However, a recent survey done in a representative city in the United States, in the State of New York, in which a door-to-door canvass was made of older persons to determine what their psychological state was as determined at the front door of their own homes, it was found that somewhere between 10 and 20 percent of those iiving in their own domiciles had psychological disorders of sufficient magnitude as to be recognizable by an untrained individual, and as to be committable or certifiable to an institution if anyone wished to press commitment.

This means that of the total number, if we take the smaller figure, 10 percent of the total number of the aged (about 152 million) about 112 million are certifiable to an institution. Suppose that we are even more conservative and say only 5 percent need immediate institutionalization.

Five percent of the 1512 million is 750,000 people, or a number exactly equal to the total number of mental hospital beds we have in the entire United States for all age groups.

If the aged alone who need psychological care were to be institutionalized, the younger age groups would be excluded.

In a sense one might say that the reason why mental illness is a problem among the aged is because we are not prepared for this enormous number of people who require our services. Aged patients admitted to mental hospitals in the United States ran in 1958 at about 40 percent of the total number of people who went into mental institutions. Just in the period of time in which I have been interested in the field of gerontology and geriatrics, roughly 11 years. that number has increased from about 25 percent, so the number of institutionalized aged mental patients has increased.

Of that number, the 40 percent, about 23 percent are diagnosed by physicians as having a psychosis based upon hardening of the blood vessels of the brain; 17 percent, a little less than half of the total 40 percent, are diagnosed as having a psychosis due to senile brain disease. In many instances in the opinion of many physicians, these diagnostic entities are regarded as unpromising for cure or treatment. This is a rather unfortunate state of affairs in the United States, because those of us who do work with the aged, who have brought to bear upon them an intensified psychological program, find that an enormous number of them can be vastly improved.

Dr. Ferderber, I think, will tell you about his experience in a general hospital. My experience in a public mental hospital has demonstrated that about 60 percent of aged persons who are admitted to public mental institutions can be vastly benefited, and of them, nearly a half or about 33 percent of the total number, can be returned to the community. But there is not yet the widespread education among our professions and our medical colleges to provide sufficient scope to treatment programs for the aged.

PREVENTIVE MENTAL HEALTH PROGRAMS FOR OLDER PERSONS

In the city that I represent, the city of Philadelphia, we have recently instituted a preventive mental health program for older adults, the first of its kind in the United States, I believe, which we have entitled the "Adult Health and Recreation Center." We are taking older people, most of them in their late sixties and seventies, bringing them at no cost to themselves to a center operated under the Public

Health Department, and with funds that come from the city and from the State of Pennsylvania, giving them a total recreational program combined with health services, diagnosis, maintenance and referral. We have found in the large number of people who just in the period of 6 months have registered for our services, (a group of about 225), nearly 80 percent have physical disorders that they were either unaware of or were neglecting.

Almost all of them were depressed. In almost every instance the depression was lifted in a period of a few days when these oldsters had an opportunity to talk to somebody. When we asked them why they felt so good in such short order, their uniform answer has been, "this is the first time in 20 years or so that anybody has listened to me." This factor of social insolation is very real.

It is my contention that there will be necessity for the development of many more such preventive psychological services throughout the United States.

We find that the cost of such services is surprisingly small. The cost is about $1.28 per contact with these patients, and it probably prevents serious psychological breakdown. I think I think you will agree with me that this is a bargain.

SCANDALOUS CONDITIONS IN NURSING HOMES

Another thing I would like to mention, Senator McNamara, is that, although in many instances nursing homes operate under scandalous conditions, I think that it is important that the public laws at all levels of government not make it mandatory that, once the diagnosis of psychosis is made in an oldster, he be placed in a mental institution, or, in other words, that a properly constituted nursing home in which there resides a psychotic oldster should have the legal right to treat him and, in addition, that, once the diagnosis of psychosis is made, an oldster be still eligible for public financial help, because, as the law now stands he often cannot receive such funds.

I think that the nursing homes, if properly constituted and if they have developed in them appropriate programs of mental illness prevention, would be appropriate places for oldsters to be cared for, and I think it would be desirable for the laws to be changed to make it possible for psychotic oldsters, since the bulk of them with any degree of mental aberration can be readily diagnosed as psychotic, to be permitted to reside in such institutions.

