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Geriatric Health in India- Needs and Gaps
Dr. Bireshwar SinhaModerator: Dr. SK Rasania
Facilitator: Dr. Niraj Roy
Plan of presentation• Definition of elderly• Demography : geriatric population• Socio-economic profile of the elderly• Health issues: to be addressed– Social issues– Psycho-emotional aspects– Financial issues– Issues related to health care system– Medical problems
• Need for dedicated health programmes in the elderly and the major constraints
Plan of presentation• Major Govt. initiatives for elderly• Other schemes and benefits• Strategies & Recommendations: to fill the gaps related to
geriatric health• Conclusion• References
Definition of elderly
• According to WHO ,most developed countries have accepted the chronological age of 65 years and above as a definition of 'elderly' or older persons.
• According to UN : 60+ years will be referred as the older population or elderly.
• In India ,"senior citizen" means any person being a citizen of India, who has attained the age of sixty years or above*
* National Policy for Older Persons Year 1999 .Ministry of Social Justice and Empowerment.GOI.
Definition of elderly (cont..)
1. Age group 60-69 years -Young old or 'not so old' 2. Age group 70-79years -Old old3. Age group 80 years and over -'older old' or 'very old'
category
The medical study of the ageing process is called gerontology The study of diseases that afflict the elderly is geriatrics
National Policy for Older Persons Year 1999 .Ministry of Social Justice and Empowerment.GOI.
Demography: Geriatric population
• Advances in medicine have increased the life expectancy resulting in an increase in the geriatric population and their proportion will only continue to rise in the coming years.
• Globally, elderly constitute 11% of total population (United Nations
Population Division report, 2010)• In India : adults over 60 years constitute 8 percent of total.
(census 2011)
• In the years 2000-2050, the overall population in India will grow by 55%, whereas population growth of elderly people above 60 years - 326% and those in the age group of 80+ by 700%,- the fastest growing group. [World population aging: 1950-2050.United Nations: Population Division, Department of Economic and Social Affairs, United Nations 2002]
Demography: Geriatric population (contd..)
Situation Analysis of The Elderly in India, 2011.Central Statistics Office,Ministry of Statistics & Programme Implementation,Government of India
States with more than 8% elderly population ( SRS 2010)
Kera
la
11.8
%
Himac
hal
Prad
esh
10.1
%
Tam
il Na
du
10.0
%
Mah
aras
htra
9.2
%
Punj
ab
8.9%
Orissa
8.
7%
Andhr
a Pr
ades
h 8.
1%
India : elderly population constitute 8 percent of total.
1961 1981 1991 2001 2011 2021 2031 2041 20510
50
100
150
200
250
300
350
24.7143.17 56.68
77.196.3
133.2
178.59
236
300.96
Geriatric population (millions)
Geriatric population(millions)
(8.2%)
Proportion of Elderly aged 60 yrs and above in India
(20%)
Socio-economic profile of the elderly in India.
Elderly persons lives in rural area.
Women
Illiterate and dependent on physical labor
BPL; vulnerable situation and without sufficient food.
Unorganized sector: irregular income; no pension
75%
48%
66%
73%
90%
Source : Census 2001 & NSSO,2004
Socio- economic profile (contd..)• Feminization of the elderly population (currently 48.2% are
women, out of whom 55% are widows; and by 2016 they will constitute 51% of the elderly population.)
The sex ratio among elderly people was 1028 in 1951 but reached 972 in 2001.
Life expectancy (at birth) for women is 67.57 yrs as against 65.46 yrs for men. Life expectancy at age 60 was found to be about 18 years (16.7 for males, 18.9 for females)
• Increase in the number of the “older-old” (above 80 years)
Health issues of the elderly- Needs to be addressed
• Health problems in the elderly cannot be seen in isolation. • Wide gamut of social, psycho-emotional and financial
correlates determine the medical problems - Needs to be addressed.
Social issues• As industrialization progresses- children move out and take
up the vocation in other places- the problems of isolation and lack of physical support of the
old parents. Disintegration of joint family support systems.
• Societal modernization - elderly abuse leading to a host of psychological illnesses.
• Lack of social security and inadequate facilities for health care, rehabilitation, and recreation.
Psycho-Emotional Aspects • One of the Spouses may pass away• Friend circle gets restricted • Retirement - worsens isolation• Negligence by younger generation• the old persons find it difficult to keep themselves occupied.• This complex interplay:
– increase the risk of mental stress– also aggravate the impact of stress related diseases as IHD
and hypertension.
