Rapport
Séance du 10 mai 2005

05-04 Le maintien de l’insertion sociale des personnes âgées

MOTS-CLÉS : eau minéralisée. saint-lary-soulan (hautes-pyrénées). source borro.
Keeping the elderly inside the community
KEY-WORDS : aging/physiology. antidepressive agents. dependency (psychology).. life expectancy. mental health. personnal autonomy. physical fitness. prejudice. retirement

Maurice Tubiana, au nom d’un groupe de travail

Résumé

L’allongement de l’espérance de vie (passée de 45 ans en 1900 à 80 ans au début du XXIe siècle) a été le phénomène le plus considérable du XXe siècle ; de plus, bien que la mort survienne à un âge de plus en plus avancé, la période terminale d’incapacité tend à se raccourcir. Le bouleversement démographique qui en résulte est l’illustration du progrès éducationnel, socio-économique et médical qui a été accompli. L’augmentation du nombre de personnes âgées a entraîné une modification de la pyramide des âges qui a été accentuée dans les pays industrialisés par la baisse de la natalité. Parallèlement on a observé un décalage croissant entre l’âge chronologique et l’apparition des phénomènes physiques et biologiques associés à la sénescence physiologique. Celle-ci a été ralentie et plusieurs des maladies invalidantes qui grevaient l’avancement en âge ont été évitées, guéries ou retardées. La santé physique des personnes de plus de 60 ans a été prodigieusement améliorée mais cette transformation de leur condition n’a pas été prise en compte dans la place qu’on leur accorde dans la société française. Au contraire, pour chercher une solution aux problèmes de l’emploi, on a autoritairement avancé l’âge de la cessation de l’activité salariale et favorisé les dispositions de mise en retraite anticipée. La discordance entre l’âge physiologique et la notion de vieillesse a, de ce fait, été accentuée car l’idée prévaut que le départ à la retraite correspond au moment où, en moyenne, on est devenu inapte à une activité régulière. Certes depuis un demi-siècle des efforts considérables ont été faits pour améliorer les conditions matérielles de vie des personnes âgées de plus de 60 ans (revenus, état sanitaire), mais elles restent considérées comme des « vieux », ce qui a de graves conséquences éthiques, sociales et économiques et rien n’a été fait pour lutter contre ces préjugés. A partir de la fin de la cinquantaine, les français se trouvent ainsi face à une situation dissonante entre une santé physique généralement excellente, et une incitation pressante à l’inactivité. Celle-ci a généralement pour effet une baisse de l’activité physique donc une altération de la santé physique qui accentue la mésestime de soi et entraîne un moindre investissement dans des activités stimulantes, une tentation de laisser aller. Plus on avance en âge, plus la santé physique, la santé mentale et sociale sont fortement liées et plus le désœuvrement risque de rompre un équilibre fragile. Il ne peut pas y avoir de vieillissement réussi chez ceux qui sont envahis par un sentiment d’inutilité. Sur le plan médical l’objectif paraît évident : maintenir aussi longtemps que possible la vitalité et l’autonomie des personnes vieillissantes donc : — développer la prévention, retarder l’apparition, ou diminuer l’impact sur la vie quotidienne, des incapacités dues aux maladies intercurrentes liées à l’âge, — améliorer la qualité de vie des sujets atteints de maladies chroniques (diabète, rhumatismes, etc.) ce qui est possible grâce aux progrès médicaux. Le coût pour la société, des actions entreprises dans ces deux directions restera très inférieur à celui qui serait observé en leur absence. Les objectifs sociaux sont moins clairs. Sans méconnaître l’existence de travailleurs entrés très jeunes dans une activité professionnelle pénible dont l’organisme a été usé et pour qui la retraite correspond à un besoin physiologique et médical, il faut s’interroger sur la place dans la société de ceux, beaucoup plus nombreux, restés aptes à une activité que l’on invite, ou contraint, au désœuvrement. On doit se demander comment préserver l’équilibre psychique de ces sexagénaires et septuagénaires plein de vigueur que l’on met au rebut ? Comment maintenir leur insertion dans la société et leur participation à la vie collective ce qui est indispensable pour leur santé et celle de la société ? Pour aborder de façon concrète ces questions, nous considérerons la population des plus de 60 ans dans son hétérogénéité en distinguant différentes situations, tout en sachant qu’il existe entre elles tous les intermédiaires.

