will be left so disabled as to permanently need sheltered and special care for the balance of their lives.

In greater and greater degree we will receive applications for domiciliation from older, severely disabled veterans because they cannot be cared for in their homes and their community.

It will be noted that at the present time, the Veterans' Administration is caring for approximately 34,000 veterans who need care for disabilities but who do not need definitive hospital treatment. Approximately 17,000 of these are in our homes (domicilaries); about 9,500 are in State soldiers' homes where the Veterans' Administration contributes to their support. As indicated above, 7,500 are in Veterans' Administration hospitals. We can expect that the total number of these incapacitated veterans needing sheltered nursing home care will continue to increase with the increasing age of veterans.

It is estimated that by 1986, 328,100 veteran patients will need care on any one day. Of this number, 304,500 will need care for non-service-connected disabilities.

Psychiatric problems

As indicated before, approximately half of the veterans requiring care from the Veterans' Administration for illness are suffering from psychiatric conditions. This compares rather closely with the proportion of psychiatric illness in the general population. The joint study of the Veterans' Administration with the Bureau of the Budget referred to previously summarizes the expected trend in the veterans psychiatric load as follows:

"The service-connected psychiatric load is expected to decline from 31,300 in 1957 to 29,200 in 1966, to 24,600 in 1976, and 22,000 in 1986. The number of veterans requiring hospitalization for non-service-connected psychiatric conditions is expected to increase from 53,600 in 1957 to 69,800 in 1966, to 85,600 in 1976 and to 100,500 in 1986. Overall, the psychiatric patient load for the entire veteran population is expected to increase from 84,900 in 1957 to 99,000 in 1966, to 110,200 in 1976 and to 122,500 in 1986.

"The responsibility for providing hospital care to veterans with psychiatric illness will generally be a public responsibility. These disabled veterans can seldom bear the expense of protracted hospitalization, so the issue is whether the Federal Government or some other governmental agency will provide the care."

Summary

It is expected that the daily need for hospital care of general medical, surgical and neurological patients which was 84,700 in 1957 will increase to 116,400 in 1966, 157,000 in 1976, and 190,900 in 1986. This is probably a reflection of the aging of our veterans. The Veterans' Administration's difficulty in care for this number is increased by the fact that the number of days of hospitalization required also tends to increase with the age of the patient. Older patients require many more days of hospitalization per illness than younger patients.

In the field of tuberculosis, the picture is more encouraging. There is a definite decrease in the need for tuberculosis hospital beds at the present time. And, it is expected that this decrease will continue until about 1966. Students of medical trends feel that the number of tuberculosis patients will stabilize from 1966 to 1986 and then begin to increase slightly. However, it is to be noted in the field of tuberculosis that more and more of the new cases are developing in the older group of patients 60 and older, and that the period of hospitalization required for these patients is also much longer.

IV. THE PROBLEMS OF THE AGING VETERAN FROM THE ECONOMIC POINT OF VIEW

Our projection of veterans who may become pensioners in the future indicates the gravity of this problem. The statistical data presented are based upon existing legislation and not upon any possible change in this legislation. In fiscal year 1959, 821,000 veterans were receiving disability pension at a cost of $797 million. In terms of the number of veterans receiving payments, as well as in cost to the Government, the disability pension program is today the second largest direct benefits program administered by the Veterans' Administration. Between 1975 and 1980, it will have become the largest. By 1975, the number of veterans on the pension rolls, 1,639,000, will be about double the current number of pensioners, and by 1955, the peak load will be reached-over 4 million veterans receiving pensions amounting to nearly $4 billion.

The veteran population is fast aging. In 1959, the average age of World War I veterans in civil life is 65-for World War II veterans the average age is 40. With advancing chronological age, economic need becomes greater by reason of reduced incomes resulting either from forced retirements because of age alone or because of disability, coupled with age, interfering with substantial employment.

