Life-Span Design of Residential Environments for an Aging Population

A Contemporary Approach to Geriatric Care in Belgium

Franz Baro, M.D., Professor
R. Dom, M.D., Professor
Department of Brain and Behavior Research
University Of Leuven

Introduction

The elderly of Belgium, defined as those persons 65 years of age or older, currently comprise of more than 14 percent of the population, a percentage expected to remain stable until the year 2000. Except in rural areas, parents and grown-up children usually do not live together. On the one hand, when children grow up, they adopt a more modern life style and choose to work outside the home, leaving the aging parents to fend for the themselves. On the other hand, the typical Belgian senior citizen prefers to live independently, viewing old-age and nursing homes as final and negative choices. The parent-offspring relationship generally entails intimacy at a distance: the children quickly respond to their parents needs when necessary¹.

In Belgium, as in other European countries, the awareness exists that care of the elderly is a labor-intensive effort which consumes a considerable share of the national health care budget. Moreover, almost 99 percent of its population, including the elderly, are covered by compulsory national health insurance.

The Belgian government has studied the issues involving elderly care within the context of the country's overall social, cultural and economic development. Since 1977, the Ministry of Public Health and Family has reexamined its policies and priorities in light of three overriding principles of health care for the aged:

that the aged should be cared for in their own living arrangements as long as possible, hence the importance of the general practitioner, the nurse, etc.
that if necessary, the means must be found to care for them through special services, rehabilitation centres or nursing homes;
that optimum cooperation among these services should be structured at local, regional and supra-regional levels².

A variety of health care services is available for the elderly. Ninety-five percent of the elderly live in their own private homes and may benefit from medical, nursing and social services provided by private or public organizations and voluntary workers. For the remaining 5 percent the institutional options available are:

Private and public old people's homes (residential) where only custodial and occasional nursing care are provided;
Private and public nursing homes for those in need of long-term nursing care;
Emergency and in-patient geriatric facilities where intensive medical, paramedical. and nursing care are available.

However, Belgium faces problems in institutional health care for its elderly similar to those found in most industrialized countries, such as:

The existence of too many acute hospital beds with high investment and functional costs,
Poor correlation between regional needs and the type of hospital beds provided,
Insufficient number of hospital beds adapted to the needs of the elderly in both general and psychiatric hospitals,
Insufficient availability of long-term care and residential facilities.

These four problems emphasize once more the fundamental difference in quality between acute and long-term care facilities, defined by the needs of the elderly. Acute-care facilities require a costly infrastructure, highly specialized and qualified medical, paramedical and nursing staff, sophisticated technical equipment as well as functional wards. In contrast, long-term care facilities should offer a caring medical attendance, a devoted, well-trained paramedical and nursing staff, a well-organized and appealing hotel service, a peaceful and home-like atmosphere with respect for privacy and territory, as well as a stimulating environment and recreational possibilities.

To realize these objectives requires an excellence of conception rarely found in geriatric health care facilities. This challenge was met by the Catholic Health Insurance Company (already running a general hospital and home service for the elderly in the region of Mechelen, Belgium), which, in collaboration with a team of medical and nursing advisors and the architectural bureau of F. Verbaenen (Kapelle, Belgium) created the geriatric center Ten Kerselaere (which, in English, means "the cherry orchard").

Facilities

Objectives

As an architectural prerequisite, Ten Kerselaere was to be designed to suit the well-being and comfort of its elderly residents. All facilities, including living quarters, would be at ground level, laid out to resemble a small village, reflecting the concept of a dynamic community. Long-term hospital care (90 beds for 60 geriatric and 30 psychogeriatric patients), nursing-home care (40 beds) and sheltered housing (10 houses) would be provided. Ten Kerselaere would be an exemplary model of the Belgian Ministry's approach to geriatric care³.

Principles

These requirements, given to the architect, were the result of a philosophy of care based on modern European geriatric concepts adapted to the local conditions of the Belgian community. Structural aspects of Ten Kerselaere were planned to reconcile the center's fairly constant residential function with its therapeutic and rehabilitation functions, continuously changing as concepts of care evolve, especially in the field of psychogeriatrics. This flexibility was reflected in the plan for subdividing the center. Ten Kerselaere would not be compartmentalized into small architectural subunits: rather, it would resemble the open community from which its residents came and where normal binding social forces could come into play such as mutual affinity and respect, common interests and related backgrounds, physical attraction and a similar handicap.

Another important consideration was the increasing number of cases of senile dementia, especially prevalent in the older elderly (approximately 20% over the age of 75-80). At present, no causal treatment is available, but the design of the facility had to deal with the secondary behavioral and psychosocial handicaps linked to this mental affliction. Thus, the residential facilities had to provide services at all stages of a progressive psychogeriatric disorder.

Implementation

To realize these objectives and this philosophy, the architect designed Ten Kerselaere to resemble a small, dynamic village where all normal daily activities take place. Rather than long narrow corridors, there are wide streets, squares, and street corners, a cafe, beauty parlor, chapel, shops, exhibits, and happenings, attracting residents to a more social life style. Strolls are encouraged via sensory stimulation in the form of children's playgrounds, small livestock, birds, flowers, greenery. Therapeutic and rehabilitation activities are discretely open for all to see, avoiding apprehension and suspicion about the unknown among the residents. Integrated into daily living, they give a positive view of their potential benefits to residents, family, and visitors alike.