Financial Issues• Old Dependency Ratio: increasing over time.
Currently : every 8 working individuals have to take care of 1 elderly but by 2050 every 3 have to take care of 1 elderly.
Financial Issues (contd..)• 70% of the elderly women and 30% of the elderly men are
totally dependant on others economically.
• Inadequate financial savings or pension plans- 90% of the working individuals are not covered under any old-age income security plan.
• Pension and social security is restricted to those who worked in the public / organized sector of industry.
• Urbanization, migration – further economic insecurity for the elderly.
Issues Related to Health care System• The current health care system lacks adequate number of trained
medical, paramedical personnel in geriatric medicine - adversely affect the health care of the elderly.
• Mobile health services for the elderly and ambulance services are limited in the rural & peripheral areas making the health care facilities difficult to reach.
• Not a very effective health insurance system in our country.
• At present, most of the geriatric OPD services are available at tertiary care hospitals and are urban based. At the primary care level, the infrastructure is grossly deficient.
• Low awareness regarding the services available.
Medical Problems of the Elderly• The burden of morbidity in old age is enormous.• Non-communicable diseases (life style related and degenerative)
are extremely common in elderly irrespective of SE status.
• In population over 70 years, ≥50% suffer from one or more chronic conditions- hypertension, coronary heart disease, cancer & joint problems. [Reddy PH. The health of the aged in India. Health Transit Rev. 2006;6:233–44.]
• The treatment/ management of these chronic diseases is also expensive (e.g. cancer treatment, joint replacements, heart surgery).
• Decline in immunity as well as age-related physiologic changes leads to an increased burden of communicable diseases in the elderly. (e.g. TB)
• Disabilities are very frequent which affect the functionality in old age compromising the ability to pursue the activities of daily living.
• Among the elderly, 10% suffer from impaired physical mobility and 10% are hospitalized at any given time, both proportions rising with increasing age. [Reddy PH. The health of the aged in India. Health Transit Rev. 2006;6:233–44]
• Over 10% of India’s elderly suffers from depression and 40-50% requires psychiatric or psychological intervention at some point in their twilight years- due to ageing of the brain, socio-economic factors such as breakdown of the family support systems, and decrease in economic independence.
Health Problems Important for Both Genders• Ocular Diseases: Cataract, Glaucoma, Presbyopia• Reduced Muscular Strength and Coordination• Accidents and Injuries• Cardiovascular Diseases: IHD, Stroke and Hypertension• Chronic respiratory illness: COPD, Asthma, bronchitis• Mental problems: dementia, depression and mood disorders.• Complication of Diabetes• Cancers : Oral, gastric, lung and colorectal cancers• Nutritional Deficiencies• Dental Problems• Hearing Defects• Increased Susceptibility to Infections : RTI, UTI• Degenerative Neurological Diseases: Alzheimer’s disease and
Parkinsonism
Problems which mainly affect the Elderly Male• Benign Prostatic Hypertrophy (BPH)
• Prostatic Cancer
• Male Sexual Dysfunction : libido, erectile or ejaculation problems.
Problems mainly concerning Elderly Females• Menopausal Problems: Atrophic vaginitis, Dysparuenia, Pruritis
vulvae, hot flushes• Urinary Incontinence
• Cancers and Other Disease of Female Genital Tract : breast, uterine (endometrial), ovarian, cervical cancers, Prolapsed uterus.
• Osteoporosis: Osteoporosis occurs in both sexes (Type-II Osteoporosis) but the incidence as well as the impact is much higher among females especially after menopause (Type-I osteoporosis).
-Weight of <58 kg may indicate risk. -In fact, a rough guide is to calculate an index as {0.2 X (Body
weight in Kg - Age in years)}; if the result is less than 2, the same indicates increased risk.
