Geriatric services--need of the hour.YV Meisheri
Dept of Medicine, Seth GS Medical College, Parel, Bombay, Maharashtra.
Keywords: Aged, Aging, psychology,Developing Countries, Health Services Needs and Demand, Health Services for the Aged, Human, India, Life Expectancy,
The human body is in a state of change as the years go by. This brings on the unforeseen discomforts engendered by the reality of aging, the need for psychological acceptance, the complex needs of the aged, a life of dependency and proximity to dying. Fear of death looms large over the elderly.
A 28 year gain in Indian life expectancy since Independence is no doubt a social achievement. There are approximately 385 million people above 60 years of age (60+) in the world today and India has 50 million of them. By the turn of the century, India will witness an unprecedented rise of more than 50% in this group, i.e. the 60+ will be 76 million in number, and one in seven in the world will be from India.
The number of aged in developing countries presently equals the rest of the world. By the year 2000 AD the aged are expected to increase by 100 million in the developing countries as compared to 36 million in the developed world, according to UN data. Concerted efforts have led to a 24% increase in life expectancy at age 85 since 1960 in the developed countries. The number of centenarians has increased form 15,000 (1980) to 25,000 (1986) and is expected to surpass 1,00,000 by the year 2000 AD. Women outlive men by 6.8 years on an average. Heart diseases, cancers and stroke account for 73% of deaths in the elderly. Twenty percent of doctor visits, 30% of hospital days and 50% of bed-ridden days are credited to elderly patients.
The definition of 'aging' or 'aged' depends upon the view from different perspectives. In USA, under Section 202 of the National Housing Act of 1959, the age at which the benefits of pension, social insurance legislation etc. commence was the 62nd year. The UN takes the 60th year as the dividing line between 'old age' and 'middle and younger' age groups. According to the Amercia Geriatric Association the geriatric patient needs to be aged 75 or above with multiple complex, interacting, psychosocial and physical pathology, both acute and chronic in India, the 60th year is conventionally taken as the point of turning old since few survived to that age until a few decades ago. Generally ¾th of the Indian geriatric population is 'young-old' between 60-70 years) and the rest 'old-old' (over 70 ears), the grandparents and the great-grandparents respectively.
An early and methodical approach to understanding the aging process by the developed countries has led to a fast rise in the 85+ group. The fastest aging countries include the US, Sweden, Japan, Germany and New Zealand. Sweden is the "oldest" country i.e. with the greatest population of the 4 elderly (22.6%). In most Asian countries, elderly 7 people are viewed with a low priority except in China, which alone approaches the rectangular population distribution approximating that of the western world, thanks to her family planning drive which has utilized the services of retired women volunteers.
Pioneer geriatricians in Scotland (1950-1960) drew attention to the fact that the elderly silently suffered the progression of disease. This led to an abrupt functional decline, which was wrongly attributed to aging. Since the first dedicated geriatric day-care hospital in Oxford in 1958, 350 more have been opened & managed by general practitioners. The Rutherglen Project introduced the concept of health screening in the elderly almost 35 years ago. Subsequent studies uncovered many medical and social needs and suggested the beneficial role of the health visitor. Williamson's multicentre survey of 2000 consecutive geriatric in-patients in the UK revealed that an adverse drug reaction contributed to hospitalisation in over 10% and nearly a third did not recover fully. Thus, emerged the 'LIFE SAVE' microcomputer based system including 1100 drugs and a number of possible interactions between them.
Surveys of community dwelling elderly have found more than 5 disabilities per person and institutional studies twice this figure. The geriatric team 12 can have positive effects on a targeted subgroup of frail elderly in-patients not only in acute care but also while planning effective after care decreasing the 'blocked bed'. Based on biological and psychological function an index of Activity of Daily Living (ADL) applicable to the elderly and chronically ill has been standardized on observations on 1001 individuals in various institutional and community settings. Over the last 30 yeas, this index has been a useful tool in the study of prognosis, effects of treatment, as a survey instrument, as an objective guide in clinical practice, as a teaching device and a measure of function. No wonder it has led to the evolution of the cardinal principle of geriatric medicine: “Impaired elderly respond dramatically to treatment”.
This global issue figured in the 1979 WHO 7th General Programme of work …….. ‘In planning for national health development all regions will collaborate with countries in formulating programmes for community-based, family focused health care of aging citizens, with special attention to their social integration in the community.’ The historic World Assembly on Aging was convened by the UN in 1982, where the Special Program for Research on Aging (SPRA) was structured on the objectives and recommendations of the International Plan on Action on Aging. The WHO's mid-term programme for the period 1990-1995 has set a series of important approaches for reducing functional dependency of the elderly. The "World Geriatric Day" is celebrated on October 1st each year.
From time immemorial, old age has been debated upon, sometimes glorified, often scorned. How the aged are looked after reflects the attitudes of a particular community, which in turn reflects the beliefs and value systems of that community. The trend differs in each country depending on the social infrastructure. 'May you live a long life' is a common phrase used as a blessing in Indian culture. The aged are still a source of pride and joy for the Indian family. This precious asset of our country with its rich experience and wisdom continues to contribute enormously towards progress of the nation. In urban-rural India, a large population of the aged is physically and economically active. A study of the profile of the aged in India revealed that the state of contentment in the aged varies form 22.1 to 52%. But, in a health questionnaire administered to 1910 rural elderly, none scored 'nil', exposing thereby, a degree of ill being in every subject. The ratio of urban v/s rural 60+ was 3.0 (568.8 m/1 92.2 m) in 1986 but by 2001 will be 2.0 (660.1 m/362.0m) showing a relative increase in the rural aged.
