agencies, and the Administration on Aging to improve information and referral services to older Americans. The VA took the initiative in matching local area agency on aging (AAA) offices with their nearest VA facility across the nation. The VA and AoA are also jointly sponsoring nutritional programs for older veterans which are to be located initially at various GRECC sites.

Further significant efforts in the VA to meet the needs of a growing aging veteran population in a comprehensive manner are described in the following sections.

2. MEDICAL SERVICE

Medical services in VA hospitals are responsible for approximately one-third of the total number of operational beds in the system. One-fourth of all patients in VA hospitals on a given day are aged 65 or older. Patients over 65 show a progressively increasing length of stay, illustrating two principal points: aging patients tend to manifest chronic diseases requiring longer periods of hospitalization and many of these patients are to be found on medical services, frequently in what is termed intermediate sections, which are staffed and equipped for the needs of longer-term patients, especially for those with hospitalizations in excess of 30 days. Moreover, as the largest group of American veterans from World War II become older (now 54.5 years on the average), VA can expect even a greater incidence of long-term illness arising from this group.

Heart, stroke, cancer, and renal diseases continue to be the principal causes of death among adults in this country. VA is making significant effort to improve care of all veterans with these conditions, which per se affect a large proportion of aging patients. VA is in process of completing programs for installing specialized intensive care, coronary care and respiratory care diagnostic and treatment capability in all hospitals. The VA dialysis program for end-stage kidney disease continues to grow and more aging patients are being accepted for long-term dialysis treatment. Hypertension, one of the principal underlying causes of heart disease, stroke, and kidney failure, is the target of a majority VA detection and treatment program. Broader implementation of the hypertension screening and treatment program should do much to ameliorate major causes of disability and death in the aging veteran.

Several programs which should have further impact on care of the aging veterans are continuing to develop in VA. Examples are improved methods of diagnosing and treating infectious diseases (pneumonia and kidney infections continue to be major problems in the older age groups); rheumatology, which is concerned with arthritis and related bone and joint conditions, major causes of discomfort and disability among the elderly; and a planned program of rehabilitation for major heart and lung disabilities.

Medical services in the VA are committeed to and involved in major emphasis on ambulatory care as a significant element of a comprehensive care program for veterans. In addition to broader services, greater use of ambulatory care as an alternate to hospitalization may yield significant cost avoidances.

3. MENTAL HEALTH AND BEHAVIORAL SCIENCE SERVICE

Mental Health and Behavioral Sciences Service has continued and expanded its services to the elderly patients in our Veterans' Administration health care facilities. We provide psychiatric and psychological consultation and services to intermediate medical services, nursing home care units, domiciliary populations and to the eight geriatric research, education, and clinical centers. The primary emphasis of mental health services are in the area of psychosocial, psychopharmacological, and psychological services.

The Mental Health and Behavioral Sciences Service is planning for the increasing numbers of aging veterans who will be availing themselves of our services. In anticipation of this large future geriatric patient population, we are emphasizing education in this area for professional staff. In April 1976, a training conference was held on "Care for the Chronic Patient." This was attended by 358 multidisciplinary staff members from facilities located throughout the VA system. Panel discussions were given on treatment, research, psychopharmacology, and program management. Workshops on patient care and specific problems were conducted. A similar educational training program will be sponsored by this service in January 1977 to be attended by over 150 participants.

Work is continuing in the area of drug prescription practices particularly in regard to psychotropic medication, so the benefits which these drugs produce can be maximally applied to patients who manifest psychiatric disturbances in addition to the physical infirmities accompanying advancing age.

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In most of our psychiatric hospitals, and in wards which treat a significant number of geriatric psychiatric patients, programs of reality orientation are almost routine so that the ward and hospital environments are actively working to reduce the experience of confusion and disorientation which often result from the institutionalization of elderly people.

As one of the major outpatient mental health programs, our Day Treatment Centers which have been functioning since 1957 are allowing many of our World War I and II veterans to remain in the community which providing a stimulating and therapeutic experience and environment without which hospitalization would be required for many of them. There are currently 52 day treatment programs treating over 5,000 patients.

During 1977, it is anticipated that there will be increasing efforts in the treatment, research and educational activities of the Mental Health and Behavioral Sciences Service to direct its attention even more to the aged veteran who is becoming such a major consumer of our health care services.

