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ConsultantPhysician, University CollegeHospital
Consultant Physician, University College Hospital
AND
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D. L. SCOTI, M.R.C.S., L.R.C.P., M.R.C.G.P.
D. L. SCOTT, M.R.C.S., L.R.C.P., M.R.C.G.P.
MedicalAdviser, RocheProductsLimited
Medical Adviser, Roche Products Limited
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© JOHN WRIGHT & SONS LTD., 1968
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MAIN SPEAKERS IN THE SYMPOSIUM ON
VITAMINS IN THE ELDERLY
J. D. B. ANDREWS, M.D., D.P.H. T. P. EDDY, C.B.E., M.A., M.R.C.S., D.P.H.
West Middlesex Hospital, London School of Hygiene and Tropical
London. Medicine,
London.
M. BRIN, PH.D.
A. N. EXTON-SMITH, M.A., M.D., F.R.C.P.
Hadassah Medical School,
University College Hospital,
Jerusalem.
London.
J. C. BROCKLEHURST, M.D., M.R.C.P. (EDIN.), R. H. GIRDWOOD, M.D., PH.D., F.R.C.P.,
M.R.C.P. (GLASG.), F.R.F.P.S. F.R.C.P.E., F.C.PATH.
Bromley Group of Hospitals, Royal Infirmary,
Kent. Edinburgh.
L. L. GRIFFITHS, M.A., M.D., D.P.H.
A. M. BROWN, B.SC, M.N.S., S.R.D. Farnborough Hospital,
Queen Elizabeth College,
Kent.
London.
E. LA C. MURPHY, M.A., M.D., D.P.H.
Ministry of Health,
R. BUZINA, M.D., SC.D.
Institute of Public Health of Croatia, London.
Zagreb.
G. F. TAYLOR, M.A., M.R.C.P.
M. M. DlSSELDUFF, M.SC.(SYD.) D. M. WATKIN, M.P.H., F.A.C.P., F.A.P.H.A.
Ministry of Health, Veterans Administration Central Office,
London. Washington D.C.
v
CHAIRMEN OF THE SYMPOSIUM
SIR CHARLES DODDS
LORD AMULREE
EDITORS' NOTE
In order to achieve rapid publication the editors have not sent the proofs to the
authors and they accept responsibility for any mistakes.
The editors acknowledge their gratitude to Miss J. Dyke and Miss J. Alexandra
in the preparation of this book.
INTRODUCTION
THIS is an account of a meeting which brought together the two disciplines of nutrition
and gerontology to discuss for a day a problem which is common to both of them. The
question of nutrition in the elderly, its adequacy and the problems posed by its
inadequacy are discussed. The results of the discussions show that the needs of the
elderly, though not accurately known, are certainly not always met. Some of the
reasons for this emerge, as indeed does the need for further research.
The meeting was sponsored by Roche Products Limited.
XI
V I T A M I NS
in the Elderly
PART L THE GENERAL PROBLEM
Chairman: Sir Charles Dodds
THE GENERAL HEALTH OF THE ELDERLY
J. C. BROCKLEHURST
HAROLD MACMILLAN, in his autobiography The Winds of Change, has said of the social
problems facing us today: 'The difficulties with which we must wrestle are almost
precisely the reverse of those that beset us in the thirties .. . inflation that has generated
a new insecurity replacing the poverty of unemployment by the distress of the old and
the retired who cannot compete in the race to match rising prices with rising incomes.
These are problems with which contemporary statesmen must concern themselves.'
No doubt, as we shall hear later today, financial insecurity is one of the great and
sometimes unlooked for problems of old people. Other problems which old people
face in our society are social isolation, loss of independence, and loss of status. The
problems which I wish to place before you at the beginning of this conference are those
of loss of health, and the effect of changes of ageing. To set the stage for what is to
follow today, I must also say something about the numbers of old people in our society,
where and how they live, and what contact they have with the medical services.
