Chapter 4: The Chief Public Health Officer's Report on The State of Public Health in Canada 2010 – Setting conditions for healthy aging

Chapter 4: Setting Conditions for Healthy Aging

By examining the health of Canadians across the lifecourse, it is apparent that there are complex interrelationships among biological, behavioural, psychological, social, and health system factors that influence healthy aging.^{Footnote 16, Footnote 302} Many events and exposures occur throughout life – from infancy to senior adulthood – that can positively or negatively influence health and well-being. As well, initiatives and interventions aimed at positively influencing health and well–being can provide opportunities to prevent illness and promote health at all stages of the lifecourse.^{Footnote 15, Footnote 16}

The previous chapter outlined the state of health and well-being of Canada's seniors and identified key areas that can impact healthy aging in Canada. These areas include: falls and injuries, mental health, abuse and neglect, social connectedness, healthy living, and care and services. This chapter will consider actions that can be taken to advance healthy aging in Canada within these same areas. Where possible, concrete Canadian and international examples are used that have either proven effective and/or hold promise to positively influence the health and well-being of seniors. Generally, these examples highlight best practices, strategies and interventions that demonstrate what can be accomplished, and identify where more work needs to be done to influence conditions for healthy aging in Canada. While the key issues are explored in detail, it is also important to understand that there are underlying conditions that can promote or work against healthy aging.

Meeting basic needs

Without the basics – adequate food, shelter, security and health care – many health issues affecting seniors cannot be adequately addressed. Chapter 3 showed that factors such as isolation, lack of independence, abuse, inadequate nutritional practices, barriers to care and higher risks for falls, injuries and some chronic conditions can all be linked to basic needs that are not being met.^{Footnote 7, Footnote 22, Footnote 303, Footnote 304}

Having adequate income is fundamental to healthy aging and Canada has been effective in reducing seniors' poverty. Compared to other OECD countries, the occurrence of low-income seniors in Canada is below the OECD average, and Canada has the fourth lowest percentage of seniors with low-income.^{Footnote 240, Footnote 305} In large part, this success is due to widespread eligibility for government income programs and public pensions such as OAS, the CPP/QPP, and the GIS.^{Footnote 238, Footnote 245, Footnote 305} The successful reduction of seniors' poverty levels can also be attributed to today's seniors having achieved higher levels of education and higher levels of income, including increased pensions and higher income from investments, and greater participation of women in paid employment over the lifecourse.^{Footnote 238, Footnote 245, Footnote 305}

While Canada has been effective in reducing seniors' poverty, about 250,000 Canadian seniors, many who are unattached senior women, still have incomes below the after-tax low-income cut-offs.^{Footnote 238, Footnote 239} Others who may experience economic challenges include seniors who provide unpaid caregiving to a spouse, child, family member or peer, or who spend a significant portion of their incomes on non-insured health (e.g. vision care) and drug costs.^{Footnote 7, Footnote 238} Seniors with inadequate income are more vulnerable to chronic disease and psychosocial stress. These seniors are also more likely to engage in riskier behaviours, live in less healthy conditions and have less access to health care than those with higher incomes.^{Footnote 306}

Seniors can be disproportionately vulnerable to an interruption in meeting their basic needs during or after emergencies and natural disasters. Ensuring that seniors are supported and their health and functional capacity is maintained in these situations is an important public health issue. Despite this, the unique needs and risks, seniors in emergencies have often been overlooked or given low priority.^{Footnote 307} It is not age, per se, that makes seniors a vulnerable group; rather, it is the combination of factors that can affect an individual's capacity to cope. This is especially true when health and social factors (such as low-income, pre-existing physical and/or mental health, and functional limitations) exist, interact and are exacerbated during an emergency situation.^{Footnote 307-Footnote 310}

Populations and regions which are underserviced prior to an emergency event experience subsequent declines in support following the event.^{Footnote 309} Displacement can further disadvantage those already compromised.^{Footnote 308, Footnote 311} This often leads to a double burden for vulnerable populations such as seniors. In some cases, previous sources of support may be lost at the same time as responsibilities increase (e.g. caring for grandchildren).^{Footnote 311} It is important to note, however, that seniors can also be a resource with respect to emergency preparedness by volunteering, caregiving and providing knowledge and skills (see Textbox 4.1 Meeting basic needs during emergencies).^{Footnote 307}

Aging in place of choice

All Canadians should be able to age in their place of choice. However, choice is just one of several factors that can determine a person's residence. Others factors can include employment opportunities, household income, family needs (e.g. proximity to extended family and caregiving), type of community (rural, urban) and health status. For seniors, the choice of where to live may involve additional considerations such as the wish to stay in their current homes and/or communities, or a preference to live in dwellings that require lower maintenance, and where they can access support.^{Footnote 274}

Although most Canadian seniors report preferring to live in private homes, evolving circumstances (e.g. losing a spouse, having no dependents, declining health, lowering of income, lacking access to services) and factors such as size, design and maintenance of the home may encourage and/or force seniors to move.^{Footnote 318} To address some of these issues, programs such as the CMHC's Home Adaptations for Seniors' Independence Program have helped homeowners and landlords pay for home adaptations to extend the amount of time low-income seniors (those with an income below the specified regional lower limits) can live independently and in their own homes.^{Footnote 62} Adaptations, such as adding handrails, installing reachable cupboards, storage and door handles, and undertaking bathroom modifications such as grab bars are intended to meet age-related disabilities. Another CMHC program that has benefited seniors is the Residential Rehabilitation Assistance Program for Persons with Disabilities, which offers financial assistance to homeowners and landlords to modify dwellings for disabled low-income Canadians.^{Footnote 63} To further address barriers associated with affordability, the Government of Canada has invested in the construction of social housing units for low-income seniors as part of its Economic Action Plan.^{Footnote 319} Provinces and territories match federal funds for affordable housing through federal-provincial-territorial agreements.

Broader community and environmental practices can also contribute to aging in place of choice by making homes and communities age-friendly. For example, community and neighbourhood development plans should include consideration of an aging population. Widespread standards can also make a difference. The current National Building Code of Canada includes provisions for safety standards such as barrier-free exits and the installation of railings. However, accessibility requirements in the Code do not apply to detached and semi-detached dwellings or to duplexes and triplexes.^{Footnote 61} Greater awareness and implementation of these barrier-free design standards by planners, builders and inspectors is needed. So too is the adaptation of barrier-free design within the broader community – a concept that is embodied into the age-friendly design approach. Projects that involve age-friendly communities aim to address standards by creating environments that are inclusive, supportive, accessible and promote all aspects of active aging.^{Footnote 10} Given the growing need for age-friendly design, it may be of interest to housing developers to introduce and incorporate modifications within new buildings.

Age-friendly communities and universal design

The WHO's Global Age-Friendly Cities Guide identifies key built, social and service environments necessary for age-friendly communities.^{Footnote 177, Footnote 320} An age-friendly city includes factors that benefit all age groups: accessible indoor and outdoor spaces, available/accessible transportation and housing, a variety of social and economic opportunities, and community support and access to appropriate health services.^{Footnote 8, Footnote 83, Footnote 177, Footnote 321, Footnote 322} These factors allow individuals to age in place and are accessible to all regardless of level of mobility or state of health. Canada has played a leading role in creating age-friendly environments through involvement in the development of the WHO's Guide, as well as through an Age-Friendly Communities Initiative. The initiative is engaging senior Canadians in planning and design within their own communities to create healthier and safer places for seniors to live and thrive. As well, a guide for rural and remote communities, similar to the WHO's Guide on cities, has been developed in Canada, acknowledging the need for all environments to be age-friendly (see Textbox 4.2 Age-friendly cities and communities).^{Footnote 82, Footnote 83}

Universal design is an important component of age-friendly communities. Universal design involves the design of products and environments that can be used by all people to their greatest extent.^{Footnote 327} The concept of barrier free and universal design has evolved since the 1950s as a result of a demographically changing and growing population that is living longer (some with disabilities), changes in legislation regarding human rights (right to access for all), as well as growing public acknowledgement of the benefits of barrier-free design and assistive technologies.^{Footnote 328} There are seven principles of universal design, including:

• equitable use for people with diverse abilities;
• flexible use that accommodates a range of preferences and abilities;
• simple/intuitive use that is easy to understand;
• perceptible use that communicates information to a range of sensory abilities;
• minimal hazards and adverse consequences of accidental/unintended actions;
• efficient and comfortable use that requires low physical effort; and
• size and space that is appropriate for a variety of abilities.^{Footnote 327}

In essence, a good design is made for everyone regardless of age or capacity. Some communities, such as Shizuoka, Japan, have adopted universal design (see Textbox 4.3 Universal design of Shizuoka). As the population continues to age it will be important to consider how communities can support and enable their citizens to enjoy healthy aging and participate in society.^{Footnote 329, Footnote 330}

In Canada, the Canadian Human Rights Commission released a report in 2006 on International Best Practices in Universal Design: A Global Review. The report provides information on various subjects such as building designs that are accessible to all users, accessibility criteria in building codes and standards in Canada, space requirements to accommodate power wheelchairs, and the use of color contrasts and changes in textures for ease of building functioning.^{Footnote 331} In 2008, the Government of Ontario adopted legislation and customer service standards for accessibility that obliges all public and private organizations to accomodate people with disabilities.^{Footnote 332, Footnote 333}

Falls and injury prevention

As noted in Chapter 3, the majority of injuries to seniors are the result of falls and motor vehicle crashes.^{Footnote 148} Reasons for injuries are complex and can be attributed to a number of risk factors at the individual and community levels. Five key areas can contribute to reducing falls and preventing injuries, or mitigating the impact of these events on the health of seniors:

• developing falls prevention guidelines;
• increasing broad education and awareness programs;
• supporting healthy behaviours and choices;
• preventing falls with safer environments; and
• preventing driving-related injuries.

Each of these areas has either shown evidence of success and could be applied more broadly or is an area of promise where further work and investigation are required.

Developing falls prevention guidelines

The implementation of health care and public health practice guidelines can help to address risk factors for seniors' falls and ultimately create conditions for healthy aging. Although guidelines do not directly prevent falls, setting practices, standards, and management and assessment applications can contribute to a broad, overall falls prevention strategy. Falls prevention guidelines are necessary to assess individual risks, behaviours and challenges, and to establish standards to minimize the number and impact of falls. As well, guidelines can involve various sectors in reducing individual and community risk factors, and incorporate assessments and interventions into a broad strategy.^{Footnote 148,Footnote 337} Across Canada, falls prevention guidelines have been developed by organizations and governments; however, no broad national falls prevention guidelines currently exist.

National efforts on falls prevention strategies have included joint action with a variety of stakeholders. For example, Health Canada and Veterans Affairs Canada established a Falls Prevention Initiative from 2000 to 2004 that involved a community-based health promotion approach to help identify effective strategies for falls prevention among veterans. Professional organizations in Canada are also developing practice guidelines for falls prevention among seniors, such as the Registered Nurses Association of Ontario, which has developed Prevention of Falls and Falls Injuries in the Older Adult – a best practices toolkit for health care providers. The toolkit includes evidence-based clinical guidelines that have been implemented, assessed and evaluated.^{Footnote 337, Footnote 338}

For the most part, the American Geriatrics Society's Guidelines for the Prevention of Falls in Older Persons (2001) has set the international standard for seniors' falls prevention strategies.^{Footnote 148, Footnote 339} These guidelines are based on evidence gathered from systematic reviews, meta-analyses, randomized trials and cohort studies.^{Footnote 339} Recommendations have been developed based on this evidence, including:

• routine care of all seniors to assess fall history and identify potential risk factors;
• evaluation of those with a history of falls for risk factors such as abnormalities in gait, reduced mobility, chronic illness, vision impairment or effects of corrective eyewear and neurological system and/or cognition abnormalities;
• multi-factorial interventions such as exercising and using assistive devices;
• single interventions such as home modifications and medication management; and
• broad interventions such as bone strengthening strategies and using appropriate footwear.^{Footnote 148, Footnote 339}

Other countries, such as the United Kingdom and Australia, have also adopted guidelines and strategies for falls prevention.^{Footnote 148, Footnote 340, Footnote 341} The United Kingdom established Clinical Guideline 21: The Assessment and Prevention of Falls in Older People (2004), which included risk identification, multi-factorial assessments and interventions.^{Footnote 148, Footnote 340} The Australian government developed best practice guidelines and implementation guidebooks for falls prevention tailored specifically to seniors' environments such as hospitals, residential care facilities and community care.^{Footnote 341}

Increasing broad education and awareness programs

Many falls among seniors can be prevented. Appropriate educational programs and awareness campaigns, combined with home-based interventions, have been shown to reduce fall rates.^{Footnote 342} The goals of interventions based on education and awareness are to increase the understanding of the risks and consequences of falling and the benefits of prevention strategies.^{Footnote 155, Footnote 337} These types of interventions must consider a variety of audiences, including practitioners who work with seniors, the broader community, seniors' families, older adults in caregiving roles and seniors themselves.^{Footnote 159} This is particularly important because, in order to reduce the risk for falling, those who work with or care for seniors need to be aware of the factors that contribute to this risk.^{Footnote 337, Footnote 343}

Several provinces/territories are initiating falls prevention awareness campaigns to educate seniors on the risks of falls. For example, the Alberta Centre for Injury Control and Research and the Alberta Medical Association launched the Finding Balance campaign in an effort to educate and raise awareness among seniors – and future generations of seniors – about the importance of healthy and safe practices.^{Footnote 344} Additionally, programs such as Alberta's Steady As You Go, that build awareness about risk factors for falls and encourage changes to activities and choices, have been shown to increase activity and give seniors more confidence (see Textbox 4.4 Steady As You Go).^{Footnote 337,Footnote 345} As noted in Chapter 3, seniors who fall may subsequently develop a fear of falling; addressing this fear should be a part of any education and awareness campaign.^{Footnote 339,Footnote 343,Footnote 346} The Canadian Falls Prevention Curriculum is an evaluated training course that was designed to build on the knowledge and skills of health care professionals and community leaders working with seniors in the area of falls prevention.^{Footnote 347} Participants learn about current effective programs and resources for screening and assessing falls risk, and how to involve seniors as partners in the development of effective strategies and interventions.^{Footnote 347,Footnote 348} Such educational programs should address the diversity of seniors (including various linguistic profiles and literacy levels) by offering programs in multiple languages and formats.