4. SOCIAL WORK SERVICE

Social Work Service provides a full range of services to older veterans and their families at all points of contact from preadmission screening through treatment and discharge planning and followup community services. Social workers provide consultation concerning problems of the elderly to hospital and regional office staffs, liaison services to community agencies on behalf of veterans, and direct services to beneficiaries and families to assist in the resolution of social problems affecting the use of health care resources.

A major thrust of social work programing has been the development of community support systems to allow and encourage the older veteran to maintain himself in surroundings that are conducive to his social and health care needs. In many cases an outreach community services program can obviate the need for hospitalization by providing vital support services to veterans and families living in their own homes. The impact of social intervention as social problems germinate is particularly important in helping veterans to maintain an optimal degree of independent functioning. Veterans who are not able to return to their own homes immediately after a period of VA hospitalization may be placed in nursing homes, personal care homes, or other special placement facilities inspected and approved by VA inspection teams. Through the Community Care program which encompasses services to veterans in the above facilities, a full range of social and other supportive health care services may be provided by hospital or community based staff. Personal care home programing for medical and surgical patients was given added impetus at a workshop held in Salt Lake City in May 1976, attended by over 40 representatives of Social Work, Nursing, Dietetics, Rehabilitation Medicine Service, and Engineering Service. Over 35,000 veterans were provided followup social services in the program during fiscal year 1976 and it is anticipated that this number will increase significantly during fiscal year 1977 and beyond as the number of elderly veterans in need of services continue to increase. Every VA facility is expected to develop capability in this vital program area. In fiscal year 1976, a total of 73,405 veterans enrolled in the Community Care program were provided services by social workers and other health care personnel. Most of these veterans are elderly or appoaching the later years.

There is increased interest in developing methods for measuring and upgrading the quality of care provided terminal patients and their families as differentiated from treating terminal disease. This is a contributing factor in the general public's concern for the right of these patients to participate in decisions involving use of life-extending equipment and procedures, obtain social and psychological supports from staff, receive assistance in control of pain, and be assured of privacy for self and family when desired.

Phase 1 of the program to be completed in fiscal year 1978 from VACO resources will be to conduct a VA-wide survey of existing policies, practices, and attitudes in terminal care. Information obtained will serve as a baseline for clinical, educational, and research efforts from which appropriate standards can be developed. With volunteer assistance, Social Work Service continues to operate Telecare programs in many VA hospitals through which contact is maintained with elderly veterans returning to their homes in isolated areas. In this way, a network of VA and community services remain available to assist those who might not otherwise be able to make their needs known, particularly in an emergency.

Social Work Service is vitally interested in the needs of the chronically ill and the elderly and has actively encouraged hospitals affiliated with graduate schools of social work to include content on the health needs of the elderly in course offerings. VA social social workers provide consultation to schools of social work in the development of appropriate course content.

With the emphasis on the aging veteran within the VA, Rehabilitation Medicine Service (RMS) has identified the elderly as one of its major concerns. RMS has a strong involvement in rehabilitation, health maintenance, and socialization programs for the aging patient. Current programs encompass dysfunction problems, socialization, physical maintenance, and community followup. The various therapies are involved with patient care in nursing home care units, intermediate care wards, halfway houses, personal care homes, compensated work therapy, incentive therapy, and others.

The various rehabilitation medicine therapy programs provide a means to a better and more meaningful life for many aging veterans through the understanding by therapists of what the involvement of the total person means. As an example, therapeutic recreation focuses not on the activity itself but on awareness of leisure time, life-styles, interelationships, needs, and the meaning of activity for the elderly. Assessment of social and a vocational skills by the occupational therapist enables patients to learn how to expand the horizons of their existence for improved functioning in whatever environment they may find themselves-home or institution.

A variety of services are provided to the veteran and/or family by RMS personnel. Included among these are life-style counseling, reality orientation, ambulatory and bedside activities such as talking books, music programs, exercises, life skills activities, games, and hobby programs. Adult educational experences which encompass current event discussion groups, movie or film strips are available as well as outdoor recreation activities such as fishing, boating, hiking, bird watching, and limited camping. The availability of these latter activities have been made possible by the formation of a cooperative agreement between the VA and the Forest Service, U.S. Department of Agriculture.