The Registrar-General's figures1 of the proportion of old people in England and
Wales are now so well known to everyone who has concern for old people that they
require only the briefest mention. Table I shows the percentage of the population who
are of pensionable age in the years 1871, 1931 and 1961, and as well as showing the
striking increase in this proportion it indicates the very large excesses of elderly people
living in the seaside resorts of South East England. Table II shows the age and sex
structure of our pensionable society; 60 per cent are women and 35 per cent are over
the age of 75. In geriatrics we tend to regard the under 75's as young, and real old
age as hardly starting until the age of 80.
1
VITAMINS IN THE ELDERLY
Table I.—PROPORTION OF POPULATION 65 AND OVER (ENGLAND AND WALES)
(Registrar-General1)
Total Percentage
1871 4-7 per cent
1931 7-4 per cent
1961 11 -9 per cent
Geographical Differences
South East 15-8 per cent (excluding London)
Midlands 10 per cent
Table II.—PEOPLE OVER 65 IN ENGLAND AND WALES
(Townsend and Wedderburn2)
By Sex
Male 40 per cent
Female 60 per cent
By Age
65-74 65 per cent
75-84 30 per cent
Over 85 5 per cent
Total number: 6,151,000 (11*9 per cent of population)
Table III indicates where old people are living. It is good news that less than 5 per
cent of pensioners are accommodated in residential homes or in hospitals. This small
percentage, however, comprises the very frail and the very dependent. They number
Table III.—ACCOMMODATION OF PEOPLE OVER 65 IN ENGLAND AND WALES
(Townsend and Wedderburn2)
Private households 94 per cent "Ì .
Hotels, boarding houses, lodging houses 1 -5 per cent / Q55 y t
Residential homes 1 -7 per cent j
Psychiatric hospitals and nursing homes 1 -0 per cent >· 4·5 per cent
Other hospitals and nursing homes 1 -8 per cent J
Table IV.—FAMILY CONTACTS OF OLD PEOPLE
(Townsend3)
Contact with Children
No surviving children 20 per cent
Of the remainder—
80 per cent saw child daily
4 per cent saw child less than once a week
Contact with Children's Home
52 per cent lived in same dwelling as married or unmarried child
25 per cent within 5 minutes walk
8 per cent more than 5 minutes but less than 1 mile
85 per cent
over a quarter of a million people in England and Wales. Table IV indicates the con
tact which old people have with their relatives. These are Townsend's figures from his
2
J. C. BROCKLEHURST
survey in Bethnal Green, and he shows that of all old people who have surviving
children, 80 per cent saw one or other of their children every day, and only 4 per cent
saw a child less than once a week. These high figures of family contact are reinforced by
his further demonstration that 52 per cent of old people live in the same dwelling as one
or other of their children, and a further 25 per cent live within five minutes walk. It is
thus apparent, in Bethnal Green at least, that very close contact exists between old
people and their families; those who are particularly at risk are the 20 per cent of the
pensionable population who have no surviving children. That these figures are not
peculiar to Bethnal Green has been shown by Willmot and Young4 whose findings in
suburbia were extremely similar.
Contacts of old people with the Health Service
It has been estimated that the 12 per cent of the population who are retired absorb
nearly 30 per cent of expenditure on the National Health Service (Office of Health
Economics6). That old people make particular demands on their general practitioners
is self evident. It is borne out by the fact that special payment is now made to general
practitioners for each person of pensionable age on their list. At the same time it has
been shown by Williamson6 and his colleagues that most of the causes of disability in
old age were in fact unknown to the patients' general practitioners. This is because
patients never reported them. These findings and similar findings by other workers
have underlined the need for some form of preventive examination of old people. It is
generally agreed that this could probably most effectively be done by health visitors,
either attached to general practitioners or working from geriatric centres.
In the hospital service old people will be found in most departments. Those who
present the most difficult problems, however, generally find their way into the geriatric
departments where the unique system of assessment, rehabilitation, and day hospital
care is particularly adapted to the special problems of old age. These particular prob
lems are the need to recognize the totality of disability arising from multiple causes—
physical, mental, and social—and the need for continued follow-up care.
