Governments around the world are beginning to recognize that their long-term care sector is in crisis. One factor contributing to this crisis is the high growth in the number of the aging population, combined with a lack of investment. According to the United Nations World Population Prospects: The 2017 Revision Population Database, in 2017 there was an estimated 962 million people aged 60 or over in the world, comprising 13% of the global population. The population aged 60 and above is growing at a rate of about 3% per year. Europe has the greatest percentage of the population aged 60 or over (25%). The number of older persons in the world is projected to be 1.4 billion in 2030 and 2.1 billion in 2050 and could rise to 3.1 billion in 2100. Further, the number of persons aged 80 or over, globally, is projected to triple by 2050, from 137 million in 2017 to 425 million in 2050.
With a growing and aging population, the number of people living with dementia is expected to increase in future decades, with corresponding implications for health care needs and use. According to the World Health Organization, 50 million people live with dementia, including Alzheimer’s disease, worldwide. As these conditions progress, they become highly debilitating for affected individuals and lead to major health impacts.
In Australia, the Royal Commission into Aged Care Quality and Safety (the “Commission”) was established to investigate how older people are cared for and report on what needs to change to make aged care services better. The Commission was established in October of 2018, after Ms. Springs and her son Clive, “lifted the lid on a system in crisis”, which resulted in the closure of the nursing home where her husband had been placed.
Mr. Springs suffered from dementia. Many people, like Ms. Springs, are of the view that a nursing home is better equipped to deal with an incapable person’s care needs. However, this is not always the case. Mr. Springs’ health worsened after he was placed in the nursing home, “he had been over-medicated, had severe bruising, was dehydrated and suffering from pneumonia”.
The Commission held hearings throughout the country, listening to evidence from family members, medical experts, aged care bodies and unions. It was clear, that this sector is under-resourced.
The Commission heard many older Australians were fearful about going into residential aged care. Some said, “they would rather poke their eyes with a pencil than have to enter a home”. Others said that “they would rather die”.
A few things became evident during the hearings. Firstly, when care workers are confronted with a difficult resident, “the first port of call was to use psychotropic drugs to sedate or restrict the movement” of the person, rather than drugs being used as a last resort, as required.
Secondly, the aged care sector requires a “massive funding boost”. Older people desire to remain in their homes longer, however, they require financial assistance in order to do so. People have been known to wait more than 12 months for a Federal Government home care package. The system will only worsen if the problem is not addressed, as a “tsunami” of people will need help as they enter old age in the coming decades.
The evidence presented to the Commission during the hearings showed that in Australia “Dementia is set to become the biggest cause of death for people aged over 85”. Dementia was described as being “the chronic condition of the 21st century”.
The other issue with the system is that the workforce is currently under-resourced, underpaid and that the minimum training that personal care attendants receive is not adequate to deal with patients who have a myriad of health problems, including dementia. In addition, the workforce is under-regulated and care workers are not subject to the same scrutiny as are nurses. Furthermore, there is no mechanism in place to monitor workers who are not fit for the challenge. 
Unfortunately, like Australia, Canada faces similar issues with the sector being under-resourced, and the abuse that some older Canadians experience by their caregivers in some Long-Term Care Homes. (see the serial killer nurse Elizabeth Wettlaufer, and the abuse of elderly people in Nova Scotia nursing homes).
In 2017, the government of Ontario established the Long-Term Care Homes Public Inquiry (the “Public Inquiry”), following Elizabeth Wettlaufer’s conviction of eight counts of first degree murder, four counts of attempted murder and two counts of aggravated assault. These offences were committed while working as a registered nurse in Long-Term Care Homes. The Public Inquiry was established because of concern for the safety and well-being of residents in Long-Term Care Homes in Ontario and those receiving publicly funded healthcare services in their homes.
During the investigation, it was revealed that abuse of the elderly in long–term care homes is happening worldwide.
With a growing and aging population, the number of Canadians living with dementia is expected to increase in future decades, with corresponding implications for health care needs and use. By 2031, it is projected that the total annual health care costs for Canadians with dementia will have doubled from those of two decades earlier, rising from $8.3 billion to $16.6 billion. Roughly 56,000 Canadians with dementia are currently being cared for in hospitals, even though this is not an ideal location for care.
The Financial Accountability Office of Ontario released a new report: Long-Term Care Homes Program: A Review of the Plan to Create New Long-Term Beds in Ontario on October 30, 2019 (the “Report”). The plan aims to create 15,000 new long-term care beds in Ontario.
Key findings from the Report include:
- The 15,000 new bed commitment is expected to cost the Province $1.7 billion over the next five years. Once all the new beds are in operation, the on-going annual cost will be approximately $970 million;
- The wait list for a long-term care bed is projected to peak at 40,200 Ontarians next year. Once all the new beds come into service, the wait list is projected to be 36,900, still higher than the wait list in 2018-19;
- Ontario’s growing and aging population will continue to place pressure on the long-term care system. Even with 15,000 new beds, an additional 55,000 new long-term care beds will be needed by 2033 to maintain the wait list at approximately 36,900 individuals; and
- Patients waiting in hospitals for a long-term care bed occupied 340,000 hospital bed days in 2017-18, a significant contributor to the problem of hallway health care. Wait times for a long-term care bed are expected to peak in 2020-21, implying that, in the absence of other health sector changes, hallway health care is expected to become worse over the next two years.