Summary

The lengthening of life expectancy (from 45 years in 1900 to 80 years at the beginning of the 21st century in France) was one of the most important developments of the 20th century. Moreover, even as death comes at a later age, the final period of life crippled by severe handicaps is being shortened. This demographic upheaval is the result of educational, socioeconomic, and medical progress. The increase in the number of elderly people has transformed the age pyramid, and this phenomenon has been exacerbated in France, as in other industrialized countries, by a lower birth rate. Currently, physiological senescence is slower, and several diseases which once incapacitated old people can now be avoided, cured or postponed. People over 60 now enjoy vastly improved health, but often feel marginalized by society. The discrepancy between physiological aging, which has slowed, and the lowering of the retirement age, creates tensions, mainly because retirement age is still considered to correspond to the time when people become unable to perform regular activity. Considerable efforts have been made over the last 50 years to improve the living conditions of the elderly (income, health), but they are still not considered as full members of the community. This situation has serious ethical, social and economic consequences, yet little has been done to counter these prejudices. When people stop working they generally reduce their physical activity too, which in turn undermines their health. But the main concern is that retirement can lead to poor self-esteem, less interest in pursuing stimulating activities, and the temptation to ‘ let oneself go. ’’ The older one gets the more physical health and mental and social well-being are linked, and idleness can upset this fragile balance. Old age cannot be lived gracefully by people who have no feeling of self-worth. Medical progress should aim at maintaining the independence of elderly people for as long as possible by developing prevention and delaying or reducing the impact of age-related disabilities and diseases on daily life ; and by improving the quality of life of those with chronic diseases (diabetes, rheumatism, etc.). The costs of such actions to society will be far less than the consequences of doing nothing. While recognizing the need for early retirement for those who started working at a young age in jobs requiring hard physical labor, the same may not be true for the majority of people who are still capable of working and are suddenly deprived of a regular occupation. How best can they remain active members of society, which is essential for their own health and for the communities in which they live ? Three groups can be identified : —

People without disabilities, whom demographers call ‘‘ the young old ’’.

Today a French person of 60 has a life expectancy of about 20 to 30 years and, on average, 15 years to live maritally. ‘ Old age ’’, a term coined in the 19th century, cannot be applied to this group. On average, the health and stamina of someone 75 years old today corresponds to that of a 60-year-old in the 19th century.

Because of the discrepancy between society’s attitudes towards age and the pace of senescence, a new age group has formed (between 60 and 75 years, albeit with great individual variations). For a large proportion of this age group, the absence of a regular occupation for such a long period generates feelings of anxiety and depression because life seems to have lost its meaning. As a result, a large proportion of people in France take antidepressants (at least 20 %, and even more with age). The large number of suicides among elderly people in France, as compared to other EU countries, underlines the extent of the problem. Maintaining an active life is the sole scientifically proven means of avoiding the negative consequences of aging, particularly among those who had manual jobs. Positive views about life after 65 years depend more on social and cultural factors than on medical ones, but medical advice can be useful.

A more flexible approach should be adopted with regard to retirement age. The wishes and the physical and mental state of the individual should be taken into account.

Medical prevention should take advantage of this transitional period (the young old) to delay senescence and to keep individuals as active as possible. A policy of
prevention should improve the cost-effectiveness of medical care and should be implemented late in the fifth decade of life. A medical check-up with personalized information on prevention and lifestyle could help to avoid medical treatment, which can fuel latent anxiety.

Several paths can be explored to provide meaning to this long period of life, according to individual tastes and abilities. All require social measures :

Prolongation of a professional activity, either in the same company or in another, full-time or part-time, would be a good solution. Retirement should be delayed for those who wish to continue working.

Another path is voluntary work, which should be properly organized.

Other people, and especially some women, prefer to take a greater interest in their family (caring for younger members or seeing to the needs of older members who have lost their autonomy).