A recent investigation into the subsequent lives of 200 patients discharged from
two geriatric departments has indicated particularly their frailty, their liability to
readmission to hospital on one or more occasions, and an expectation of life of only one
or two years for a large number of these patients. Table Vindicates some of the general
Table V.—GENERAL FINDINGS IN 200 CONSECUTIVE PATIENTS
DISCHARGED FROM TWO GERIATRIC DEPARTMENTS
(Brocklehurst and Shergold1)
Male 40 per cent Female 60 per cent
Age: 60-70 14 per cent
71-80 41 per cent (46 per cent)*
81-90 43 per cent \ 7 «er centi*
91+ 2 per cent /ΠUV percent;
Reasons for admission: Medical 71 per cent
Social 3 per cent
Both 26 per cent
Dead at 1 year after discharge 28 per cent
Dead at 2 years after discharge 45 per cent
* Figures in brackets indicate the percentage of total pensionable population in these age-groups.
3
VITAMINS IN THE ELDERLY
findings in this survey (Brocklehurst and Shergold7). It shows that while the sex ratio of
patients discharged from these geriatric departments is the same as that in the general
population, their age structure is very different, and in fact 45 per cent of these patients
are 81 years old and over compared to only 17 per cent of the general population in
that age-group. It indicates that although 71 per cent of the patients were admitted for
purely medical reasons, 3 per cent were admitted for purely social reasons and 26 per
cent for a combination of both social and medical reasons. At the end of two years
after leaving hospital, 45 per cent of these patients had died. Although this seems a
high figure, it must be compared with that for patients of all ages leaving acute medical
wards ; of these 25 per cent were dead two years later (Curran and Ferguson8).
Perhaps the most important responsibility laid upon the clinician who deals with
illness in the elderly is the need for him to recognize the total extent of disability in his
patient rather than thinking in terms of a single disease process. Multiple pathology is
the rule in old age. In a study of 200 patients admitted to a geriatric unit Wilson and
his colleagues9 found an average of six diseases to be present in each patient. They also
say that 'what may mislead us into taking a vague view of illness in the elderly is that
their complaints are so often less defined and strident than those of the young, and so
much more difficult to evaluate'. It is because of this lack of clear definition that the
practice of medicine in old age is so difficult and so demanding, and it is precisely
because of these difficulties that a clear statement should be made of each disease process
which is present, and an assessment then be made of the totality of disability which they
all comprise. Rehabilitation must involve the treatment of as many of these single
disease processes as possible, associated with the reactivation of the whole patient to
promote his maximum independence and allow his return to the community, perhaps
in a new social setting.
In conclusion, not only have we to consider disease processes whether physical,
mental or social, but we must also reckon with changes due to ageing itself. In all our
researches in old people, therefore, and not least in vitamin research in old age, which is
to be our particular concern today, we must remember not only to define changes in
structure and function but also to try to decide whether these may be pathological in
their nature or whether they may form part of the inevitable process of ageing.
REFERENCES
1. REGISTRAR-GENERAL, Statistical Review of England and Wales, 1961, Part II, Tables, Medical. London:
H.M.S.O. (1963).
2. TOWNSEND, P., and WEDDERBURN, D., The Aged in the Welfare State, Survey Report 1962 & 1963. London:
Bell (1965).
3. TOWNSEND, P., The Family Life of Old People. London: Routledge & Kegan Paul (1957).
4. WILLMOTT, P., and YOUNG, M., Family and Class in a London Suburb. London: Routledge & Kegan Paul
(1960).
5. OFFICE OF HEALTH ECONOMICS, Old Age, London (1968).
6. WILLIAMSON, J., STOKOE, I. H.,GRAY, S.,FISHER, M., SMITH, A., MCGHEE, A., and STEPHENSON, E.,Lancet, 1,
1117(1964).
7. BROCKLEHURST, J. C, and SHERGOLD, M., Geriatric Patients leaving Hospital. To be published (1968).
8. CURRAN, A. P., and FERGUSON, T., Further Studies in Hospital and Community. Oxford: Nuffield Provincial
Hospital Trust (1962).
9. WILSON, L. A., LAWSON, I. R., and BRASS, W., Lancet, 2, 841 (1962).
4