Although disability pension eligibility is based essentially upon permanent and total disability, VA has provided for special consideration of age in nonservice-connected cases. Older veterans, those 55 and older, may qualify for pension with permanent disability which is less than total if such disability makes them unable to secure and follow substantially gainful employment. The percentage of disability required is determined by the veteran's age, for example, veterans 55 through 59 years of age need 60 percent disability, 60 through 64 need 50 percent, 65 and older need 10 percent.

With the special consideration of age being given to disabled veterans, the economic impact of reduced incomes of our aging veteran population resulting from forced withdrawal from gainful employment is being softened. VA's disability pension program is providing a measure of security for older veterans who are in need and unable to work.

In 1954, 75 percent of VA pensioners with outside incomes of less than $400 were 55 years of age or older. Of all pensioners with incomes of less than $400, 70 percent had no dependents. Of all pensioners with dependents, 45 percent had incomes of less than $400.

V. RESEARCH IN AGING

The Veterans' Administration has a special program devoted to research in aging; however, it is to be remembered that all of the research in the Veterans' Administration may have some bearing on the aging problem. The 170 hospitals with an average daily patient load of 111,000 and the 17 homes (domiciliaries) with an average daily patient load of 16,800 supply a uniquely enormous number of individuals all subject to the aging process in which the Veterans' Administration can observe and evaluate its research in aging. The excellence of the staffs and the uniformity of records are two important factors which make the large-scale interhospital studies conducted by the Veterans' Administration of inestimable value.

Our research-in-aging devotes itself to the following areas of study:

(1) The biological aspects of aging in the cell, the organ, and the organism.

(2) The changes which age produces in the individual.

(3) Special deteriorations usually attributed to age are especially noted in elderly patients.

(4) Special pathological conditions which have a great incidence in the aged and are the greatest causes of morbidity in these patients.

We have 87 studies in the first three categories of which 20 are laboratory investigations and 11 are clinical bedside studies of the aging process. In the second category, there are in progress 13 laboratory investigations and 26 clinical studies. The Veterans' Administration has special bacteriological, biochemical, inorganic chemical, steroid chemical laboratories studying the problems of the elderly patient. In addition, there are studies going on in nutrition, physiology, psychology, and pulmonary function. All of the studies are aided by special laboratories devoted to pathology, hemotology, electromicroscopy, pharmacology, and surgery.

At the present time, the Veterans' Administration has 262 separate research investigations going on in the field of cancer, 399 in the field of cardiovascular disease, 242 studies of nonmalignant diseases of gastrointestinal tract, 138 studies of nonmalignant disorders of the genitourinary system, and 87 investigations of skeletal and joint abnormalities of which 22 are aspects of the problems of arthritis. Diabetes is being studied in 44 independent studies.

In addition to these researches being pursued by individuals, or teams within a hospital, there are the cooperative studies in which observations are pooled by clinicians in several hospitals. Studies include evaluation of therapies for malignancy, coronary heart disease, cerebrovascular accidents, intestinal disorders and diabetes. There are 22 subjects, totally, under investigation.

Further, there are investigations followed collaboratively between investigators in Veterans' Administration hospitals and non-Veterans' Administration members of medical faculties. An example of this type of research is a study

of the nutritional aspects of atherosclerosis centered in the Veterans' Administration Hospital, West Roxbury, in which members of the Harvard staff are active participants.

Psychologic problems of the elderly are being studied on an extensive scale at the Veterans' Administration Hospital, Kecoughtan, Va., and at the Veterans' Administration Center, Martinsburg, W. Va. These studies are centered on a broad program for the investigation of many aspects of long-term care. Histochemical studies of ground substance and the role of steroids in the therapy of atherosclerosis are examples of special research laboratory studies.

Finally, surveys to learn the incidence and natural history of such conditions are glaucoma and presbycusis are being conducted in Veterans' Administration clinics and hospitals. Self-government of patients and domiciliary members as well as other modes of increasing motivation are being tried in several domiciliaries and hospitals.

