hospital events, and could be construed as valid reasons for hospitalization in the absence of other solutions.

The absence of other solutions is apparent rather than real. It is not a simple matter of people not wanting to find other solutions. Rather it is a matter of despair, anxiety, and ignorance as to what other solutions might exist. For example, much breakdown among the aged can be prevented by sound medical care, with particular attention to the delicate problems of fluid balance and biochemical equilibrium. Proper attention to sensible schedules of exercise and rest; sleep and wakefulness; nutrition; and psychological needs for affection, self-esteem, and intellectual stimulation can be shown to prevent and even reverse mental breakdown. Skilled use of tranquilizing and energizing drugs can help maintain balance. Some disturbances are caused by small strokes,

whose effect may be naturally self-limited. These facts are too little known. A basic aspect of the problem is the concept in medical teaching that mental symptoms in the aged are the result of irremediable brain damage and thus irreversible. Whereas forgetfulness and confusion are viewed as normal accompaniment of senile brain deterioration, behavorial disturbances appear to be superimposed; the result of circulatory, nutritional, or psychological deficits as noted above. It is the behavorial disturbances, which to a significant degree appear to be preventable and/or reversible, rather than confusion per se, which bring about admission to mental hospitals. In their most acute and severe phases, such breakdowns may require periods of close and specialized care that a psychiatric hospital can provide.

Some more serious behavior difficulties are occasionally noted. These again are related more to an accentuation of previously existing personality traits than to changes resulting from aging itself.

Thus, as the behavior disturbances arise the family and the family physician, or the nursing home staff and the medical consultant, come to the conclusion that the situation is hopeless and that mental hospitalization is the only solution. It is important to bear in mind that these decisions are made, in a majoriy of instances, in good faith. Despite the best of intentions, significant differentials in cost of care would be bound to exert an influence. The tragic feature is that with the difficult aged person out of the situation, those remaining rapidly reach a new adjustment in which after a short period (probably less than 6 weeks) there is no further room for the aged member.

In summary, there should be two broad approaches to programs in this area, (1) acute intensive psychiatric treatment where necessary, and (2) prevention of mental breakdown and subsequent hospitalization if possible. In regard to the former, there should be provision for temporary admission or commitment for aged persons, if they require psychiatric care, until through intensive efforts reversible symptoms can be reversed. In regard to prevention there appears little question but what prompt, intensive medical care by physicians properly trained in geriatrics could prevent much mental hospitalization in this age group (we emphasize the educational aspect of this problem and define "geriatrics" as including an understanding of mental and emotional problems of the aged).

With the development of nursing homes in Minnesota, and suitable programs in them, we have seen a decrease in mental hospital senile commitments. A continuing increase in nursing home beds; the establishment throughout of staff training, volunteer, and socialization programs; and an increase in affiliated community and hospital psychiatric facilities could be expected to have a significant effect on the incidence of mental hospitalization among the aged. Yours respectfully,

DAVID J. VAIL, M.D.,

FIRE SAFETY IN HOMES FOR THE AGED

Medical Director.

[This report prepared and submitted for Cyrus E. Magnusson, State fire marshal and commissioner of insurance, by Eugene L. Weber, assistant commissioner of insurance-fire investigation supervisor.]

Fire protection problems of the nursing and boarding care home are filled with tribulations and satisfactions to the State agency responsible for this service. In the State of Minnesota this responsibility is that of the office of the State fire marshal. The importance of the mission overshadowed the tribulations

and provided the determination to our State among the best in the assurance that fire safety became as much a part of this industry as medical care.

The 1951 legislature passed a "law for licensing hospitals and related institutions" for the State department of health which, we believe, paved the way for the original success we had with our program. This law read, in part:

"The State board of health shall, in the manner prescribed by law, adopt and enforce reasonable rules, regulations, and standards under sections 144.50 to 144.58 which it finds to be necessary and in the public interests and may rescind or modify them from time to time as may be in the public interest, insofar as such action is not in conflict with any provisions thereof.

