A STUDY ON THE HEALTH AND SOCIAL PROBLEMS OF A GERIATRIC POPULATION IN A RURAL
AREA OF KANYAKUMARI DISTRICT,
THE TAMILNADU Dr. M.G.R MEDICAL UNIVERSITY In partial fulfilment of the requirements for
the
M.D COMMUNITY MEDICINE
A STUDY ON THE HEALTH AND SOCIAL PROBLEMS OF A GERIATRIC POPULATION IN A RURAL
AREA OF KANYAKUMARI DISTRICT, TAMIL NADU
Dissertation
Submitted to
THE TAMILNADU Dr. M.G.R MEDICAL UNIVERSITY In partial fulfilment of the requirements for
the award of the degree of
M.D COMMUNITY MEDICINE
Branch XV
APRIL 2017
A STUDY ON THE HEALTH AND SOCIAL PROBLEMS OF A GERIATRIC POPULATION IN A RURAL
THE TAMILNADU Dr. M.G.R MEDICAL UNIVERSITY
This is to certify that this thesis titled “A STUDY ON THE HEALTH AND SOCIAL PROBLEMS OF A GERIATRIC POPULATION IN A RURAL AREA OF KANYAKUMARI DISTRICT, TAMIL NADU” is a bonafide work done by Dr PRIYA RAVINDRA PANICKER during the period 2014 -2017. This has been submitted in partial fulfilment of the award of M.D. Degree in Community Medicine Branch – XV by the Tamil Nadu Dr MGR Medical University, Chennai.
Dr KANIRAJ PETER, MD
[Co-guide]
Professor & Head
Department of Medicine Sree Mookambika Institute of Medical Sciences,
Kulasekharam, Kanyakumari, Tamil Nadu -629 161
Dr Rema V. Nair, MD DGO
Director,
Sree Mookambika Institute of Medical Sciences,
Kulasekharam Kanyakumari
Tamil Nadu -629 161 Dr K VIJAYAKUMAR, MD
[Guide]
Professor & Head
Department of Community Medicine Sree Mookambika Institute of
Medical Sciences,
Kulasekharam, Kanyakumari, Tamil Nadu -629 161
I, Dr Priya Ravindra Panicker hereby submit the dissertation titled “A STUDY ON THE HEALTH AND SOCIAL PROBLEMS OF A GERIATRIC POPULATION IN A RURAL AREA OF KANYAKUMARI DISTRICT, TAMIL NADU” done in partial fulfilment of the award of M.D. Degree in Community Medicine [Branch –XV] in Sree Mookambika Institute of Medical Sciences, Kulasekharam. This is an original work done by me under the guidance and supervision of Dr K Vijayakumar and Dr Kaniraj Peter.
Dr Priya Ravindra Panicker
ACKNOWLEDGEMENT
With overwhelming thanks and gratitude I submit this effort to God Almighty for being my constant source of support and strength throughout the course of the study.
I extend my sincere thanks to Dr Rema.V.Nair, Director and Dr C.K Velayuthan Nair, Chairman of Sree Mookambika Institute of Medical Sciences, Kulasekharam for providing the necessary facilities for the successful completion of this study.
I also express my sincere gratitude to the Principal, Dr Padmakumar and the Vice Principal, Dr Mookambika R.V and the Deputy Medical Superintendent Dr Vinu Gopinath for providing all the necessary facilities for completing the study.
I express my heartfelt gratitude to my guide and HOD Dr Vijayakumar K, for his valuable suggestions, critical views and constant
encouragement throughout the study.
I extend my sincere thanks to my co-guide Dr Kaniraj Peter, Professor and HOD of General Medicine for his valuable suggestions during the study.
I humbly thank my former professor and HOD, Dr Usha Devi for her constant support and encouragement for my study. I wish to express my thanks to Dr Jayasree C.S, Associate Professor, Dr Prashant Solanke,
and guidance throughout the study.
I wish to thank my former Assistant Professors, Dr Liaquat Roopesh and Dr Lena Charlette and Mr Kumar, former statistician for their advice and help in formulating the study protocol.
I also thank my Assistant Professor Dr Srilatha for her support and encouragement in enabling me to complete the study.
I also thank my senior post graduates Dr Vishnu G Ashok and Dr Krishnaprasad for their suggestions and advice at each stage of my
study.
I thank my fellow postgraduate colleagues and juniors for their support
and encouragement during my study. I express my sincere gratitude to Miss Jossy, Lecturer in statistics, and our department office staff Kumari B. Ambika and Melba J for all their technical and moral support.
I wish to express my heartfelt gratitude to all the elderly persons who agreed to participate in the study.
Sl. No Contents Page Number
1 INTRODUCTION 1- 5
2 OBJECTIVES 6
3 REVIEW OF LITERATURE 7 – 40
4 MATERIALS & METHODS 41 – 49
5 RESULTS 50 – 85
6 DISCUSSION 86- 93
7 SUMMARY 94- 96
8 CONCLUSION & RECOMMENDATION 97
9 BIBLIOGRAPHY -
10 ANNEXURES -
Introduction
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1. INTRODUCTION:
1.1 INTRODUCTION:
The proportion of elderly in the world population is increasing, thanks to improved life expectancy, resulting from better food habits, better sanitation, medical advances and greater prosperity, as well as falling birth rates. Such is the rate of the demographic transition that by 2050, the older generation (aged 60 years and above ) will outnumber those under 15 and even make up more than one-fifth of the global population. 1 These demographic changes are progressing fastest in the developing countries, especially in India which will soon become home to the world’s second-largest population of over -60s. Yet the experience of ageing is different across various geographic and national environments. Much success has been achieved in the control of public health problems leading to increased life expectancy. But this has been led down by the inadequacy of health and administrative systems around the world in ensuring equitable distribution of felt needs of the greying population.
The developed countries going through a demographic transition also have to face the epidemiological transition. However, the epidemiological transition has not accelerated as much as the demographic transition in India. 2 The elderly face a greater amount of ailments when compared to other age groups, especially in developing countries. They are susceptible to the life
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style diseases and disabilities as well as the emerging and re-emerging infectious diseases. The mixed profile of communicable and non communicable diseases among the elderly population in developing countries places a huge burden on the existing health care delivery system. The exorbitant costs of health care services often result in impoverishment of the family rather than improvement of the health of the elderly.3 The medical problems faced by the elderly need to be understood from a socio economic perspective in order to truly improve health care service delivery and utilization.