VI. REHABILITATION PROGRAMS-GENERAL

Rehabilitation in the VA is not limited to the physical care of the patient or member but encompasses the restoration of his total well-being. Thus, we find specialists in physical medicine, social services, psychology and volunteer services as well as a specialist in the field of medicine and others, concentrating on the particular needs of the older veteran.

Within the limits of its resources the VA is today:

(1) Arranging for foster home care for incapacitated veterans not requiring hospital care.

(2) Tailoring recreational programs to the special needs of the older patients in hospitals and members of domiciliaries

(3) Extending social casework services in all the facilities of the VA. These are especially helpful to the aging veteran and his family.

(4) Using vocational counseling for evaluating members and patients for jobs within and outside the medical facility.

VII. REHABILITATION PROGRAMS-IN THE HOSPITAL

The term "rehabilitation" when applied to long-term chronic or geriatric patients in hospitals, has a broader connotation than it did immediately after World War II and various shades of meaning. Understanding this is essential. Fifteen VA hospitals have formal bed services for long-term, chronic patients. In addition, many hospitals have units for the care of these patients which are not designated as long-term care wards.

Attempting to “rehabilitate" this type of patient in terms of returning him to his home as a useful member of the community is an extraordinarily complex problem. Nevertheless, VA's responsibility for the rehabilitation of this type patient does not cease. We face a more difficult yet highly essential task within existing limitations. For many of these individuals "rehabilitation" means bringing them the opportunity to live at the maximum mental and physical level attainable within the hospital community.

Therefore, "rehabilitation" when used to describe the program of treatment and activities for this type of patient amounts to maintenance therapy whose objectives are:

(1) Continue self-care ability as long as possible.

(2) Delay the necessity for maximum nursing care.

(3) Improve morale of geriatric and chronic, long-term patients and members.

(4) Fill a need for sustaining therapy by the development of specialized larger group techniques.

(5) Screen geriatric, chronic, long-term patients and members to determine those with the will and capacity to improve under more intensive and more individualized therapy.

In order to attain the most useful function of which the patient is capable, it is essential that studies be made to evaluate the residual potentials which the patient possesses. This is done by performing one or more proven tests which allow us to evaluate the patient's probability degree of improvement in range of motion of joints and in strengthening their coordination of muscular activity. All of this is done with a view of improving the patient's physical capacities to fulfill his daily living needs and his interest and zest in life. It is to be remembered that no living human being is considered as unimprovable, even though

the goals which he may eventually attain are extremely limited. It may only provide for reeducation and training for self-sufficiency to move from the bed to a wheelchair, or to learn to care for his personal needs. However, such goal once achieved opens a whole new environmental world to this patient. He is happier for having obtained a degree of independence. This provides him with fresh dignity and new purpose in life. Also, it is important to remember that this increased and renewed interest in living often prevents other distressing debilities due to inactivity and lack of interest in developing.

For another patient, the treatment goal based on medical assessment may not be so restrictive in its ultimate aim. The patient's rehabilitation potential may show greater promise, and through retraining, even though slow, he may progress from bed to chair, from chair to ambulation, first with braces and crutches, and then perhaps with only a cane, and from this to useful, interesting, purposeful activity. In either situation, the test procedure and results have served as a basic guide in planning the patient's total treatment program.

To help the patient acquire the ability to move freely and to restore his feeling of independence requires the effort of a team of trained people, each in a separate field of activity. Once the patient has attained useful function and mobility, these advantages must be retained by being put to purposeful activity. When it is determined that the patient has reached his maximum possible improvement, a maintenance program of physical exercise and activity designed to prevent regression and to stimulate conscious effort will replace the initial retraining program. This is often accomplished by group activities in which the patient learns to interact with other individuals having similar disabling conditions

The problem of care of disabled patients is forever increasing. The obligation of overcoming disabilities adds more and more disabled to our load. Since the problem of relief of disabilities in our aging veterans is but a part of the total physical medicine and rehabilitation program in our hospitals, we find that the staffs of therapists involved are having to make decisions between the needs of the young and old patient because there are not enough trained therapists to do the total job. The problem then becomes one of doing the best one can that is possible in a given time.