Reaching seniors with awareness and education programs involves using various tools and methods of communication such as information sessions with presentations, question and answer sessions, discussion periods and printed materials (pamphlets, newsletters). Group sessions can also be advantageous, as they encourage socialization, idea sharing and peer support. However, to facilitate participation, group sessions should be held in accessible locations and take into account perceptions that may affect participation levels and motivation for seniors. For example, seniors may hesitate to participate in falls prevention programs, regardless of their age, for fear of being viewed as frail or vulnerable to injury.^{Footnote 337, Footnote 351} Initiatives that are effective in encouraging seniors to be actively involved address a range of abilities and adapt to differences in language, culture and social status.^{Footnote 337}

Supporting healthy behaviours and choices

While education can play a key role in reducing the risk of falls, it is not enough on its own. Exercise programs that are aimed at reducing falls typically incorporate cardiovascular endurance, balance, flexibility and include general activities such as walking, cycling and aerobic movements.^{Footnote 148, Footnote 343} Additionally, initiatives and programs aimed at falls prevention should consider individual behaviours and lifestyle, as these can influence the risk and impact of falls among seniors. For example, physical activity can improve balance, mobility and reaction time, increase bone density and, for those who have experienced a fall, it can reduce recovery time.^{Footnote 148, Footnote 337} A meta-analysis that examined the effectiveness of various types of exercise programs found that balance-training programs, in particular, positively influenced the prevention of falls, and programs that offered several training sessions a week were more effective than ones with less frequent sessions.^{Footnote 148} While strength and flexibility programs also had health benefits, there was no indication that they directly prevented falls.^{Footnote 352} Broad exercise interventions that encourage maintaining an active lifestyle over the lifecourse can reduce the risk of falling by 15% and the number of falls by 22% in senior adulthood.^{Footnote 148} Commitment to exercise is a lifelong activity and physical activity programs should target younger populations to engage in regular and sustained programs over the lifecourse.^{Footnote 353}

Research from the University of British Columbia's Centre for Hip Health and Mobility reinforces these ideas. The Centre's integrated research programs work to prevent falls and hip fractures with programs that span childhood through to senior adulthood. Programs and research in areas such as early disease detection, education and training of clinicians, interventions for seniors at risk, and research information sharing among practitioners are showing promise in reducing falls and minimizing need for hip replacement.^{Footnote 354} Research shows that fractures can be prevented through appropriate training and exercise over the lifecourse.^{Footnote 354}

Clinical management of chronic and acute illness is necessary in order to assess and manage individual exercise programs and reduce the risk of falls.^{Footnote 148, Footnote 343} Falls can be caused by adverse reactions to medications taken to treat chronic illnesses. Therefore medication review and modification, where appropriate, is a critical part of the assessment of the risk of falls and the ability to recover from falls.^{Footnote 148, Footnote 337} This medication review requires a greater knowledge of appropriate medication use (e.g. the lowest effective dosage specific to symptoms), common drug interactions and an understanding of the influence of medications on an individual's daily activities – including the ability to walk and use assistive devices and equipment. One approach to addressing drug interactions and associated health risks is to establish and maintain a drug database on common drugs used by seniors. Canada has a mandatory national Drug Product Database that includes human pharmaceutical and biological drugs, veterinary drugs and disinfectant products, and also contains product-specific information on drugs approved for use in Canada.^{Footnote 355} This database is a good information resource for health care professionals on various medications. However, information on an individual's current medication use and possible side effects is typically kept by their health care provider and is not available to others in the health community (including other health care providers and pharmacists). Saskatchewan has developed a Pharmaceutical Information Program that is a centralized electronic system of patient medication records (see Textbox 4.5 Pharmaceutical Information Program).^{Footnote 356, Footnote 357} Adopting a broad drug management system could reduce the risk of adverse health outcomes associated with drug use, such as falls, and increase the capacity of health care professionals to monitor and manage prescriptions and distribution of drugs at pharmacies.

While using assistive devices (AD) can offer seniors a greater sense of freedom, mobility, independence and confidence, their improper use can be unsafe and create a risk of falls.^{Footnote 148} Health care providers need to be fully aware of proper uses and safety precautions associated with AD and ensure this information is shared with all users. Focus group participants of the Health Canada/ Veterans Affairs Canada Falls Prevention Initiative (including individuals, health service providers and AD stakeholders) reported that the use of AD by seniors can be viewed as stigmatizing and symbolic of aging and inevitable decline, impacting an individual's willingness to use such a device.^{Footnote 148} Canada's Mobility Program educates seniors and their families on the positive benefits of using AD, addresses and dispels the stigma associated with these devices and works to provide practical information on usage by combining humour and expert advice. The British Columbia Institute of Technology's AD Anti-Stigma Project implemented among seniors, health care professionals and the media, has reached seniors in the communities of Oliver, British Columbia, Nipawin, Saskatchewan, and Middleton, Nova Scotia. Occupational and physical therapists are using resources developed from this project, and it is being expanded across Canada with workshops and multi-media tours.^{Footnote 358}

Promising research on AD is underway to address a range of environments that seniors may experience while using them. In order to assist people coping with daily life and disabilities, Toronto Rehabilitation has established a laboratory with a massive hydraulic motion platform containing several research modules that simulate inclement weather (such as cold and snow), the interior of a single-storey house, as well as hospital or nursing home environments.^{Footnote 359}

Greater awareness is needed on the benefits and possible risks associated with AD use, as is finding ways to promote education and research in this area.^{Footnote 148, Footnote 351} In addition, specific training for those who work directly with individuals using ADs, is required.

Preventing falls with safer environments

Since most falls occur in or near the home, performing a home assessment and then maintaining and/or modifying home environments can be effective in reducing the risk of falls and enhancing overall safety.^{Footnote 148, Footnote 337} Home modifications may include added stair rails, improved lighting and renovated washrooms. Some seniors may be physically unable to make the required changes and/ or be unable to afford the modification(s) to address home safety issues. There may also be some reluctance to modify homes as a result of perceived stigmas. For example, some seniors may perceive such modifications as revealing their disability, aesthetically unappealing, making a home appear like a hospital or devaluing their home.^{Footnote 360} Programs that support seniors should focus on the benefits of home modifications in preventing falls and encouraging safety, and providing help with renovations and associated costs, where necessary (see the section "Aging in place of choice" earlier in this chapter).^{Footnote 337} Occupational therapists report that involving clients in the creation and development stages of modifications, as well as providing visual examples of completed projects (e.g. photographs of similar projects), have had success in addressing seniors' reluctance to make modifications.^{Footnote 360} Home modifications have had some success in preventing subsequent falls.^{Footnote 361} Much of the success relies on the programs being suited to the needs of seniors and being delivered by a trained health care professional.^{Footnote 362} Home modifications can improve functional ability and increase daily activity performance within the home and these modifications can, therefore, support these seniors to age in place.^{Footnote 363}

Creating safer environments within communities can also address specific factors that cause falls.^{Footnote 337} Community involvement can raise awareness and encourage acceptance and commitment to falls prevention programs.^{Footnote 337} To ensure participation, communities must break down barriers such as ageism and stigmatization of seniors who take part in falls prevention programs. Such programs need to create opportunities to motivate and encourage participation by appealing to a diverse population with varying needs, abilities, accessibilities, cultures and languages.

Preventing driving-related injuries

While some negative public perceptions exist about seniors and driving, it is important to note that age is not a determining factor when it comes to unsafe driving.^{Footnote 364} Assumptions on an individuals' capacity to drive based on age contributes to ageism (see the "Addressing ageism" section later in this chapter).^{Footnote 365}

Creating policy about road safety for all drivers is a balance between individual rights and broad public safety. As with other age groups, only a small proportion of seniors drive unsafely. Often an incident involving a senior driver is the result of driving with an illness or functional limitation (including that caused by the use of medication). Most senior drivers assess their own ability to drive safely and restrict their driving as warranted; however – where circumstances dictate – all provincial/territorial jurisdictions require that physicians report medically at-risk drivers to appropriate authorities. While the Canadian Medical Association's Determining Medical Fitness to Operate Motor Vehicles provides guidelines for physicians, there are still no clear distinctions on functional limitation and ability to drive safely.^{Footnote 144,Footnote 366} In addition, health care providers may be hesitant to apply the guidelines because of the potential adverse affects on health such as seniors' reduced participation in activities, and isolation that could result from a loss of driving privileges.^{Footnote 366}

Addressing seniors' road safety involves raising awareness about safe driving as well as engaging in further research on clinical practices and public driving policies. The Public Health Agency of Canada collaborated with the Canadian Association of Occupational Therapists and McGill University to develop a National Blueprint for Injury Prevention in Older Drivers that is directed at preventing injury by promoting safe driving practices. The Blueprint investigates several options for safer driving and injury prevention such as offering refresher driving courses for at-risk drivers and encouraging policy makers to introduce incentives (such as tax credits and conditional licensing) for course participants.^{Footnote 367} A Canadian research program, Driving Research Initiative for Vehicular Safety in the Elderly (Candrive), has also been created to examine ways to improve the safety and health related quality of life of older drivers using a national multi-disciplinary, collaborative research approach to identify, analyze and examine the issues pertaining to the safe operation of vehicles by seniors. Candrive has several objectives, including developing knowledge (e.g. methods and tools to assess driving fitness) applying the findings into clinical practice and health and transportation policy, and implementing broad public awareness campaigns.^{Footnote 368} Since its initiation in 2002, the Candrive research program has developed partnerships with key seniors groups, as well as government and non-governmental agencies, a collaboration that has resulted in:

• a driving and dementia toolkit, an older driver resource guide for physicians;
• the Canadian Medical Association's Determining Medical Fitness to Operate Motor Vehicles;
• a Canadian Consensus Conference on Dementia (driving); and
• numerous national and international workshops on assessing medical fitness to drive.^{Footnote 368}

Promoting safe driving is paramount among all licensed drivers, including seniors.

Mental health

The issue of mental health among seniors is under-addressed, although awareness and research in this area is on the rise. Generally, compared to other age groups, mental health data on seniors is limited, as are the services, evaluated programs and interventions specifically targeted for this population. A key barrier to improvements on this issue is the misconception that mental health problems are an inevitable consequence of aging. As a result, mental health issues among seniors can often go unrecognized, undiagnosed and untreated.^{Footnote 369}

Regardless of age, mental health is important across the lifecourse. Although some people never experience mental health issues, others may develop them as they age or experience them over the lifecourse. Those who have or develop a mental illness can still experience positive mental health and/or well-being if it is identified and addressed in a timely manner. While this can become more difficult with the existence of a co-morbid condition, disability, drug/medication use, or a lack of social and economic support, appropriate interventions, policies and programs can ensure that mental health issues at any age and with any compounding factors can be prevented and/or addressed.

The following discussion highlights four areas that specifically address the mental health of seniors, including:

• promotion of mental health;
• anti-stigma and awareness;
• knowledge translation and exchange; and
• broad mental health strategies.

Each of these areas has either shown evidence of success and could be applied more broadly, or is an area of promise, where further work and investigation is required.

Promotion of mental health

All Canadians can benefit from the promotion of positive mental health and well-being. This is an important aspect of healthy aging that should be supported through all stages of the lifecourse. Further, mental health can be influenced by the socio-economic determinants of health.^{Footnote 370} In particular, social connectedness and healthy behaviours can positively affect and influence an individual's overall well-being and ability to cope with stress and life changes.^{Footnote 370} As a result, promoting mental health also involves initiatives that target the environmental, social, economic, and health and social service-related determinants of healthy aging.