The problems arising out of the phenomenon of population ageing pose mounting pressures on various socio -economic fronts including pension outlays, health care expenditures, as well as medical and psychological problems. The developed and industrialised nations remain far ahead of developing countries in handling population ageing. This work needs to be done across the various domains of income security, health status of the elderly, capability and providing an enabling environment for the elderly. The inequality in health, income and education that exists in the population is further exaggerated in the elderly population especially among the elderly of low and medium income countries.1
Japan can be taken as a role model in this field, since it adopted a comprehensive welfare policy in 1960s for handling population ageing.
Universal healthcare, low unemployment rates, progressive taxation, income
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redistribution plans and an universal social pension are just some of the measures that have enabled Japan to have not just the oldest but also the healthiest population in the world.1
Rapid urbanisation and societal modernisation, along with increasing prevalence of dual career families has led to a breakdown in traditional family values. This in turn has led to fragmentation of the family support framework, economic instability, social isolation and elderly abuse -both physical and mental abuse. These socio-economic issues are further aggravated by the lack of social security and adequate health care, rehabilitative and recreational facilities. In developing countries like India, the situation is made worse by the fact that pension and social security is largely restricted to those in the public sector or in the organised sector of industry. 4 Low levels of awareness about the various pensions which can be used as a tool against destitution also put the elderly at a disadvantage.1
After the era of the Millennium Development Goals in 2015, the new Sustainable Development Goals that are set forward envisions sustainable development that is inclusive and universal, ‘leaving no one behind’. The goals of ‘No poverty’, ‘Zero Hunger’, ‘Good Health’, ‘Gender Equality’,
‘Decent Work’ and ‘Reduced Inequalities’ are aimed at people of all ages, especially among the elderly who are more vulnerable to these inequalities.1 These targets are hard to achieve, unless there is international commitment and strong political will to do so. There is a need for a global framework for
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the international community to develop an ageing enabling policy or programme for the elderly. Even more so, there is a stronger need to make sure such policies are implemented true to its spirit, ensuring that no elderly person is left behind.
For developing such a framework, it is essential to have a clear understanding of the existing health situation and variations across rural – urban and gender distributions of the elderly. Census data reveal a higher proportion of elderly live in rural areas (53.7%) when compared to urban areas (46.3%) in Tamil Nadu.5 This shows that the need for elderly care is more in rural areas. Hence there is an acute need for expanding provision of geriatric care in the rural areas, beyond the tertiary level located in urban areas. This expansion should also factor in the socio economic determinants of the health problems of the elderly and their health seeking behaviour.
1.2 RATIONALE:
The health problems and the content of health care services are different for the geriatric population. In the context of the increasing proportion of geriatric population in India, it is essential to have an understanding of the pattern of health problems and related factors to provide appropriate services.1 The morbidity profile and perception of health problems among the rural elderly, the variety of available health services in the rural areas, and the factors affecting the utilization of health care services
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are all very different from the urban population. There is a need for disaggregated data on the health status of elderly in the rural areas of Kanyakumari, Tamil Nadu, since the available review is lacking in details of morbidity and the related socio economic factors of rural elderly. It is possible to get more precise information on the health problems and associated factors by well planned research only. Hence this study will evaluate the health problems of the elderly and its relationship with the key socioeconomic factors in a rural area of Kanyakumari district of Tamil Nadu.
Objectives
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2. OBJECTIVES:
The objectives of this study are:
1) To identify the health and social problems, as perceived, by the elderly people living in a rural area of Kanyakumari district, Tamil Nadu.
2) To study the association between key socio-economic factors and the perceived health problems of the elderly in the study area.
Review of Literature
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3. REVIEW OF LITERATURE:
3.1 APPROACHES TO AGEING IN INDIA:
In traditional Indian culture, the human life span is divided into 100 years. Manu, the ancient law giver, in his ‘Dharmashasthra’ had divided human lifespan into 4 ‘ashrams’ or life stages- the first was
‘Brahmacharya’, the celibate life of a student where a boy completes his education ; the second stage was ‘Grihastha’, where he becomes a man and assumes the life of a householder, husband and father. After discharging his duties and responsibilities to his family and society, he reaches the
‘Vanaprastha’ stage where he forsakes material things and seeks spiritual growth. When he is ready to renounce his world completely, he enters the final stage of ‘Sanyasa’ or asceticism.6 Though these stages are described traditionally for the roles of men, their female counterparts are expected to follow them as well. Looking after and caring for one’s parents are considered to be a basic ‘Dharma’ or duty of a person. Respect and obedience to one’s elders was always an integral part of India’s culture and family system.
ACROSS THE WORLD:
Traditionally in China and Japan, the elderly are revered for their wisdom and they occupy higher social status and prestige. Ageing is not just
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a biological process; it’s a cultural one too with the elderly taking up more visible and respected roles in the society. In Chinese culture, Confucius in
‘The Book of Filial Piety’ has identified taking care of elders in their old age as a central ethical obligation of an individual.7 A older person’s 60th or 70th birthdays are usually events of celebration marking the passage into old age.
Greek and Roman cultures also attach great value to their elders and the wisdom gained through their experience.
In Greek culture, old age is honoured and celebrated. Romans attached great value to the wisdom attained by the elderly and the old were expected to act with dignity so as to set an example to the younger generation. Native Americans accept old age and imminent death as a fact of life and without any fear. In contemporary Western societies, the elderly are seen as non productive and dependent people who are “out of step with the times”.
Becoming old is seen as losing value or even becoming dependent on others.
Youth is given so much importance that people take exorbitant and extreme measures to keep themselves from ageing.8
In short, while the ancient Indian and Eastern literature promotes an all-accepting view of ageing, the western world tends to regard ageing from a scientific viewpoint and attempts to clear the questions of why, how, where, when of ageing. Understanding these concepts would help in delaying ageing and reducing the morbidity of ageing.
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3.2 THE BIOLOGY OF AGEING
All living beings age, with certain exceptions, have a finite life span.
Ageing process encompasses changes over multiple physiological systems.