The fact that Ten Kerselaere is built on ground level only helps to blend activities and services and create a harmonious atmosphere.

Functional Activities

Services

Ten Kerselaere consists of four functional sections:

The long-term hospital care facility offers 60 beds for geriatric and 30 beds for psychogeriatric care;
The nursing-home facility offers 40 beds for geriatric and psychogeriatric care;
The ainbulatory/day facility can provide geriatric and psychogeriatric help for 15 persons per day;
The sheltered housing facility is made up of 10 houses.

Personnel

Ten Kerselaere is run by a chief administrator, a head of nursing, and three administrative assistants.

The medical staff is represented by a full-time geriatrician, a part-time neuropsychiatrist and a part-time general practitioner. The former two are responsible for the long-term hospital care and ambulatory/day care facility, while the general practitioner staffs the nursing home. In addition, consultants in diverse specialties are available upon request.

The Paramedical term includes physical and occupational therapists, a speech therapist, vocational therapists, social workers, and a part-time psychologist. The nursing staff to patient ratio is 15/30, 9/30 and 3/10, respectively, for the long-term hospital care, nursing home and ambulatory/day care facilities. The technician services consist of a maintenance crew, and the hotel service is adequately staffed by kitchen and custodial employees. A chaplain is available for counseling and religious services. Paramedical and nursing trainees, a well as volunteers, complete Ten Kerselaere's personnel roster.

Patient Population

The prerequisites for admission to Ten Kerselaere involve a diagnostic examination and preparatory contact with the future resident's family.

Admission to either the geriatric or psychogeriatric unit is based upon the candidate's medical condition. However, the selection for the former unit mainly depends, in order of importance, upon a low ADL score (Activities of Daily Living), the need for prolonged rehabilitation, and the type of social problems, while selection to the latter unit chiefly depends upon the presence of severe behavioral problems linked to social problems and the need for prolonged rehabilitation.

The long-term hospital care facility serves three groups of patients:

Patients needing prolonged treatment due to the poor general condition linked to a multipathology (i.e., organic, mental, locomotor, social);
Patients requiring prolonged functional rehabilitation;
Patients in need of terminal care.

Effective treatment of these problems calls for successful integration of medical and nursing care remedial therapies, and active reintegration and discharge policies.

Evaluation of Services and Care

In its first four years, Ten Kerselaere admitted approximately 1,000 patients to its long-term hospital care facilities, excluding the day care population. Of these, 79 percent entered the geriatric and 21 percent the psychogeriatric unit.

Based on the principal diagnosis upon admission, the geriatric unit's utilization data showed the following profile: 29 percent stroke/multiple cerebral infarctions; 22 percent osteoarticular problems; 11 percent behavior problems such as confusion, depression and dementia; 10 percent malignancies: 20 percent multipathologies (e.g., cardiac, pulmonary, gastro-internal); 4 percent Parkinson's disease; and 14 percent other neurological disorders (e.g., multiple sclerosis). As for the psychogeriatric unit, the profile was as follows: 72 percent dementia including senile dementia Alzheimer type and multi-infarct dementia; 18 percent confusion; 4 percent manic-depressive psychosis; 3 percent vital depression; and 3 percent Korsakow syndrome.

The discharge data for the geriatric unit yielded the following pattern: 46 percent returned home, with 9 percent continuing to use the ambulatory/day care unit, 21 percent died, 14 percent were admitted to an old people's home, 12 percent entered Ten Kerselaere's nursing home, and 7 percent were returned to a general hospital. As for the psychogeriatric unit, 32 percent of the patients returned home, with 5 percent of them continuing to use Ten Kerselaere's ambulator/day care unit, 14 percent died, 29 percent entered an old people's home, 13 percent were admitted to Ten Kerselaere's nursing home, 8 percent entered a general hospital, and 4 percent a psychiatric hospital.

Until now, only descriptive data have been collected regarding Ten Kerselaere's residents. Formal quality assessment studies are presently under way to detain the impact of this geriatric center. A current study on senile dementia Alzheimer type is seeking to compare the differential outcome of these patients at Ten Kerselaere with a comparable group in a nearby mental hospital. Another study examines the changes in health status, somatic and psychological, upon entry and discharge in Ten Kerselaere and another geriatric institution.

Conclusion

The architect of Ten Kerselaere, F. Verbaenen, has been awarded national and international prizes for the design of the center, which has already shown itself an exemplary fulfillment of the contemporary Belgian approach to geriatric health care. Residents, staff, and visitors alike have expressed satisfaction with the center and the quality of life and care there.

The creation of new centers like this one entail a crucial challenge at a time when economic restraints stand face-to-face with the potential for constructive solutions to the increasing problem of health care for the elderly.

ENDNOTES

1. World Health Organization Regional Office for Europe, "The Elderly in Eleven Countries: A Sociomedical Survey," Public Health in Europe 21, Copenhagen (1983).

2. World Health Organization Regional Office for Europe, "Psychogeriatric Care in the Community," Public Health in Europe 10, Copenhagen (1979).

3. F. Verbaenen, "Hoen goed is het patient zijn?" A-plus 78 (1982): 11-13.

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