There is today in psychiatry a trend away from mental institutionalization. There is a trend toward community care of all forms of psychological problems. Since we are not building new mental hospital buildings and do not have adequate institutional facilities for the care of disturbed age, I think the nursing home and other domiciliary care should be fostered by enabling legislation. Also, I think that there should be some provision made in the law to make it possible for an oldster, psychotic or otherwise, to receive appropriate allocation of funds commensurate with decent living.

Those are just a few of the points I wish to make, Senator, in order not to duplicate the remarks I have already submitted.

Senator MCNAMARA. Thank you very much, Doctor. I am sure your stressing the mental problems of the aged is most important, and the committee is very appreciative of your contribution.

STATEMENT OF DR. MURRAY FERDERBER, SCHOOL OF MEDICINE, UNIVERSITY OF PITTSBURGH, CONSULTANT ON PHYSICAL MEDICINE AND REHABILITATION, ALLEGHENY COUNTY INSTITUTION DISTRICT; CHAIRMAN, PENNSYLVANIA COMMISSION ON RESTORATIVE MEDICAL SERVICES

Senator MCNAMARA. The last panel member we have with us today is Dr. Murray Ferderber of the School of Medicine, University of Pittsburgh, consultant on physical medicine and rehabilitation, Ållegheny County Institution District. He is chairman of the Pennsylvania Commission on Restorative Medical Service.

Dr. Ferderber, we are glad to have you here today.

I see you have a short statement, and we would be glad to have you proceed in your own manner.

(Dr. Ferderber's prepared statement follows:)

During the past 13 years I have traveled an average of 20,000 to 40,000 miles yearly for the purpose of visiting some 240 or more institutions which, presumably, exist for the care of the chronically ill and aging. Many of these same institutions were surveyed and existing facilities carefully analyzed at the personal invitation and request of those in charge. As a result of these visitations, and based on experiences at the Allegheny County Institution District of Pittsburgh where I began rehabilitation work in 1946, we now know that an average of 25 percent of institutionalized patients could live outside of these facilities if there were available such services as decent or adequate lodging, visiting nurse and visiting medical care.

The first requirement-decent or adequate lodging-is difficult to meet because of the minimum allotment for patients on public assistance. In order to maintain themselves within the amount apportioned they must climb stairs to second or third floor rooms since accommodations on the first floor, which in most cases are so essential, are usually more expensive and beyond the budget set by public assistance.

There are few large centers in this country where adequate visiting nurse services are available to help maintain the oldster in more familiar surroundings. I purposely choose the term "restorative medical services" rather than "rehabilitation" as applied to this group since the end result of physical rehabilitation is self-care and there are few opportunities for employment for them that could insure a fixed, nominal income.

Public officials in their endeavor to save money are frequently shortsighted in the type of homes which they maintain for the aging and aged. There is a peculiar concept for this, but verified, that many of these so-called poor houses, poor farms, alms houses, etc., are for the specific purpose of keeping old folks indefinitely rather than using the revolving door principle of sending them back into their respective communities where most desire to live. After all, the older the human, the less desire for change in living habits or locale.

Little or nothing is taught regarding the aging process in our schools of medicine and affiliated medical training facets. Thus, when these same persons are full professionals there is a great deficiency in their knowledge of the potential of these same people. An example of this might be cited in that when this writer was an intern a fractured hip in the older person usually meant demise. Today, it is not considered to be nearly as serious a disability as it was then. In this same connection, patients with fractured hips lay in bed for weeks, perhaps months. Today they are moved along much more rapidly and progressively without permitting the body to deteriorate. We have factual data to substantiate this at the Allegheny County Institution District (Allegheny County Hospital), as well as in other onetime devastating disabilities of an aging and aged group such as strokes, amputations, or the various neurologic complaints.

Since we have no apparent means of changing the retirement age, we at least must have certain areas where the oldsters may congregate, not only for recre ation but to engage in handiwork, etc., which is a source of enjoyment-as a labor of love rather than labor per se.

In conclusion, we are paradoxically-a young nation with a rather huge aging population for whom no preparations have been made, economically, medically,

socially or industrially. We therefore need the efforts of all concerned-those in public office both national and local, the whole of the medical profession and, finally, the public which will have to do more than pay lip service to this problem.

Dr. FERDERBER. Senator McNamara, I am greatly overwhelmed by the erudition of those who have preceded me. This is my first appearance before any Government official when I was not asked about income tax. However, my relationship with that organization has been very satisfactory.