Because each individual’s family, social, and health situation is unique, there is no single solution for all, and bridges should be built between these different measures.

The government, local authorities, unions, companies, and not-for-profit associations should combine their efforts to facilitate experimental approaches and their evaluation. About one-third of over-60s say they would like to stay active, and there would certainly be more if retirees were better informed.

However, the challenge should not be underestimated, as the image of retirees often remains, at least in France, associated with disability and an inability to adapt to change. Society at large is not yet aware of the biological revolution. The aging of the population is perceived with sadness rather than rejoicing at the possibility of prolonging an active life.

People whose disabilities can be overcome : maintaining the independence of ‘‘ the old ’’.

Some handicaps inevitably occur as we age, and are often the consequence of diseases which cause sensory problems (hearing, sight) or motor disorders (arthritis of the hip or knee, osteoporosis). Other treatable health disorders may also appear.

As long as a person’s mind remains alert, social insertion is not only possible, but should be facilitated, and society should mobilize itself toward this aim. This third group, situated between those without disabilities and others who are incapacitated, comprises about ten million people in France. They suffer some disability but could still live normally if society made the necessary effort (which has a relatively low cost). This requires changes in the public transportation system and public services (escalators, elevators, and ramps). Over the ages of 65 to 75 years, stairs become a problem and should be replaced by ramps. Urban planning and administrative services should take into account the difficulties the elderly encounter in going about their daily lives. Such changes would make all the difference as to whether a person can lead a relatively normal life or is forced to stay at home, frustrated at being excluded from society. The consequences are serious, not only for the elderly, but also for society as a whole, if only in terms of cost. Better training of healthcare providers and information for the public at large would help with the detection and correction of these small disabilities. Confucius’ saying : ‘ When an individual is starving do not give him a fish but teach him how to fish ’’ is particularly relevant to the elderly.

Severe disabilities appear with age. At older ages, new difficulties appear because of recurring illnesses.

The onset or progression of chronic disease diminishes a person’s physical capacities. The incidence of various diseases increases rapidly with age (Parkinson’s disease, for example), but many can be prevented or treated effectively. In spite of their new circumstances, as long as people’s mental functions remain compatible with a normal life, all should be done so that these individuals maintain activities that give meaning to their lives. They should be encouraged to make plans, to take an interest in others, and to develop satisfying human relationships both inside and outside of the family.

Being able to remain at home is preferable and possible, as long as the home is adapted to the particular needs of the elderly and outside help is provided for housework and other domestic tasks. Machines, computers and telecommunications should, in the near future, help the elderly in their daily lives, in particular by enabling them to feel less isolated and abandoned.

Dependence.

Some individuals lose their autonomy gradually, notably because of degenerative brain diseases. The proportion of people who become dependent in France increases from around 10 % at 80 years to 30 % at 90 and 40 % at 95. When this occurs, handicaps that were formerly overcome leave people dependent. Half a century ago this situation used to occur around the age of 70 or 75, but now occurs around 85 —- the average age at which people need to be institutionalized. The problems associated with their specific situation are not addressed in this report.

The number of elderly people will soon increase markedly, and it is time to implement a strategy aimed at making sure they remain part of the community. If people are not to experience old age as a time of waiting for death, it is important that their existence is given meaning, and that they be usefully occupied and remain integrated in the community.

The French National Academy of Medicine makes the following proposals and recommendations :

1 — Feelings of uselessness and low self-esteem are the main source of psycho- logical disorders in the elderly. Efforts must be made to remove all forms of age discrimination and other barriers that impede paid or voluntary work for those who are willing and physically able to pursue such activity.

— In the absence of recurring illness, age erodes physical and mental capacity very gradually : handicaps are not an inevitable result of aging. Prevention, early detection and treatment of small disabilities can contribute to maintaining a long, fulfilling existence. This mission has taken on a new dimension with the rapid increase in the number of elderly people, and the healthcare system should prepare for it by developing geriatric training for all health professionals and by providing adequate institutions.

— Aging is a physiological phenomenon. This should be taught and explained, so that society does not receive a distorted image of aging through precon-
ceived notions, and gives the elderly their rightful place. The ongoing biological and medical revolution remains largely unknown to society at large.