There must be a plausible molecular level change that would explain the finite lifespan of various tissues. Various theories which attempt to explain ageing and mortality exist in abundance but they have been largely developed from studies in cell or animal models. The various biological theories that attempt to explain ageing include:
1. Evolutionary Senescence Theory of Ageing:
It is the most widely accepted overall theory of ageing. The theory mainly focuses on the failure of natural selection to affect late-life traits. Thus genes with harmful late-life effects may be continuously passed from one generation to another. Hence this theory is called the mutation accumulation theory.9
2. Cross-linking or glycation hypothesis of ageing:
This is based on the observation that as we age, the proteins, DNA, and other structural molecules of our body develop inappropriate cross-links to one another. These links decrease the elasticity of protein and inhibits the activity of proteases resulting in defective proteins. Cross-linking of the skin protein collagen (partly responsible for wrinkling and other age-related dermal changes), cross-linking of lens proteins (causing age-related cataract) and cross-linking of proteins in the walls of arteries or the filtering systems of
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the kidney responsible for a part of atherosclerosis and age-related decline in kidney function are examples supporting the role of Cross-linking theory in Ageing.9
3. Oxidative damage/ Free Radical Hypothesis of ageing:
This suggests that the free radicals that escape the action of antioxidants cause oxidative damage that accumulates over time resulting in damage to DNA, proteins, mitochondria and ultimately causing ageing and diseases like cancer, CAD and Alzheimer’s disease.9
4. Wear and tear theory:
The Wear and Tear theory, put forward by Dr. August Weismann, a German biologist, in 1882 notes that cells and tissues have vital parts that wear out from repeated use, killing them and resulting in ageing.10
5. Rate of Living theory of ageing:
This theory proposes that energy consumption limits longevity. In other words, an organism’s metabolic rate determines its lifespan. This idea was consistent with the discovery that reactive oxygen species (free radicals), a by-product of normal metabolism, can damage cells and contribute to aging.9
6. Replicative Senescence hypothesis of ageing:
This is based on the fact that human cells have limited reproducing capacity. That is, they can undergo up to 40- 60 divisions (Hayflick Limit) but
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then can divide no more. This limit is because of the shortening of the chromosomal telomeres due to cell division or oxidative damage. When telomeres become short, they can break, occasionally prompting inappropriate responses from DNA repair mechanisms. This can cause chromosomal damage or cell death, both of which may contribute to age-related diseases and conditions.9
7. Neuroendocrine hypothesis of ageing:
This theory is based on the fact that the Hypothalamo Pituitary Axis which regulates the body’s hormone production becomes less functional, and this can lead to high blood pressure, impaired sugar metabolism, and sleep abnormalities.9
None of these theories have been definitely able to explain ageing phenotypes in humans on their own. They have to be operationalized into feasible assessments and research in humans as longitudinal studies, in order to test the hypothesis that some of these processes are correlated with physiologic ageing over and beyond chronological age.
3.3 EFFECTS OF AGEING ON HEALTH
Geriatrics requires an insight into the multi dimensional effects of disease manifestations, consequences and response to treatment. In younger adults, diseases tend to have more clear cut signs and symptoms with well defined risk factors; however, the same disease in older people may have a
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less distinct pathophysiology and are often due to failed homeostatic mechanisms of the body.11
Systemic consequences of aging usually affect four main domains:
1. Body Composition: Increased Waist Circumference, steady decline in Lean Body Mass, loss of muscle mass and quality and loss of bone strength
2. Balance between Energy Availability and Energy Demand: Sick older people often use up all available energy to perform basic activities of daily living;
causing an imbalance between energy demand and supply- resulting in chronic fatigue and activity restriction.
3. Signalling Networks that maintain Homeostasis: Decreasing sex hormone levels like oestrogen, testosterone, etc, as well as increasing inflammatory mediators and antioxidants will cause a dysregulation of the signalling network that maintains the body’s homeostatic networks.
4. Neurodegeneration: Age related brain atrophy after the age of 60 years results in associated decline in cognitive and motor function- varying from mild cognitive impairment without disability to severe impairment and impaired coordination. Age related changes occurring in the autonomic system affect the cardiovascular and splanchnic system.
All these systemic changes develop in parallel and some affect each other through several feedback loops. Higher fat mass, leading to metabolic syndrome, is often associated with low testosterone levels, higher sex hormone binding globulin levels and increased levels of pro inflammatory
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markers. These cause an altered signalling mechanism leading to neurodegeneration. Insulin resistance is also associated with impaired cognitive function.
The ageing process results in an increased susceptibility to diseases, comorbidity and polypharmacy, low resistance to stress, high rates of disability, confounding diagnosis and loss of personal autonomy. Many chronic diseases increase in prevalence with age; with a single person usually having multiple chronic diseases- that may be due to increased susceptibility to co-occurring problems. Functional problems that pose difficulties or require help in performing basic activities of daily living (ADLs) increase with age and are more common in women than in men. Although the age- specific prevalence of disability is decreasing, this decline is very small when compared to the overwhelming effect of population aging. Chronic diseases and disability lead to increased use of health care facilities and this in turn leads to increased health care expenditure. However, latest innovations in medical technology and expensive medicines exert a greater influence on health care costs than population aging itself. 11
3.4 DEMOGRAPHY OF AGEING:
3.4.1 GLOBAL SCENARIO:
Population ageing is the phenomenon where older people form a proportionately larger bulk of the total population. It is now taking place in nearly all the countries of the world, bringing about a drastic change in
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economies and societies. Population ageing results from decreasing mortality, increasing life expectancy and, most importantly, declining fertility. Globally, the number of older persons (aged 60 years or over) is expected to more than double, from 901 million people in 2015 to more than 2 billion in 2050. That is, older people will make up for more than one fifth of the total population in the world. Globally, the proportion of older persons above 80 years (the
“oldest old”) within the older population was 14 percent in 2013 and is projected to rise to 19 percent in 2050. Older persons are projected to exceed the total number of children in the world for the first time in 2047.12
Strong regional disparities exist with Sub Saharan Africa being the
“youngest region” with 6% of its population over 60 years while Europe is the
“oldest region” with 22% elderly. Japan has a “hyper- ageing” population with more than one third of the population over 60 years. China has the largest number of elderly in its population – 209 million people.12
3.4.2 INDIAN SCENARIO:
Population ageing is happening fastest in the developing countries.
