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HEALTH PROBLEMS IN ELDERLY Pravin Pisudde

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Framework Definitions Introduction Demographic trends Physiological/Biological changes in aging Health and medical problems Mental health Determinants of active aging & graceful Health promotion in old age Social support in old age Intervention to modify risk factors Screening for disease in old age Health care provisions

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Definitions Aging Means predictable, progressive, universal deterioration in various physiological systems, mental and physical, behavioural and biomedical system. Gerontology Scientific discipline which deals with the phenomenon of ageing and all issues related to this process. Geriatrics/geriatric medicine Branch of medicine deals with diseases of the old age.

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Some terms Elderly- 60 years and above Old- 80 years and above (1973 expert committee on the planning and Organization of Geriatric Services) Young old Upto age of 75 yrs biological function in comparable to adult person Old old Upto age of 85 yrs biological function has declined significantly Very old over age of 85 yrs and requires the help og care givers

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Definitions Biologically: Aging begins at least as early as puberty and is continuous process throughout adult life. Socially: Members of society who are perceived as being old vary with the cultural setting and from generation to generation. Economically: Defined in terms of retirement from the work-force. Chronologically: As an indicator of expected residual life span.

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Introduction Inevitable process The Problem Vast reservoir of experience and maturity In old age, the need for economic, health and emotional wellbeing assume special significance. Traditionally, family provided these comfort for its ageing members(principle of reciprocity among generations). In contemporary world, these bases of family have weakened due to lessening of dependence on family assets for economic sustenance; prevalence of values of individualism and other such developments.

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Family is still considered the mainstay of social support for the elderly in India. India Govt. was never unmindful of the welfare of the elderly Constitution of India, under article 41, the state shall, within the limits of its economic capacity and development, make effective provision for securing the right to work, to education and to public assistance in case of unemployment, OLD AGE, sickness and disablement and in other cases of underserved want. This promise has been fulfilled to the extent that the later governments were committed to labour welfare and made several provision for social security. Provide economic security the worker in the unorganized sector that constitute almost 90% of the work force and also those who live BPL(Real challenge).

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Percentage share of person 60 years and above in the total population by sex, India 1901-2001(3)

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Why this increase? Change in birth rate 39.9(1951) to 23.5(2007) Change in death rate 27.4(1951) to 7.5(2007) Average life expectancy at the age of 60 years has increased from 12.4 years in 1950(1) to 17 years in the year 2002 and expected to be 20.8 in the year 2050(2) The number of elderly has also increased from 19.61 million in 1950 to 81.09 million in 2002 and expected to increase to 323.82 million by the year 2050.

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Comparative percentage distribution of population in India & Maharashtra

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Impact of demographic transition Impact on health The morbidities and disabilities has increased Greater stress on families To produce work force to deal with population Integrated approach of various disciplines Social outcomes of demographic transition Single elderlies Increase in female widowhood Income security Agricultural dependency Dependency Economic demographic transition Increase in elderly dependency ratio from 9.8(1951) to 11.3(1991)

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Physiological/Biological changes in aging Cardiovascular Total cell mass Fat storage upto 65-70 Central & peripheral neural network Myocardial cells Tissue compliance/dispensability Respiratory Bronchial cilliary function Dyspnoea Mucus accumulation Alveolar exchange surface Dead space

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Nervous system Cell and fibre loss Neuro-axonal degeneration Central conduction Catecholamine synthesis Catecholamine disposal Bone Mass and mineralization Osteoporosis Musculoskeletal disorders Tendon elasticity Joint flexibility

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Muscle strength Muscle mass Muscle diameter Speed of contraction Max. voluntary strength Control of movements Thermoregulation Tolerance to heat Sweating Vasodilation Skinfold thickness

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Excretory system Renal mass(70%) & perfusion(50%) decrease Digestive system Loss of teeth Salivary & gastric secretion Special senses Reaction speed Acuity

