not change too much.

Kashiwa-no-ha is a new “new town” that builds on this model. It is developed with a view to the future: to pioneer solutions for social challenges. The town has a planned population of 30,000 and is situated between Tokyo and Tsukuba. Similar to Yukarigaoka, Kashiwa-no-ha is a public-private academia partnership that aims to develop a city of health and longevity, a smart city, and a new industry-creating city. The city promotes ageing-in-place, wellness and health promotion in a community setting, and allows for middle-aged residents to benefit from mutual assistance within the community. Age-friendly services provided in communities include the provision of transportation, buildings, libraries, and shopping centres, among other support structures that are specifically catered to meet elderly and youth needs.

Large investments and multiple investors are increasingly common for the development of integrated communities that can address social challenges, such as environmental sustainability and population ageing. That these communities can be sustainable and can grow are important.

Enabling the elderly to successfully age-in-place and for the youth to have connection to the old, goes down to the design of a community in Japan: of creating the appropriate physical and social environments to ensure that the appropriate interconnections exist at the local level: between the service user, informal carer and professional; between various aspects of the healthcare system and across all relevant sectors, even though such coordination may not exist at the national level. Promoting inclusiveness of elderly ensures community sustainability and growth over time. It also enables the elderly to stay in the same communities as their families as they continue to age.

With one of the highest proportions of elderly in the world, Japan undoubtedly has more structures, funding mechanisms and institutions in place to support the aged. The importance of tackling the aged society is recognised at the national level in Japan (even though local communities have their own successful initiatives targeting aged people in highly rural areas). The Ministry of Health Labour and Welfare is the agency responsible for policy making and administration of the workforce, national pension system, national healthcare system, national nursing care insurance system, etc. While most initiatives related to ageing and planning involve and have been initiated by the national government, who has the authority to secure budget and distribute it to each local government, national/state/local governments also pay. The ventures are also open to other partners. Thus, while the Japanese Government seems to take on a large burden of caring for the aged, so do the other stakeholders in Japanese society.

The benefit of multi-stakeholder engagement to create these integrated communities is that the burden of the elderly is shared among a wide variety of stakeholders. Another advantage is that elderly needs can be provided more downstream at the community level, assuming that enough support structures are present in the community and home setting to enable that to occur. This ensures that all people in society can continue to remain productive, socially engaged and age-in-place in urban settings. It also helps ensure that the communities that are built or redesigned can successfully grow to address the rising social challenges facing Japanese society in the years ahead.

Field diary: Yukarigaoka by catforehead
Notes from AAIF Conference in Singapore, April 2012
Notes from unpublished research brief.