About two thirds of the world’s older persons currently live in developing countries. By 2050, nearly 8 in 10 of the world’s older population will live in the less developed regions.13According to United Nations Department of Economic and Social Affairs (UNDESA) 2015 data , India had more than 116.6 million elderly in 2015. They have projected that the proportion
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of Indians aged 60 and above will rise from 8.9% in 2015 to 19.1% in 2050.14 This amounts to a remarkable figure in absolute terms.
Census of India 2011 data reveals the total population of aged above 60 years amounts to 103.8 million people . Among the main drivers of ageing in India , Kerala has the highest proportion of elderly in the population (12.6%), while Goa (11.2 %), Tamil Nadu (10.4% ), Punjab (10.3% ), Himachal Pradesh (10.2%) follow close behind with all these values scoring above the national average of 8.6% of elderly in total population in 2011.15 This is when the proportion of elderly in India was only 7.4% in 2001. Old age Dependency Ratio (ODR) is rising due to higher Life Expectancy at birth - from 131 in 2001 to 142 in 2011. Kerala with an ODR of 196, Goa (168), Himachal Pradesh & Punjab (161) and Tamil Nadu (158) are the top states with an ODR above the national average.15 3.5 HEALTH PROBLEMS OF ELDERLY:
3.5.1 MORBIDITY TRENDS AMONG ELDERLY:
Morbidity trends in Developed Countries:
Developed countries in North America, Western Pacific and European regions have undergone an epidemiological transition in that communicable and infectious diseases are being replaced by Non Communicable Diseases (NCDs) as the main contributors of morbidity among the adult population. In the United States of America, 80 per cent of all the people more than 65 years of age have at least one chronic condition and 50 percent have at least two of
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them. Diabetes Mellitus affects one out of every five persons more than 65 years of age. Approximately 10 percent of elderly people above 65 years and 47 per cent of elderly people above 85 years are estimated to suffer from Alzheimer’s Disease (AD).16
Akushevich et al in a study to evaluate patterns in the incidence of aging related diseases among over 34,000 elderly found a maximum incidence for Cardio Vascular Diseases (CVD), followed by Neuro Degenerative Diseases (NDD), mostly Alzheimers Disease and Dementia. But the high numbers of Alzheimers may be because the data was obtained from institutionalized individuals. The incidence of Cancer and NDD recorded an increase in incidence with age across both sexes. However since secondary data was used, the date of chronic disease onset cannot be defined with the same precision but the age adjusted incidence rates found here are in agreement with contemporary studies on similar populations.17
Morbidity Trends in Developing Countries:
In a study done among 345 elderly patients in a tertiary level hospital in Nigeria by Nwani and Isah, the overall prevalence of multi morbidity – described as two or more chronic diseases, was 49 per cent among the elderly.
Hypertension was identified as the main chronic disease in 51 per cent of the cases, whereas Diabetes accounted for 42.9 per cent, Cerebro Vascular Accidents (CVA) accounted for 26 per cent cases, Hypertension causing Congestive Cardiac Failure accounting for 12.5 per cent and neoplasms for
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8.1 per cent. The comparatively high prevalence of multi morbidity may be because the study was done in a tertiary care hospital.18
Woo E K et al assessed morbidity and related factors among 2700 elderly subjects in South Korea and found a prevalence of 78% of atleast one morbidity. Women had a higher mean number of morbidities than men. The most prevalent morbidity was Hypertension (37.5%), followed by arthritis (15.6%), diabetes (14.9%), osteoporosis (14.1%) and gastric ulcer (13.1%).
More than half of the elderly had at least one Cardio vascular morbidity such as Myocardial infarction, Hypertension, Stroke, angina or congestive cardiac failure. Diseases of the musculoskeletal system were significantly higher in women than men.19
Khanam et al studied the pattern and prevalence of multi morbidity among the people above 60 years in a rural area of Bangladesh using a multi disciplinary medical team and described an overall prevalence of multi morbidity among the study population as 53.8%, and it was significantly higher among women, elderly who were single, illiterates, and persons in the non-poorest quintile of socioeconomic strata. The most common morbidity was Arthritis, accounting for 57.5 per cent and Hypertension accounting for 38.7 per cent.20
Morbidity Patterns across India:
The elderly population of India experience the double burden of a host of non-communicable diseases (NCD) as well as the spectrum of
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communicable diseases. It is projected that the NCD related disability will increase and contribute to a higher proportion of overall national disability, along with the greying of the population.21 In a study conducted in rural Pondicherry in 2006, the main complaints experienced by the elderly were given as decreased visual acuity due to cataracts and refractive errors (57 per cent), followed by joint stiffness and joint pain (43.4 per cent), dental and chewing complaints (42 per cent), hearing impairment (15.4 per cent) , hypertension (14 per cent), skin disease (12 per cent ), chronic cough (12 per cent), heart disease (9 per cent), diabetes (8.1 per cent) , asthma (6 per cent) and urinary complaints (5.6 per cent).22 Strokes or neurovascular events account for 30 per cent of newly diagnosed seizures in elderly patients.23
Patterns of health conditions of elderly from rural and urban areas of Shimla revealed that 84 per cent of the elderly were suffering from at least one medical problem. Musculoskeletal problems were found to be the most common morbidity at 55 per cent followed by Hypertension at 40.5 per cent.
Females had more number of morbidities than males. A significantly higher proportion of women suffered from musculoskeletal problems, hypertension and diabetes while chronic obstructive pulmonary disease was observed more in men. Hypertension was more prevalent in the urban elderly than in their rural counterparts. Widowed persons had more mean number of morbidities than married older persons. The mean number of morbidities was higher in
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urban elderly than with rural elderly and this increased with age. Two thirds of the elderly were seeking treatment for their problems.24
A morbidity profile of elderly (elite elderly versus slum elderly) in urban areas of Agra by Srivastava et al in 2009 - 10 revealed musculoskeletal disorders (37.2 per cent), mainly arthritis, as the major cause of morbidity.25 This was followed by GIT disorders (36.4 per cent), low vision (35.8 per cent) and Cardiovascular disorders (25.4 per cent). Musculoskeletal problems, visual problems and dental problems were more among slum dwellers of Agra than the elite areas while a statistically significant difference was seen in Cardiovascular morbidity of the elite (32.65 per cent) versus the slum dwellers (18.43 per cent). Hypertension was found to be the main cause for cardiovascular diseases with a higher percentage in elite elderly (27.35 per cent) than slum elderly (17.96 per cent). Poor oral hygiene was thought to be responsible for higher dental caries in slums (23.92 per cent) when compared to wealthy elderly (5.71 per cent). They also found a positive correlation of age with the number of health problems.25
3.5.2 DISABILITY TRENDS AMONG ELDERLY:
Elderly are more prone to functional disability by way of prolonged duration of natural course of diseases, multiple chronic ailments, and impaired homeostasis and physiological functioning due to the process of ageing.