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Nutrition Micronutrients like protein, fat, carbohydrates and some minerals which are needed in big amount Calcium and phosphorus Vitamins and minerals are needed in less amount(Vit A, C, E, iron, selenium & iodine) Energy needs of aging individuals are decreased Increase in body weight Degenerative diseases Obesity, DM, HT, CAD, Stroke are more pronounced Anti oxidant has to be consumed in lots amount Decrease water content of body

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Psychological changes Personality change in mid life and old age Loose their intelligence and competence Difficulty in doing task that involved speed Psychological issues in old age Life satisfaction Loneliness Adjustment and well-being Cognitive changes

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Social changes in old age Bereavement/Widowhood Retirement Loss of social status Agism and generation Changes in family and living arrangements Older people lives alone

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Health and Medical problems Elderly people suffer from both communicable as well as degenerative Ds. The elderly are highly vulnerable to the infectiouos disease Immune functions and atrophic change in various organs. The psychological changes in the old age lead to impairment cough reflex, impairment circulation and tissue perfusion. Deficient collagen synthesis and poor wound healing. Poor nutrition and high intake of immune suppressive drugs. Joint pain and cough are the most common health problem among elderly.

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Other remote disease include blood pressure, heart disease, urinary problem & diabetes. A major killer among elderly was discovered to be respiratory disorder in the rural areas & disorder in the circulatory system in urban areas. Lack of adequate nutrition was one of the contributory factors for the ill health of the elderly. Diet taken by them was deficient in micro nutrients, like iron, vitamin A, riboflavin calcium etc, deficiency of Vitamin A leads to poor vision, dry skin, and weakened immunity.

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Change in the Status: Economic and Emotional Dependence As age advances, dependence on others be it difficult, children, grandchildren or relatives, increases and this is accompanied by compromise with dignity, independence and participation. This loss of status is more pronounced in middle class families, Lack of adjustment in multi-generation households has increased the vulnerability of the aged.

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Distribution of Old age death by system(60+) in rural India (Top 5 causes)(4) Disorders of the RS33.7% Disorders of the CVS21.6% Other clear symptoms18.1% Disorders of the CNS9.6% Fever6.6% Distribution of Old age death by disease (60+) in rural India (Top 5 causes)(4) Bronchitis-Asthma25.8% Heart Attack13.2% Paralysis8.4% Cancer7.1% TB of lungs5.8%

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Cause of Death(5)65-69 years70+ MaleFemaleMaleFemale Infectious and parasitic disease13.29.69.36.5 Neoplasms5.36.94.13.8 Endocrine system4.96.54.14.5 Disease of haematopoetic system1.51.81.41.9 Mental disorder0.20.1 Disease CNS1.92.31.9 Disease of the CVS38.336.336.9 Disease of the RS8.27.19.710.2 Disease of the GIT5.13.53.22.4 Disease of the GUT1.81.7 1.2 Ds of the skin & subcutaneous tissues 0.20.30.2 Ill defined conditions15.719.524.127.3 Injury and poisoning3.53.32.92.6 Other causes0.10.50.30.4 All causes100

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SystemInstitutionalizedNon Institutionalized MalesFemalesMalesfemales CVS16.3922.3126.0918.52 RS32.7833.134.7825.92 CNS14.7617.2715.215.56 Endocrine11.4710.7915.223.7 Genitor-urinary19.6710.7910.869.25 Nutritional24.5923.7426.0933.34 Locomotor26.2436.6936.9550 GIT24.634.5419.5738.88 Psychiatry18.0317.2721.7429.63

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Magnitude of health problem Percentage distribution of physically immobile elderly by Age, Gender and Residence RuralUrban AgeMaleFemaleTotalMaleFemaletotal 60-6422.7119.9321.319.118.0718.59 65-6920.8819.8820.3724.6619.8322.34 70+56.4160.1958.1356.2462.159.17