"In the public interest the board, by the rules, regulations, and standards, may regulate and establish minimum standards as to the construction, equipment, maintenance, and operation of the institutions insofar as they relate to sanitation and safety of the buildings and to the health, treatment, comfort, safety, and well-being of the persons accommodated for care. Construction as used in this subdivision means the erection of new buildings or the alterations of or additions to existing buildings commenced after the passage of this act." The standards permitted under the law became effective February 10, 1952, and read, in part:

"Fire protection. Fire marshal approval required. Fire protection shall be provided in accordance with the requirements of the State fire marshal. Approval by the State fire marshal of the fire protection of the institution shall be a prerequisite for licensure."

The fire marshal realized that it would be necessary to have detailed standards to insure uniformity in the surveys and decisions of the field and office personnel at all times. Our first standards for nursing and boarding care homes was adopted and effective July 1, 1952. Although it was not as rigid or restrictive as we know and accept laws and standards to be today, it did meet with some opposition from the industry. However, we overcame this by attending industry meetings, explaining the new regulations and selling the need for safety; while pointing out the substandard conditions existing. It soon became apparent that the industry realized that we were not trying to regulate them out of business and the compliance received is a compliment to this progressive group. Patience and understanding were needed by both the operators and the regulatory body to obtain "compliance by convictions."

Although codes, standards, and regulations designed to provide increased fire safety for the occupants of nursing and boarding care homes do cost money, it must be remembered that this expenditure also increases the valuation of the property.

In the early days of operation with the new regulations, most of the homes were of the type converted from old dwellings, hotels, and occasionally an old hospital building. The Federal Hill-Burton Act which provided financial assistance to communities for the construction of hospitals actually was responsible for a part of the growth in the nursing home program. Those communities that took advantage of the Federal assistance suddenly found themselves with an old hospital building that had very little value other than to convert it into a nursing or boarding care home.

When the fire marshal began the inspection program of these properties, we found that the most common criticisms were:

1. Inadequate number of exits and improper location of many of the existing exits.

2. No identification of exits.

3. No fire alarm or fire detection systems.

4. Stairways open and unprotected.

5. Boilerrooms unprotected.

6. Maintenance and laundry equipment located in open basement areas. 7. Excessive storage of combustible materials, such as lumber, furniture, clothing, etc., throughout building.

8. Exit corridors of passageways were inadequate in size and location. It was in these areas that we concentrated our initial efforts. These were the very obvious hazardous conditions that had to be corrected in order to insure minimum safety from fire. Combustible storage rooms, maintenance shops, laundry rooms, and boilerrooms were isolated by separate enclosures of fireresistant construction. Fire alarm systems and electric exit signs were required in all-wood or wood-frame interior homes housing eight or more residents or patients; automatic sprinkler systems were required in wood or wood

frame interior buildings that housed or cared for 24 or more patients or cared for bed patients on the second floor. Regardless of the total number, additional exits were ordered either inside or outside the building; identification was required for all exits and exit passageways were enlarged and relocated to permit safe travel.

By 1956 we observed a trend toward more new construction. This included additions to existing facilities and completely new facilities housing from 25 to 100 persons. It was also apparent that the fire safety standards needed revising. We, therefore, decided to gain legislative approval of our program by requesting authority to establish a fire safety code for several types of buildings and occupancies. This approval was granted by the passage of the following enabling act in 1957.

Minnesota Statutes of 1957, Sections 73.41 Through 73.44

SECTION 73.41. The State fire marshal, after holding a public hearing in accordance with Minnesota statutes, section 15.042, shall establish a fire safety code. The regulations in the code shall provide for reasonable safety from fire, smoke, and panic therefrom. In all hospitals, nursing homes, rest homes, board and care homes, as defined by the board of health, schools, hotels, as defined by Minnesota statutes, section 60.91, subdivision 2.

SECTION 73.42. REQUIREMENTS OF CODE. The code shall specify reasonable minimum requirements for fire safety in new and existing buildings and facilities. Regulations may be in accordance with the size, type of construction and nature of use or occupancy of such buildings or facilities. No regulation made in accordance with sections 73.41 to 73.43, shall be inconsistent with the provisions of the statutes nor impair the rights of municipalities to enact ordinances and make orders with respect to buildings as provided by law, so far as such ordinances or orders specify requirements equal to, additional to, or more stringent than the regulations issued under the authority of sections 73.41 to 73.43. SECTION 73.43. FILING OF CODE AND AMENDMENTS. The code and all amendments thereto shall be filed with the secretary of State and published in accordance with Minnesota statutes, sections 15.046 to 15.049, and in addition thereto a copy shall be provided each local fire marshal, fire chief, building inspector, or other governmental official who requests a copy of the code.