No progress can be made if the public retains outdated notions about old age.

2 — Between severely handicapped and ‘ normal ’’ people, there is now a third category resulting from longer life expectancy, namely individuals with slight disabilities (poor eyesight, hearing, difficulty climbing stairs, etc.) This third category corresponds to more than 10 million people and its number will inevitably grow with the increase in life expectancy. People in this category could lead relatively normal lives if public transportation, administrations, and public services took their existence into account, which is currently not the case. The cost of such efforts would be relatively small. Urban planning, architecture, and television should reflect this new situation and cease to ignore the change in the age pyramid. Major efforts have been made in this field in other countries. The current state of affairs in France is even more unacceptable given the fact that it is the least advantaged groups who suffer the most from this disinterest in the needs and difficulties of the elderly.

3 — When more severe handicaps appear that do not alter mental functions, it is best for the elderly to be able to stay in their homes with the help of a variety of measures that maintain contact with the outside world and thereby avoid isolation and abandonment. Care-givers should receive support, and family and social ties should be strengthened. The usefulness of machines, computers and telecommunications should be further explored in this field.

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L’Académie, saisie dans sa séance du mardi 10 mai 2005, a adopté le texte de ce communiqué moins une abstention

Ce rapport, dans son intégralité, peut être consulté sur le site www.academie-medecine.fr

RAPPORT 05-05 au nom de la Commission XI (Climatisme — Thermalisme — Eaux minérales)

Sur la demande d’autorisation d’exploiter, en tant qu’eau minérale naturelle, telle qu’elle se présente à l’émergence et après transport à distance, l’eau du captage « Borro » situé sur la commune de Saint-Lary-Soulan (Hautes-Pyrénées)

Eugène NEUZIL*

Par lettre en date du 9 février 2005, adressée à Monsieur le Secrétaire perpétuel, la Direction Générale de la Santé (Sous-direction de la gestion des risques des milieux, bureau des eaux) soumet pour avis à l’Académie nationale de médecine le dossier relatif à la demande d’autorisation d’exploiter, en tant qu’eau minérale naturelle, telle qu’elle se présente à l’émergence et après transport à distance, l’eau du captage « Borro » situé sur la commune de Saint-Lary-Soulan (Hautes-Pyrénées).

SITUATION GÉOGRAPHIQUE

La commune de Saint-Lary-Soulan provient de la fusion administrative, en 1963, des deux villages de Saint-Lary et de Soulan ; cette petite bourgade de 800 habitants se trouve dans la haute vallée d’Aure, à 12 km au sud de l’important croisement de routes représenté par la petite ville d’Arreau, au confluent de la Neste d’Aure et de la Neste du Louron. Saint-Lary-Soulan, situé à 830 mètres d’altitude, est dominé par des pics montagneux dont la hauteur est comprise entre 2500 et 3000 m. Ce village, très typique de la région, est traversé par l’ancienne voie pré-romaine qui permettait de franchir les Pyré- nées. Il a été plus tard une étape importante sur le chemin de Saint-Jacques* Membre correspondant de l’Académie nationale de médecine.


* MM. G. ARBUZ, H. HAMARD, F. KUNTZMANN, R. MOULIAS, D. PELLERIN, M. RAINFRAY, O. SAINT-JEAN, J. TOUCHON, M. TUBIANA (Président et rapporteur), C. VIMONT. ** Membre de l’Académie nationale de médecine. Le groupe souhaite rendre hommage à la mémoire d’André Bonnin qui avait accepté d’être secrétaire et rapporteur du groupe. Décédé brutalement cet été après la première réunion du groupe, il n’a pu effectuer cette tâche. Le groupe voudrait aussi exprimer sa reconnaissance à B. Guiraud-Chaumeil, Membre de la Haute Autorité de Santé et à Mme Héritier, professeur au Collège de France, pour leur aide et leurs très utiles suggestions. Ils remercient aussi A. Colvez de Montpellier pour sa contribution.

Bull. Acad. Natle Méd., 2005, 189, no 5, 995-1005, séance du 10 mai 2005