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Russia's elderly live rough lives, and the state offers almost no help, but officials say everything is about to change

Source: Meduza

Responding to widespread criticism of the government’s plan to raise the retirement age, Russia’s state-controlled media has been busy telling readers how important it is to live vigorously into old age to avoid becoming a “grumbling old fogey.” “For many people, a pension is an excuse to stop being active, to become frail, and not to want anything, or to want to do things but not to do them, because their finances or health don’t allow it,” explains one op-ed published by the Rossiya Segodnya news agency. The message to readers is clearly that the reason for older people’s unhappiness is that they retired too early. In reality, Russia is a particularly hard place to grow old. According to the 2015 Global AgeWatch Index, compiled by the NGO HelpAge International, Russia’s “report card” ranked it 65th out of 96 countries. When judged on life expectancy and mental well-being, Russia falls to 86th place. Meduza’s medical news editor Darya Sarkisyan takes a closer look at Russia’s geriatric care infrastructure and how officials have promised to change it.

Anatoly Grishin’s degenerative joint disease eventually became so bad that he couldn’t get out of bed. Living alone in Ryazan, he’d lost touch with his relatives, and they lived far away in Siberia, anyway. That’s how Mr. Grishin ended up at a government-run geriatric center, where the staff mostly ignored him. Speaking to Meduza, he says he basically “lay dead” for three months, until the “Joy in Old Age” Foundation heard about him. A nonprofit with a dozen years of experience working with nursing homes, the foundation effectively saved Grishin’s life.

The foundation’s director, Elizaveta Oleskina, telephoned Alexey Sidnev, the head of the Senior Group company, which owns several private geriatric centers, and convinced him to help. Mr. Grishin was soon transferred to the Malakhovka Center outside Moscow in an act of pure charity (most patients at this facility have to pay to be here, and the cost is considerable). Grishin experienced pain just trying to stand, but the doctors helped him manage, and the center’s psychologist got him to believe that walking wasn’t as scary as it seemed.

Once he could stand, Grishin’s rehabilitation got underway: training with specialists and exercising at the fitness center. Today, the 75-year-old can walk on his own — with the help of a cane, but at a surprisingly brisk pace. He’s already capable of living alone again, but he fell in love at the center and wants to get married. His fiancee, however, can’t survive without special care, and the staff doesn't know what to do. The only thing Grishin complains about today are the bedsores he got at the state-run nursing home that still haven’t healed entirely.

Russia’s nursing homes are designed like warehouses for the elderly

Most Russian elderly clinics house people who need entirely different kinds of assistance: some people suffer from dementia, others have become temporarily disabled (for example, they can’t walk and need rehab), and others could be living on their own, if they hadn’t lost their homes. (Older people are often left homeless thanks to fraudsters or rapacious relatives).

Elizaveta Oleskina calls this a “warehouse” system, arguing that it’s effectively impossible to help people under such conditions. The state resorts to “human storage,” Oleskina says, because officials see only two options for elderly care: people either live at home and a social worker visits once a week (or twice, at best), bringing groceries, or they’re sent off to a clinic.

“Warehousing” also inspires unhealthy attitudes toward the patients at nursing homes, Oleskina warns. “The staff at geriatric clinics simply lack the concept that if you invest in a bedridden patient who’s struggling after a serious operation, they might be on their own two feet, going home, in two months,” Oleskina told Meduza. Speaking at the “Society of All Ages” conference, she recalled how a regional health minister once assured her in complete seriousness that bedridden patients should eat their meals while lying down.

Alexandra Kuzmicheva, who works with Oleskina, says this attitude about the elderly is common among care professionals who simply “burn out.” “There are a lot of nursing homes where everybody on staff — right up to the director — is really burned out,” she explains. “Their salaries are low (the nurses are earning no more than 8,000 rubles [$120 a month]), they might have 50 bedridden patients between the two of them for a single shift, and at night they might even be alone on their floor.”

The elderly often turn to their families for care, but the work requires intense training

Sometimes the elderly have relatives who can provide proper care: for example, by hiring a competent healthcare professional. These workers are known somewhat disparagingly as “babysitters,” but their services actually require a great deal of knowledge and training. Caregivers know how to help people stand again, how to wash patients, how to dress them, how to prevent bedsores, and how to treat them, if they appear, and the list goes on. A physical therapist, moreover, can tailor special exercises to help a patient become more mobile and independent.

These services are expensive, however, and relatives often decide to care for their loved ones themselves. Many people have to quit their jobs to make this work, becoming amateur caregivers. This can be a trying ordeal, as constantly caring for older relatives is enormously stressful. People frequently start taking out their frustration on the elderly, while slipping into depression. Sometimes, they lose the ability to communicate normally, and all they can do it complain about the burden of caregiving. Spend some time with people who care for relatives with dementia, and it’s easy to understand how these attitudes emerge.

