Call for a complete change in the healthcare system

A change in the healthcare system needs to be viewed in the same light as the new construction of Landspítali National Hospital, it is a similarly extensive project but no such work is underway. Elderly patients with chronic diseases often receive a lot of medication that can have serious side effects. Then gender differences can arise in the excretion of drugs.

This is among the things that Pálmi V. Jónsson, a physician, geriatrician, and professor emeritus at the Faculty of Medicine of the University of Iceland, says in an interview with mbl.is about the issues of the elderly in the healthcare system.

“I call this the blind spot, it is this emergence of chronic diseases that came about because we now live much longer, my life expectancy now is 14 years longer than when I was born. When we get older, we are also completely different than when we were younger. There is just a systemic mess in this.”

Jónsson recently gave a talk at the Doctors’ Days in Harpa, discussing chronic illnesses in older people.

Admissions can be attributed to side effects of medications

“The blind spot of the health service in geriatric care lies in the way chronic illnesses and multiple illnesses are managed. We are never more different from each other than when we are very old, in our prime we are not the same,” Jónsson is quoted as saying.

He then says that average life expectancy has increased every year since 1840. It has gone from 45 years to 80.9 years for men and 83.8 years for women.

He goes on to say that older people are fundamentally different from middle-aged people. Age-related changes in all organs are equivalent to diseases, and chronic diseases therefore multiply with age.

The risk of many chronic diseases doubles every five years after the age of 65. By delaying the disease by five years, the number of people who have symptoms 15 years later can be halved.

He also says that elderly people often receive too much medication and that almost 10% of people admitted to the medical department over the age of 75 can be attributed to side effects of medications.

The responsibility of the ministry and the Icelandic Medical Association

"We need to take a systemic approach to this," Jónsson says. He believes that representatives of each medical specialty should be in three places; in the hospital, outside the hospital or in the community, and the health care system. These three parties then need to define who does what at what time, in the most efficient way.

“If this is defined for every single specialty, and especially for chronic diseases, then it will be completely clear who is responsible for, for example, the diagnostic work, who is responsible for the treatment and so on,” he says.

“In my opinion, the responsibility lies on the one hand with the Ministry of Health and on the other hand with perhaps the Icelandic Health Insurance.”

He says they can jointly set up such a project and in that process it will be possible to better define the responsibility of each professional and how individual diseases are followed up.

This will define teamwork, for example with nurses and clinical pharmacists. In this way, the burden of these diseases can be managed and all healthcare professions can be utilized for the cooperation defined for each disease. “Because doctors are a limited resource.”

He also says that this is a large project that may be costly to implement, but can be successfully implemented with good cooperation.

Gender differences in drug excretion

Jónsson's presentation also states that as the system stands now, a doctor can diagnose a disease and consider the patient to be doing well at a specialist outside of a hospital or at a health care facility and then feel that they do not need to follow up on the patient's case. It is complicated when an older patient is involved.

"Because chronic diseases, as the name suggests, take a long time, varying lengths of time depending on the disease, but can last even 10, 15 years or more. Then it may be that the follow-up shifts during this period. So as time goes by and people have had chronic diseases for longer, get older and accumulate more than one disease, then a new level of complexity arises. That is why we need to define this."

Such an analysis needs to be done for all disease clusters in the upper ages using planning and engineering methods. Professional hospital leaders and specialist services outside hospitals and health care also need to come to the table.

“Rapid access to new diagnosis and initial treatment must be ensured, as well as follow-up thereafter,” Jónsson says, who says it is “deplorable when special dietary services are needed and they are not available until six months later.”

His presentation also states that gender differences can occur in the excretion of drugs. An example is the sleeping pill Imovane, but a 7.5 mg dose of it for men corresponds to a 3.75 mg dose for women. However, a 7.5 mg dose is a general guideline when it comes to using the drug. Women are therefore in reality receiving a 100% higher dose than they would need of the drug.

Similar projects to the renovation of the National Hospital

“So I think that in reality we need to use some kind of formal working methods like I imagine that planners or even engineers have. When you think about it like this, you see that this is a pretty extensive project,” Jónsson says, pointing out that the organization of health services at the community level is “no less extensive than renovating the National Hospital.”

“I have sometimes said that this is no less of a task than renovating the National Hospital at Hringbraut. How many architects, engineers, building officials and so on have been called in to review all the issues outside. Then there are all the professionals who need to come in to set the whole process in motion inside the hospital. There is nothing comparable going on outside the hospital,” Jónsson says, pointing out that even family doctors find themselves dealing with issues for which they do not have the appropriate specialist knowledge. He gives an example of this.

“For example, right now, during Doctors’ Day, there is a call from GPs to define who is responsible for diagnosing ADHD. They say, ‘We don’t have the expertise to monitor ADHD and renew medication responsibly.’ That’s just one example, but there are many more.”

In his talk, Jónsson also points out that activities of daily living are fourteen times better at predicting death than diagnoses. Subscribers can read Jónsson’s article from the Morgunblaðið’s article collection, which states that “physical activity is the cornerstone of healthy aging, both by extending life and improving quality of life.”