Disability increases the burden on the family by way of economic costs, need for hospitalization or nursing care and premature death.
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Disability trends across the world:
In the United States, Arthritis affecting nearly fifty five per cent of the elderly population is the main cause of disability. However analyses have shown declining trends in prevalence of chronic disability. The proportion of 65 to 74 year olds that are not chronically disabled increased by 2.6% and the proportion of 75 to 84 year olds who are not disabled increased by 5.4% over a thirteen year period in 1995. Decline in disability prevalence was reported for Germany, France and Japan but with an increase in reported prevalence of chronic conditions. Australia has recorded an increase in disability prevalence in people aged 75 years and older.26
Disability trends in India:
Census 2011 data reveals the most common cause of disability among the elderly as locomotor and visual disability.27 In a study to assess the prevalence of physical disability among elderly in a rural block of Tamil Nadu using Barthel Index, women were found to be more affected with physical disability than men. Overall prevalence of disability was 20.6 per cent- climbing stairs was the most difficult domain. Statistically significant difference was found in Barthel scores across the age groups 60-69, 70-79, and 80 years and above.28
Functional disability, as assessed by Instrumental Activities of daily Living (IADL) scores in the Report on the status of the Elderly in select states of India, 2011 reveal that difficulty in carrying out the IADL tasks is
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significantly higher among elderly men than elderly women for all but the following three domains – laundry, housekeeping and food preparation. With advancing age, the IADL activities needing assistance increases. Women and rural elderly were at a disadvantage compared to men and urban elderly, respectively. Functionality also follows a strong socio economic gradient in India, revealing that the wealthy elderly have access to better health care and facilities than the impoverished elderly.29
Reducing severe disability from disease and health conditions is one key to bringing down health and social costs. Health and economic disability can be alleviated by environmental characteristics that will ultimately determine whether an older person can remain independent despite physical disability or limitations.
3.5.3 MORTALITY TRENDS AMONG ELDERLY:
The statistics on elderly mortality by the Government of India attributes one third of mortality to cardiovascular disorders. Respiratory disorders account for 10% while infections including tuberculosis account for another 10%. Cancer related mortality comes to around 6% and accidents, poisoning and violence come to 4% with similar rates for nutritional, metabolic, gastrointestinal and genitourinary infections.30 Max et al in their study showed that perceived loneliness was an important contributor to the effect of depression on mortality. Thus, in the older elderly, depression was associated with mortality only when loneliness was present.31
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While Cardiovascular disease was found to be the most common cause of death among the older population, several chronic conditions like chronic bronchitis, anaemia, high blood pressure, chest pain, skin conditions, rheumatism, kidney problems, edentulism, etc are also commonly reported.
Several re-emerging diseases are also known to cause mortality depending on the place of residence, socioeconomic status.32
3.5.4 MENTAL HEATH:
Conditions like depression or dementia are at times not addressed as health needs and are dealt with informally within the family or community.33 Dementia or depression are not considered the purview of health physicians and adequate mental health services are not available . This results in a “dependency anxiety” among the elderly- they felt the need to curtail their dependence upon the family and were worried about telling them their health problems. Depression is also associated with perceived loneliness among the elderly.33
In a community based study to find out risk factors associated with depression among the elderly population, Sengupta and Benjamin in Ludhiana found prevalence of depression among elderly to be 8.9% and significantly higher prevalence of depression among urban elderly, females, older elderly, those living alone, functionally impaired and cognitively impaired elderly. Here Geriatric Depression Scale (GDS-15) with a set of 15 Yes or No questions was used as an effective tool for screening of depression in elderly.34
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For treatment of late- life depression, pharmacotherapy alone is also not sufficient as proven by a cluster randomised trial done in eastern China by Chen and Conwell from 2011–’13 among elderly diagnosed with major depression. They found that patients assigned to Depression Care Management intervention (DCM)- which included standard treatment guidelines by physicians, care manager training for nurses and counselling with psychiatrists, had a better outcome, higher chances of remission, better quality of life, greater satisfaction, lesser perceived stigma about depression treatment and more family support than the usual regime of antidepressant medication.35
3.5.5 MALNUTRITION:
A community based cross sectional study by Vedantam et al in 2010 for assessing the nutritional status of elderly using the Mini Nutritional Assessment (MNA) questionnaire found low MNA scores in more than 60 per cent of the elderly. Older age, decreased food intake and consuming fewer meals were found to be significantly associated with lower MNA scores.36
Sedentary lifestyles, decreased physical activity due to disability, altered dietary habits, tobacco and alcohol consumption, decreased social participation are all contributing factors to emerging issues like overweight and obesity among the elderly, especially in urban communities. Rajkamal et al in 2015 in their study on urban elderly in Puducherry revealed a prevalence of 41.4 per cent for overweight and 4.5 per cent for obesity. Occupation,
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education, alcohol consumption and smoking were found to be significantly associated with this phenomenon.37
Still, under nutrition outweighs over nutrition in terms of the scope of the problem and the resulting preventable morbidity.
