Guest editorial: Clinical challenges in residential care

Prior to the Second World War, highly dependent elderly people unable to live on their own received care through a number of religious orders and “poor homes” throughout Canada.[1] In BC, nursing homes or residential care facilities did not exist. The increase in the number of disabled veterans requiring skilled, ongoing medical care after 1945 led to the creation of the nursing home model that exists today. 

Over the past two decades, two major changes in Canada have put pressure on this care sector: an expanding number of seniors and an increase in morbidity for this population. These changes now require us to re-examine the model.

As elsewhere in Canada, seniors in BC are the most rapidly expanding age group in the province and are expected to grow from 13.7% of the population today to almost 24% by the year 2031.[2] Although many seniors lead healthy and active lives, a significant number suffer from multiple chronic health problems that limit their activities and require many social and health services. For example, over 250 000 Canadians have dementia, a figure projected to rise to over 750 000 by 2031.[3] 

Similar large increases have been projected for mental health disorders, cardiovascular disease, and impairments in mobility. Many future innovations in service delivery for seniors will involve interdisciplinary and multi-agency collaboration. And much of the burden for the care needed will fall in community (including primary care) settings, rather than hospital settings. 

Fortunately, there is growing awareness that primary care physicians working in residential care need to reconsider how patient care should be delivered in the ever-changing and complicated context of an expanding population of frail seniors. Great debate has ensued in the literature regarding the role of chronic disease guidelines in patients with comorbidities and reduced life expectancy. Similar discussions have explored how to deliver care to such medically frail patients in a health system where skilled nursing is not always available.

This theme issue examines a number of the key concerns faced by BC’s primary care physicians caring for the elderly in residential care. Drs Mazowita and Kozak discuss the difficult situation faced by physicians attempting to apply chronic disease guidelines when treating frail patients with reduced life expectancy and multiple comorbidities. 

Dr Gallagher outlines challenges and treatment options in pain management, and the importance of reassessment and titration when using opioids. 

Drs Drouillard, Mithani, and Chan discuss best practices in the management of behavioral and psychological symptoms present in elderly patients with dementia. 

The issue concludes with an article by Dr Kow and Ms Carr and Ms Whytock that outlines the challenging clinical and systemic issues that affect managing urinary incontinence in residential care. 
—Jean-François Kozak, PhD
—Akber Mithani, MD

Dr Kozak is the research director of the Primary Care of the Elderly Research Group in the Department of Family and Community Medicine, Providence Health Care. He is also a faculty member in the School of Population and Public Health and in the Centre for Health Evaluation and Outcome Sciences at the University of British Columbia. Dr Mithani is director of the Primary Care of the Elderly Research Group, clinical associate professor in the Department of Psychiatry, associate in the Department of Family Practice at UBC, and College of Family Physicians of BC Researcher of the Year (2011).