SECTION 73.44 VIOLATIONS. Any person who violates any provision of the fire safety code shall be fined not more than $200 or imprisoned not more than 3 months or both. No person shall be convicted of violating the fire safety code unless he shall have been given notice of the violation in writing and reasonable time to comply.

(Copies of the code are available upon request to: State fire marshal, 230 State Office Building, St. Paul, Minn.)

This newest fire safety code for Minnesota may not be as restrictive as some found in other States but it is a workable code. It is workable because it still permits the conversion of existing buildings without sacrificing fire safety. We now require fire alarm systems for all the licensed homes and automatic sprinkler protection for those wood or wood-frame interior buildings that house bed patients on the second floor or have a total capacity of more than 15 patients. Perhaps the major restriction placed on the conversion type building is that no building of wood or wood-frame interior construction over 2 stories in height will be accepted.

Our requirements for new buildings are very similar to other codes in that we permit only fire resistive incombustible materials for construction.

The adoption of this new code was made without opposition from the industry when the public hearing was held. We hasten to explain that this was not because of a lack of interest on their part. The State nursing home association was most helpful and cooperative during those trying months while the code was being formulated. Their committee and the committee of the fire marshal met at least six times to explore and discuss all the changes proposed. Without their cooperation we could have spent many additional months before final acceptance of our code.

This report would not be complete without making mention of the support and cooperation we have received from the Minnesota Department of Health. The dedication displayed by personnel from that department made it possible for us to double our efforts, so that today we have developed a successful working team in the two State departments. Although the department is the licensing

agency for nursing and boarding care homes, no license is issued until a clearance has been received from the State fire marshal for fire safety.

Medical science has done well to increase our life span which to us means a steady increase in the development and expansion of the nursing and boarding care home business. More and more of our aged will be spending their last years, either by assignment or voluntarily, in one of these homes. We believe that everyone, regardless of age and regardless of the type of building they live in, are entitled to the assurance that the State has done its job in requiring fire safety for them.

Our State fire marshal records are public to all for study or review, in the hope that from them may come ideas that will improve our own efficiency.

PREPARED STATEMENT OF MRS. IRENE H. WILLIAMS, CONSULTANT ON AGING, COMMUNITY HEALTH AND WELFARE COUNCIL OF HENNEPIN COUNTY, INC.

I am sure I express the sentiments of all those working in the broad field we have come to call aging when I add my word of greeting and appreciation to this Senate committee which has done so much to alert and inform the Nation about its unfinished business regarding older citizens.

The community in which you are meeting has, through its health and social service organizations, given increased and particular attention to older people for at least 15 years. To mention only a few of our earliest efforts, local senior citizens clubs began in 1947, as did our family and children's service foster home placement program. The after 60 hobby show was started in 1950; our day center, council house for senior citizens, in 1952. Hennepin County Welfare Board was the first public assistance agency in the Nation to employ in 1950 a group work consultant to spearhead development of social organizations of older people.

For 42 years a full-time consultant on aging has been employed by the community health and welfare council, and it has been my privilege to hold this position (the most exciting, challenging, and rewarding in 25 years of social work). Working through planning and study committees and relying on our older citizens as full partners and guides in the problem-solving process, we have sought to coordinate, strengthen, and stimulate services, to gather facts, offer assistance in setting up new programs, provide for better communication, and carry on a broad-scale educational campaign.

Our philosophy has been that older people must remain (or regain the status of being) fully integrated in the life of the family, neighborhood, and community. Our primary efforts have been to make their needs and desires understood, and to achieve the kind of services and community atmosphere which facilitate achievement of the good life. Our gratification has come from the high level of interest and support throughout the community, the inspiring leadership of our senior citizens themselves, and the constructive changes and improvements in programs and facilities across the board. Our frustrations have emerged from the contrast between what has been accomplished and our dreams for what we would wish to achieve.