3.5.6 SELF REPORTED HEALTH:
Rahman and Barsky used Self Reported Health (SRH) as a multifaceted indicator to measure the health status of the elderly population in a community in Bangladesh. In their study, they found older elderly were more likely to report poor self rated health than their younger counterparts and women report significantly worse self reported health than their male peers at each age group.38
In India, Singh and Arokiasamy reported similar findings among female elderly in their study based on the 60th NSS data. Poor Self Rated Health is found to be more common among older women (26 per cent) than older men (22 per cent). The proportion of elderly with poor self reported health increased with age and was the highest in the oldest age group, ie, more than 80 years for both sexes. Poor self reported health was also found to be the highest in those who were widowed for both sexes, with the proportion of women being higher than men. Educational achievements and income showed a negative association with poor self reported health for both sexes.39
Odds of poor self reported health were more among the oldest old women than among the oldest old men. Older men who were partially
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economically dependent were more likely than their economically independent counterparts to report poor health. Similarly, fully economically dependent elderly of both sexes were more likely to record poor self reported health than economically independent women.39
3.6 SOCIAL CHALLENGES FACED BY ELDERLY:
3.6.1 DEPENDENCY:
According to the 60th National Sample Survey (January – June 2004), the old age dependency ratio was found to be higher in rural areas (125) than in urban areas (103). Among elderly males, 313 per 1000 males in rural areas were fully dependent when compared to 297 per 1000 males in urban areas.
However among the elderly females, 757 per 1000 females in urban areas were dependent when compared to 706 per 1000 in rural areas.40 Old age Dependency Ratio was found to be the highest in Kerala - 196, the state accounting for the highest percentage of elderly with Tamil Nadu at a lower but still relevant 158, both of which are higher than the national level of 142 in 2011 census.15
3.6.2 FEMINIZATION OF ELDERLY POPULATION:
Women tend to live longer than men and tend to outnumber older men almost everywhere but this has the downside that they often experience poor health and increasing disability. In 2013, globally, there were 85 men per 100 women in the age group 60 years or over and 61 men per 100 women in the age group 80 years or over.13 While elderly women tend to have stronger
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social networks than elderly men, lack of access to paid employment (hence lack of savings), less decision making power in the family and community and for some, vulnerability to gender based violence throughout their life course are all causes for a disadvantaged old age for women. In some societies, widowed or single women (either through divorce or never having married) are considered to be of lesser social relevance than others. In India, there was a definite feminization of the elderly population previously but there is a declining of sex ratio now; according to the 2001 census, the gender ratio among the Indian elderly is 1028 females for 1000 males in 1951, finally dropping to 972 females per 1000 males in 2001.41 However in past two decades, the trends have reversed and the sex ratio is now 1033 females per 1000 males, the highest since 1951. Unmet health needs are more pronounced among the 33.1% of the elderly who were reported to have lost their spouses, of whom a larger relative proportion is female.41
3.6.3 HEALTH SEEKING BEHAVIOUR:
A study among the elderly of Maharashtra and Uttar Pradesh in 2010 found that the older elderly (70 years and older) were significantly less likely to seek treatment when compared to the 60-69 category, while Muslims were between 62% and 49% respectively more likely to seek treatment, when compared to Hindus. This study found that elderly in SC/ST categories were 54% less likely to seek treatment for existing conditions in Maharashtra when compared to other castes. Finally, high school graduates were four times as
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likely in Maharashtra and twice as likely in UP to seek treatment when compared to illiterates.2
Sharma et al in a study among the elderly in Himachal Pradesh found that nearly 65.8 per cent of the elderly sought treatment for their health problems. There was considerable use of over the counter drugs, around 12.5%. Among the reasons cited for not seeking treatment, most common reason cited was the morbidities were part of old age. Elderly living in urban areas were significantly more likely to access health services than the rural elderly, the reason being that they live closer to these services. Gender, literacy, income and marital status were not found to be significantly related to health seeking behaviour.24
3.6.4 AWARENESS OF WELFARE & SOCIAL SECURITY MEASURES:
Even when health services are available, uptake is low because of lack of health promotion and community outreach. In a study in the rural community of Meerut, awareness among elderly about available geriatric welfare services were about 53% and only 4% reported using them.42 In a clinic based study in Karnataka in 2009; it was found that only 35.7% were aware of geriatric welfare services and only 14.6% had used them.43
Social security pension, like old age pension, widow pension, agricultural pension, etc, even though meagre in amount, create a sense of financial security for the elderly. But the coverage of these schemes has to be improved to make an indelible impact on the impoverished elderly.44
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3.6.5 PERCEIVED BARRIERS TO HEALTHCARE ACCESS:
Most elderly require long term care, which includes home nursing, residential care, community care and assisted living and long stay in hospitals.
But these arrangements are usually very expensive and the economic burden placed on the care-giving family is very huge. A key barrier to accessing health care is that most elderly require home-based care following illness based confinement along an age gradient. Sample survey data suggests that as many as 64 per 1000 population in rural areas and 67/ 1000 in urban areas are confined to home. For very senior citizens (age above 80), as many as one in five are confined.41 Sharma et al described the perceived distance to the health care facilities as a key reason not to access healthcare among the elderly of Himachal Pradesh.24
3.6.6 AREA OF RESIDENCE:
According to the Census 2011, 71% of the elderly population lives in rural areas while 29% reside in urban areas.27 According to NSSO data, 28.3
% of aged in rural areas and 36.8% in urban areas suffer from one disease or another and of the total 72% of the unemployed elderly, 69% is rural.45The greater reported morbidity from urban areas is misleading since higher proportions of elderly reside in rural areas as compared to urban areas but may be due to the fact that more geriatric centres and tertiary care facilities are in the urban areas.46
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3.6.7 LIVING ARRANGEMENTS:
Urbanisation and migration in search of better job opportunities and living conditions have resulted in the elderly generation being left behind at home. Property-less elders have a higher probability of living alone, being in old age homes and being looked after by relatives other than their children when widowed.47 Arrangements of “living apart but together” are seen to be increasing, where joint family does not live in the same residence but strong social support is immediately available, especially in times of health crises.
But “discourses of neglect” may occur, where- in their daily needs are invisible to those who support them during crises.48 A study in rural Kashmir also revealed a significantly lower rate of depression among the elderly living in a joint family system than elderly living without any family support.49
Globally, 40 percent of older persons aged 60 years or over live independently, that is to say, alone or with their spouse only. Independent living is far more common in the developed countries, where about 75% of older persons live independently, compared with only 25% in developing countries and 12.5% in the least developed countries. 13
3.6.8 SOCIAL ISOLATION:
Persons involved in well rooted, positive relationships have better adaptability and a greater sense of independence and well being than those without any important personal relationships. Loss of important relationships
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will result in feelings of emptiness, loneliness and depression. Social isolation is a major risk factor for functional difficulties among the elderly.31
3.6.9 ELDERLY ABUSE:
A study by Help Age India in 2013 among elderly over 60 years across 24 cities in India revealed 23 per cent Elder abuse at the national level, whereas at the state level Madurai reported the highest level of Elder abuse (63%) followed by Kanpur where 60% of elderly reported experiencing abuse. Amritsar has the lowest experience of Elder abuse (0.71%).
