How distance complicates caring for ageing parents
Caring for parents who can no longer care for themselves can be difficult. With increasing mobility, today’s adult children are even more challenged by geographical and emotional distances as their parents grow older.
“Over the last two years I’ve been back to the United States every two-and-a-half months,” says Swiss resident Carol McEowen, who travels regularly to see her elderly parents.
Coming and going is becoming more common for millions of people worldwide. The number moving from one country to another more than doubled – from 2 million to 4.6 million annually – during the decade 2000-10, compared to the previous 10-year period.
According to a joint studyExternal link by the United Nations and OECD, last year there were about 232 million ‘international migrants’ (a person living for one year or longer in a country other than the one in which he or she was born).
McEowen’s case is typical. She grew up an hour south of New York City and now lives in the Swiss capital, Bern. Another sister lives elsewhere in the US. Their parents lived in their home for 45 years, until her mother developed Alzheimer’s disease and daily life became even more difficult for the couple due to extreme weather conditions.
Hurricane Sandy “was bad in terms of hurricanes, but my parents’ area was fairly hard hit, and they didn’t have power for a month,” says McEowen. Her older sister brought supplies twice – a nine-hour drive from North Carolina.
A month later a bad snowstorm followed the hurricane. “My father called me every time a tree fell, at two in the morning,” says McEowen.
Difficult relations
Deciding how to care for an ageing parent is often a source of conflict and debate for families, says sociologist Thomas Geisen from the School of Social Work at the University of Applied Sciences and Arts Northwestern Switzerland.
Even after arrangements are made, there’s constantly a need to keep up discussion and communication, says Geisen. Emotional conflicts “are quite common” when families live at a distance.
Sometimes these distances are also emotional.
Heinz Keppler (not his real name) is the oldest of four children who grew up in Bern. One brother lives in Thailand, and the other has been living in the US “for about 40 years. The last time I saw him was in the late 80’s,” says Keppler.
“We’re a very problematic family,” says the 73-year-old. “We don’t like each other very much.”
Keppler’s mother lived alone in her own apartment until the age of 93, when she was hit by a car. Keppler and his sister lived not far away and were able to help their mother. “But my ‘dear’ brothers didn’t make the slightest effort,” says Keppler. “They didn’t lift a finger.”
Family conversations were out of the question. “We don’t talk to each other.”
Maintaining contact
“Often you have one relative who is very close and who takes all the burden of the care arrangement, and you as a sibling are far away,” says Geisen. “You are not so often there. Your contact with your parents is not that routine, not on an everyday basis.”
Today, keeping up relations over distance is easier than in the past due to technology, says Geisen, but studies have shown that “even Skype – where you can see the person – does not replace the identification, the feeling of being together which is given when you have everyday relations with the persons you are close to. The personal contact makes a huge difference.”
But personal contact often comes at a price.
At the same time that McEowen was tending to her failing parents in the US, her German husband was travelling to Munich every three weeks to visit his newly widowed father.
“The last few months we’ve been playing tag with each other. He’ll come home, I’ll go,” she says.
On the move
An interactive mapExternal link produced by the Pew Research Global Attitudes Project gives a country-by-country glimpse of immigrants’ and emigrants’ origins and destinations between 1990 and 2013.
Approximately one in ten Swiss citizens lives abroad.
“If you have such mobility around the world then of course family relations become more demanding, more challenging – especially when care arrangements are involved,” says Geisen.
The “only child” phenomenon
Some people don’t get along with their siblings. Others don’t have any. “Only children” are facing a unique problem in China, which currently has a population of around 1.4 billion. The Chinese government instituted a “one child per family” policy to reduce population growth in 1979. These children now have no siblings to share the responsibility of caring for ageing parents.
Carmen Gretler, a dual Swiss-Chinese citizen, is an exception. She was the third of three girls born to a couple in Guangzhou, a city in the south of China, close to Hong Kong.
But only one of the three still lives in China. Gretler has lived in Geneva for 16 years and another sister lives in the US. The sister in China is busy, says Gretler. “She’s a businesswoman.”