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(A)Rural AgeCough Piles pain JointsBP Heart disease Urinary problem diabetes 60-6435.63.3746.076.473.263.22.04 65-6933.82.9848.56.223.533.211.78 60+34.373.2546.966.423.743.531.73 70+33.6933.3546.656.524.33 1.41 (A)Urban AgeCough Piles pain JointsBP Heart disease Urinary problem diabetes 60-6424.163.6538.3718.536.443.25.65 65-6924.253.838.7017.656.883.15.62 60+24.953.5839.1616.65.935.234.76 70+24.523.5838.7917.486.344.025.27 Percentage distribution of Type of chronic Disease among the Indian Elderly by the age and Residence

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Mental health Over 10% of Indias elderly suffers from depression 40-50% of elderly requires psychiatric or psychological intervention. The principal mental disorders of old age are depression and dementia. Schizophrenia is another disorder found in the old age eg. Paranoid psychosis which began in later life; Delirium is usually the result of infections

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Another dimension of mental health that has been neglected so far has been the gender dimension. Alzheimers is a disease of longevity and women outlive men and are more likely to be victim of dementia. Delirium is also common in women as they are extremely sensitive to things like anaesthesia, drug toxicity and infections. Depression is a common condition among women: life time risk of depression in women is 25% as compared to 7-12% for men; 1/3 of the cases of depression in women go untreated.

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Percentage Distribution of Elderly According to Impairments AgeVisionHearingWalking 60-6428.97.811.9 65-6932.88.915.7 70-7435.61219.9 75-7945.319.829.7 80-8454.531.244.2 85-9066.733.343.3 90+6066.773.3

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Determinants of active aging and graceful aging Gender and culture Social services and social networking Health system Economic factors Income Work Social protection Factors in physical enviroment Personal factors

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Health promotion in old age Physical activity Regular and moderate physical activity Healthy eating Divide food intake in 3-4 meals To eat fruits, vegetables Food with fibres Avoid fatty foods Addictions Medications

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Social support in old age Social support Connecting with family members, friends, neighbours work colleagues & community groups Education and literacy Continuous training in the work place and life long learning opportunities in community Violence and abuse Confronting & reducing this violence through multi- sectoral and multidisciplinary approach is required

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Intervention to modify risk factors Population strategy Health protection Health promotion Health education Environmental facilitation Life style and behavioural change Nutritional intervention Specific protection High risk strategy

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Screening for disease in Old age Breast cancerMammography CataractClinical examination of eyes Cervical cancerPap smear Colo-rectal cancerStool occult blood Coronary heart diseaseRisk analysis, ECG, stress ECG DeafnessClinical evaluation and audiometry DementiaMental state examination(MMSE) Diabetes mellitusBlood glucose estimation Diabetic retinopathyFundoscopic examination and fluorescin angiography DyslipidemiaLipid profile GlaucomaIOP by tonometery HypertensionPeriodic BP recording Lung cancerChest Radiograph OsteoporosisBone densitometer after risk assessment Prostate cancerRectal examination, blood PSA level

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Provisions for economic security of older persons Civil services scheme of the central and the state government: In 1998, there were 7.3 million civil services pensioner in India in 1998, the average pension to average wage for civil services was 45.1%(IMF, 2001).. The main social security for the Civil Servant are non- contributary, unfounded DB pension which is indexed for both prices and wages, and has fairly generous commution provisions(up to 40% of the pension benefit can be taken in a lump-sum) and survivors benefits(called family pensions). The DB pension schemes provide a maximum replacement rate of the 50% of the average salary during the last 10 months of the service.

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Public sector enterprise: this include insurance companies, reserve Bank of India, public sector banks, electricity boards, oil companies such as ONGC, industrial entities etc. which have their own pension. Voluntary Tax advantaged saving schemes: These comprises of the Post Office Saving Bank schemes(constituting 10% of GDP), Public Provident Fund(PPF) and the group annuities of life Insurance companies(these are currently regulated by the IRDA).

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Government Schemes for poor elderly Targeted public distribution: A scheme of distribution of tier system to households below poverty line(BPL) and above poverty line food grains at high subsidized rate entitled to 10 kgs of food grains schemes cover about 600 lakh families. Annapurna: Under this scheme 10 kg food grains per person per month free of cost will be provided to indigent senior citizens. Initially this benefit was admissible to those persons who were eligible for old age pension but were not presently receiving the pension.