VIII. REHABILITATION IN OUR HOMES

The Veterans' Administration home (domiciliary) is a sheltered home, and the problem of rehabilitation here becomes a part of the problem of planning for the total day's activity of the member. The facilities which we have often makes this very difficult. To understand this, it is necessary that we understand the history of the Veterans' Administration homes (domiciliaries).

Shortly following the Civil War increasing numbers of young veterans-some wounded, many were ill adjusted-aimlessly roamed the streets of our cities and towns. As a means of meeting this problem, the Government set up domiciliaries for these veterans to give them shelter and some care. Because they were young and lately out of the military, discipline was considered essential and also was familiar to the men. Therefore, our domiciliaries were arranged in a barracks-type military setup. These homes provided the kind of shelter these young veterans were used to, and barracks-type of discipline seemed natural. Thus, we built large open-house facilities, and these were organized under military pattern and regulation. They probably served well the needs of these young, homeless, disabled soldiers. However, as our veterans began to age and as our homeless veterans sought shelter from the Government these barrack-type installations with military organization and discipline ill suited their needs. At the same time, these domiciliaries or homes were not ideally situated to serve the older veteran's community interests. Many have been initially located in out-of-the-way places because of the citizens' general desire to have them out of sight-somewhat the same attitude as obtained in determining the location of mental hospitals. Our home member, thus, is now separated from his community.

Today the Veterans' Administration recognizes the needs of veterans in our homes, and we have attempted to change the environment in which he lives. The use of military titles and the military organization have been dropped. However, the physical facilities remain, and it is difficult to convert large open barrack-type dormitories into chambers giving comfort and privacy to old men. The Veterans' Administration in making studies in this field.

At the Veterans' Administration Center, Wood, Wis., in April 1956, there was begun a domiciliary pilot program with two principal purposes in mind. First, human being are worthy of effort to elevate their lives wherever they are found in the community, in the hospital, in the domiciliaries, or other congregate-living situations. Second, improvement and development of the domiciliary program offers an additional opportunity to educate men who have been thrown out by society back to social patterns which again can integrate them with their social environment. It is hoped by such training that men who have felt themselves outcasts and not useful to their neighbors can again learn to socialize and find a place within the society of their community.

This pilot study comes only after several decades of relatively constant unchanging domiciliary operation. It is designed to open an era of strikingly new and dynamic approach to the member in a sheltered living environment. Out of this has developed a planned activity program where each member's waking hours are taken up with activities tailored to his physical and mental capacities, and designed eventually and optimistically to return him to his home, his community, and to his family if he has one.

This program is new. We have great hopes for it, and those engaged in its implementation are dedicated and enthusiastic. Finding ways to motivate our older veterans may be a difficult problem, but we hope to give to these older men renewed interest in living, renewed vigor in carrying on the problems of life.

IX. RESULTS IN TERMS OF COSTS

The accounting system of the Veterans' Administration makes it impossible to segregate the cost of rehabilitation programs for older people in our hospitals and homes from those of the younger veteran, so that it is impossible to estimate what rehabilitation costs are for older people. We have figures of our total rehabilitation cost, but this includes a very large segment of young and seriously disabled patients.

Senator MCNAMARA. We will be glad to have that for our record. Thank you.

Mr. MORSE. We certainly concur that the inquiry you have undertaken is a most urgent one and a most necessary one, the inquiry into the aged and aging.

With the thought of being helpful I have brought along some charts which we prepared in connection with our long-range planning and are normally in our chart room. I believe they illustrate rather dramatically the magnitude of the problem of the aged and aging veteran. And I know of no evidence which indicates that the problems of the elderly veteran are any different than those of the elderly nonveteran. There are today 23 million living veterans in civil life. Together with their dependents they number 45 percent of our national population.