RMS has involvement in various work therapy programs enabling the older veteran to feel that he/she is a contributing member of the community with numerous skills to offer. RMS at two hospitals, VAH Sepulveda, Calif., and VAH St. Cloud, Minn., have been particularly successful in involving elementary and high school students in remotivation programs with elderly patients. A number of RMS programs focus on having older veterans contribute their special skills in fabricating articles for needy children's activities in the community. RMS continues to provide and support activities of senior citizen groups, special geriatric calisthenics/exercise programs, and social and picnic outings in cooperation with community Golden Age groups. In addition, the USO show committee has added college or university shows as a touring group to VA health care facilities.

Care of the elderly is being stressed at many RMS workshops, conferences, and hospital visitations. The concept of rehabilitation that encompasses a meaningful life-not custodial and apathetic--is the major focus in providing care.

6. NURSING

Nursing Service feels a commitment to improve both the amount and kind of services it makes available to the aged ill veteran. Knowledge is expanded in the field of gerontology and geriatrics and Nursing Service strives to keep abreast of new developments in improved means of meeting the needs of this significant group. Nursing Service has as objectives the improvement of the knowledge base for gerontological nursing practice by all levels of nursing personnel in the field. We seek innovative models of care delivery.

Standards of gerontologic care have been completed by Nursing Service in fiscal year 1976 and will be published by the VA early in 1977 along with educational guidelines for gerontologic nursing. Both the standards and the educational guidelines have applicability to health professionals other than to nurses. The format allows each team member, irrespective of disciplinary orientation, to assess his or her performance in meeting the needs of the aged individual. Full implementation of the gerontological standards will require interdisciplinary

collaboration. Nursing Service believes that it will have provided an organizing focus for such collaboration in the writing and publishing of the standards.

Nurses throughout the VA system are serving in expanding roles, particularly in the care of the aged individual. Nursing Service sees a distinct need to offer preventative and maintenance services to the elderly veteran. Through an extention of the hospital based home care program we believe that it will be feasible to maintain the aged person in the home, improve the quality of life, and reduce costs of care.

7. AUDIOLOGY AND SPEECH PATHOLOGY

It has been clearly demonstrated that the incidence of speech, hearing, and language disorders rises sharply in the upper age levels. More than 28 percent of all persons 65 and older have impaired hearing compared with fewer than 1 percent of those under age 25 who have hearing loss. Speech and language disorders occur in approximately 2 percent of young adults as compared with an incidence of 45 percent among nursing home patients ranging in age from 52 to 94.

The restoration of communicative functioning to the maximum extent possible is required if the elderly are to be able to participate in normal family and social relationships, in recreational activities, and if they are to maintain a feeling of self-worth. To meet this challenge, VA has established audiology and speech pathology services at 88 health care facilities. Eligible veterans are furnished hearing aids and are provided training in their effective use. Vocal rehabilitation assists those with voice problems while the patient whose larynx has been removed is taught alternative means of speaking. Finally, the large number of elderly brain-damaged patients, usually a consequence of stroke, are offered asphasia therapy by competent speech pathologists.

8. DIETETIC SERVICE

Nutritional care is considered part of the total treatment program for aged veteran beneficiaries. Nutrition education, as a component of this process, is a continuing endeavor. Veterans are instructed both individually and in groups. The aged veteran's wife or other family member is also instructed whenever possible. This instruction may take place at bedside, in a nutrition clinic, or in the home. Teaching these veterans to plan nutritional meals within their budgets, and too, oftentimes, to cook for themselves is a sizable task.

Assessment of the aged veteran's nutritional status looks into the underlying causes of inadequate food intake. Psychological, sociological, and physiological aspects of aging all play a part. Poor dentures, loneliness, and limited incomes are prevalent factors. In the hospital setting, a dining room atmosphere rather than eating all meals from a bedside tray fosters resocialization and is used as a teaching technique.

With the rise in cost of medical care and maintenance of the disabled, society is beginning to realize the need to research the relationship of nutrients with diseases of the aged. A nutritional component will be included in the eight geriatric research, education, and clinical centers instituted thorughout the country.