23
COMMON MORBIDITIES IN ELDERLY IN INDIA
Cataract &Visual impairment- 88%
Arthritis & locomotion disorder-40%
CVD &HT – 18%
Neurological problems- 18%
Respiratory problems including Chronic bronchitis-
16%
GIT problems 9%
Psychiatric
problems- 9%ICMR report- survey 1984-85
Number of persons aged 60 years and above reporting a chronic disease (per 1,000 persons)
NSSO, 2004
Number of disabled per 100,000 elderly persons for different types of disability
NSSO, 2004
Need for Dedicated Health care programme for elderly
Decrease in physical ability / Economic inadequacy
Increase vulnerability to diseases
Chronic, disabling and multiple Health problems
Different approach and management
Degradation in family values
Rising Population
27
Major constraints for geriatric health care
Lack of specialized and
trained manpower
Geriatrics not yet a popular
specialty
No dedicated health care
infrastructure
Major Govt. initiatives
28
National Policy On Older Persons (NPOP) -1999
Recommendations by working group of planning commission -2006 for national programme
Maintenance and Welfare of Parents and Senior Citizens Act – 2007
Announcement of National programme for Health Care of Elderly during Budget speech (2008-09)
Approval of “National programme for Health Care of Elderly” by Ministry of Finance - June 2010
GOVT. STRATEGIES FOR ELDERLYMinistry of Social Justice & EmpowermentNational Policy on Older Persons (NPOP), 1999The Policy envisages State• support to ensure financial and food security, health care,
shelter and other needs of older persons,• equitable share in development, protection against abuse and
exploitation, and availability of
• services to improve the quality of their lives.
Maintenance and Welfare of Parents and Senior Citizens Act, 2007
• A senior citizen including parent who is unable to maintain himself from his own earning or property owned by him, then it is an obligation of the children or relative, to maintain his needs so that he / she may lead a normal life.
• If children or relatives, neglect or refuse- Tribunal may order them to make a monthly allowance which shall not exceed 10,000/month.
• Establishment of old age homes- one must accommodate minimum of 150 senior citizens.
• Separate beds for elderly in all Govt. hospitals.• Separate queue for the elderly in hospitals.• Treatment facilities for chronic degenerative diseases &
research
NATIONAL PROGRAMME FOR HEALTH CARE OF ELDERLY (NPHCE-2010)
NPHCE 2010
The M
ainte
nance
and W
elfar
e of
Pare
nts an
d Senior C
itize
ns Act,
2007
.National Policy on
Older Persons (1999)
31
Ministry of Health & Family Welfare National Programme for the Health Care of
Elderly (NPHCE)-2010Objectives• Easy access to promotional, preventive, curative and
rehabilitative services - through community based primary health care approach.
• Identify health problems - provide appropriate health interventions in the community & strong referral support.
• Capacity building- medical and paramedical professionals; the care-takers within the family for providing health care.
• Referral services through district hospitals, regional medical institutions
33
Core Strategies
Community level - domiciliary visits by trained health
care workers.
PHC/CHC level - equipment,
training, additional human resources
(CHC), IEC,
District Hospital -10 bedded wards, additional human
resources, 8 RMC - PG courses in Geriatric
Medicine, and training
IEC using mass media, folk media
and other communication
Strategies for NPHCE 2010
34
Supplementary Strategies for NPHCE
Promotion of public private
partnerships in Geriatric Health
Care.
Mainstreaming AYUSH and
convergence with programmes of
Ministry of Social Justice and
Empowerment in the field of geriatrics.
Reorienting medical education
to support geriatric issues.
35
Regional Geriatrics CentersSr No Regional Institutes States Linked
1 All India Institute of Medical Sciences, New Delhi
Delhi, Haryana, Uttarakhand, Punjab Himachal Pradesh, M.P.
2 Institute of Medical Sciences, Banaras Hindu University, Uttar Pradesh
Uttar Pradesh, Bihar, Jharkhand, West Bengal
3 Grant Medical College & JJ Hospital, Mumbai, Maharashtra,
Maharashtra, Goa, Northern Districts of Karnataka,Chattisgarh
4 Sher-e-Kashmir Institute of Medical Sciences, Srinagar, Jammu & Kashmir
Jammu & Kashmir
5 Govt. Medical College, Tiruvananthapuram, Kerala,
Kerala, Southern Districts of Karnataka & Tamil Nadu
6 Guwahati Medical College, Guwahati, Assam Assam & NE States
7 Madras Medical College, Chennai, TN. Tamil Nadu, Andhra Pradesh, Orissa
8 SN Medical College, Jodhpur, Rajasthan Rajasthan & Gujarat
Schemes under other Ministries
Ministry of Railways• Separate ticket counters for senior citizens at various
(Passenger Reservation System) PRS centres if the average demand per shift is more than 120 tickets
• Concession in rail fare for male-30% and female-50%
Ministry of Civil AviationAir India provides concession up to 50% - male (65 years and above) - female ( 63 years and above) in air fares.
