The First two-year MEAMA course that started in 2003 by a group of Middle-East and European Professors had finished in July 2005.

The First Session

The first session took place between Oct 2-5 , 2003 . The participants came from six Middle-East countries. The members of this small enthusiastic group were all very much engaged in the problems they will face in older people in the nearby future. During the course the participants presented lectures about the situation in their own countries. The teachers' state of the art lectures focused on demographic aspects in the Middle-East area. Differences were observed between the countries. The MEAMA seems to be an excellent forum for the exchange between countries and the discussion for developments. Other subjects we discussed were heart failure, diabetes mellitus, osteoporosis, dementia, depression and behavioural disturbances. The evaluation by the participants was excellent, with correct critical and constructive remarks.

The Second Session

The second session took place in Tripoli between 8-11, 2004. Development with the second session was the support of Case Western University and the concurrent
first annual Middle-east Conference of Age & Aging

From 8 through 11 April, 2004, the second session of the first MEAMA course was organized in Tripoli, Lebanon. In contrast to the first session this session was divided in two parts, the regular course for a limited number of participants and a one day symposium, accessible for physicians from Lebanon. Financial reasons were the background of the course-symposium combination. The costs for a course with highly qualified speakers from several countries in the Middle-East and the European Union can not be afforded by a small group of participants.

The symposium was the First Annual MEAMA Symposium for continuing professional development for geriatric medicine for physicians from Lebanon and the participants of the MEAMA course. Several speakers from the Middle-East, the European Union and India presented lectures about pharmacotherapy in older patients, depression, pulmonary diseases, peptic ulcer disease, falls and walking problems and decisions regarding the end of life. A well chosen and well presented mixture of relevant clinical problems in older patients.

The main objectives of the course' session were: care for older patients: who should be referred to hospital and which facilities needs a hospital to meet the problems of older patients? In addition common problems in older patients were discussed.

The course opened with a state of the art lecture by prof. S.M. Karandikar from India. He presented data and discussed how in India the coordination of health care services and social services offered better and more comprehensive care for older people. Dr P. Overstall, form the United Kingdom, presented information about the interaction between the services available in the community and the support that can be expected from the hospital. The third speaker, prof. S.A. Duursma, from the Netherlands, discussed the organization of and services to be given by a hospital unit for geriatric medicine. The participants discussed in small groups questions regarding an old patient who had to be admitted to a hospital department for geriatric medicine. The questions were: What do you expect from the hospital as patient's general practitioner? What do you expect in the hospital as the patient herself? What do you expect in the hospital as the daughter who regularly cared her mother at home? What will be the approach of the nurses in the hospital to the patient and what is the position of the daughter? After these discussions dr P. Overstall gave an informative lecture about the issues in nursing homes and how to improve the long term care.

The second day started with lectures by the participants. Dr Sami Helou, from the United Arabia Emirates, focused on the role of the community health nurse, the community physician and the community physiotherapist. Attention was also given to the role of the hospital nurse, who is engaged with discharge planning for older patients. Dr Oscar Shucri described the three health care systems in Jordan, the governmental system, the private system and the United Nations Programme for Refuges. He also reported the start of the Jordan Society for Gerontology and Geriatrics, to stimulate the development of the services for health related problems in older people. Fatima Habib reported about Bahrain, she described the elderly care units of the government and private organizations. One of the Bahrain hospitals has a department for geriatric medicine as part of the department of internal medicine. Bahrain has a specialized hospital for psychogeriatric patients.

Prof. dr S.M. Karandikar followed these presentations with a draw how to develop community based services in developing countries. He stressed the focus on community services to be client centred and family centred. Special attention should be given to the access of information and communication and the cooperation amongst providers of health care services. Education and how to introduce programmes about teaching elderly care in an undergraduate medical school was covert by prof. F. Amin from Bahrain. He presented the well developed and nicely organized programme at the Bahrain university. The participants continued the programme with groups discussions about how older patients will experience the services at home and how to set up and manage a team for individual services at home. Enhancing independence through the use of assistive technology was well presented by dr M. Halimi from Lebanon.

The last day of the course opened with an overview by Dr A. Abyad, from Lebanon, regarding the needs for care by older patients, the important role of the care giver at home and the support of the family. Mrs Lorita, participant from Lebanon, presented a nice paper on exercises in older persons. Dr Nazih Kamal Eddine, participant from Lebanon discussed the interesting problems of visual impairment. In a combined presentation dr Mohammed Al Shaqi, participant from Saudi Arabia and dr Emad Esbaiti, participant from Kuwait, a good overview was given of quality indicators for scientific journals and for research projects. Dr A. Abyad continued this subject with a state of the art lecture regarding how to write a research protocol. Hormonal substitution in older women and men was the nicely presented lecture of prof. dr C. Netelenbos from the Netherlands. Ten years ago hormonal substitution in women was well accepted, however, the increasing number of publications with negative effects changed the ideas about oestrogen and progestogen substitution therapy. For men the pro's and contra's regarding testosterone substitution are still under discussion.

The final part of the programme was the evaluation by the participants. Like after the first session the participants gave well documented critical remarks. Suggestions were: to coach the participants during the preparation of the students' state of the art lectures; ending the day programme at 17.00 hour; the symposium day at the first day of the programme in stead of the third day in this session; more attention for the typical problems in the Middle-East region and more pharmacotherapy in the programme. Friendly was the judgement about the session: it was well organized in a good venue and well qualified speakers were attracted for the course. The last remark especially regards all speakers, they all accepted travelling economy class and did not receive any financial allowance for there presentations. In this way they all supported the goal of the MEAMA, to stimulate the development of health care services for older people in the Middle-East area.

The number of people attending the conference day was 100 physicians and paramedical staff. The number of participants in the workshop was 16 participants representing six countries. The evaluation by the participants was excellent, with correct critical and constructive remarks. The third session will take place in Sept 30th, -Oct 3, 2004 in Bahrain and the fourth session between 1st of April to 4th of April 2005 in Tripoli.

The Third Session

From 1 through 3 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 which 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 advise.

The main objective for the session was quality of life. It was introduced by prof. Miel Ribbe. Quality of life is an individual experience and it changes over time during 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 problem 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.

The Fourth Session

The fourth session took place in Tripoli, Lebanon between July 7th to 10th , 2005. The session was attended by ten participants and six of the participants finished their four sessions of training. The six graduating participants became part of the newly created network. The executive board planned to continue the course in the future. Dependant on the developments of the services for the health related problems for older people in the Middle East area the future programmes will be adapted to the specific needs. The idea is not only to teach and train people, but also to give support in the process of the development in the countries by adaptation of the programmes. A very beneficial side effect we want to reach is the development of a useful network for the participants of the course. For this reason we make all participants a 'member of the MEAMA' after the graduation and will offer them the opportunity for feed back, positions as speakers and participation in special activities of the following courses.