Programs and initiatives that target behaviors as well as other determinants of health have had some success at improving mental health and well-being. For example, a randomized controlled trial in the Netherlands called Healthy and Vital promotes healthy living and physical activity among older Turkish immigrants by combining two-session segments – one on health education and the other involving a physical exercise program.^{Footnote 371} This population, which has been identified as "hard to reach" through universal health promotion activities, had better overall mental health and well-being outcomes as a result of the combined sessions. Positive outcomes were particularly noted among the oldest sub-group.^{Footnote 371}

The Active Living in Vulnerable Elders (ALIVE) Program promotes health and well-being by targeting efforts at low-income seniors living in apartment complexes. ALIVE's purpose is to enhance the quality of life for seniors through exercise classes, health information sessions and newsletters that emphasize independent living approaches. Outcomes have included an increased understanding of the health benefits of exercise as well as reports from participants that they were "feeling better" and enjoyed the social interactions and comfort of the program.^{Footnote 372}

Healthier communities can also contribute to good mental health through design and other considerations that encourage inclusion of all members regardless of age or ability. Communities with resources that offer opportunities for socializing and provide support within an environment where programs and services are easily accessible are also of benefit (see the section "Age-friendly communities and universal design" earlier in this chapter). To be considered age-friendly, communities must consider factors that will affect the mental health and well-being of seniors. To address this issue, the Canadian Coalition on Mental Health has developed and will facilitate the continued development of best practice guidelines for the assessment, treatment and management of key areas of seniors mental health within communities.^{Footnote 373}

Anti-stigma and awareness

Stigma can affect individuals, families and caregivers and occur in a variety of settings. Stigma can have adverse health and social outcomes by impacting an individual's ability to socialize, work and volunteer, as well as to seek help and treatment.^{Footnote 375} Some seniors with mental health disorders experience the double impact of being stigmatized for old age and for having a mental health issue. In addition, the stigma experienced due to a mental illness can result in poorer quality of care, marginalization outside care systems, warehousing (a process of abandoning an individual within an institution), social distancing and isolation, abuse and neglect, as well as unnecessary institutionalization.^{Footnote 374} While there are anti-stigma initiatives in place in Canada around mental health, work to date has primarily been focused on younger adults.^{Footnote 374}

Misconceptions related to certain mental health disorders such as depression, dementia, delirium, substance abuse and personality disorders can lead to further stigmatization. For example, dementia can be mistakenly considered to be a natural part of the aging process.^{Footnote 374} Seniors who have experienced some loss of memory and recognition can be treated by those around them as if they are not present and capable of making choices and decisions. A mental health issue such as substance abuse is often publicly perceived to be a disorder found only among younger populations and, therefore, is often not recognized among seniors.^{Footnote 374}

Increasing awareness of mental health disorders and the importance of good mental health is beneficial to all Canadians. Through awareness, misconceptions about aging and mental illness can be challenged and stigmas can be eradicated. This, in turn, can reduce barriers to treatment and care for seniors experiencing mental health issues. With improved education and awareness, individuals, caregivers, family members and health care professionals can be better equipped to identify and assess mental health issues in seniors. Furthermore, the dissemination of information on programs and services can help seniors, caregivers and families to identify options for further education, intervention, care and assistance, if required.

In 2009, the Mental Health Commission of Canada launched a ten-year anti-stigma/anti-discrimination initiative called Opening Minds. This initiative is the largest systematic effort to reduce the stigma of mental illness in Canada.^{Footnote 376, Footnote 377} Through Opening Minds, several programs have now been launched that address community mental health care education such as: Changing Minds (St. John's), Extra Ordinary People – Centre for Building a Culture of Recovery (Penetanguishene), Brandon University Psychiatric Nursing Program (Brandon), and Stand Up for Mental Health (Vancouver). Each of these programs uses different techniques (such as narrative, comedy and panel presentation) to inform health care professionals about the realities of living with a mental disorder.^{Footnote 378} While these programs are promising, the focus of this initial work is on youth and raising awareness among health care professionals.^{Footnote 376} More work needs to be done to address discrimination/stigma experienced by seniors.

Australia, New Zealand, the United Kingdom and the United States have implemented broad anti-stigma campaigns and strategies from which Canada can learn and build. Programs such as New Zealand's Like Minds, Like Mine and Scotland's See Me: Scotland are examples that use social marketing campaigns to address public attitudes and challenge stigma by encouraging the social participation of people with mental health problems.^{Footnote 379, Footnote 380} More work and research are still needed to examine the overall effectiveness of anti-stigma campaigns in reducing stigma, changing views of mental health and illness, and identifying future directions for research.^{Footnote 381} Anti-stigma campaigns have had limited success due to insufficient support and evaluation in campaign development and follow-through.^{Footnote 375} As well, existing campaigns tend to target whole populations rather than focusing on age-specific issues. While seniors' mental health issues can be addressed in a broader context, some consideration should be given to age-specific situations.

Knowledge translation and exchange

The Canadian Coalition for Seniors' Mental Health (CCSMH) works with partners across the country to facilitate and advocate for initiatives that enhance and promote seniors' mental health. The CCSMH also established national guidelines on the prevention, assessment, treatment and management of seniors' mental health issues.^{Footnote 207, Footnote 384} In 2005, the CCSMH's National Guidelines for Seniors' Mental Health Project was created to develop evidence-based recommendations in four key areas: delirium, depression, mental health issues in long-term care homes, and suicide risk and prevention. The resulting guidelines were the first national interdisciplinary guidelines created to address these issues.^{Footnote 207, Footnote 384} The CCSMH has also since created guides for seniors and families based on the national guidelines.^{Footnote 385}

Following the development of the CCSMH guidelines, seven pilot projects were established across Canada to implement them in a variety of settings. For example, a Late Life Suicide Prevention Toolkit was developed for health care providers and educators in health education programs at universities and colleges that provides health care providers with interactive, case-based DVDs, the CCSMH National Guideline for the Assessment of Suicide Risk and Prevention of Suicide, a clinician pocket card, as well as materials for educators.^{Footnote 386, Footnote 387} In addition, the CCSMH developed Suicide Prevention among Older Adults: a guide for family members to assist seniors, families and others to recognize suicide risk factors and warning signs and methods to address these risks. This guide shows promise in translating knowledge regarding suicide risk and prevention among seniors.^{Footnote 388} Guides for seniors and family members were also created to address the topics of depression, delirium and mental health issues in long-term care homes.^{Footnote 384}

Currently, the majority (estimated to be 80% to 90%) of long-term care residents have a cognitive and/or mental health disorder.^{Footnote 206, Footnote 207} In addition, nearly half of residents have a diagnosis and/or symptoms of depression with associated negative health, function, social and/or quality of life issues that need to be considered in care facilities.^{Footnote 221} The proportion of long-term care residents with mental health disorders may be even underestimated given the challenges in diagnosing seniors, particularly those in care facilities. However, recent studies (2010) have found that standardized clinical assessment instruments provide better information to identify seniors at risk of poorer health outcomes as a result of depression or symptoms of depression by focusing on specific symptoms and behaviours. The instruments can also monitor the effectiveness of interventions put into place.^{Footnote 221} For example, in Whitehorse, Yukon, assessment instruments for depression symptoms have been used by health care providers to identify and understand patients with depression whose needs may have otherwise gone undetected. Through this process, providers are better able to deliver more focused and comprehensive care plans. Staff report results in reducing residents' depressive symptoms and improving factors that contribute to the quality of their life.^{Footnote 389}

The state of health found among seniors in residential care requires action such as adjustments to the number and skills of staff, support services and facility environment resources required to care for this vulnerable population. The current lack of sufficient resources has resulted in adverse outcomes in health and well-being such as overmedication, misuse of restraint tactics, staff stress and turnover, and the warehousing of individuals.^{Footnote 206} By sharing information on mental health disorders with a range of health care professionals and the general public, a better awareness and understanding of these disorders can be established, and steps to better manage and meet the needs of facility staff, residents and family members can be identified.

The National Initiative for the Care of the Elderly (NICE) is an example of an initiative that recognized the importance of using knowledge exchange networks to disseminate research into practice. The NICE networks have developed a training curriculum component that brings together those who work in each knowledge area to share information across professions such as medicine, nursing, rehabilitation and social work who work with seniors. NICE operates through a network of Theme Teams and Committees dedicated to improving the care of seniors in Canada and abroad. It covers several key areas of seniors' health, including caregiving, dementia care, elder abuse, end-of-life issues, mental health, ethnicity and aging (see Textbox 4.7 The NICE Elder Abuse Team: Knowledge to Action Project later in this chapter).^{Footnote 390-Footnote 392}

Translating research into practice is also a goal of the Canadian Dementia Knowledge Translation Network (CDKTN). The purpose of CDKTN is to facilitate and accelerate knowledge translation through a national network of researchers and user communities focused on Alzheimer's disease and related dementias (ADRD). The goal is to facilitate and accelerate knowledge translation through the network in order to build capacity, as well as address services gaps in ADRD diagnosis, treatment and care.^{Footnote 393}, ^{Footnote 394} This initiative is also working to build and develop long-term national and international collaboration.^{Footnote 395}, ^{Footnote 396} Currently, CDKTN membership includes over 200 researchers and care providers across Canada. It covers three key theme areas, including: education and training in knowledge translation; Canadian dementia resource and knowledge exchange; and patient/caregiver centered knowledge translation. The three areas integrate to create outcomes such as increased patient and caregiver access to information about dementia, and increased uptake and application of research findings on dementia care.^{Footnote 397}

A pan-Canadian initiative to support research and share information about seniors' mental health issues, causes, treatments and interventions would be beneficial. It would provide an opportunity for collaboration within multiple sectors and among various stakeholders across Canada and, quite possibly, with international partners. The Mental Health Commission of Canada has initiated a Knowledge Exchange Centre to provide access to evidence-based information about mental health and mental illness and to enable people across the country to become engaged. Within this Centre, knowledge exchange networks focused on the mental health of seniors could advance research and development to better serve this population.

Broad mental health strategies

Mental health strategies and policies need to be flexible enough to respond to diverse needs.^{Footnote 398} Some current national mental health strategies currently exist that focus on the specific mental health issues of certain subpopulations of seniors. For example, Veterans Affairs Canada's Mental Health Strategy provides services based across four areas – service continuum, capacity building, leadership and partnerships – and emphasizes a "whole person" approach, while also building capacity to assess, support and treat those living with post-traumatic stress disorder.^{Footnote 399}

The Mental Health Commission of Canada (MHCC) has developed a framework, Toward Recovery and Well-Being: A Framework for a Mental Health Strategy in Canada, to address the current and future mental health needs of all Canadians, including seniors. The strategy will work to enable everyone living in Canada to have the opportunity to achieve the best possible mental health and well-being.^{Footnote 398} To build the strategy, the MHCC has established eight advisory committees to advise and engage stakeholders, including one focused specifically on seniors' mental health. This committee is working to ensure that a lifecourse perspective, as well as the mental health of seniors, is included in the work and initiatives of the Commission. Committee work includes identifying strategies to specifically target seniors' mental health, including anti-stigma/anti-discrimination initiatives.^{Footnote 373, Footnote 373} Similarly, a First Nations, Inuit and Métis Advisory Committee is concerned with promoting the overall mental health of Canada's Aboriginal peoples, including seniors. Overtime, it aims to meet needs while ensuring that its structure reflects cultural beliefs and increases knowledge and understanding of cultural safety, social justice, ethical accountability and diversity competency. As well, it is promoting and developing Indigenous-determined ethical guidelines in the delivery of front line mental health and addictions programming in Aboriginal communities.^{Footnote 401}

Another initiative with national implications is the Seniors' Mental Health Policy Lens (SMHPL), which has been endorsed by the Seniors' Advisory Committee of MHCC. SMHPL is an instrument that was created to strengthen the capacity of government and nongovernmental organizations to develop policy, legislation, programs and services that promote and support the mental health of seniors. Developed by the British Columbia Psychogeriatric Association, the SMHPL is also an analytical tool for identifying and predicting unintended direct or indirect negative effects of current and planned efforts on seniors' mental health. The tool achieves this by considering a range of factors such as income and accessibility of services.^{Footnote 402} The Association has also developed guidelines to support the mental health needs of seniors who are dealing with cancer care. These guidelines provide a unique perspective of the intersection between chronic disease and mental health, and provide practical information for caregivers.^{Footnote 403}

Preventing abuse and neglect of seniors

As reported in Chapter 3, abuse or neglect affects between 4% and 10% of seniors in Canada.^{Footnote 283} Only recently considered an issue of global concern, abuse and neglect still remains hidden and under-reported.^{Footnote 274,Footnote 287,Footnote 404} While the data on the abuse and neglect of seniors is limited, the fact that it occurs at all is unacceptable; therefore, further addressing this issue through interventions, laws and policies is necessary for the protection and health of all Canadian seniors. The following discussion highlights three key areas that have shown evidence of success or promise in identifying and reducing abuse and neglect of seniors:

• laws and legislation;
• awareness, education and training; and,
• strong and sustainable communities.

Laws and legislation

In Canada, criminal, family violence, adult protection and adult guardianship laws can help protect seniors from abuse and neglect. While the criminal law applies across Canada, civil laws vary by province/territory and may be applied differently depending on the mental capacity of the adult being abused and neglected.

Forms of abuse such as fraud, assault, uttering verbal threats and criminal harassment are considered crimes under the Criminal Code of Canada.^{Footnote 297} In addition, violation of provincial laws that protect seniors related to guardianship, health law, substitute decision-making and succession legislation, such as abuse of power of attorney or contravention of trustee acts, are offences within provincial/territorial jurisdiction.