Ministry of FinanceSome of the facilities for senior citizens of 65 years and above• Income tax exemption up to Rs. 2.40 lakh per annum.
•Deduction of Rs 20,000 (Section 80D) is allowed to an individual who pays medical insurance premium for his/ her parent or parents, who is a senior citizen.
•An individual is eligible for a deduction of the amount spent or Rs 60,000, whichever is less for medical treatment of a dependent senior citizen .• Extra 0.5% interest for the elderly on fixed deposit.
Privileges and Benefits
Annapurna Scheme Launched 2000-2001 By Ministry of Rural Development 10 kgs of food grains per month is provided free of cost to the
person >65 yrs but not getting pension under IGNOAPS 4,66,286 beneficiaries-in year 2011-2012Indira Gandhi National Old Age Pension Scheme (IGNOAPS) Launched in 2007 Beneficiaries: ≥ 60 years and belonging to BPL family Pension amount : Rs 400 (Rs 200 from central and 200 from
state govt.)
Strategies & Recommendations to fill the Gaps in Geriatric health
Geriatric care – as a part of primary health services• Care at rural areas should be strengthened.
• Training of Medical Officers, Peripheral health workers & volunteers
• Screening camps & mobile clinics for reaching out to the elderly population- particularly focussing on NCD’s and chronic diseases of the elderly.
• Involve NGO’s particularly in difficult to reach areas.• Conduct a comprehensive baseline morbidity survey- Ensure
good quality geriatric health care services according to felt needs in the area concerned.
Strategies & Recommendations
Primary health services (contd..)• “Community Geriatric Health Workers” may be trained to
provide home care to the disabled elderly population. (e.g. community based project in Cochin, known as “Urban Community Dementia Services”)
• Employment of a trained female medical officer to address the increasing health problems of elderly women.
• Strengthening the elderly in the process of self-help by means of physical, psychosocial, and vocational rehabilitation
• Capacity building of the community leaders
Strategies & Recommendations
Strengthen secondary level health facilities• Set up geriatric wards• Distinct OPD services providing screening services as well as
curative and rehabilitative services
At the tertiary care level• Set up a comprehensive multidisciplinary team- providing
specialist services.• Separate facility: Everything under one roof
Strategies & Recommendations
Prevention of health problems• Geriatric health problems must be addressed at all three
levels of prevention. • Health promotion measures (such as avoidance of alcohol
and smoking, physical activity, immunization for influenza, tetanus, and injury prevention);
• screening for noncommunicable diseases, such as diabetes, hypertensions, cancers, psychiatric disorders, nutritional anemia, and tuberculosis;
• rehabilitation: visual aids/mobility aids , physiotherapy
Strategies & Recommendations• Focus on vulnerable groups - Below Poverty Line or other
marginalized sections of the society. • Professional training in Geriatrics and Gerontology needs to
be promoted – gross lack of expertise in the field.
• Economic security: At the national level, mixture of pension schemes and social security schemes can help to the elderly.
Review BPL categorisation Improve present allocations in Social Pensions (NOAPS) Age Limit for Annapurna to be made 60 years and not 65 years. Strict implementation of “Maintenance and Welfare of
Parents and Senior Citizens Act, 2007”
Strategies & Recommendations
• Role of Media : Make the people aware about the problems and services available. and create of positive perception of the senior citizens in the society.
• Research in Geriatrics and Gerontology: common chronic and neuro-degenerative disorders like Alzheimer's disease, the process of ageing, pharmacokinetics and pharmacodynamics of drugs, health system research and research in alternative medicine.
Conclusion• The steady increase in life expectancy- as witnessed – actually a
triumph brought about by advances in medical knowledge.
• This current trend in demographics coupled with rapid urbanization and lifestyle changes have led to an emergence of a host of problems faced by the elderly in India.
• Old age can’t be cured but we can prevent the health problems in the elderly by increasing the awareness and timely interventions.
• Improving the quality-of-life of the elderly calls for a holistic approach and concerted efforts by the health and health-related sectors - the policy makers and health planners must be well prepared to face this challenge.
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“You do not heal old age. You protect it; promote it;
extend it”
Thank you