Since time does not permit a full sharing of our experience, learning, and recommendations, I would like simply to emphasize some of the basic supportive services which the planning committee on aging of the community health and welfare council believes are imperative. We know we will have increasing numbers of older people. We assume, from all available evidence, that retirement incomes will rise, health levels will improve and that older people will prefer to live as independently as possible in homes and neighborhoods of their own choosing. There seems no question that both individual happiness and community well-being will be enhanced by this kind of dignified and self-determined living. However, large numbers of persons, especially as they reach very advanced age, cannot hope to achieve this goal without a network of services being available in every local community. The Social Services Section of the White House Conference on Aging stated as a basic principle:

***High priority should be given to services which will enable persons to continue to live in their own homes, or will make it possible for them to return to their family or to independent living when feasible."

We believe this principle cannot be overemphasized.

Services necessary to achieve these ends would include: personal and family counseling; protective and/or guardianship services; home medical nursing care;

housekeeping aids; volunteer visitors, shoppers, and escorts; foster homes, educational programs of all kinds; recreational facilities (centers, clubs new devices); volunteer service opportunities; information and referral services.

Our experience indicates that often only a very small amount of counseling or other assistance is sufficient to work out safe and gratifying living arrangements, which are accompanied by individual peace of mind, and community economy. We regret that many of the above services are still sketchy and fragmented, if developed at all, and we have a long way to go before we can be satisfied that we have even tested their full usefulness. Demonstration projects and creative experimentation are urgently needed in the fields of home care, friendly visiting, and provision of household helpers in this community.

I would like to mention, also, the importance of especial services aimed at health maintenance. It has been demonstrated in Minneapolis that older people have an intense interest in educational programs designed to prevent breakdown and maintain physical fitness. Over 500 men and women, aged 50 to almost 90, enrolled in two 4-week nutrition and cooking classes conducted in 1958. Their sustained attendance and enthusiasm, as well as their responses to evaluation questionnaires, showed their strong motivation toward health improvement and their interest in additional courses in special diets, home management, budgeting, exercise, foot care, et cetera.

Annual "Health Days for Senior Citizens," sponsored by the Hennepin County Medical Auxiliary, and related programs in senior citizens clubs have met some of the need for continuing health education and have all attracted eager audiences. Much, much more remains to be done in this area, and radio and television should be employed in bringing information to a larger audience. We know that sound teaching requires a personal touch and we hope to continue developing our own local educational programs. However, the preparation of really good audiovisual materials which could be loaned to local communities would be most helpful to those of us struggling to stretch our limited resources of time and funds.

I have barely suggested a few of the services required to keep people independent, active, and well in their own homes. This general goal presupposes that there will be decent and suitably priced housing in which they can remain. This is a matter of grave concern. In Minneapolis we have been thrilled with the development in public housing for the elderly. Our high rise apartment, in operation for 2 years, is claimed by many residents to have transformed their lives. Neighborliness, informal visiting, self-help, group activities have been built into the pattern of living, partly through the unobtrusive guidance of an on-the-scene social worker. We are heartened not only by plans for an additional 1,056 units of public housing, but by proposals of a few philanthropic groups to develop similar kinds of apartments. We are also worried about achieving enough such safe, economical, and convenient homes for all the older people who will need them.

We urge continued attention to these twin objectives: services to help people remain in their own homes, and homes in which they, and the community, can feel pride.

PREPARED STATEMENT OF BEA KERSTEN, AFL-CIO COMMUNITY SERVICES
REPRESENTATIVE, HENNEPIN COUNTY, MINN.

Chronic disease and disability resulting from an aging population are currently the Nation's No. 1 medical problem.

Minnesota is among the leading States in longevity of its residents. It is estimated by 1975 better than 15 percent of the population in our State will be over age 65.

While the shortage in nursing homes in Minnesota of a few years ago has been greatly alleviated there is still much cause for concern in our State and throughout the Nation.

The care given in too many nursing homes and homes for the aging is limited primarily to nursing and custodial care with no restorative or rehabilitation services. As a result the great majority of the people in these homes deteriorate physically and mentally to the point of total disability.

Much of this could be prevented and the people in these homes could maintain or regain varying degrees of personal independence in meeting the normal demand of daily living if they were provided restorative and rehabilitative services.