Many provinces and territories have protection and guardianship laws that provide additional civil measures to protect older adult victims of abuse as well as a range of social service interventions to protect older adults in cases of physical or mental deterioration.^{Footnote 297, Footnote 405-Footnote 412} Several jurisdictions also have legislation relating to institutional abuse to respond to reports of abuse of persons in care.^{Footnote 297, Footnote 413-Footnote 417} In addition, most jurisdictions have family violence legislation that provides civil protections to victims of family violence, including emergency intervention orders.^{Footnote 297, Footnote 418-Footnote 426} In Quebec, human rights legislation may also help protect adults in situations of abuse by specifying the rights of dependent adults.^{Footnote 427}

Balancing protection with the need to respect seniors' independence is an issue for Canadian health care and community service workers. While laws are in place to protect Canadians, sometimes there is a lack of awareness of and a reluctance to pursue action under these laws. Addressing abuse and neglect raises difficult questions and poses legal and ethical dilemmas for health care and community service providers. Many lack the necessary training and information and are ill equipped to appropriately identify signs of abuse and neglect. Also, it can be challenging to simultaneously adhere to the practice guidelines that are specific to their discipline, the provincial laws (with respect to vulnerable seniors) and the rules governing their place of employment.^{Footnote 428} In many cases, seniors who experience abuse from family members wish the abuse would stop but fear isolation and loss of family relationships. As such, incidents of abuse and neglect within this demographic often go unreported.^{Footnote 429} This may also be due to a lack of understanding about what constitutes abuse and neglect of seniors and the associated laws that criminalize abusive behaviour.^{Footnote 429, Footnote 430}

Awareness, education and training

Preventing abuse and neglect of seniors involves raising awareness and changing attitudes. Prevention strategies, practices and programs that address abuse and neglect are – for the most part – unevaluated for effectiveness. As broad awareness of abuse and neglect of seniors increases, it is expected that prevention programs will be further developed, available data will increase and comprehensive evaluations will take place.^{Footnote 283} Therefore, increasing awareness and investing in education programs about abuse and neglect of seniors will have important benefits:

• to increase the capacity of social and health professionals who work directly with seniors to identify abuse and find appropriate supports;
• to inform potential victims of their rights and the actions they can take to protect themselves; and,
• to raise awareness among seniors, their families, neighbours and communities about the issue and existing supports that are available to help seniors and caregivers deal with the situation.

A key part of any abuse strategy is to increase the capacity of social and health care providers to identify signs of abuse, to work with affected individuals and their families and to recommend appropriate action/support to address the problem. The World Health Organization recommends training primary care workers on what to watch for and how to play an active role in the prevention of abuse and neglect, given that a systematic review revealed that most professionals underestimate the prevalence of some abuse and neglect of seniors.^{Footnote 404, Footnote 431} As well, it was reported that only a quarter of American physicians are aware of the American Medical Association guidelines on elder abuse. Those health care professionals who have had some training on this issue are most likely to detect abuse and to recommend appropriate interventions.^{Footnote 431} Similarly, studies in the United Kingdom showed that most general practitioners report that education and training would be beneficial to them in identifying and managing cases of abuse and neglect of seniors.^{Footnote 432} In Canada, some seniors' outreach workers reported that abuse and neglect prevention training increased their knowledge and gave them the tools for identification of abuse and neglect. The training also reviewed guidelines for reporting suspected cases as well as addressing health and social outcomes of abuse and reporting abuse.^{Footnote 283} While it was considered to be useful, participants reported that it would be beneficial if the training programs covered a range of abuse issues (such as financial, physical, emotional) and were offered to various health and social care providers from fields such as medicine, social work, policing and criminal justice, religion, education and policy/decision-making.^{Footnote 283}

Broad public education and awareness practices that address family violence and child abuse have had some success and could be applied to abuse and neglect prevention for seniors (see Textbox 4.6 Federal Elder Abuse Initiative).^{Footnote 433} Fundamental to the success of education and awareness programs is providing information to reduce stereotyping and age-based assumptions (see the section "Addressing ageism" later in this chapter), as well as targeting a range of populations. Programs that specifically target seniors are important for two reasons: to help seniors acknowledge their own situation as well as to help recognize situations of abuse among peers. Seniors' programs need to provide information, break down barriers of stigma and blame, as well as identify positive opportunities for seniors to be active and participate in their communities (e.g. as mentors and leaders).^{Footnote 434} In addition, given the diversity of Canada's senior population, education programs should discuss abuse and neglect in culturally appropriate language and context.^{Footnote 283}

Since caregiving roles are often filled by family members and others in relationships of trust, targeting family members in terms of education and awareness is an important prevention initiative. This can help to identify acceptable and unacceptable behaviours toward seniors, as well as assist family members and others in addressing their own stress, health and well-being. Family dynamics, including history of domestic violence, substance/alcohol abuse and psychopathology of the caregiver are some of the issues that need to be examined when determining family caregivers at risk to abuse. Viewing abuse and neglect of seniors as a societal issue, not just a private family matter, has the potential to raise the urgency of the problem of abuse and neglect in the context of family caregiving, and lay the foundations for better care and for social change. The Families Commission of New Zealand recommends using an ecological framework that encompasses the individual, the family, the institutional setting, the local community and the broader society in which the caregiver and care receiver live.^{Footnote 441} Broad caregiver assessments have been established as a best practice for overcoming barriers to promoting and sustaining caregiver health, however more research is required to better meet the needs of care recipients and to better support their caregivers.^{Footnote 442, Footnote 443}

Internationally, there is growing recognition that education and awareness around abuse and neglect prevention will require the creation of knowledge and information networks in order to identify current and emerging issues, to develop strategies and frameworks and to share information and best practices. Canada has made progress in creating networks for abuse and neglect prevention with the Canadian Network for the Prevention of Elder Abuse, as well as provincial networks such as the Ontario Network for the Prevention of Elder Abuse, the Manitoba Network for the Prevention of Abuse of Older Adults and the B.C. Community Response Networks.^{Footnote 444-Footnote 446}

Many health care professionals working in institutional settings (e.g. long-term care facilities) report witnessing some form of abuse and neglect in institutions at some point during their careers; however there is little information on best practices for preventing this abuse.^{Footnote 450} The reasons for this abuse may include residents' level of cognitive impairment which exceeds or tests caretakers skills and capacity to cope, a perceived loss of respect and rights of individuals who are disabled and incapacitated, the disconnect between institutions and the broader external community, and systematic problems (e.g. inadequate staffing, misunderstanding of duties, financial constraints and fear of reprisals for residents who report abuse).^{Footnote 450} Addressing abuse and neglect of seniors must recognize the broader systemic issues of specific staff training and skills, ageism and resource allocation to care for seniors in regulated/unregulated care facilities.^{Footnote 451} Prevention needs to focus on overcoming these challenges.

Training on appropriate care and abuse and neglect prevention can build capacity to help ensure that seniors in care are protected from harm and that they live in safe and respectful environments. Approaches used to prevent abuse and neglect in institutional settings include developing and executing a variety of education and training initiatives to help staff identify abuse and increase the knowledge and skills they needed to prevent it.^{Footnote 450}, ^{Footnote 451} Little is known, however, about the effectiveness of training for health care professionals working within institutions; more work is necessary to better understand abuse and neglect of seniors in these settings.^{Footnote 431}

Strong and sustainable communities

Coordinated community-based efforts for addressing abuse and neglect have been shown to be as, or more promising, than sporadic and uncoordinated efforts. A coordinated community development approach should map community resources, develop common understandings of abuse and build communication and service networks. This process is collaborative and can lead to the development of inter-agency protocols and coordinated prevention and intervention approaches. Sectors such as legal, social, education and health care services need to partner to prevent abuse and neglect, protect and support seniors who may be at risk.^{Footnote 283}

Seniors themselves have a role to play in their communities as leaders, as well as advocates for healthy aging and abuse and neglect prevention. They can become involved by learning about their rights and how to talk to other seniors about challenging issues such as abuse and neglect.^{Footnote 452, Footnote 453} There are also steps seniors can take to protect themselves such as staying active and socially connected.^{Footnote 454} They can also ensure that their financial transactions take place automatically through financial institutions (and can be monitored accordingly) and that matters concerning power of attorney and property are addressed by people of trust.^{Footnote 452} Identifying people of trust can be difficult, however, and eventually problematic if the position of trust becomes one of abuse. Active steps can be taken to address an abusive situation such as telling someone and understanding that abuse can happen at any age to anyone, and that abuse is a violation of rights that is not the fault of the victim.^{Footnote 454} Interventions must include roles for victims in the community. Building capacity at the community level is important to address the problem of abuse and neglect of seniors.

Social connectedness

There is a direct relationship between social connectedness and well-being; having family, friends and feeling a sense of belonging to a community contributes to good health.^{Footnote 12}, ^{Footnote 177} The following discussion highlights three key areas of action that contribute to encouraging and improving social connectedness:

• addressing social isolation;
• volunteering; and
• addressing ageism.

Each of these areas has either shown evidence of success and could be applied more broadly, or is an area of promise where more work and investigation is required.

Addressing social isolation

For some seniors, social engagement and minimizing marginalization can depend on access to community facilities, transportation and affordable activities, as well as on having meaningful roles in society.^{Footnote 12, Footnote 177} Seniors who live in rural and remote areas may be at risk for social isolation because of their physical location. Seniors caring for other seniors can also be at greater risk for isolation due to responsibilities that may leave them little time or energy to engage in outside activities. Immigrants who come to Canada as seniors may also experience heightened isolation as they try to adapt to their new community, especially if they experience language barriers that create difficulty in accessing services and being socially engaged.^{Footnote 7}

Addressing social isolation is important at all stages of life, as social patterns are developed and maintained throughout the lifecourse. The cumulative impacts of isolation can be greater, however, as people age and as opportunities for social engagement become less frequent due to factors such as poor health, loss of loved ones, loss of roles/responsibilities and decrease in income.^{Footnote 455-Footnote 458} Achieving greater social connectedness for isolated seniors requires supportive environments that offer a range of options for engagement, meaningful roles and respect within the community.^{Footnote 12} More research will be needed about the quality of community-based support networks, as well as the perception and acceptance of these support networks among seniors at greatest risk.^{Footnote 459}

There are a variety of targeted interventions that address social isolation among seniors. These include one-on-one support and educational group sessions.^{Footnote 460} A systematic review of the effectiveness of these interventions found that group interventions that covered a range of topics and encouraged expression were successful over time.^{Footnote 461} In addition to targeted interventions, social engagement can be encouraged through programs that foster integration within the community. In Canada, the New Horizons for Seniors Program (NHSP) funds initiatives to improve the quality of life for seniors through participation in active living and social activities.^{Footnote 462} NHSP also supports initiatives that promote respect by enabling seniors to share their knowledge and experiences, and raising awareness of issues facing seniors such as abuse (see Textbox 4.8 New Horizons for Seniors Program).^{Footnote 462}

Given the potential adverse impacts of social isolation on the health of seniors, future programs should consider supporting transportation initiatives for seniors, increasing service delivery and including service to remote areas.^{Footnote 460} It is important to increase community awareness of services for seniors. As well, developing outreach strategies for programs and services for seniors will require identifying which populations are underutilizing services and targeting attention to those seniors (and their networks) in program marketing plans.^{Footnote 460} The age-friendly communities project (see the section "Age-friendly communities and universal design" earlier in this chapter) seeks to engage seniors and their communities in making these communities healthier and safer by creating policies, services and structures designed to support and enable active aging and continued participation in society.

Studies have examined interventions for effectiveness in reducing social isolation among seniors; however, the impact of these interventions – having measureable health and social outcomes – has been limited. Much more research is needed on developing and evaluating interventions that can be effective in this area.

Volunteering

Chapter 3 highlighted positive health outcomes associated with volunteering, especially during the senior years.^{Footnote 255} Additionally, many seniors rely on informal care networks that are often run by volunteers. Both help to underline the necessity of ensuring that Canada has a strong volunteer base in the future. Generally, seniors volunteer because they have available time as well as experience and skills to offer their communities.^{Footnote 471, Footnote 472}

Recent trends indicate that seniors are the least likely age cohort to volunteer; however, those seniors who volunteer commit the highest average number of hours to volunteering.^{Footnote 471} As the population changes, so do volunteer patterns.