The report states that the primary drivers of the longer wait time is attributed to the high growth in the number of Ontarians aged 75 and over, combined with a lack of investment in new long-term care beds. In 2018-19, the Province spent $61.5 billion in the Ontario health sector, of which $4.3 billion, or 7 per cent, was spent in the long-term care homes program area.
HOW DO WE INJECT THE SYSTEM WITH TLC?
A holistic approach needs to be taken in order to alleviate the strain that the sector is experiencing to accommodate the flood of people that will require residence in Long-Term Care Homes in the coming years. The support and active involvement of the various role players that contribute to the aged care sector (such as the Ministry of Health and Long-Term Care, Long-Term Home Facilities, the Colleges, the administration, and registered staff members, as well as family members) is essential.
Even though Canada’s Long-Term Care Homes Act, 2007 and its regulations impose clear standards for long-term care homes and a rigorous inspection regime to enforce those standards, there is still room to strengthen the system to prevent some seniors from falling in the cracks. The final report of the Public Inquiry released on July 31, 2019, includes 91 recommendations that are to be implemented to improve the aged care system in our country, some of which cost money and others do not. The recommendations are based on four systemic responses, namely: prevention, awareness, deterrence, and detection of abuse.
Five provinces have strategies or dementia action plans in place or are in the process of developing their own dementia strategies, namely: Nova Scotia, Quebec, Ontario, Alberta, and British Columbia. In addition, some provinces and territories, such as New Brunswick, are developing seniors’ strategies that will address dementia as well.
The government of Canada is also contributing to improving the system. On June 17, 2019, the Government of Canada, released the country’s first-ever national dementia strategy: A Dementia Strategy for Canada: Together We Aspire. The strategy addresses the overwhelming scale, impact and cost of dementia in Canada through three key objectives:
- Prevent dementia;
- Advance therapies and find a cure; and
- Improve the quality of life of people living with dementia and caregivers.
The 2019 federal budget is providing $50 million in funding over five years to support the implementation of the Strategy.
While the recommendations of the Public Inquiry, Ontario increasing the number of beds in Long-Term Care Home facilities, and the provincial and federal governments contribution through providing funding and carrying out awareness programs is a step forward in dealing with this “chronic condition of the 21st century”, our efforts need to be increased if we want to see an improvement in our aged care system.
 World Population Prospects: The 2017 Revision Population Database, UN Department of Economic and Social Affairs, online: http://www.un.org/en/sections/issues-depth/ageing/ [Accessed on 15.11.19].
 World Health Organization. Dementia – Fact sheet online: https://www.who.int/en/news-room/fact-sheets/detail/dementia [Accessed on 15.11.19]
 Royal Commission into Aged Care Quality and Safety – Plain English, online: https://agedcare.royalcommission.gov.au/Documents/about-the-royal-commission.pdf [Accessed on 14.11.19].
 Meagan Dillon, ”What have we heard at the Royal Commission into Aged Care Quality and Safety so far?” ABC News, 22 Feb 2019, online: https://mobile.abc.net.au/news/2019-02-22/first-fortnight-of-hearings-for-royal-commission-wrap-up/10837116 [Accessed on 15.11.19]
 “Elizabeth Wettlaufer: Canadian nurse’s confession released” BBC News , June 6, 2018, online:
https://www.bbc.com/news/world-us-canada-44377735 [Accessed on 16.11.19]
 Kayla Hounsell “Reports reveal 46 abuse cases over 2 years in Nova Scotia nursing homes”, CBC News, October 25, 2017, online: https://www.cbc.ca/news/canada/nova-scotia/long-term-care-abuse-protection-for-persons-in-care-1.4368714 [Accessed on 16.11.19].
 The Long- Term care Homes Public Inquiry Final Report, Volume 1, at page 4, online: http://longtermcareinquiry.ca/wp-content/uploads/LTCI_Final_Report_Volume1_e.pdf [Accessed on 16.11.19].
 Public Health Agency of Canada, Neurological Health Charities Canada. Mapping connections: An understanding of neurological conditions in Canada. Ottawa (ON): Public Health Agency of Canada; 2014. Report no.: HP35-45/2014E-PDF. Available from: http://publications.gc.ca/site/eng/9.699466/publication.html
 Alzheimer Society Canada, online: https://alzheimer.ca/en/Home/Get-involved/Advocacy/Latest-info-stats
 LONG-TERM CARE HOMES PROGRAM: A Review of the Plan to Create 15,000 New Long-Term Care Beds in Ontario, Oct 30, 2019, online: https://fao-on.org/en/Blog/Publications/ontario-long-term-care-program [Accessed on 14.11.19]
 2007, S.O. 2007, c. 8
 O. Reg. 79/10
Alzheimer Society Canada, Canada’s national dementia strategy, online: https://alzheimer.ca/en/Home/Get-involved/Advocacy/National-dementia-strategy-guide [Accessed on 20.11.19]
 A Dementia Strategy for Canada: Together We Aspire, online: https://www.canada.ca/en/public-health/services/publications/diseases-conditions/dementia-strategy.html [Accessed on 16.11.19]
 Alzheimer Society Canada, Canada’s national dementia strategy, online: https://alzheimer.ca/en/Home/Get-involved/Advocacy/National-dementia-strategy-guide#budget [Accessed on 20.11.19]