18% of Italians are older than 65 years, which constitutes an important challenge for medical assistance. The older we get the better assistance we need. It is necessary to establish new and effective social policies to promote a healthier lifestyle.

The progressive ageing of population in developed countries is an actual fact and it is so discussed that its importance is being decreased. Nevertheless, we all acknowledge this situation but it has never been faced in a constructive way. The data about Italy show that population is not only aging but also transforming and decreasing progressively due to a decline in both fertility and birth rate, which happens to be one of the lowest in the world. In Italy, 18% of the population is older than 65 years and the predictions calculated by Istat show that this percentage will reach to 34.4% in 2050. People older than 80 years represent today a 4.3% of the population and could reach a 14.2% in 2050. This type of demographical revolution is due to many factors as, for instance, the growth of technological advances in Medicine, lifestyle changes and a deep modification in social mechanisms. If this transformation is not supervised and faced in an appropriate way it can lead us to unexpected situations. It seems obvious that the parameters used as a base to calculate the resources and the assistance services must take into account the big changes that population faces with a very different life expectancy from what it was 20 years ago. The increase of life expectancy is something we must consider in an optimistic way but its consequences may also create difficulties. Nevertheless, in my opinion this phenomenon must be studied and valued from the point of view that population is growing older and will continue this way, but in a healthy way so people can enjoy the best life quality as possible. In fact, the elderly are an irreplaceable resource; they are the guardians of our historical memory, they hold a life knowledge that is fundamental in order to understand the evolution of our society and they are gradually becoming a reference social sector for governments and markets. They are a more extent population but are also more active in their own social context; they are also healthier and less affected by disabilities and other illnesses that require some services sustained by sanitary systems’ budgets. In fact, the increase of the life average has a direct consequence on the number of people getting ill and suffering chronic pathologies. Almost a 12% of people over 65 years old suffer from diabetes and among the factors that predispose to this illness we can find unhealthy habits as an incorrect diet, lack of physical activity and obesity. Less than half of the elderly Italian population has normal weight conditions, only 38% of men and 44% of women. Furthermore, 20% of people older than 65 are affected by lung obstructive chronic illnesses, serious dysfunctions of the respiratory track that cause 13% of hospital admissions originated in most cases by cigarette smoking (also in passive smoking), dust and pollution. 10% of people older than 80 years have suffered heart failures while deafness affects 1 out of 2 people older than 75. Finally the number of non self-sufficient elder people in Italy in 2004 reached 2 million. I think we must highlight that most of those illnesses affect not only the health sector but also the social context at large. Our consumption habits, lifestyles and social practices will be determining in our oldness quality. Coherent and coordinated political measures should be taken for illness prevention and health promotion in order to produce and favour a wholesome diet in detriment of tobacco and alcohol, to fight atmospheric and industrial pollution and to favour a life and work style less stressful and with more physical activity. We have real date and previsions rather alarming that can help us in guessing how our society will be in 40 years. We can not afford wasting a precious time, we must stimulate and carry out concrete immediate policies to be able to see the results in the next generation, our children’s one.

Fourth place in Europe’s life expectancy. Older but lonelier women.

INEQUALITY – Health assistance is female: women, daughters and domestic staff members take care of men, but the opposite hardly ever happens.

Women’s health, even if it’s fragile, usually goes unnoticed. There are several factors affecting women’s health in a negative way. More attention must be paid to women. They live longer than men, are more exposed to chronic diseases and take more medicines. They also have a very important role in families since they are supposed to take special care of their relatives. But the reality is different. Italian women’s health has improved in the last years, reaching the fourth position in life expectancy in Europe right after Switzerland, San Marino and Sweden but different social and economic conditions and current life styles contribute in creating inequality among the regions even in the health services’ offer. Heart pathologies are no longer exclusive to men but the main cause of women’s mortality. In fact, women’s hearts are smaller, lighter and more fragile and cause in Italy 30,000 deaths per year. After 50 years without legislative protection, women are more exposed to this risk also by the confluence of other factors like diabetes and hypertension. Despite all this, a recent English research showed that illness diagnosis and therapy is less considerated, causing a raise in death risks. Alzheimer is another disease that affects more women, especially those over 65 years, with a 7.5% impact on women and 5.2% in men. In such cases, women are also charged with the men’s assistance. According to Censis (the Italian institute of social and economic research) in 80% of the cases a woman takes care of a sick person. This situation has a strong economic and social impact: frequently women are forced to quit or reduce their jobs in order to be able to assist a relative with Alzheimer. There are also some kinds of tumours related to age like breast, uterus or lung tumour. Thanks to an early detection lots of women can recover and return to their careers, where they have to face discrimination and lots of problems related to the management of labour conflicts. On the other hand, problems related to menopause must be considered. We ought to remember that prevention plays a fundamental role and that hormone therapies prevent osteoporosis and colon and rectal cancer, even if they slightly increase the risk of breast cancer. When facing this problem it is important to make a balance of women’s needs, production and selling of medicines and the need of saving money for the national sanitary service. There is still a lot to do for women’s health from the research point of view by overcoming gender prejudices and also in prevention. Health demand is typically feminine while supply is more masculine. This could cause an unbalance between supply and demand and also an inefficient resource assignation.