Current seniors are motivated to volunteer in different ways than their predecessors. While previous generations of seniors were more motivated to volunteer through religious-based organizations, this is less of a primary driver for today's seniors. Many are interested in applying their work experience in a volunteer situation and/or are looking for incentives such as learning new information or a new skill, participating in a meaningful experience and meeting new people. Those who have had a positive volunteer experience at a younger age are more likely to continue to volunteer during senior adulthood.^{Footnote 472} As well, seniors' volunteering practices are influenced by cultural factors. For example, the Iqaluit Roundtable (one of nine roundtables held by National Seniors Council on positive and active aging and volunteering in 2009) identified that the Inuit culture does not recognize the term volunteering; however a similar concept is the practice of "people helping people." An important focus for Inuit seniors helping people is intergenerational communications and educating youth on Inuit traditions.^{Footnote 471}

Tapping into the recently retired population provides an opportunity to engage seniors in volunteering; however, organizations need to be flexible and allow volunteers the chance to pursue other activities over and above volunteering.^{Footnote 253} Younger seniors (those aged 65 to 75) who are still involved in work/post-work activities or external activities may be too busy to volunteer.^{Footnote 472} In addition, volunteers are interested in volunteer opportunities where they see they are making a difference. Over-use of volunteers can be a problem as it can limit incentives and positive outcomes associated with volunteering. Volunteer organizations must also take into consideration that seniors often have to limit volunteer activities for health reasons.^{Footnote 253} Employers can establish volunteering practices through supporting pre-retirement volunteering by offering flex-time opportunities at the workplace.^{Footnote 472} Tax incentives could provide recognition for contributions as well as reimburse volunteers for hidden costs associated with volunteering.^{Footnote 471}

Overall, seniors are less likely to volunteer than other age groups; however, those seniors who do volunteer donate more volunteer hours annually than any other age group.^{Footnote 471} The value of unpaid assistance provided by seniors is significant.^{Footnote 7} They can adopt key roles in the community and, in fact, many voluntary organizations would not function without the contributions made by seniors.^{Footnote 473} A sense of belonging to the community is strongly associated with involvement in voluntary organizations or associations – if seniors feel attachment to their community, it is more likely the community will be a sustainable age-friendly place to live.^{Footnote 73}

Canada needs to develop a greater understanding of its senior volunteers, what motivates them to become involved, how to recruit and maintain them, as well as how to recognize their unpaid work. Canada also needs to adopt a volunteer strategy that recognizes the dynamic volunteer environment, addresses emerging challenges and promotes the benefits of being a recipient or donor of volunteer activities. The strategy may consist of a number of components:

• identifying new senior volunteer opportunities that rely on higher levels of skill and experience;
• communicating the benefits of volunteering to individuals, communities and seniors' organizations;
• adapting requirements to suit the changing demographic of volunteers so as not to rely repeatedly on the same individuals and/or offer the same outcomes;
• developing a shared understanding of volunteerism;
• creating meaningful incentives for volunteers such as opportunities to learn something new;
• preparing for unexpected conditions and emergency situations;
• including volunteers in the planning and design of volunteer positions; and
• facilitating opportunities for volunteer coordination within funded program grants.^{Footnote 472}

Addressing ageism

One factor often impeding seniors in participating and contributing to society is ageism.^{Footnote 274, Footnote 475} Ageism involves assumptions about older persons based on negative stereotypes and society's preoccupation with youth and looking young.^{Footnote 80}

Changing negative views of aging is critical to creating conditions for good health and well-being among seniors. The goal of the Madrid International Plan of Action on Ageing (2002) was to establish positive ways to portray and view aging.^{Footnote 274} A component of this plan is to empower seniors to fully and effectively participate in the economic, political and social lives of their communities through income-generating and voluntary contributions.^{Footnote 80} However, empowerment does not take place in a single moment and must be sustained over time. Societies must strive to ensure that seniors are recognized and appreciated.^{Footnote 80, Footnote 476} The foundation for valuing aging should be laid early and be adaptive to diversities within the population.^{Footnote 80}

Valuing aging starts with changing values and attitudes. Intergenerational initiatives between seniors and youth can promote a better image of aging and can be rewarding for everyone involved.^{Footnote 274} Efforts to address ageism should include a component on issues of caregiving and exclusion and discrimination in an institutional setting. Supporting caregiving and placing a positive value on aging and care for seniors will ensure progress is made toward combating ageism.

To address ageism, the significant contributions made to society by Canadian seniors must be acknowledged.^{Footnote 7} Seniors' paid and unpaid work contribute to families, communities and the Canadian economy.^{Footnote 7, Footnote 274} Many seniors provide care to spouses, children, grandchildren, friends and neighbours, in addition to donating their time as volunteers.^{Footnote 7} With the growth in population of those aged 65 years and older, this important contribution can be expected to increase.^{Footnote 7}

Some countries have initiated anti-ageism campaigns, such as the Scottish government's See the Person, Not the Age, which has worked within communities and the voluntary sector to break down age-related stereotypes.^{Footnote 477} While Canada does not have an anti-ageism strategy, it has invested in the development of age-friendly communities that promote social connectedness and respect for seniors, which are key to combating ageism in society (see the section "Age-friendly communities and universal design" earlier in this chapter).^{Footnote 83} Some provinces/territories such as Quebec, Nova Scotia and Newfoundland and Labrador are working toward addressing ageism with positive aging campaigns.^{Footnote 478-Footnote 481} In June 2010, the Government of Canada introduced a Bill to establish an annual National Seniors Day in recognition of the contributions seniors make to Canadian society.^{Footnote 482}

In First Nations, Inuit and Métis communities, the term Elder is a title given to individuals who – in recognition of their knowledge, wisdom, experience and/or expertise – enhance the quality of community life and provide guidance to community members through counselling and other activities. Most Elders are seniors or older members of the community, but age is not necessarily a defining factor. To be an Elder requires earning respect through actions and words. As with many seniors, Elders have addressed many obstacles over their lifecourse and hold invaluable knowledge and skills in areas such as language, culture and traditions that they can transfer to others while bringing balance to their communities.^{Footnote 483, Footnote 484} Initiatives such as the Canada Council for the Arts' Elder/ Youth Legacy Program recognize the important role of Elders in Aboriginal culture. The program provides support for Aboriginal Elders to teach youth from their communities about traditional arts with the goal of continuing the legacy of artistic practices within their communities.^{Footnote 485} Similar initiatives designed to recognize and value the knowledge and expertise of seniors in the general population could help create more positive views of seniors and aging in communities across the country and foster respect between generations. Iqaluit Roundtable found that Elders identified that intergenerational teachings of Inuit traditions was a primary goal for Elders helping others.^{Footnote 471}

Healthy living practices

In May 2005, the Federal, Provincial and Territorial Ministers Responsible for Seniors endorsed Healthy Ageing in Canada: A New Vision, A Vital Investment. The report focuses on five priority areas for action: social connectedness, physical activity, healthy eating, falls prevention, and tobacco control.^{Footnote 7, Footnote 12} Although two of the priority areas (falls prevention and social connectedness) are discussed in other sections of this chapter, all areas are considered interconnected, and programs and interventions that address each priority area can have an impact on others. For example, participating in regular physical activity can reduce the risk of falling and of developing certain health conditions, and can also increase social interaction.

Healthy living practices are about creating conditions for individuals to make choices and engage in behaviours that support healthy aging, such as staying physically active and eating well, and to avoid choices and behaviours that are detrimental to health, such as smoking and excessive drinking. Although these behaviours are based on individual decisions, it is important to note that these decisions are influenced by physical, social and economic factors experienced over the lifecourse.

This section highlights six areas where programs and interventions are making progress in creating conditions for healthy aging:

• providing community support and infrastructure;
• raising awareness about physical activity;
• encouraging healthy eating;
• addressing smoking, alcohol and drug use;
• ensuring health literacy for seniors; and
• supporting opportunities for lifelong learning.

Each of these areas has either shown evidence of success and could be applied more broadly, or is an area of promise where further work and investigation is required.

Providing community support and infrastructure

Seniors who have been involved in their community, and/or who have been physically active over the lifecourse, generally continue these practices as they age. Supporting seniors in continuing healthy habits, as well as encouraging them to become more active in their communities, requires a safe and vibrant community and surrounding environment.^{Footnote 7, Footnote 12} Safe pedestrian crossings, well-maintained sidewalks, recreational pathways, and access to indoor walking programs and community centres offer opportunities for daily physical activity. Indoor mall walking programs, for example, have adopted existing infrastructure to create a no-cost environment for seniors to interact socially and stay fit in safe, barrier-free spaces.^{Footnote 488} Programs such as Active Living BC support seniors engaging in physical and social activities by providing discounts to art galleries, provincial parks, museums and theatres, and for buses and ferries.^{Footnote 489} As well, all age groups benefit from infrastructural development that facilitates activity and engages those with mobility-limiting disabilities.^{Footnote 327}

Generally, seniors spend much more time at home and in their own neighbourhoods than other age groups. Limited mobility may further localize the activities of some seniors. As a result, being able to get outside and having access to green space and community spaces close to home are important determinants of positive health for seniors. The design and overall attractiveness of the outdoor and community spaces are also important to attracting usage.^{Footnote 490}

A review of international studies of seniors' participation found that a number of adverse community factors such as a lack of attractiveness, and a perception of poor safety due to unattended pets and poor lighting, led to an overall decrease in physical activity.^{Footnote 491} The challenge for communities and organizations is to make physical activity more accessible and attractive to senior Canadians regardless of age, ability and interest. Creating and adapting environments for physical activity is also important in regions of Canada where winters are severe and may limit seniors' activities. For example, the Elders in Motion Fitness Program, a collaborative program of the Dene Nation, the Northwest Territories Recreation and Parks Association and the Canadian Centre for Activity and Aging, encourages elders' participation in physical activity in their local recreational centres, as well as trains elders to be fitness leaders in their communities. Communities incorporating age-friendly designs and adaptations that encourage seniors to get active and involved in local programs have had success in creating neighbourhoods conducive to healthy aging.^{Footnote 492}

In long-term care facilities as well as independent seniors' residences, creating environments that encourage physical activity and recreation among residents can be challenging given their range of functions, capacities and interests.^{Footnote 176} Facility limitations are also a consideration, including lack of space, specialized equipment and staff – especially staff trained in this area. There has been much media attention on the use of video exercise games to increase the physical activity of seniors, particularly those who are living in institutional settings or who face barriers to participating in physical activity outside the home/community centres.^{Footnote 493} Mental health benefits were found to be associated with use of video exercise games among residents with depression who engaged in a 12-week "gaming" program. The use of games that coach people (of all ages) into fitness programs has been shown to increase confidence, interest and physical performance. Seniors involved in the study were found to respond better to a human coach than to a simulated character.^{Footnote 494, Footnote 495} Supporting this finding is additional research that shows physical activity interventions that are led and guided and/or managed by a coach, health care professional or therapist have been effective in maintaining seniors' commitment and interest in such programs.^{Footnote 495}

Raising awareness about physical activity

The Special Senate Committee on Aging reports that despite the known benefits of being physically and mentally active during the senior years, some Canadians still do not recognize the importance of remaining active across the lifecourse and into senior adulthood. While many assume that slowing down is protective of health, evidence shows that living an active lifestyle can prolong the number of years in good health. A comprehensive seniors' health strategy would help to create conditions for healthy aging; however, many current strategies are broad, and do not specifically address the needs of seniors.^{Footnote 247}

Promising efforts to encourage health over the lifecourse include Canada's Physical Activity Guide to Healthy Active Living, which highlights how Canadians can build physical activity into their daily lives.^{Footnote 496} Canada's Physical Activity Guide to Healthy Active Living for Older Adults is designed specifically for seniors and includes the key messages "it is never too late to benefit from physical activity" and "being active promotes health and independence and can lessen the impacts of aging".^{Footnote 178} The guide also outlines how seniors can choose activities that are of interest to them and that may be done in a variety of settings. It also recommends lesser-impact and lower-risk activities for those who have certain health issues such as heart conditions, osteoporosis and arthritis, as well as for those who are concerned about falling, being unsteady and exercising in various weather conditions.^{Footnote 497}

Education and awareness around the benefits of active living for seniors can also help to challenge assumptions about age and capacity (see the section "Addressing ageism" earlier in this chapter). Despite broad national physical activity promotion programs, the number of seniors engaging in physical activity has not been increasing. This may be the result of assumptions about age and what seniors can/should do, as well as the fact that many seniors assume that, if they are in good health, they do not need to participate in physical activity programs or initiatives. Others may feel self-conscious about engaging in certain activities in a public setting where they may not have the same abilities as younger participants.^{Footnote 12} There are also barriers to behavioural change among disadvantaged communities where there are costs associated with physical activity programs as well as other social factors at play. Factors, such as living in a disadvantaged community, can have impacts outside of the addressing capacity of local public health and social services. Individual factors such changing/ transitioning income (e.g. living on retirement income) and physical ability may increase a need to develop new, less costly or less physically intense activities. Free or low-cost initiatives targeted to low-income seniors can be offered in specific communities and participation can be encouraged. Affordable activities such as walking and biking can also be promoted.