When their mother was diagnosed with cancer three years ago, Gretler felt she had to step in. “I called my boss, I went to Bern to get a visa, and I went home immediately. . . .I wanted to share the burden. Because I knew [my sister] wasn’t able to do everything.”
Call me! It’s the law
It’s not just in case of sickness that Chinese children have a duty to care for their parents. In July 2013, the Chinese government instituted a law requiring adult children to maintain regular contact with their parents through visits and phone calls. Parents can even sue children who don’t take care of them.
But Gretler says this doesn’t change the fact that China isn’t as family-oriented as it used to be. The aged are becoming “more and more lonely,” she says. “That’s a serious problem now in China. Before, a big family, like two or three or even four generations, would live under the same roof. But that was a half century ago. It’s not the same anymore.”
For McEowen, travelling regularly to the US has had not just a physical and financial toll but also an emotional toll. Her father died over the summer, and she feels even more responsible for her ailing mother.
“You can’t do everything for them – you’re so far away,” she says. “How do you come to terms with that?”
Ageing population
The Federal Statistical Office estimates that by 2060, 28% of the Swiss population will be 65 or older, up from 17% in 2010. And in a country with one of the highest life expectancies in the world, increasing numbers of retirees will be overseeing the care of parents who are in their 90’s.
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Wanted: young doctors for old patients
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As people live longer, the need for doctors who can deal with the issues facing the elderly is growing. However, the job of a geriatrician is losing out to other medical disciplines, such as neurosurgery or cardiology, in the battle for new recruits.
The intensive care unit at Bern University Hospital is busy. Nurses check monitors and change bandages of patients hooked up to beeping machines. Doctors travel in a group from bed to bed, transferring information at one of the three daily handovers.
Out of 51 beds, 40 to 45 are generally filled, says Stephan Jakob, chief physician for interdisciplinary intermediate care. And the average age in the unit is increasing.
“Ten years ago, it was not much above 60,” he says. “Now the average age is 65, but with a huge range, up to 90-95. And there are procedures which we didn’t use, let’s say ten years ago, for older patients, like transplantation, invasive treatment for stroke, artificial hearts. Now, because patients are getting older, these are increasingly used also for these patients, and they stay longer than the younger patients. So we need more beds.”
The needs of the ageing
Many problems that affect the elderly begin at a point where people don’t think of themselves as old. Already by the age of 50, one in five Swiss residents suffers from two or more chronic illnesses simultaneously, according to the Swiss Health Observatory. And patients aged 75 to 84 made up a fifth of all patients in Swiss acute care hospitals in 2012. In the United Kingdom, the average patient is more than 80 years old.
Treating the elderly requires special knowledge, says Thomas Münzer, president of the Swiss Geriatric Society and a chief physician in St Gallen. “They mostly have three or four or five different medical problems which need to be managed very carefully. And here we need to have the information about the biology of ageing, and we have to know that an old body functions differently from a younger body,” he says.
Training new doctors
There are special knowledge or skills needed for medical care of older people, and they have to be learnt, says Andreas Stuck, who heads the geriatrics department at Bern University Hospital.
Future doctors first need to learn the special ways disease appears in older persons. They need to learn how to communicate. They need to consider ethical issues, such as “whether you choose very proactive care with very intense treatment in a 90-year-old person as compared with palliative pain relief”. For this, they need to have special knowledge and skills for diagnosis and management of diseases in older patients, Stuck says.
To help standardise what medical students learn about geriatrics, Stuck and a group of European researchers collected input from 49 experts in 29 countries to develop consensus on a ten-point list of minimum requirements – knowledge and skills that new doctors should possess after medical school. The study, published in March 2014, concluded: “Major efforts will be needed to implement these requirements, given the large variation in the quality of geriatric teaching in medical schools.”
Furthermore, it’s not just young medical students who have to learn to deal with elderly patients: physicians must respond to the needs of older patients throughout their careers, Stuck says.
