The Elderly - Part I

This book was published in the year 2002

THE ELDERLY
By Mohan Pai, Omashram Trust, Bangalore

Preface

Omashram is very happy to put together this document about the elderly in India. We have tried to cover as many aspects about the old age as possible and by no means the document is all comprehensive. The material contained here has been gleaned from various sources - books, articles, documents, etc. The “old age” population is growing at an accelerated rate all over the world and India is no exception. In 1991, the population of 60 years and above was 56 million (6.8%). In 1999, it has crossed 70 million and is expected to reach 177 million by 2025. The growth rate of elderly population (37.3%) is twice that of general population (16.8%). One out of seven elderly in the world is an Indian. Average expectation of life from 60 years in 1991 is expected to reach 70 years by the year 2025. Dramatic demographic changes pose multiple challenges. The country is not geared to manage such a large older population. The rapid rise in elderly population is not met with expansion of health care and social security measures. There is a very realistic fear that the quality of life of the population might be compromised. The age-old joint family system in India is steadily breaking down. About 30% of elders live separately. Loneliness, dependency, poverty, lack of protection for their lives and property are some of the main problems faced by the elders. Hardly about 11 % of the elderly in India are covered by the various pension and retirement schemes and the large majority (89%) remains uncovered without any social security protection. Government support and efforts have been tardy and half hearted, lacking both resources and political will. The main purpose of this document is to create and spread awareness about the plight of the elderly and to help the elderly work towards ‘active ageing’ and improving quality of life.

Mohan Pai
Managing Trustee
Omashram Trust, Bangalore
October 15, 2002
Vijayadashami

1. The Age of Ageing

Graying population is one of the most ‘significant characteristics’ of the 20th century and the first quarter of the 21st century known as the “age of ageing”. Along with the world population, Indian Elderly are also “ageing in old age”. Ageing is a phase of life and a biological process. Every organism born, ages with time and decays. Ageing is a life-long activity - from birth we grow older through infancy to childhood to adolescence to adulthood and onwards. The most widely used measure of ageing is chronological age, since it is the simplest and most comparable. But chronological age in itself is inadequate to explain the condition of people in later life. The term ‘old’ is often associated with alteration in individual’s biological, psychological and health capabilities and changes in social roles. People aged sixty years and over are also considered as persons in the “third age”.

DEMOGRAPHY AND AGEING
Demographers interpret ageing as an outcome of changes in fertility and mortality rather than a natural process in itself. The term “demographic transition” refers to a process where by society moves from a situation of high fertility and mortality to one of lower rates. This transition is characterised first by decline in infant and childhood mortality as infectious and parasitic diseases are controlled., Reduction in fertility implies a decline in the proportion of the young in the population. Reduction in mortality means longer life span due to control of epidemics and life threatening diseases. Whole population begin to age when fertility rates decline and mortality rates at all ages improve. “Population Ageing” involves a shift from high mortality! high fertility to low mortality/ low fertility. India is now undergoing such a demographic transition. The population of elderly (60 +) in India has risen from 5.6% in 1960 to 6.3% in 1980 and is expected to be 7.7% by 2001 and 9.5% in 2020. India will soon qualify as a “Graying Nation” as per U.N. Definition. Life expectancy at birth was as low as 32 years in 1947 and by 1990 it had risen to around 60 years. The crude birth rate that was 42 per 1, 000 population has declined to 30 in 1990. It is estimated that crude birth rate now may be. around 25 and crude death rate less than 9 per thousand.