Interventions that offer incentives, such as tax credits, provide leadership options, and increase the visibility of active and healthy seniors have had some success, such as Canada's ParticipAction, which highlights and profiles examples of Canadians of all ages who have challenged themselves and social norms.^{Footnote 498} Also, there is no reason to believe that tax incentives for encouraging physical activity similar to the Canada Children's Fitness Tax Credit could not also be effective for seniors.^{Footnote 471}

Some seniors are less active than others, including women, minority groups, those with lower levels of education, people who are isolated or live in an isolated community, those living with one or more chronic conditions (including cognitive impairment), and individuals without family or friends to assist them.^{Footnote 7, Footnote 176} A targeted approach should be used to encourage physical activity in these less active groups. As well, consideration should be given to the location of services, the ease of access through transportation networks, as well as affordability. For those with mobility or other limitations, initiatives can be undertaken to encourage engagement in physical activity through home-based programs where success can be measured in terms of the development of strength, flexibility, interest and motivation (see Textbox 4.9 VON SMART Program).^{Footnote 499}

Textbox 4.9 VON SMART program

The Victorian Order of Nurses (VON) is a national, non-profit organization that has provided community-based health care across Canada since 1897. Among their many programs, SMART (Seniors Maintaining Active Roles Together)® was created to help seniors become more physically active. The goal of SMART is to promote health and maintain seniors' independence through home-based and group exercise programs.^{Footnote 499, Footnote 500} SMART addresses several age-related health determinants by creating social support networks, providing exercise and educational development, improving personal health practices and increasing access to health services.^{Footnote 499}

The SMART initiative includes an in-home program that provides individuals aged 55 years and older with supervised exercise in their home as well as a group exercise program available within the community. Programs are delivered by trained volunteers between 31 and 76 years old, with the majority being peers.^{Footnote 499, Footnote 500} SMART targets seniors living independently in the community, especially those with health risks and who may also be restricted by cost, transportation or limited abilities.^{Footnote 499}

Since its inception in the mid-1990s, the SMART program has contributed positively to improving the health and attitude of its participants. An evaluation done in 2004 reported that since joining SMART, 34% of its participants became more physically active outside of their regular SMART class. Statistically significant fitness measurement results were also observed during the 16-week monitoring period and participants improved their physical endurance, strength, flexibility, balance and agility.^{Footnote 499}

Furthermore, an evaluation completed in 2008 demonstrated that 50% of the participants of both programs reported their health improved after completing the VON SMART program. More than 90% of the seniors participating in the in-home program stated they were able to maintain or improve their function and mobility, while all the group program participants indicated they maintained and improved their function and mobility. It was also reported that the social aspect of both VON SMART programs was a significant reason for participation and was listed as a primary benefit of both programs.^{Footnote 500} By September 2008, 18 communities across Canada had developed one, or both VON SMART programs.^{Footnote 500}

Encouraging healthy eating

Addressing issues with seniors eating practices and nutrition often involve creating positive attitudes toward food, addressing issues of social connectedness and health conditions, as well as preventing food insecurity (including among seniors living in northern and remote communities). There is limited information on the effectiveness of nutrition interventions targeted at seniors. Broad upstream population interventions, such as food fortification to address nutritional deficiencies can potentially increase nutrients for the whole population. However, many food fortification interventions have been primarily intended to improve prenatal health and are not targeted to seniors.^{Footnote 501}

Broad programs work to ensure food security among the population as a whole and strive to ensure physical and economic access to sufficient, safe and nutritious foods to meet dietary needs and food preferences for an active and healthy life. Canada's Action Plan for Food Security is one example of this type of broad program and addresses a wide range of issues related to foods and production including right to access, reduction in poverty, food safety, access to traditional foods and an appropriate monitoring system.^{Footnote 502} Broad programs such as Nutrition North (building on the previous Food Mail Programs) were established to reduce the cost, increase access and promotion of healthy foods (nutritious perishable foods and traditional, northern foods) to eligible communities in the Yukon, Northwest Territories, Nunavut, Alberta, Saskatchewan, Manitoba, Ontario, Quebec, and Newfoundland and Labrador.^{Footnote 503} During the Food Mail program pilot (2009), key project informants reported that nutritious perishable foods were more readily available, inexpensive and of a higher quality than before the pilot; however, levels of food insecurity and progress with changing behaviours varied between communities, and among subpopulations of all ages.^{Footnote 503} Although such programs improve food access across the population, they do not address the unique conditions and factors associated with food issues for seniors such as isolation and mobility issues.^{Footnote 502} The report Healthy Aging in Canada: A New Vision, A Vital Investment, discussed at the beginning of this section, calls for greater nutrition interventions that directly target seniors; these interventions are scarce and their evaluations are rare.^{Footnote 7,Footnote 12}

For seniors, nutrition and social relationships can be linked. For example, those who report being lonely, isolated or depressed often lose interest in eating. As well, many seniors question the need to prepare food for one person as the effort may outweigh the perceived benefits. Programs that encourage seniors to cook for themselves, or for friends and groups, encourage better eating practices and simultaneously contribute to being socially connected and enhancing positive mental health.^{Footnote 7, Footnote 12} Seniors' groups that teach cooking and meet for dinner or lunch regularly encourage healthy eating among those who may be undernourished due to inadequate food consumption and/or skipping meals.^{Footnote 504}

Poor oral health, including tooth loss, among seniors can influence food choices and lead to poor nutritional outcomes.^{Footnote 268,Footnote 505,Footnote 506} These factors are often more prevalent in long-term care facilities where other conditions such as functional difficulties that limit teeth cleaning and self-feeding, as well as medications, can increase tooth decay and impact eating habits. While many seniors may have received good dental care earlier in the lifecourse due to employer health insurance plans and greater access to services, management of oral health care declines with age due to access and affordability.^{Footnote 270,Footnote 505,Footnote 506} In a review of the Oral Health of Seniors in Nova Scotia, it was reported that seniors' oral health issues should be integrated into public health frameworks, including: regular reporting on indicators related to seniors' oral health; developing, implementing, monitoring and evaluating oral health care of seniors; and developing oral health awareness campaigns that specifically target seniors.^{Footnote 507} The Canadian Oral Health Strategy recommended a national standardized method of monitoring oral health indicators in Canada.^{Footnote 508} In response, an oral health component was included in the Canadian Health Measures Survey, 2007 to 2009.^{Footnote 269}

As noted in Chapter 3, poor nutrition can have adverse health impacts.^{Footnote 7, Footnote 180, Footnote 181, Footnote 190} There has been some success with nutrition awareness programs targeted to seniors, as well as nutrition screening among at-risk seniors to identify problems and assess solutions (see Textbox 4.10 Seniors in the Community Risk Evaluation for Eating and Nutrition) but these efforts and their evaluation are limited. Practices that encourage healthy eating among seniors need to address the broad range of factors that influence nutrition, including food choice, oral health and health, social and economic vulnerability.^{Footnote 7, Footnote 509} As well, education programs are needed that provide information and that challenge assumptions about healthy weights and eating practices for seniors.^{Footnote 7} Further research and knowledge is also needed to better understand the determinants of seniors eating habits, as well as increased evaluation of interventions.

Addressing smoking, alcohol and drug use

While about 9% of seniors (65 years and over) currently smoke (see Chapter 3), there are few seniors' smoking cessation programs, limited successes associated with these programs, and very few program evaluations and compilation of best practices.^{Footnote 7, Footnote 192-Footnote 194} Also, while there are positive health outcomes for seniors who quit smoking, there is still little research regarding seniors' motivations and barriers. More work needs to be done to increase the knowledge, awareness and effectiveness of seniors' smoking cessation programs.

Smoking cessation interventions primarily targeting youth have not been as effective with seniors.^{Footnote 516, Footnote 517} These two groups have very different attitudes and experiences related to smoking. For seniors, awareness campaigns that depict a loss of independence or quality of life or highlight the impact of smoking on the health of a loved one have been most effective in encouraging seniors to quit.^{Footnote 516-Footnote 518} Peer support for smoking cessation has had some success, especially when former senior smokers testify they were able to stay smoke free and saw improvement in their lives. Seniors need to be able to relate to other seniors and be aware that it is never too late to quit. Broad smoking cessation for all age groups is rarely achieved using a single point of entry or one single intervention.^{Footnote 517}

As with smoking, programs targeted at seniors and/or risk factors for seniors in terms of alcohol and drug use are limited. A variety of treatment approaches can be used or combined to address seniors with substance abuse issues. Peer-led self-help groups, such as Alcoholics Anonymous, have had some success with seniors in building social relations and mentoring among people of a similar age.^{Footnote 517} Brief interventions, as well as cognitive-behavioural treatment approaches, address the individual's motivations, thoughts and beliefs that underlie substance use problems. Similarly, outreach services provide treatment in the senior's home and overcome barriers inherent in requiring the senior to travel to receive services. Many intervention techniques that involve targeted programs to seniors and seniors helping seniors through support have had some success.^{Footnote 12}

It is also important to note that alcohol and drugs may be used by seniors to address chronic pain issues and/or insomnia. Interactions with prescription or over-the-counter medications can cause further health impacts, including decreased medication effectiveness, disorientation that may lead to falls or an increased risk of overdose.^{Footnote 205} Drug and alcohol cessation programs targeted to seniors should consider these issues, as well as other causes of substance use (e.g. loneliness, depression) to increase their effectiveness.

Ensuring health literacy for seniors

Health literacy is influenced by a number of factors including education, income, cognition, health and functional conditions.^{Footnote 73,Footnote 277,Footnote 279} Among seniors, health literacy is specifically influenced by aging; as a decline in health literacy skills may occur as people age, and by the fact that the current cohort of seniors generally has a lower level of education than younger age groups. Compounding this issue is the fact that as people age they are more likely to require health care services, information and treatments. This is a concerning issue in regards to seniors who lack the health literacy skills necessary to make basic health decisions and to access and accurately assess relevant health information.^{Footnote 276} The ability to acquire information can be further compromised by challenges with mobility, access to service, language, and level of technological skills and social engagement. Addressing health literacy among seniors will require better recognition of the issue and widespread action to engage individuals, communities and policy-makers to manage and improve health literacy levels among seniors as well as all other age groups.^{Footnote 280}

A low level of health literacy often results in the inability of seniors to access programs and services and to adhere to treatment regimes or disease management protocols.^{Footnote 280} These activities often require that an individual manoeuvre through systems of paperwork and information, which are often a barrier to receiving appropriate care. Awareness campaigns should encourage seniors to keep abreast of their own health and care issues (if possible). As well, seniors can work toward improved health literacy through daily reading, which evidence shows can improve health literacy scores by 52%.^{Footnote 280} Health literacy campaigns should also reinforce the benefits of posing questions to health care providers and pharmacists, and help to identify various sources and means of accessing additional health information, including the identification of a trusted individual to act as a health champion.^{Footnote 280}

All levels of government have a responsibility to address health-literacy challenges. Governments can apply plain-language principles to all health information and related services (such as medical insurance forms and medication labels) and support the translation of health-related materials in various languages in areas with populations of linguistic minorities. Communities can offer outreach programs to vulnerable populations, such as seniors who are immigrants, have low levels of education, have mobility issues or live in underserviced areas.^{Footnote 280}

Further, educating health care professionals about health literacy issues can enable them to better serve a diverse group of seniors who may otherwise have difficulties making informed decisions about their health and their options for care. The use of medical interpreters, for example, can assist health care professionals in ensuring that at-risk seniors receive and understand accurate information and instruction. Interpreters can, in turn, provide assurance to seniors with language barriers that their concerns and any issues they may have are properly communicated to their health care provider and/or pharmacist.^{Footnote 519}

In providing revised or targeted health information materials and services, there is also a responsibility to monitor effectiveness of these actions to ensure needs are being met. Gathering information on health literacy trends and issues is necessary to continue providing effective support for those in need.

Supporting opportunities for lifelong learning

Efforts to become more socially engaged can be enhanced through educational and/or lifelong learning opportunities. Seniors who participate in these activities can create and foster new interests and knowledge and maintain or increase their involvement in their communities. Participating in a learning activity can increase quality of life, prevent loss of brain function and improve cognitive skills, which may include improving or maintaining literacy skills.^{Footnote 280}

It is important for seniors to recognize the mental health benefits of continued learning and the educational opportunities available to them. Communities need broad approaches and guidelines to find collective ways of overcoming barriers to participation, developing learning programs and sharing best practices. A number of approaches can be used to improve access to lifelong learning:

• awareness efforts that encourage the participation of seniors;
• better information exchange on activities, programs and opportunities for and among seniors and across communities; and
• incentives for seniors to engage in learning (e.g. tax credits, reduced rates).

Educational programs are available to seniors within many settings. Local school boards offer continuing education programs, with courses ranging from adult high school curriculum to general interest courses. Many of Canada's universities and colleges support seniors who are interested in enrolling in degree/diploma courses by offering low or no-cost tuition as an incentive. Some seniors may be interested in learning at a post-secondary institution but may be deterred by the added responsibility and potential stress of exams and schoolwork. For these individuals, the option to audit courses and/or tailor programs to seniors has had success in encouraging their participation (see Textbox 4.11 Opportunities for lifelong learning: University of the Third Age). For example, the Seniors College of Prince Edward Island, an affiliation of the University of Prince Edward Island Centre for Life Long Learning, provides learning opportunities for seniors with a range of interest courses across three regions of the province.^{Footnote 520}

A seniors' knowledge network can serve as a communication mechanism for creating awareness of learning opportunities within various communities and providing an information exchange among network members. However, seniors who are educated or who participated in learning activities across the lifecourse are more likely to continue to participate in lifelong learning.^{Footnote 274} More work needs to be done to encourage those who are less likely to uptake learning programs to participate.

Care and services

For generations, Canadians have provided care for family members/peers who are sick and/or aging inside and outside the home. The majority of seniors' care (about 72%) is provided through informal sources – both family members and friends.^{Footnote 73} However, although demographic patterns have evolved and more individuals (particularly women) are participating in the workforce, care often coincides with other responsibilities such as formal working arrangements and child care.^{Footnote 529, Footnote 530} For a number of seniors, formal care providers can help them maintain independence at home by offering support for acute/ chronic health conditions and with meal preparation and daily activities.

The various levels and services of seniors' care can be complex. As well, the transitions between levels of care are not often smooth.^{Footnote 274} Seniors can experience difficulties in accessing, affording and deciding on the right care. In addition, decisions on care can impact the individual requiring care, the individual's family members and caregivers, as well as health care providers. The question for public health, health care and social services is how to best meet the needs of Canada's seniors now and in the future. What can be done to support individuals and their caregivers to ensure the best care in their place of choice?

Much research exists on the range of care opportunities that are or could be options for Canadian seniors. The following section highlights five areas of care that play important roles in aging:

• home and community care;
• assisted living and support;
• long-term care;
• palliative and end-of-life care; and
• integrated care.

While each addresses some of the needs of seniors, it is clear that Canada can do more to ensure a broader range of needs are met and to create a continuum of care in the future.