Specialists vs generalists
Geriatricians – physicians who specialise in the ageing population – serve in a variety of settings, from hospital care and home care to long-term care and terminal care. They are also involved in overseeing geriatric care and geriatric education.
Jürg Schlup, president of the Swiss Medical Association, says it’s reasonable to require a university hospital’s geriatrics department to be headed by a geriatrician. But according to Münzer, not until 2014 did every Swiss medical faculty have a chair in geriatrics, “so we are far behind in terms of training and education”.
In Switzerland it’s not just geriatricians who care for old people. “The majority of healthcare for older people is provided by family physicians, by hospital physicians, by specialists who have responsibilities for care of older people,” says Stuck. Thus “whatever discipline you choose, you will need special training in geriatrics as part of your training, and that covers the span from pre-graduate to postgraduate training.”
The Swiss doctor shortage
Providing specialised care for the elderly is complicated by the fact that in Switzerland there is a shortage of doctors overall.
“This lack of doctors has its roots in four principal developments in our country,” says the SMA’s Schlup.
“First, the number of medical students is too low. Second, the demand for services is increasing with the ageing of the population. Third, the number of doctors working part-time is growing. And fourth, the number of hours physicians are legally allowed to work per week was reduced from 60 to 50” in 2005.
Currently, about one third of the physician workforce in Switzerland is hired abroad, says Schlup, and in ten years that proportion is expected to increase to 50%.
“Thanks to the foreign physicians we’re doing well,” says Schlup. “But Germany, which exports its doctors, is now trying to get them back. We can’t run the system without them.”
Already, medical disciplines are fighting to attract enough young doctors. “If you work for a surgery department or an internal medicine department or a dermatology department, there is very big competition” to recruit students, says Schlup. That means there are even fewer potential candidates for careers in geriatrics.
Who will choose geriatrics?
“We are desperately seeking young physicians who are interested in training in geriatrics,” says Münzer.
But today’s medical students “want to become sports medicine physicians or ophthalmologists or neurosurgeons or whatever,” he says. “Nobody really says, ‘I want to become a geriatrician’. But I think some people make the decision later in their career.”
Gianna Negri, a young assistant physician in the geriatrics department of Bern’s Ziegler hospital, says she hasn’t decided whether she wants to become a geriatrician, but she likes working with old patients.
“A lot of young doctors think geriatrics isn’t exciting, she says, “but I don’t agree at all. I don’t find it boring. We have a lot of days that are challenging and full of action.”
“I think I have one of the most interesting professions existing,” says Stuck, who chose geriatrics in the 1980s.
Münzer, too, is satisfied with his career choice.
“It’s not that spectacular compared with cardiac surgery or neurosurgery,” says Münzer. “You can’t make a lot of money with it. And you’re treating diseases that are not very sexy, like dementia or frailty or falls and fractures and osteoporosis.”
Still, treating the elderly is “intriguing and fantastic”, he says. Every patient is different, and every approach is individual. “And if you look at the numbers, actually, this is the field of the future.”
Some health issues associated with ageing include falls and bone fractures, incontinence, malnutrition, osteoporosis, Parkinson’s syndrome, dementia including Alzheimer’s disease, bed sores (in bedridden patients), multiple medications and drug interactions, loss of autonomy, and the dying process.
The birth of geriatrics
Geriatric medicine was developed by pioneers in the United Kingdom in the late 1800s and early 1900s. In 2012, geriatricians were the largest group of consultant physicians (1,252 out of 12,221) belonging to the Royal College of Physicians. In Switzerland, on the other hand, geriatrics is a relatively new discipline.
The Swiss Gerontological Society, founded in 1953, is a national organisation focusing on the subjects of “old age” and “ageing”. But of its 1,400 individual members, only around 300 are actually geriatricians and organised in a daughter society, the Swiss Geriatric Society.
It wasn’t until 2000 that the Swiss Medical Association, under the auspices of the Swiss Institute for Continuing Medical Education, developed a three-year specialisation in geriatrics for doctors with degrees in general internal medicine.
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