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Subsidized Insurance Schemes: The Govt. of India as well as several state governments have launched a variety of subsidized insurance scheme for the benefit of the weaker section of the people through the life insurance Corporation of India and General Insurance Corporation of India. One such scheme introduced is a pension scheme administered through GIC is Jeevan Arogya. In August 2000, many of these scheme were discontinued and replaced by a new scheme called Janshree. Under this scheme insurance benefit has been raised to Rs. 20000 for the natural death and Rs. 25000 for the partial disability.

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Government of India has also introduced another Insurance scheme for the benefit of agricultural worker called Khetihar Mazdoor Bima Yojna on 18 th 2001. Lump sum payment of Rs 20000 on natural death. Lump sum payment of Rs 50000 in case of death due to accindent. Lump sum payment of Rs 50000 in case of permanent disability or Rs. 25000 in case of partial disability due to accident. Rs. 100 to Rs. 1900 per month will be entitled for pension to the agricultural worker. On death after commencement of pension the family will be paid a lump sum amount ranging from Rs. 13000 to Rs. 250000 depending on the entry to the scheme. The insured person has to pay a premium of Rs.1 per or 365 per annum.

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Varistha Pension Bima Yojna: Its is a governments subsided pension scheme announced for senior citizen aged 55 years and above, in the union Budget 2003-2004. The scheme is being launched to provide an annual return of 9% per annum. Dada-dadi bond: Central government announced new Dada-dadi Bond from April 1, 2004, which will be a new saving instrument for senior citizens. Persons above the age of 60 will be eligible to subscribe to this bond, which will carry a return higher than the market rate of interest.the income from interest. The income from interest of this bond is exempted from income tax.

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Health care provision Health security is one of the basic pre-requisites for an enjoyable life in old age. First and foremost is the concern of healthy ageing. Availability of geriatric care and resources of the foot of medical bills. To cover the medical expences of the elderly there are some schemes run by government and some by public sector and private sector insurance schemes. Central or state government based system includes Central Government Health Schemes(CGHS) and Employees state government Scheme(ESIS) which is estimated to cover 20 to 30 million population The community based Universal Health Insurance Scheme was announced in union budget (New India Assurance Company Ltd. is implementing this scheme). The scheme run by the member based NGO cover about 5% of the population. It is estimated that 20 million employees may be covered by such reimbursement arrangements. Under the Insurance of GIC, LIC, UTI covers 3.4 million

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Policies of Life Insurance Companies Nav bharat: It is close ended scheme for senior Citizen between 50 -70 years of age. Disability benefits include partial disability and disability due to sickness. Sum assured is Rs 15000 to 20000. LIC has other policies includes Asha Deep and Jeevan Asha. Asha Deep, includes cancer, paralytic stroke, renal failure, and coronary artery disease. Jeeven Asha includes respiratory system, lympathic system etc in 2% of sum insured is also available. UTIs Senior Citizen Plan: This policy is akin to bhavishya Arogya Policy. The insured gets life long cover after a pre-determined retirement period. There is no pre-exiting exclusion and there is no provision for the return of the amount on withdrawl from the scheme. Jan Arogya: This policy was introduced primarily to meet the needs of poor people both urban and rural. The policy is essential a medi-claim policy with the reduced sum of Rs 5000 only.

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References Sharma SP, Xenos P; Ageing in India: Demographic Background and analysis based on Census material: Occasional paper No.2 1992;RGI, New Delhi. World Population Ageing: 1950-2050. Dept of Economic and Social Affairs Population Division, United Nations. New York:2002 www.censusindia.gov.in Data-Office of the registar General. 1997, reference book Active Ageing in New Millenium by Abha Choudhary. Health information of india(1996) directorate General health Services MoH&FW, Govt of India, Delhi Survey of Causes of death(rural) registrar General of India, 1991 Study by Dr VS Natrajan at Chennai HelpAge International

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