Home and community care

Home and community care services are received primarily at home or in the community, rather than in a hospital, supportive housing or long-term care facility setting.^{Footnote 531} Home care can bridge the gap between independent living and living in a residential care facility, as well as provide opportunities for seniors to continue to live at home if this is their place of choice.^{Footnote 531} A range of care is delivered by various individuals including regulated health care professionals (e.g. nurses, occupational therapists), non-regulated workers, volunteers, friends and family.^{Footnote 531, Footnote 532} Programs can offer an array of social services including homemaking and assistance with bathing, meal preparation and recreational activities. For many individuals, assistance with living at home can decrease and/or delay care in a hospital or long-term care facility.^{Footnote 531, Footnote 533} For the most part, evidence shows that home care can be a lower cost alternative to residential care among recipients with similar care needs (even when informal care time is valued at replacement wage).^{Footnote 534, Footnote 535} Differences in cost arise when type and level of care changes, which underlines the need for a planned and targeted approach to home care to ensure cost efficiencies.^{Footnote 534, Footnote 535}

Being able to provide home care across a variety of populations and communities can be difficult. While many seniors with care needs prefer to live independently, being able to access culturally and care-appropriate services in their community can be challenging (e.g. for those who live in rural and remote communities or those who are part of a vulnerable population). Some programs, such as Health Canada's First Nations and Inuit Home and Community Care (FNIHCC) Program, have been developed to provide comprehensive, culturally sensitive, accessible, effective and equitable services that respond to the health and social needs of First Nations and Inuit communities.^{Footnote 536, Footnote 537} FNIHCC funds essential services such as care assessment and management, home nursing services, in-home respite care, personal care, and linkages with other professional and social services. Evaluations show that since its inception 10 years ago, FNIHCC has built community health capacity by developing home and community services where there were no such services before. Also, the participation of First Nations and Inuit peoples in all stages of development has directly resulted in a strong sense of program ownership.^{Footnote 537} FNIHCC has been able to provide services to individuals within their own communities who would otherwise have had to seek these services elsewhere.^{Footnote 537, Footnote 538} Complementing the FNIHCC is Indian and Northern Affairs Canada's Assisted Living Program, which provides services that are specifically directed at First Nations seniors with functional limitations who may require assistance to maintain their independence.^{Footnote 539} Programs such as FNIHCC have been effective addressing home care issues of First Nations on-reserve and Inuit communities, however, similar programs could be adapted to address the home care needs of Aboriginal communities in other jurisdictions.

Canada's Veterans Independence Program is a national home care program that helps eligible veterans remain in their homes or communities for as long as possible.^{Footnote 60, Footnote 540} In 2005-2006, the VIP provided support to approximately 97,000 veterans.^{Footnote 541} It works with existing services and programs in the local community to meet veterans' unique care needs.^{Footnote 60} Those who qualify for the VIP can receive a range of health, personal and household services. Further, additional services are available to eligible veterans for such things as ambulatory health care, transportation expenses for activities that foster independence, nursing home care, and home adaptations that improve an individual's capacity to make a meal, bathe and sleep. The VIP has also been expanded to extend services to low-income and/or disabled survivors of veterans and civilians who served during World War I, II or the Korean War. In addition to assisting participants with care needs while living at home, the VIP participants have reported good levels of satisfaction with the program.^{Footnote 60, Footnote 540, Footnote 541} Another successful initiative for Canada's veterans, the Overseas Service Veterans "at Home" Project, has demonstrated the benefit of providing at home options for veterans who are waiting for long-term care placement (see Textbox 4.12 Overseas Service Veterans "at Home" Project). The VIP has been recommended as a model for broader home care programs and is being adopted more broadly.^{Footnote 542}

The success of programs such as VIP are based on the provisional policy of a continuum of service or graduated care model, emphasizing the need for early identification, assessment and intervention to prevent undue health system dependency. Providing a wide variety of service options is also important to be able to respond to changing needs and differences in need among individuals and the communities that support them. As well, initiatives should include provisions for working with provincial, territorial and community programs (such as VIP) to complement existing services rather than duplicate efforts.^{Footnote 274}

In Alberta, the Continuing Care Strategy is intended to deliver services that provide Alberta seniors with options to stay in their homes and communities for as long as possible. This client-focused strategy prioritizes the health and personal care required for seniors to "age in the right place." Alberta is working on an evaluation and assessment of the strategy in order to examine if the right level of service is being provided in the appropriate setting.^{Footnote 544} Internationally, Australia's Home and Community Care aligns domestic, health and personal care services with the goal of meeting the needs of individuals who require assistance with daily living (including seniors) to help them maintain independence and reduce unnecessary admissions into residential care.^{Footnote 545}

Over ten years ago, the National Forum on Health (1997) offered a number of recommendations, including one on home care that launched broad discussion about home care delivery in Canada. These recommendations also highlighted three areas for action to move toward a more integrated system of health care: providing options that ensure quality of life and reduce the risk of institutionalization; care that is appropriate to patient needs, cost-effective and support to caregivers; and, a system with a single point of entry that assesses needs on a case-by-case basis.^{Footnote 546} Since the release of the findings of the National Forum on Health, other debates have focused on integrating home care services; however, questions still remain and more work needs to be done in this area.

Supporting caregivers

Informal care providers play a vital role helping seniors to live at home. These efforts can reduce impacts on long-term care facilities and hospitals as well as help to maintain seniors' independence and capacity to live in their homes and communities.^{Footnote 274, Footnote 532}

While most caregivers report that they are generally coping or coping very well with their caregiving responsibilities, some may experience adverse health and social outcomes.^{Footnote 260} Caregivers, themselves – especially family caregivers – may be prevented from working outside of the home, or have to reduce/change hours of work, may incur unreimbursed expenses, and may experience social isolation, and/or mental and physical fatigue with longer-term health outcomes.^{Footnote 73} For some caregivers, this unpaid work can go unrecognized by the care recipient, family, co-workers and communities.^{Footnote 547} Canada, as a society, values caregivers and all Canadians have a role to play to support caregivers in their daily activities.

Supporting caregivers is complex as individual and situational needs vary. Many players need to be involved, including governments, employers, stakeholders, communities, and individual Canadians. In Canada, there are several programs to support caregivers which vary from financial support (including wages, tax relief, and labour policies) to community supports and services.^{Footnote 530}

The federal government provides a range of supports, including the Caregiver Tax Credit, the Eligible Dependant Tax Credit and Infirm Dependant Tax Credit, and the transfer of the unused amount of the Disability Tax Credit, which recognize the reduced ability of caregivers to earn and consequently pay income tax as a result of supporting a dependent.^{Footnote 305, Footnote 548-Footnote 552} Tax recognition for a dependent spouse is also provided through the Spousal Credit.^{Footnote 553} Under the Medical Expense Tax Credit, caregivers can claim on behalf of a dependent relative, up to $10,000 in eligible medical expenses.^{Footnote 554, Footnote 555} The federal government also offers targeted programs for caregivers of populations under federal responsibility. The Canada Pension Plan General Drop Out provision automatically exempts from a person's pension calculations up to 15% of his or her years of low- or no-income for a variety of reasons, including caregiving responsibilities.^{Footnote 556} Labour policies such as expanded and flexible paid leave for caregiving, are believed to be beneficial in helping to balance work and caregiver tasks. Canada's Employment Insurance Compassionate Care Benefit provides financial support to caregivers who require time away from their jobs to take care of gravely ill family members or friends.^{Footnote 305, Footnote 557} In addition, the Government of Canada is investing in research over the next three years to fill knowledge gaps on key caregiver issues.^{Footnote 305}

While each province and territory organizes health services differently, most provide provincial tax credits for caregivers, home and continuing care supports and services, along with important resources for caregivers such as respite programs, counselling and support groups. Some Canadian employers also offer a variety of flexible work arrangements for employees with family and caregiving responsibilities (e.g. telework, flexible work hours, provide on-site adult day care centers) so that employees can better balance work and care responsibilities. These kinds of initiatives can be mutually beneficial to employers by reducing costs incurred due to absenteeism, higher rates of illness for working caregivers, and the loss of skilled employees who leave work for caregiving responsibilities because of a lack of flexibility.

During national caregiving consultations for the Special Senate Committee on Aging, many participants emphasized that support for caregivers and care receivers are interrelated and issues span jurisdictions.^{Footnote 274} When seniors caring for seniors were asked about the types of assistance that would be useful to them in order to continue to provide care, 40% reported occasional relief or sharing of responsibilities, 30% reported financial assistance, 25% reported requiring more information about the nature of the long-term illness and how to be an effective caregiver, and 16% reported wanting counselling.^{Footnote 214, Footnote 262} While care receivers' access to home care and related supports can have positive impacts, it is difficult to assess the quality of benefits and challenges associated with these impacts. In order to better support informal care, more needs to be known about caregivers (e.g. the short- and long-term health and social outcomes of providing care).

With the aging of the population, an increase in the incidence of disability, more women in the workforce, and the emergence of smaller, less traditional, more dispersed families, it is anticipated that the number of informal caregivers needed in the future is likely to increase. Consequently, how to support caregivers is a topic of much debate in Canada and other countries. The debate centres on issues of what is appropriate, ethical, meets needs of caregivers and care-receivers, and considers policy priorities. The need increases as the demand for caregivers increases and the supply simultaneously decreases as a result of demographic changes, workforce participation and patient health conditions.^{Footnote 530} Considering the future needs of caregiving in Canada, more can be done to improve conditions for caregivers.

Other countries also have programs in place to support caregivers that include tax relief, paid leave, wages and broad community supports. Australia's National Respite for Carers Program offers community-based respite services in a variety of settings (home, residential and away) as well as a network of caregivers who can provide counselling, information and advice. Australia also provides a Carer Payment (a bi-weekly payment to those providing eligible care) and a Carer Allowance (a non-taxable supplementary payment available to caregivers who provide daily care to those with a severe disability or medical condition).^{Footnote 558, Footnote 559} Norway's health and social service policies cover a broad range of supports and services for caregivers, including its Social Services Act and Action Plan for the Elderly that support caregivers with respite care and caregiving wages.^{Footnote 560} Sweden has national measures to support family based caregivers such as its Care Leave Act, which provides caregivers opportunities to receive paid leave to support seriously ill family members and its Social Service Act, which encourages communities to support local caregivers.^{Footnote 561}

Assistance for caregivers can also come from the private sector by providing support to employees with caregiving responsibilities. Companies such as the United Kingdom's BT Global Service (a telecommunications company) supports employees, who are also caregivers, with flexible work hours, remote access or work-from-home arrangements.^{Footnote 562-Footnote 565} As a result of these arrangements, BT reports higher productivity and job satisfaction among these employees.^{Footnote 566-Footnote 569} By providing opportunities for family to care for other family members, the capacity of caregivers is increased, the ability of seniors to age in place of choice is maintained and the number of people relying on residential care is reduced.

Broad home care strategies

Canada does not have a home care strategy that addresses issues for both caregivers and care recipients. A national strategy would include several key components:

• education and training of caregivers to determine best practices for care;
• efforts to support and communicate across provinces/ territories and all communities in Canada;
• efforts to raise awareness of the critical role caretakers play in the lives of many Canadians; and
• efforts to develop of working options for people who work and are also caregivers.^{Footnote 570}

A greater understanding of home care and the role it plays for individuals, families and communities is required. So, too, is better knowledge around the relationship of home care to public health and health care activities. Additionally, more needs to be done to raise awareness of home care practices and the role they play in care provision, share best practices, support caregivers and identify issues and barriers to moving forward.^{Footnote 570}

Assisted living and support

Assisted living can address transition periods when individuals' needs for care exceed what is available in their own homes but do not require the attention and intensity of the service found in a long-term care facility.^{Footnote 571} Filling this gap is addressed through a range of both private and public-style housing options that offer services ranging from housekeeping and meal preparation to transportation and social activities.

Generally, in Canada, work still needs to be done to ensure that seniors have access to affordable supportive housing offering appropriate levels of services in places of choice. Regulations for supportive living vary by jurisdiction – in some areas there is a landlord-tenant relationship and in other jurisdictions it is classified as health services.^{Footnote 274} Services need to be regulated to ensure standards are met, costs are managed, and health and safety concerns are addressed.

It is important to ensure that needs are met for all seniors and that gaps in basic service are not determined by income.^{Footnote 274} In general, those with higher incomes have access to a greater range of supportive housing opportunities, whereas those with lower incomes can face a housing shortage based on access, availability and affordability.^{Footnote 572} Facilities that offer specific services or tailor to needs can be expensive and uninsured. Often too, there are increased costs associated with providing services at times of greatest need and vulnerability. Ideally, supportive housing fills the needs associated with transitional care and minimizes health impacts such as isolation and discomfort as seniors move between levels of care. Some jurisdictions are beginning to manage access to assisted living and support through a single entry point in order to provide appropriate and timely care. While this approach is successful in some areas, difficulties exist in the creation of systems that are too complex to navigate.

In smaller, rural and remote communities, seniors may experience barriers to accessing assisted living and support that can result in displacement to larger urban centres and/or accepting service gaps and facing adjustments in their needs/housing type.^{Footnote 82} Making do with fewer services because needed services are not available in the local community can result in extended hospital stays and/or living in a long-term care facility before it is necessary or beneficial, or remaining at home and at risk with no support.