A large segment of alcohol-dependent veterans is now elderly. The ravages of alcoholism often result in severe malnutrition. In the process of overcoming their alcohol dependency, it is important that the dietitian teach the elderly improved eating habits and when physically possible, restore them to normal nutritional status.

9. VOLUNTARY SERVICE

The Veterans Administration Voluntary Service program provides two ave nues for enrichment of the lives of older Americans. For patients and domiciliary members, the program supplies companionship and personal services; for the older volunteer, it provides the satisfactions of social involvement and of being welcome contributors to the well-being of others less fortunate.

It is estimated that the major age group now active among the monthly average of 108,000 volunteers at VA health care facilities consists of men and women over 50. Some of these volunteers have been active for up to 30 years. Others are being brought into the program consistently through VA staff involvement with such local and State level agencies as senior citizen centers, councils, and conferences on aging, and national agencies including the Federal

ACTION agency's retired senior volunteers program (RSVP) and the American Association of Retired Persons.

Every effort is made to assign these older volunteers to the most satisfying activity consistent with their individual capability and physical status. Assignments range from packaging medications in the hospital pharmacy to job counseling, from teaching candidates for high school equivalency examinations to accompanying wheelchair and litter patients between wards and clinics. Among the older volunteers now active are a number with special qualifications. One example is a retired executive who has organized and oversees the operation of a community resource center for social work service at a large metropolitan area hospital. Another is a woman recovered from glaucoma and cataracts who works weekly with a blind patient, helping him to communicate effectively and keeping him up to date on current events.

Geriatric patients and domiciliary members are an ongoing concern of the voluntary service program and involve the services of volunteers from teens to nineties. Companionship, recreation, reality orientation and socialization are major innovative activities requiring volunteer participation is the year-round series of monthly gourmet dinners devised by the dietetic service, psychology service, and voluntary service staffs at the Buffalo VA Hospital for patients on gerontological wards. Designed to help restore impaired social awareness and skills, the dinners are planned for patients selected by the medical staff.

The patients are dressed for dining out and are accompanied by volunteer dinner companions, also dressed for the occasion, to an area of the hospital setaside and decorated by volunteers. At tables set with accoutrements and flowers donated by voluntary organizations, the volunteers guide the conversation and encourage good manners while helping to make the specially prepared dinner an eagerly anticipated pleasure. The program is a good demonstration of the therapeutic role volunteers often play in helping to bridge the distance between home and institution for the older patient.

10. DENTISTRY

Virtually every aged veteran is affected by the consequences of dental decay or periodontal disease. The result of neglected dental caries and advanced periodontal disease to the aged patient is infection, pain, and ultimately loss of teeth.

For the aged, in particular, loss of teeth means a decrease in masticatory function at a time when efficient dental function is increasingly desirable due to changes in nutritional requirements.

It is a firm contention of the VA that restoration and maintenance of oral health is a major health goal of the agency, vitally necessary to improve the health and quality of life of our older veteran patients.

The Veterans Administration system provides access to dental care for aged veterans through several diverse acute, and long-term care programs in their hospital and domiciliary facilities.

To insure that the need for dental care is emphasized and upgraded in health care facilities, the office of dentistry has embarked on multidisciplinary educational programs by means of regional conferences with chiefs of dental service. The first of these geriatric symposia was held in September 1976 at the Regional Medical Educational Center in Birmingham, Ala. Open to the general medical community, as well as VA health care providers, this conference provided the attendees with information from several medical disciplines including dietetics, nursing, social work and research pertaining to the unique health problems of the aged and the importance and interrelationships of a healthy oral cavity to systemic and psychological well-being.

The dental delivery system established by the VA under current legislation for the long term, hospitalized, aged veteran is carried out in a three-phased, integrated, fashion. The first phase is an evaluation of the oral health status and treatment requirements of a major portion of the geriatric patients eligible for dental care. This includes oral pathology screening, periodontal examination, restorative examination, prosthetic examination, as well as correlation of these findings with the overall psychological and socioeconomic status of the individual as determined through a medical team approach.

The second phase is the delivery of optimal treatment combined with an integrated system of preventive care. The latter comprises a program of home care instructions, including mechanical plaque prevention procedures, and oral hygiene maintenance of remaining oral structures and prosthetic appliances.