Hospital studies and epidemiological studies have provided a prevalence rate of mental morbidity of 9/1000 in the geriatric population. Thus, there are 4 million severely mentally ill, elderly persons in the country. Affective disorders form 21- 39.9% of the mental illness, depression (13 - 22.2%) being the most common, followed by late paraphrenia and organic syndromes. Henderson has commented on the lack of epidemiological data on dementia, especially senile dementia Aizheimer's type (SDAT) from developing countries. However, SDAT is not infrequent in India, where dementia contributes to 20% of mental morbidity in hospitalised elderly. The high frequency of multi-infarct dementia is in consonance with reports from other Asian countries like Japan. Detailed morphological, ultrastructural and immunochemical features of neuronal pathology in a case of Alzheimer's disease were recently reported by Shankar et al. Described as the disease of our century, SDAT is likely to become a major geriatric problem in the coming years, next only to depression.
The traditional Indian joint family has gradually fissured with socio-cultural and economic transformation and the support enjoyed hitherto by the aged (from family and community) is on the decline. Three fourths of our aged still live with their relatives. The totally isolated elderly person is still rare.
The extent of family jointness and social integration were studied in Madurai in 3 different studies (ICIVIR task force study 1981-84 and 1984-88 and Geropsychiatric morbidity in Madurai, 1987) These studies revealed that 'family composition' per se did not differ in those with illness (physical or psychiatric) and those not staying with a family did not necessarily ensure healthy integration and living alone was not a barrier against social integration. Nevertheless the lack of family and social integration was significantly more in the psychiatric group living alone. The rate of complete suicide in the 50+ was around 12/100,000. All three Durkheimian types of suicides occur in the elderly - a sense of isolation leads to "egoistic suicide", social deregulation and normlessness predispose to "anomic suicide", and some seniors eliminate themselves to ‘unburden’ their family (the ''altruistic type").
The problems in the aged do not stop short with mental illness. Physical disability, too, takes its toll. Ophthalmological problems (mainly cataract) and degenerative joint disease top the list followed by neurological, cardiovascular, dermatological and urinary problems. Malignant disease accounted for approximately 0.5% of the mobidity in a rural elderly population. However, no longitudinal studies dwelling on the influence, of factors at younger age on the quality of life in late years, has been reported for the Indian population.
Are we then ready to meet the challenge of aging so ably conquered by the developed countries over the last 30 years? Care of the elderly in India began in 1973 and with the efforts of physicians devoted to the cause of the elderly, the Geriatric Society of India (GSI) was born in 1979. The family catering to the problems of the elderly has grown and now includes agencies like the Age Care India, Help Age India, The Gerontological Society of India, The Elderly Journal, The Association of Retired Pensioners and the Senior Citizens. Eight national level conferences and one international conference have been held in India over the last six years.
Though India participated in the World Health Assembly in 1982, there is a general reluctance in caring for the elderly and the concept is yet not popular amongst professionals, family members, community, the popular media or the government. It is understandable that it has no emotional appeal, no immediate rewards and the problems are chronic. But can we ignore medical illnesses, social insecurity, widows without grown-up children, social apathy towards the old and retired, the intergeneration conflict, stagnation of society's productive youth and socioeconomic growth, lone and low income elderly, those who need long term care, the elder abuse and exploitation?
We are faced then with the prime duty to care and provide for the age "a task where we cannot risk to fail". Though we have begun we need to gear up and pace fast.
A laudable effort is the Indian Kaliandiri experience (1987) of health education in preventive gerontology. This study was conducted in 1910 rural subjects aged 60+ in a PHC and its sub-centres near Madurai. The follow up at 3 years covered 97% of the probands. The study demonstrated that total health care of the rural aged was possible within the existing infrastructure with few additional inputs. An immediate implementation of this health care model on a countrywide basis could generate "reliable data" defining the problems of the elderly. Presented with this accurate data, the policy makers will surely be more receptive. A single national policy with no Central and State level disparity is sure to emerge then. Legal provision for this already exists in the Indian Constitution where welfare of the elderly is included in Articles 38, 39 (e & f) and 41. Section 2013 of the Hindu Adoption and Maintenance Act, 1956 and Section 125 of the Code of Criminal Procedure, 1973 require each person with sufficient means to maintain his or her aged or infirm parents.
Our health care system relies on the patient approaching the health provider and this is precisely what the aged do not do. Adding a more active case finding facet (mobile health team, domiciliary nursing) would address the problem. Encouraging determinants of good quality "old age" identified, by many cross sectional studies include a positive self-concept, a favourable perception of interrelationship with family members, a belief in Karma philosophy and after life and a flexible outlook in habits. Such unique Indian qualities will make our task easier but if tackled with medical men alone will touch only the tip of the iceberg. It requires integration throughout medicine and community (family, care-takers, voluntary organizations), rather every health care and speciality physician must have adequate training and knowledge in the principles of geriatrics, which is essentially a service discipline. Kudos to the foster care programmes already started in Madras.
Though the life expectancy has increased from less than 20 years in ancient Greece to more than 70 years in the United States of America today, the maximum life span of our species (110 years) is yet unaltered. Research in about 30 laboratory groups is underway to identify "rogue" genes so that they could be controlled and directed to behave. This may slow down the aging process and increase the normal life upto 130 years. Until then, "We cannot heal the old age, but let us protect it, promote it and prolong it" - Sir J Ross.