Senator MCNAMARA. We hope this appearance will be a little more pleasant than the previous one.

Dr. FERDERBER. A little more pleasant, but a little more emotional. My work is done at the level where I am one of those who have to worry about people who go into institutions, people who cannot get into institutions but who cannot live satisfactorily on the outside. Right after my separation from the service in 1946 I started in what was known as the poorhouse of Allegheny County.

To go back to the Dickens concept of a poorhouse, it is a place where they would take you in if your home and barn burned down, and take you to church, and send your children to school until you were relocated. It was also understood the people were not supposed to become ill. There is also today a rather unfortunate bit of tradition that, to my way of thinking, plays a greater part in our prejudices, and I must include the chronically ill as well as the aging.

PUBLIC HEALTH ASPECT OF AGING PROBLEM

I was very much impressed by your opening statement, saying that this was a matter of public health. I suppose I will not get into too much difficulty with my conferees by saying that I feel this is just as much a public health problem as strontium 90 in milk, or polio in children, for the reason that I wonder whether we realize that the number of oldsters with tuberculosis is strictly on the increase. I wonder whether we realize the traditional view, which is most of the time magnifient but almost always narrow, which thinks of people in public health-and I am not a public health figure-as people who make certain that stores are clean and toilet seats are sanitary, and that restaurants maintain the proper sanitation.

Let us develop this for a moment. There are many-I will not go into the numbers-a great number of so-called poorhouses or county homes, county poorfarms in these United States. It has been my ill fortune to have visited between 235 and 250 of them in the last 13 years. It is rather interesting, too, the level of medical care is virtually at the most meager level that one could expect.

Why is this?

This is based on tradition because the poorhouses were meant to be built in order to dump individuals who were neither wanted in the community nor needed. When they became ill, they had a sick call, during which some physician came in, hired, I suppose, at a very meager stipend, to look over and see what was wrong with these individuals.

There were very few county institutions in these United States that had any sort of medical service whatsoever.

It is rather amazing to know-Dr. Linden referred to it, and this subject may be a little unpleasant, but I think perhaps the truth is

never very pleasant either-that at the Allegheny County institution, our county home, we had wards in the female infirmary in which people had been incarcerated, not legally but medically, anywhere from 30 to 70 months. These people were incontinent, Senator.

This is not a very pleasant thing, to be listed as unclean. They were put into a little bay of a building.

It is rather amazing that people who were using 11 pieces of linen for 24 hours, in about 8 to 12 weeks dropped down to 2 pieces of linen for 24 hours-merely pointing up that something better than animal care is needed so far as our county institutions and homes for the aged are concerned, to put them in a general classification.

What happens to people when they become ill and they enter? Naturally, Dr. Linden knows better than I, they simply must go in voluntarily.

It is a rather interesting fact, though, that with the costs outside, whether it be hospitalization, medical care or support of a family, these people became indigent, not only financially but medically and physically indigent. Most places cannot provide for them.

ALTERNATIVES TO INSTITUTIONALIZATION

It is a rather interesting point that we have found that approximately 25 percent of those people who now are living at the Allegheny County hospital or institution could live on the outside if a few simple things were provided: first, decent housing-and I do not mean housing devoted entirely to the aged, for the simple reason that they become a legion of the damned when you throw a great number of oldsters together, as was proved during the war when we threw together a category of one group of indigents. Actually, it is segregation of a

sort.

We found that, besides places to live, these people needed a modicum of care. I choose to call it maintenance medical care where we could have good visiting nursing care or public health care-the name varies, of course, with the locality-where we would have visiting medical care, physicians.

"STRIKE BACK AT STROKE"

At this point I would like to talk again about tradition in my own profession, in which we, as medical students, learned a great deal about embryology, how we build up the bodies, and histology, et cetera. But we were never taught a thing about the breakdown or the aging process. Therefore, we, as interns, were never oriented. When we saw a stroke, that was that.

Surprisingly enough, recently our own Public Health Service published a very magnificent brochure on "Strike Back at Stroke." As you know, we have approximately 1,250,000 each year, a rather constant population.

In traveling 20,000 to 40,000 miles each year it is fantastic to me how few physicians have either known about it or know anything about its content. Condemn us if you will, but I think we must go back to the health profession's basic, to school of medicine, nursing, therapy, technicians, and so forth, where we can develop people who are thinking of and looking at these problems of the aging process or chronic illness.