Trivandrum recorded a percentage of 22.14 of elderly abuse. Among those who faced abuse at a national level, only 30% made an attempt to report the incident. 63.2 % of elderly in Tamil Nadu and 75.8% in Kerala did not report the abuse. Elderly abuse was mostly defined as disrespect (79%), verbal abuse (76%) and neglect 69% at the national level. Verbal abuse and economic exploitation were the forms of abuse predominant in Tamil Nadu. 50
3.7 SOCIOECONOMIC FACTORS AFFECTING ELDERLY HEALTH 3.7.1 Socioeconomic Status:
According to the American Psychological Association, various studies have shown that Socioeconomic status (SES) plays a key role in determining the quality of life of the elderly population. Decline in health and death of a spouse common among older adults are factors that can affect the financial status of the elderly. Older individuals with lower SES are more likely to have lower Health Related Quality of Life (HRQOL), smaller social networks and
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lower quality of social relations. Poverty is considered a risk factor for anxiety and decline in mental health among the elderly. Older persons with less than a high school education are at a greater risk for depression. Lower academic achievements have been consistently associated with higher incidence of Alzheimers disease later in life. Good social networks have been shown to act as a buffer to stress but older persons living in poor neighbourhoods are more likely to have underdeveloped and poorly integrated social networks. 51
While studying the effects of Socioeconomic status on mortality among community dwelling elderly across four American communities, Bassuk et al found that higher socioeconomic status- whether measured by household income, occupational prestige or education , was associated with lower mortality. For men, all the three socioeconomic indicators, ie, income, prestige and education were associated with mortality across all four cohorts.
In the case of women however, an association was found only for income. 52 Eighty three per cent of the elderly population, studied by Jerliu et al in a population based study in Kosovo, had at least one chronic disease of which the majority were cardiovascular diseases and forty five per cent of them had at least two chronic diseases. Factors associated with mutimorbidity were female sex, older age, self perceived poverty and the inability to access medical care.53
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Monteverde et al in their population based study across seven cities of Latin America and Caribbean found that the probability of being disabled among the elderly persons was 43 per cent higher for those from poorer backgrounds than those from good ones. Early life poor socioeconomic conditions - described as poor socioeconomic conditions in childhood, ie, before 15 years of age, were found likely to increase the probability of suffering from multiple co morbidities than from a single disease during the older ages. This seems to be an extension of the ‘Barker’s Hypothesis’
mechanisms. 54
Chen C X et al in their study to establish a correlation between socio economic status and Health Self Management among elderly in China found that Health Self Management behaviour was better among the urban elderly, those with college education and a higher personal monthly income. This statistically significant difference may be due to the huge economic disparity existing between rural and urban areas in China. 55
3.7.2 Educational Status:
White et al in 1998 found that education was a significant predictor of healthy aging in regression models that combined elderly men and women. As educational attainment increased, so did the likelihood of healthy aging.
Among men, perceived income adequacy and life satisfaction with finances are more important in predicting healthy aging than education. However, for women, education is the more influential predictor of healthy aging. Income
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may mediate the relationship between education and healthy ageing among men, but not women.56
3.7.3 Employment :
66% of elderly men and 28% of elderly women in rural areas were working while in urban areas, only 46% of elderly men and 11 % of women were working, as per Census 2011 data.27
3.7.4 Psycho social Factors:
Availability of company, active interactions with family, social participation and positive attitudes towards life were identified as the psychosocial factors having significant impact on the health of rural elderly by B R Dahiya et al in a house to house survey in Haryana.57
3.8 INTERNATIONAL EFFORTS FOR PROMOTING ELDERLY WELL-BEING
The spotlight was focussed on well being of older persons when the United Nations first adopted the UN Principles for Older Persons in1991, with the aim of making sure older people across different backgrounds were able to live with dignity, security and freedom from exploitation or abuse. They should also receive adequate health care, family and community support, legal, social and formal services as required. October 1st was declared as the
“International day of Older Persons” from 1991 to focus the spotlight on this issue every year.58
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In order to increase awareness about gerontological issues, the challenges of population ageing, and the role of research in influencing policy decisions on national and international political agendas, the United Nations declared 1999 as the “International Year for Older Persons” with the theme being – towards a society for all ages.58 On October 1st the same year, WHO came forward with the campaign of
‘Active Ageing’ in order to ‘remain active and healthy in later life with the right lifestyle, family support and policies that reduce social inequality and poverty.’
The celebrations and walks held in 97 countries across the globe over a 24 hr period ended with a Global Embrace on October 2nd that served as a launch for the Global Movement for Active Ageing by WHO.59
The European Union Partnership came out with a ‘Healthy Ageing’
concept in 2006. ‘Healthy Ageing’ is about optimising opportunities for better health, so that older persons can take an active part in society and enjoy an independent and high quality of life. This holistic concept is based on key determinants like access to services, proper nutrition, education, environment and accessibility, physical activity, social inclusion, new technologies, employment and volunteering and long term care.60
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3.9 NATIONAL EFFORTS FOR PROMOTING ELDERLY WELL BEING
3.9.1 SCHEME OF INTEGRATED PROGRAMME FOR OLDER PERSONS (IPOP):
This scheme was introduced in India since 1992 and has been revised in April 2004. It provides financial aid to State Governments, Panchayati Raj Institutions (PRI), Urban local bodies and Non Governmental Organizations (NGOs) for the administration of Old Age Homes, Day Care Centres, mobile Medicare Units, Physiotherapy units, Geriatric training centres and counselling centres for the elderly.61
3.9.2 INDIRA GANDHI NATIONAL OLD AGE PENSION SCHEME (IGNOAPS):
IGNOAPS was started by the Indian Government in 1995 to provide pension of Rs 200/ month to elderly above 60 years and Rs 500/ month to elderly above 80 years, in families below poverty line (BPL). It was planned to extend this to all families in all states in a phased manner.61
3.9.3 NATIONAL POLICY ON OLDER PERSONS (NPOP):
In pursuance of the UN General Assembly Resolution 47/5 to observe 1999 as the International Year of Older persons and the assurances to older persons maintained in the Indian constitution (Article 41), the Government of India announced the NPOP in 1999. The Policy sought to assure the older citizens that their well being and welfare was a major concern of the State. It
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promises help for their financial security, healthcare, housing and protection from exploitation so that they could live a purposeful and peaceful life with dignity.62
The central role of family is acknowledged in the Policy- Integration between generations is required for a strong social support system for the elderly. NPOP also pushed for widening the coverage of old age pension for all elderly, irrespective of APL or BPL. Rate of monthly pension should be revised periodically in step with financial inflation. The settlement of pension and retirement benefits should be prompt and delays should be made accountable. Considerate taxation policies and rebate for medical treatment were the other benefits suggested in the Policy.