The “Joy in Old Age” Foundation argues that it also hurts the state when people have to care for loved ones themselves. In a report, titled “International Experience in Creating Long-Term Care Systems,” the foundation points out that people caring for elderly relatives more often quit their jobs, live near poverty, and stop paying taxes.

State aid for the elderly is tangled in red tape

There is government assistance for families caring for elderly and sick relatives, but it’s not easy to get. Simply calling the local social services office won’t cut it. “To receive entitlements based on the severity of his conditions (a social worker, a ramp at the entrance of their apartment building, treatment at a special health spa, training, or any rehabilitation), a patient has to visit multiple agencies,” explains Nyuta Federmesser, the director of the Moscow Palliative Care Center, pointing out that the patient in question has to make all these trips himself, getting his disability papers, his rehabilitation equipment, arranging his pension, and so on.

Together with the “Joy in Old Age” Foundation and the “Vera” group, the St. Philaret’s Orthodox Christian Institute started training outreach workers (specialists to help people navigate the bureaucracy and claim all their entitlements, organizing their treatment and assisting with all the paperwork). The plan is for these outreach workers to find jobs at charities, nursing homes, hospitals, and hospices. Right now, however, this is still the only such training program in the country.

Government agencies don’t consider it their job to seek out older people who might need help. Even when someone is discharged from the hospital after a serious operation and it’s obvious that he’s in no condition to care for himself, social services might never even hear about him, says Oleskina, explaining that hospitals and social services report to different agencies and fail to coordinate their work.

In Russia today, there are a great many lonely elderly people — people who need help, about whom nobody even knows — says Senior Group head Alexey Sidnev. He describes an experiment in Volgograd where postal workers who delivered pension checks to people’s homes were asked to assess who, in their view, needed assisted-living or in-home care. Respondents listed three times as many people than were actually getting help. Elizaveta Oleskina, meanwhile, says it’s pointless for the government to go looking for people who need assistance until the state refines its own treatment system. In many regions across the country, for example, there aren’t enough spaces in nursing homes or social workers on staff to accommodate all the elderly people who need care.

Russia has good private nursing homes, but they can cost a fortune

The Senior Group’s Malakhovka Center outside Moscow was designed by specialists from Israel, where the elderly care system is particularly advanced. Malakhovka treats patients who need around-the-clock care. “For example, our beds can be lowered flat on the floor,” Alexey Sidnev explains. “If someone has dementia, the railing won’t stop him, and he can climb over it from a dangerous height. In this case, it’s better to lower the bed to the floor, so at least the patient rolls onto the floor, instead of falling.”

The Malakhovka Center goes to great lengths to protect its patients: for example, the restroom doors open from the outside (even when occupants lock the doors), the floor colors were selected to help people with dementia orient themselves and find the walkways (the center of the hallways is painted red, and the sides are gray, which dementia patients avoid, thinking it’s empty space, Sidnev says), and there’s either a window or a lamp at the end of every corridor, also to help people orient themselves. Many patients suffering from Alzheimer’s disease regularly try to leave their care facility. The “Akulovo” rooming house (another Senior Group property) actually installed a special bus stop for patients with dementia who want to leave. The bus never comes, and the patients go back to their rooms, when they forget why they were waiting.

Accommodations in these geriatric center isn’t cheap. According to Malakhovka’s website, one month’s stay can cost as much as 260,000 rubles ($3,900). If the patient is from Moscow, there are less expensive options: the center is registered with the city as a social-service provider, and Muscovites can get part of their bill subsidized. Even in this case, however, the monthly bill can still run higher than 100,000 rubles ($1,500). Russia has more affordable nursing homes, of course, but they’re more often than not located in poorly modified buildings and they don’t always abide by the principles of evidence-based medicine.

Russia doesn’t have enough geriatricians

In 1995, Russia first recognized “geriatricians” as a distinct medical professional; in 2016, the country got its first formal procedure for rendering “geriatrician” assistance; and in April 2018 a 600-page national geriatrics guidebook was published for doctors. Geriatrics grew into a separate medical field because people’s bodies change considerably as they age. For example, multiple chronic illnesses appear simultaneously, prescription medications counteract, and specific psychological problems develop.

According to geriatricians, ordinary physicians often fail to treat elderly patients effectively because they don’t understand the peculiarities of advanced age. For example, it’s common knowledge that the risk of unwanted side effects rises to 100 percent when patients are taking more than 10 prescriptions (which isn’t so rare). People taking so many medications are also more likely to fall and injure themselves. Of course, this doesn’t mean such patients shouldn’t receive care. Speaking at this year’s Geriatrics and Gerontologists Conference, Russian Health Ministry Chief Geriatrician Olga Tkacheva said all patients need treatment, but not for everything. Doctors need to determine what jeopardizes a patient’s autonomy and treat that, she argued.

Geriatricians say Russians could live longer if the country had adequate medical care for its elderly population. A better system would also help older people avoid unnecessary suffering in their twilight years.

