Authors
Sijmen Duursma, the Netherlands
Abdul Razzk Abyad, Lebanon
Fawzi Amin, Bahrain

From 1st - 3rd September, 2004, the third session of the first MEAMA course was organized in Bahrain in the Kingdom of Bahrain. Seventeen participants from six Middle-East countries participated in the session. Originally a one day symposium on aspects of quality of life was planned at the day before the third session. For the participants of the course this symposium would have been the first day of the session. Unfortunately, because of an unavoidable change in the date of the course, the symposium had to be cancelled. A disappointment was compensated by the presence of two highly qualified speakers, who participated during the whole session with excellent presentations and fruitful discussions. It was a pleasure for both participants and organizers to have Prof. Dr. Miel Ribbe from Amsterdam, the Netherlands, and Prof. Dr. Palmi Jonsson from Reykjavik, Iceland, available for information and advice.

The main objective for the session was quality of life. The topic was introduced by Prof. Miel Ribbe. Quality of life is an individual experience and it changes over time during one's life. It has to be expressed by the individual or to be observed by others and it is based on resources, abilities and goals. It has social, psychological and health related indicators and environmental and cultural dimensions. Dr Abdul Razzak Abyad discussed the typical problems related to quality of life in older patients with dementia. He focused on how to improve quality of life in these patients, how to handle personal freedom and how to measure patients' mental incapability. Special attention was given to non-verbal communication with these patients. The groups' discussions focused on quality of life in patients with chronic heart failure, on haemodialysis, with depression or in the end stage of life. The general conclusion was the differences in the needs and measures for each group of patients.

Dr Adel Al-offi presented the results of a community geriatric team for mental disorders in Bahrain. Consultations are offered at home, in nursing homes and in hospitals. The model was cost effective and postponed hospitalisation or admittance in a nursing home.

The level of adherence to the guidelines for diabetes mellitus in older patients in Canada was discussed by Al Malik Waleed from Saudia Arabia. The use of aspirin and blood pressure control were good, however, the measurements of HbA1c and the lipid profile was measured in less than 15% of the patients. Physicians know the guidelines, but do not use them in older patients.

How to select a guideline from the increasing number of guidelines? Prof. Fawzi Amin recognizes six domains for the quality of a guideline: 1. the scope and purpose; 2. the stakeholder involvement; 3.te rigour of development; 4. the clarity and presentation; 5. the applicability; 6. the editorial independence. A critical review of a guideline should be followed by a discussion how to implement the guideline. For simple problems the guidelines are usually simple, for complex problems the guidelines are mostly broad and complicated. The groups' discussions asked for guidelines for special problems in patients, but also for caregivers, rehabilitation, safety and environmental risks and lifestyle improvement. For the nursing homes attention was asked for the end of life problems and cognitive functioning. For hospital discharge guidelines were requested. Guidelines for outpatient clinics were felt to be difficult to develop, for example regarding non-verbal communication.

In a second lecture prof. Miel Ribbe emphasized the subjective, dynamic, normative and comprehensive aspects of quality. And quality care includes the impact, the process and the output. Quality indicators and the minimum data set were discussed, followed by an introduction of the interRai group and instruments. Several members of the participants showed serious interest to participate in a study of the interRai, to get information end insight in the Arabic patients. It offers the possibility to compare the outcomes of the Arabic world with other countries and cultures.

As an area of the world, different from the Arabic world, prof. Palmi Jonsson was invited to explain the health care system in the Nordic countries of Europe: Norway, Sweden, Finland, Denmark and Iceland. Iceland has the highest life expectancy for people over 65 years of age in Europe. The limited population of Iceland made it possible to set up a system to keep older people at home as long as possible and to offer nursing home care only when needed. The success and the problems of the system were discussed. A problem in the system is the insufficient coordination between the institutions. Another problems is that general physicians have not been accustomed to visit patients at home. Because the incidence of chronic diseases in patients roughly doubles per five years increase of age, a programme for prevention has been developed in Iceland, with preventive measures for the age group 15-40 years, the age group 40-50 years and the age group 50 to 70 years and older.

As in former sessions the participants evaluated the session and made suggestions for subjects of special interest for the last session of the course. The six subjects with the highest score of interest will be included in the programme of the next session: education and training for general practitioners and team members; how to start a society for gerontology and services for older people; theories about the process of ageing; nutrition, weight loss and adipositas; falls and fall prevention; management models in health care services for older people.

The course was accommodated by the Bahrain Ministry of Health in the attractive Novotel, build in accordance with the typical old Bahrain architecture. A major sponsor for the course was the Merck Institute of Aging & Health. The Ministry of Health of the government of Bahrain offered excellent support and Gulf Air offered generous and excellent travel facilities for the European speakers. The acceptance of a board position by prof. Miel Ribbe will strengthen further development of the board and will support the preparations for the second course, to be started in the autumn of 2005.