A National Council for Older Persons was formed for implementation of this policy with a detailed review every 3 years. Specific strategies were spelled out with focus on financial security, Health care and Nutrition, Education, Welfare and Protection of life and property of the elderly.62
3.9.4 NATIONAL PROGRAM FOR THE HEALTH CARE OF THE ELDERY (NPHCE):
National Program for Health care of the Elderly is an articulation of the Indian Government’s Policy on Older Persons. It aims at identifying health problems of elderly and providing effective interventions in the community, providing easy access to community based Primary health Care and proper referral services, and equipping medical and paramedical staff for geriatric
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care, all in convergence with National Rural Health Mission, AYUSH and the concerned ministries of the Government.63
It identifies the need for Reorienting Medical Education to help medical students identify and address geriatric issues. Other recommendations include domiciliary visits by geriatrics trained Health Workers, Geriatric facilities in primary Health Centres, Community Health Centres and District Hospitals with adequate beds, wards and equipment, and encouraging more Public Private Partnerships (PPP).
NPHCE addresses geriatric health care problems and their management through Institutional heath care system; but it throws less light on Home based care for elderly persons. Information Education Communication (IEC) activities that promote healthy ageing with more focus on Yoga or other relaxation techniques for prevention of NCDs as well as reducing disability should have been given more importance.
Programs for elderly should not be limited to an audience of elderly alone, it should include their families and immediate support systems too, so that they are aware of these services and can avail of these services without the monetary burden. Increased PPP especially in case of rehabilitation of the disabled and bedridden elderly and provision of equipments like wheelchairs, walkers, hearing aids, hospital beds should be supported.63
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3.10 NEWER INITIATIVES FOR THE CARE OF ELDERLY:
According to Sir James Sterling Rose, “You cannot heal old age; you protect it, you promote it and extend it.” Any measure of improving the health and functional capacity of the older population starts with the adoption of a healthy lifestyle in youth, or at least by forty to fifty years of age.
IMPROVED ASSISTED LIVING FACILITIES:
Assisted living facilities are a class above the average Old Age Homes in India, providing more private housing facilities, 24 x 7 medical and nursing care for the elderly who require some help with day to day living. Such facilities are few and far between in India, existing only in metropolitan cities like Gurgaon and Pune (Epoch Eldercare) and Chennai (Ashirwad Care Home). But the prohibitive costs of such facilities keep them out of reach of the middle or lower class elderly. Another disadvantage is that the elderly are detached away from their usual place of residence and their families, and this may produce psychosocial adjustment issues and a sense of abandonment in them. Low cost assisted living facilities near their native place which allows for visits from their family will be a better option.64
COUPLING ELDERLY DAY CARE WITH ANGANWADIS:
In Kerala state, a novel idea of combining elderly day care with Anganwadi Centers (AWC) has been proposed recently. The elderly can be dropped off at the AWC by their working children in the morning and picked up again in the evening after work. The physically able elderly can engage the
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preschool children attending the AWC, impart moral values to them and lend a helping hand to the AW workers as well. The presence of the cheerful, young children will also improve the psychological well being of the elderly.65
ELDERLY FRIENDLY PANCHAYATHS:
The State Government of Kerala has proposed a new set of initiatives to create Elderly Friendly Panchayaths through special geriatric clinics at PHCs, Ramps with bar handles at Government offices to provide a ‘Barrier free environment’. Wheelchairs, lifts & provision of drinking water, clear signboards or proper announcing systems at Government offices are some of the other ‘elderly friendly’ measures proposed. Creating Hunger Free Panchayaths by ensuring that the elderly do not go without food, at their homes or in the hospitals.65 The ongoing Annapoorna scheme in Tamil Nadu also aims at a hunger free Elderly population by providing 10 kg rice per month to the vulnerable elderly.66 But this measure is not appropriate for those who are unable to cook on their own- provision of cooked meals would be better suited for these cases.
MOBILE MEDICAL UNITS:
The Mobile Medical Unit Services provided by NGOs like HelpAge India should be strengthened to increase their coverage into the rural areas as well and to provide new services like Disability aids, Yoga, Psychological therapy.66 These measures will help in psycho social adjustment of the rural elderly.
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Ensuring universal pension coverage to guarantee social security to the elderly and improving access to good quality healthcare that is appropriate and affordable across their lifetime is a crucial need of the older citizens.
Providing the older men and women decent work opportunities and accessible public transport are some of the measures which will help advance their independence and ensure psychological wellbeing.
Materials & Methods
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4. MATERIALS AND METHODS:
1.1 STUDY DESIGN
This was a community based cross sectional study where the perceived health and social problems of the elderly were compared at the same time, without any interventions or manipulation of the social environment.
1.2 STUDY SUBJECTS
Elderly people, more than 60 years of age, currently residing in rural area of Thiruvattar block
1.3 INCLUSION CRITERIA
Elderly people more than 60 years of age who were permanent residents of Thiruvattar block and who gave consent to participate in the study.
Permanent residents are defined as the people who have been residing in the area for at least six months.
1.4 EXCLUSION CRITERIA
Debilitated or seriously ill elderly who could not give a coherent reply to questions.
1.5 STUDY SETTING
Thiruvattar block area of Kanyakumari district. Kanyakumari is the southernmost district of Tamil Nadu, with the second largest population