Maria Gantman, who works as a gerontopsychiatrist at the Mental Health Center private clinic, says she regularly encounters elderly patients who have been receiving inadequate medical care. “People with dementia can’t say where it hurts or what hurts, and they just appear to be anxious,” Gantman explains. “They’re often sent to a psychiatrist to get a prescription for sedatives, instead of trying to find out the underlying reason for their declining health. As a gerontopsychiatrist, I’ve treated patients with undiagnosed pneumonia, pleurisy, and other illnesses. As a rule, other doctors have examined them before me, but they didn’t show the patients enough attention, dismissing their condition as the progression of Alzheimer’s disease.”

New regulations state that physicians and general practitioners are supposed to refer elderly patients who need specialized care to a geriatrician. For every 20,000 elderly people assigned to a local outpatient clinic, there’s supposed to be one such physician. In reality, Russia has far fewer geriatricians than it needs. According to Olga Tkacheva, the country currently has just 18 geriatric centers, 1,880 geriatric beds, and 221 geriatric offices. Every year, only eight doctors in residency get their specialty in geriatrics, and a little more than 100 become geriatricians through occupational retraining. Tkacheva admits that it isn’t enough.

Specialists who spoke to Meduza also warned that there are some lingering concerns about how Russia trains its geriatricians. The new national guidebook is based predominantly on scientific research and mostly observes the best practices, but it still has some peculiar “Russian features,” such as endorsements of drugs with unproven efficacy, like Fabomotizole, Actovegin, Cortexin, Cerebrolysin, and others.

The state promises to fix the system

In early 2016, Russian officials approved an action plan to improve living conditions for older citizens. In the summer of 2017, at a meeting between Vladimir Putin and representatives from several NGOs, Elizaveta Oleksina told the president that the government’s strategy failed to account for many problems in the care and treatment of the elderly. As a result, the action plan was amended, and the Labor Ministry and Health Ministry were charged with implementing the revised strategy.

Reforms to Russia’s current system of elderly care are supposed to be finished by 2024, but so far the changes have only been instituted in six pilot regions. The new strategy proposes that everyone who needs care will be divided into different categories and offered treatment, including at home. “In long-term care, it’s very important not to steal patients’ autonomy,” says Alexey Sidnev, who also took part in the discussion about innovations in healthcare for the elderly. “If someone can hold a spoon even a little bit, then he’s going to hold it, and we’re not going to feed him. If he can brush his own teeth, but maybe it takes him five minutes, we’re going to wait — though of course it would be easier for staff to do it for him and get back to their duties.”

If relatives decide to care for patients themselves, the state is supposed to offer help, including with training at schools for home care. Russia’s Health Ministry says these schools are coming, but so far they’re almost nonexistent.

In Moscow, in addition to the reform efforts at the federal level, city officials are trying to improve the care available to the elderly. In October 2017, the Moscow Health Department and Social Protection Department enacted regulations that, at least in theory, should help reduce the practice of “warehousing” (when patients are housed somewhere without regard for their specific needs). The new rules require nursing homes, psychoneurological clinics, and palliative care facilities to share information about patients and determine where individuals can get the best, most appropriate care.

Officials hope to improve services offered to older people who live at home by consolidating the bureaucratic obstacles they face into a single coordinating center. The center is already operational, accepting applications for palliative care. According to Tatyana Kravchenko, the chief physician at the Palliative Care Center, patients’ relatives or primary-care doctors can now submit paperwork on their behalf. Afterwards, someone from the center (a doctor, nurse, or social worker) is supposed to visit the individual and explain to family members how to care for them and furnish their homes. If necessary, staff will also bring medicines, first-aid materials, wheelchairs, and anything else that’s required.

Problems with elderly care aren’t just organizational, and the biggest issue is patients’ mental health

Russia’s healthcare reforms are supposed to accommodate older people’s basic physical needs better, but officials are also introducing changes intended to reduce social isolation. Not having anyone to talk to, some elderly people actually call the paramedics and try to get hospitalized, desperate for human interaction. In the worst cases, loneliness even drives some older individuals to suicide.

“Depression among the elderly isn’t the loud, obvious despair and suffering you see in young people,” writes Maria Gantman. “It’s quiet conversations about death, a gradual, subtle refusal to eat, and a quiet suicide without warning (usually poisoning themselves with their own pills). They plan everything carefully and don’t draw unnecessary attention to themselves.” Suicides by senior citizens are actually more common than teenagers killing themselves.

The “Joy in Old Age” Foundation helps nursing homes will a lot more than just household necessities like good mattresses and adult diapers. Most of the group’s work boils down to talking to elderly people. For example, volunteers visit old people’s homes and the foundation runs a program called “Grandkids by Correspondence,” where patients get letters from volunteers. Just one letter a month from a perfect stranger, it turns out, can vastly improve a person’s mood and raise their quality of life.