The housing sector can play a key role in addressing individual and community needs with its knowledge of available options. For example, Independent Living B.C. helps low-income seniors who require support to remain independent by working with British Columbia Housing – in partnership with CMHC, housing providers and health authorities – to deliver a program to eligible participants who require personal care but not long-term care.^{Footnote 573} In remote areas, where access to care is limited, some progress is being made with federal investment in housing for low-income seniors, and renovation and retrofits in Canada's North and on-reserve in First Nations communities. For example, the On-Reserve Non-Profit Housing Program (section 95) assists First Nations community members, including seniors, in acquiring suitable, adequate and affordable rental housing on reserve. The program supports First Nations in the construction, purchase, rehabilitation and administration of affordable housing in communities such as Michipicoten (Ontario) where a high proportion of the population is older, and there is a growing need for affordable housing for seniors.^{Footnote 574, Footnote 575}

Long-term care

Long-term care services provide residential supervised care that includes professional health services, personal care, and services such as meals and laundry.^{Footnote 576} The range of services in long-term care varies and most facilities are provincially/territorially monitored (with the exception of services to on-reserve First Nations communities, veterans and offenders, which are federally addressed).^{Footnote 576} Long-term care is also complex and there is no consistency in the terms used across Canada to describe this type of care and the services offered.^{Footnote 576}

Although extended health care services are covered under the Canada Health Act, long-term care is non-insured and often requires user fees. Not understanding the distinction between insured and non-insured care can cause individuals to experience challenges in navigating, paying for and waiting to access long-term care facilities.^{Footnote 274} Costs and care vary across Canada, with different levels of care and sources of funding. Variation is due, in part, to differences in private and publically funded beds (and the care associated with those beds). A majority of long-term care facilities are privately owned and care can often be costly. For publicly funded facilities, significant waiting periods for a placement is typical. Waiting periods can cause gaps in care as well as displacement. Additionally, long-term care is not portable across provinces/territories such that subsidies, waiting periods and fee-for-services vary and can present barriers to seniors who are trying to move across provincial/ territorial borders.^{Footnote 274} This is often a difficulty for seniors who wish to move into the same community as other family members or live in the same facility as a partner, relative or friend.

In general, individuals entering long-term care facilities are older and have greater health care needs than in previous generations. In particular, there is an increase in those who are frail, have severe dementia and/or have multiple health conditions. In order to provide care to this vulnerable population, there is a need for specialized care and special care units within long-term care facilities that requires higher staff numbers and better training in key geriatric fields.^{Footnote 8, Footnote 274} Shortages of trained staff and accommodations within facilities contribute to difficulties in access. It is important that governments and communities work now to ensure that appropriate facilities and services are in place to meet the long-term care needs of Canada's current and future seniors population.

Palliative and end-of-life care

In recent decades, palliative and end-of-life care has gained increased recognition by health care providers, educators, governments and the general public as being an important and valued component of care that requires appropriate and compassionate support to individuals and their families/friends.^{Footnote 577} The purpose of palliative and end-of-life care is to provide services such as pain and symptom management, psychological, social, emotional, and spiritual support, as well as bereavement support for caregivers and families. Palliative and end-of-life care can occur in a range of settings such as hospitals, long-term care facilities, hospices, and private homes. Funding may come from a range of sources, including various levels of government, private sources and charitable donations.^{Footnote 577, Footnote 578} Ideally, care is provided by an interdisciplinary team that may include nurses, physicians, social workers, various therapists, spiritual advisors, bereavement support workers, volunteers and informal caregivers.^{Footnote 577} Each year, palliative and end-of-life care impacts the well-being of many Canadians. The Canadian Hospice Palliative Care Association estimates that for each death in Canada, an average of five additional Canadians are impacted.^{Footnote 578, Footnote 579}

Access to palliative care is a concern in Canada. It is estimated that only 16% to 30% of Canadians who die have access to, or receive needed hospice palliative and end-of-life services, and even fewer receive grief and bereavement services.^{Footnote 578} While many individuals are dying in hospitals, few are receiving care designated as inpatient palliative that may be required. Despite findings that about 70% of individuals report a preference to die at home, most individuals are dying in hospitals, few of which offer in-patient palliative care services.^{Footnote 578-Footnote 580}

As aging in place of choice is critical to healthy aging, so too is dying in one's place of choice. Addressing the discrepancy between what is preferred and what is possible is an issue requiring further consideration in palliative and end-of-life care planning. Establishing options for end-of-life care depend on the capacity of health care professionals, families, caregivers and volunteers and the overall ability to provide adequate end-of-life care that are also consistent with the individual's wishes. Additional training for health care professionals and support of palliative and end-of-life research may be necessary to provide the proper tools to assess and support individual and family needs, raise awareness and achieve effective practices.^{Footnote 577} There is a need for an integrated system that can effectively coordinate transitions between home, palliative, long-term and hospital-based care in order to provide the highest quality and most cost-effective care possible.

Not enough is known about the demand for, supply, quality or costs of palliative and end-of-life care in Canada. At the population level, it is difficult to assess the extent to which the needs of individuals and their families are met.^{Footnote 580} Health system data as well as differences in perception of the services available and how needs have been met vary across the country. More information is also needed about the type, amount and appropriateness of care to address and manage pain, bereavement and other support, as well as the effectiveness of end-of-life care programs.^{Footnote 580} In addition, more information is needed the effectiveness of end-of-life care programs. As Canada plans for future palliative and end-of-life needs, improvements to data and information systems will be required.

Canada has made progress in addressing palliative and end-of-life care. From 2004 to 2009, CIHR funded $16.^{Footnote 5} million for palliative and end-of-life care research, primarily for teams in areas such as care transitions, caregiving, pain management, care for vulnerable populations and program evaluation.^{Footnote 579, Footnote 581} Furthermore, through the 10-Year Plan to Strengthen Health Care, the Government of Canada has provided support to provinces and territories to improve the quality and accessibility of home palliative care.^{Footnote 305} The Employment Insurance Compassionate Care Benefit is a key support for people who need a temporary leave from work to care for someone who is gravely ill. This program was recently extended to self-employed Canadians.^{Footnote 305, Footnote 582}

From 2002 to 2008, Health Canada supported the work of the Canadian Strategy on Palliative End-of-Life Care.^{Footnote 577} Under the strategy, five collaborative working groups focussed on initiatives around best practices and quality care, education for formal caregivers, public information and awareness, research, and surveillance. Key accomplishments included a core set of performance measures for accreditation and guiding principles of palliative and end-of-life care; a palliative and end-of-life framework to promote awareness and increased dialogue on palliative and end-of-life care; tools for knowledge translation to move from research to practice and policy; and the development of electronic networks to share information, research and best practices.^{Footnote 577} While the strategy has come to an end, the Government of Canada continues to support a variety of initiatives.

Other organizations are also looking at palliative and end-of-life health issues. The Canadian Coalition for Seniors' Mental Health, in collaboration has developed the adapted National Guidelines on the Assessment and Treatment of Delirium in Older Adults to end-oflife settings.^{Footnote 581}

As Canada's population grows older and lives longer, (in many cases with chronic illnesses and functional limitations), palliative and end-of-life care will need to be coordinated to manage complex service issues.^{Footnote 580} Palliative and end-of-life care must best reflect the right kind of care, at the right time and in the most appropriate settings. This growing need is a call to action to work together to achieve the best care possible for all Canadians.

Integrated care

Aging well involves having choices of where to live, having access to health care and social services, and living in supportive communities. However, many seniors report having unmet health, social and care needs.^{Footnote 73} Often this results in a gap in care and, from a health systems perspective, is inefficient and more costly. While Canada has had success with long-term care, and with acute and emergency care, there are limitations in addressing the continuum of care along a range of care needs – from home care to palliative care. As well, underserviced communities may not be sufficiently integrated to meet the needs of seniors with chronic and other health conditions.^{Footnote 586, Footnote 587} Difficulties are experienced by seniors who have to navigate, manage and pay for a range of care services. Difficulties also occur in the transition between care providers, as seniors move from home-based care to assisted living and/or long-term care.

The care of seniors needs to be part of mainstream health care. This involves developing comprehensive and integrated systems of care addressing seniors' varying needs without the differences in eligibility and costs.^{Footnote 587} Outcomes of integrated care are a higher quality of care and lower costs for that care.^{Footnote 586, Footnote 587} A key component of integrated care is to develop a broad home care strategy and recognize the contribution that home care plays in meeting the needs of seniors. Providing opportunities for seniors to maintain their independence for as long as possible is estimated to effectively save health care monies that are otherwise spent on early admission into long-term care facilities.^{Footnote 586, Footnote 587}

There is much debate about integrated care, its effectiveness and the practical implementation of such a strategy.^{Footnote 274} In Canada, several approaches have been developed for integrated-style care. For example, the Hollander and Prince Continuing Care Model builds on the strength of home and community-based services and applies transitions across all levels of health care.^{Footnote 533, Footnote 587} The model has 10 key elements of continuing care – five in each of administrative best practices and service delivery best practices. It is based on empirical analysis of the problem and builds upon Canadian traditions and successes in service delivery for persons with ongoing care needs.^{Footnote 533}

Other projects examining integrated community-based services for this vulnerable population, such as the System of Integrated Care for Older Persons (SIPA) and the Program of Research to Integrate Services for the Maintenance of Autonomy (PRISMA) studies in Quebec, have also generated growing interest within Canada and abroad because they address care delivery systems from a primary health care perspective (see Textbox 4.13 Models of integrated care for the frail elderly).^{Footnote 587} Maintaining an integrated system requires a single access point, strong leadership and advocates managing clients through the system. Given the complexity of care issues, Canada needs to address the disconnect between levels of care. However, it is also important to recognize that an integrated strategy within a Canadian context may be difficult to coordinate given the federal/provincial/territorial environment within which it would be required to operate.

Some countries have integrated community and continuing care into their universal health care. For example, Japan has one point of contact that handles assessments to determine needs and levels of care and manages transitions between levels and types of care.^{Footnote 588} Since the Japanese universal health care system is relatively recent compared to Canada's, policy-makers in that country had the opportunity to anticipate the increase in its seniors population and the need to incorporate care functions within that health system (see Textbox 4.14 Providing long-term care – the Japanese experience).

Summary

The areas highlighted in this chapter (meeting basic needs, aging in place of choice, falls prevention, mental health, abuse and neglect of seniors, social connectedness, healthy living practices, and access to care and services) are critical areas where Canada, as a society, can make a difference in creating the conditions for healthy aging. While there are proven and promising interventions, there are also many gaps in knowledge, information and best practices. As a result, it is evident that there is more to know and more to do.

Falls among seniors are often preventable and therefore initiatives that support falls prevention can significantly improve the health and well-being of Canada's seniors. Falls prevention guidelines establish and promote safer practices and more universal style designs. Establishing safe and barrier-free environments and supporting conditions for physical activity to increase strength, flexibility and balance can make a difference in reducing falls. Broader awareness and education of what can be done by individuals and health care professionals can also reduce the risk of falls.

Not enough is known about the mental health of Canada's seniors. Education and awareness programs are working to dispel myths about aging and mental health, and to break down associated stigmas. Senior-specific initiatives and strategies are important to address and manage mental health and mental illness among seniors and their families and caregivers. As well, broad mental health strategies are needed for all Canadians.

Addressing the complex issue of abuse and neglect of seniors involves a range of activities such as applying laws and raising awareness of rights within these laws. Broad awareness and education programs are working to help caregivers and seniors understand what constitutes abuse with the aim of preventing such incidents, while additional efforts can assist professionals and individuals identify cases of existing abuse and how to respond appropriately. However, many people remain uninformed, and more work is required to develop and populate knowledge networks and reduce stigmas and blame that can become barriers to addressing the problem. Communities can play a strong role in preventing abuse and neglect of seniors.

There are positive impacts on the health of seniors who take an active role in their community and who are socially engaged. Interventions that encourage seniors to become involved in group activities can have positive health outcomes. So, too, can efforts around the creation of age-friendly cities and communities, inclusive design and the eradication of ageism that can all contribute to social inclusion. Volunteering can also impact health positively by allowing seniors to remain socially connected and by recognizing their value in terms of the benefits to all of society (economically, socially and otherwise) realized from their contribution to the voluntary sector. As such, more needs to be done to encourage, keep and invest in Canada's senior volunteers.

Engaging in healthy behaviours requires raising awareness of the benefits associated with these behaviours. However, programs such as physical activity guidelines and smoking cessation initiatives need to be specific to seniors' unique situations. As well, engaging in healthy practices depends on having environments that are safe, barrier-free and attractive. It is also important to not only understand the benefits of healthy behaviours but also to be knowledgeable about health information.

The various levels and transitions between seniors' care services are complex. Seniors can experience difficulties in accessing, affording and deciding on care. There are many levels of care and within these levels some interventions are working toward planning and managing transitions associated with change in need. Some jurisdictions have made progress with broad strategies to meet the needs of seniors, as well as to support caregivers, but efforts must continue. Better awareness and understanding around levels of care and options within communities would support seniors and address the needs of caregivers and the impacts of caregiving. Better support for research in areas such as palliative care would also be of benefit. Further, best practices found across jurisdictions may prove valuable lessons to future efforts in this area.

In fact, the promising interventions and initiatives profiled in this chapter illustrate the broad range of sectors in society that can make a difference in identifying and implementing effective programs with measurable outcomes. These efforts provide a starting point from which to draw inspiration, think, plan and act, however, more work remains. One area where progress is needed is in the active inclusion of seniors themselves. Their insights based on varying needs, experiences, skills and abilities will go far in creating strategies and interventions that most effectively contribute to healthy aging in Canada. Chapter 5 highlights priority areas to collectively work toward healthy aging in Canada.