Assistance – ITALIAN ANOMALIES – The level of provisions remains unequal among the regions: it is fundamental to reach a better balance.

The ageing of population among industrialized countries puts a lot of pressure not only on pension systems but also in sanitary systems and assistance programmes for non self-sufficient people. Italy is the only country in which the amount of aid designated to dependant people (accompaniment benefit) has been fixed on (450 euros per month) for all recipients without income graduation. On the contrary, in France the amount varies –in each level of seriousness- according to the economic capacity of the beneficiary. In Germany (as in Italy) the total amount of provisions does not depend on the beneficiary’s economic conditions, the German funds for dependency is financed by a specific compulsory contribution that changes according to the person’s income. There are no univocal theorical arguments to support the fact that the possibility of being entitled to an accompaniment benefit should not depend on the income; the need to assign better resources for the poor and dependant should be the object of a conscious debate. The changing character of the number of recipients in Italian regions is very high, since it varies from 37 help subsidies for one thousand inhabitants in Calabria to 16 in Trentino Alto-Adige to the 26 in the national average. There are no certain elements to establish whether they are too many for one region or too little for another: we only know that the differences among the regions are very high. It is possible that criteria to accede the accompaniment benefit are too elastic; it is also possible that this benefit is used as a substitute for other non-existing welfare institutions. Certain parity mechanisms benefiting poorer regions and the union of the help subsidy with the Istat could contribute to the enforcement of the system’s equality.  The accompaniment benefit entails to the State expenses more than 8 billion euros (almost 0.6% of GDP) against 1, 6 million in provisions. If we take into account that the incidence of disabilities in each gender and age sector is the same in Italy as in France or Germany, we are able to obtain an approximate estimate of the amount of people in Italy that would benefit if the same criteria were applied. Considering just people over 60 years old (the target of the French programme) this research shows that if German criteria were applied in Italy the number of subsidies would raise to the 30%, but applying the French criteria was applied, the number of recipients would be less than 20%. In review, the Italian anomaly is not the amount of recipients but the lack of adequation of mechanisms to guarantee an equal level graduation, so-called provisions, since non self-sufficient people in Italy in worse condition and with less money are seriously penalized. The effort made in some regions to overcome the limits of the State actions is very praiseworthy; for instance, Liguria has recently created a provision assignation fund proportional to the seriousness of necessity and the recipient’s economic capacity. Apart from regional initiates, which are very different, there is a need for a harmonization aiming at guarantying essential and equal levels throughout the country.

Elements for thinkings and proposals for comparison

Legal information – According to law, sick people, including those with Alzheimer or other kinds of senile dementia have the right to:

-health assistance during the whole period (without duration limits) of the intense phase. The hospitalization must be free and guaranteed by the national Health system in hospitals, private clinics and other kind of medical centres;

-social and health assistance during the stability phase, also for non self-sufficient people. An economic contribution of the patient is required for hospitalization (also in this case without duration limits) that must be assured by the national Health system and by city councils through Rsa (Health assistance residences) or similar. If the patient is over 65 years old and is not self-sufficient or holds a certificate of serious disability would only contribute according to his own personal resources (income, immovable and movable property) according to section 25 of law 328/2000 and decrees 109/1998 and 130/2000.

-to be transferred from hospitals, private clinics and other medical centres to social and health institutions (Rsa, subsidized houses, etc.) on behalf of the national Health service without interruption in the assistance.

Proposals to encourage home staying

a) A law for home assistance:

As we all know, it is preferable for people ill of Alzheimer and other senile dementia forms to stay at home or at the matrimonial home. In fact, at home life quality is higher compared to the one offered in hospitals and the patient can also live in better health conditions. Now, patients have no right to home assistance (only family doctors are entitled to give it). Among the goals of the meeting is to demand to the Government and regions the necessity of passing a law that guarantees the right to home provisions in the following cases:

-no medical nor other contraindications;

-the person can remain conscious and can receive medical and nurse assistance and rehabilitation if necessary;

-the spouse or other person shows his readiness to assure the support needed at home and is suitable according to local sanitary institutions criteria;

-emergency interventions are previewed in the case that the spouse or other person would no longer be able to provide help, even in the cases that the patient must be admitted in the appropriate institutions;

-the expenses paid by Asl or city councils are inferior to those that would correspond in case of hospital admission;

-the spouses and other persons are recognised as family volunteers and receive a sum on behalf of the Rsa as a refund of home assistance expenses, including those derived from the substitution of the person at charge due to his family or personal tasks (shopping, errands, etc.)

b) Day centres:

On the other hand, it would be necessary for regions and Asl to establish at least one day health centre for people suffering Alzheimer or other kinds of senile dementia so the main provisions for the patient and the support and advice for relatives can be assured. Day centres should guarantee an assistance of at least 40 weekly hours (8 hours, 5 days). The centre expenses, including transportation and food, should be carried by the national Health service.