Kerala State is a good example which perhaps is, passing through the last stage of demographic’ transition. As per the latest estimates (lIPS and ORG Macro, 2001), life expectancy at birth is around 74. The below replacement level fertility and high life expectancy have resulted, inevitably, in having the highest proportion of aged population in the country. As per estimates, Kerala has 11 % of population above 60 years. This has resulted in the fast growth of small sized nuclear families during the last two decades.
Over time, the older population itself will grow older. There were 8.2% people above 75 years in 1996. There are now 76 million people in 60+ age group. One out of seven older persons in the world is from India.
In India, age 60 is used as a cut off point to identify people as old. However. this is an arbitrary way of labeling a person as old. Ageing is a highly complex process. Not every one ages with same speed and in the same manner. Physical, social, economic, psychological, educational and cultural factors determine the ageing process. Old people are a heterogeneous lot, much more so in India. Different parts of the country are experiencing varying levels of development. Urban and rural areas present contrasts in factors that determine quality of life. In developing countries, there is a trend for premature ageing as a result of illiteracy, poor hygiene, malnutrition, poverty and such other factors.

2. The Plight of the Elderly

As human life advances from childhood to youth and from youth to manhood, at every stage there is a meaningful and responsible role to play. At the same time, every stage of human life is exposed to numerous “risks” and “hazards” associated with occupation and age. In this process, as it advances from manhood to old age, new stresses and strains engulf human existence. The family has generally been. the traditional primary source of the social, economic, psychological and physical support for the aged. However, the elderly get affected due to lack of support from children who would have grown into adulthood and are in the web of fulfilling their own priorities. Joint family system is slowly vanishing from the society and nuclearisation of the family is the process of the present day social set-up. And due to lack of any worthwhile scheme of social insurance or social assistance these elderly become one of the marginalised and vulnerable sections of the society. Emerging changes in the demographic, social and cultural mores of the society is also one of the major causes behind the unfavourable scenario of the twilight zone of human life. The intensity of old age problems varies from rural to urban, and ageing from person to person and of course from men to women
ECONOMIC CONDITION
The problems of the elderly essentially concern:
1. Lack of Income Security
2. Absence of appropriate Health Care
3. Deprivation of Social and Emotional needs
4. Lack of Personal Security.
In general older people are considerably poorer than young active members in the work force. In India old age is associated with lowering of economic status, financial insecurity and at times abject poverty. The reasons are:
1. Only about 10 per cent of the people are employed in organised sector where they can expect regular income, pension or other benefits after retirement. As of 1991, there were 7 million elderly who were employees in public and private sector and 53 million in unorganised sector. Low wages, job insecurity, lack of legal and governmental provision to protect their rights make 90% wage earners vulnerable to poverty.
2. 60% of those who get retirement benefit, are found to become fhlancially dependent on others within two to three years after their retirement.
3. Joint families used to provide succour to the old, disabled and infirm earlier. Nuclear families cannot or may not provide for economic needs of older member.
4. Though the needs of elderly reduce to begin with, as years go by, they increase due to health reasons. It is then difficult to cope with the declining finances. Hence, physical, financial and emotional dependence goes on increasing.
5. Increasing number of elderly get disillusioned and lead a miserable life resulting out of their blind faith and love for their children.
6. There is a large segment of older women who had always been dependentr economically on the family. They will be hard hit, if families are not supportive in their old age.
7. Traditionally, children were considered as “old age security”. With decline in birth rates, and nuclear families, old people are forced to fend for themselves.
8. In India, there is already considerable poverty. People living in marginalised conditions are likely to become increasingly so when they grow old and disabled.
9. Health problems increase with ageing. India lacks comprehensive medicare policy. Even optimal health care is expensive. As people live longer, they outlive their resources (if any) as medical expenses eat into their savings.
Dependency
Economic well being of a society is often measured by dependency ratio. Persons under 15 years and above 60 are assumed to be economically inactive and depend on population aged 16-59. Dependency ratios are calculated taking these three segments of population. Inadequate income and poverty lead to dependency on bread earning/care taker group (16-59 years of age). Dependence rate is very high in India, and is around 53 percent in 2001. For every working person in the future, there will be 2 dependent persons. In turn this trend creates economic, social, health and psychological . pressure on care givers. The National Sample Survey Organisation (NSSO) 42nd round of studies show that nearly half of the aged persons in India are fully dependent on others. Out of these three fourths· are supported by their children. Rural elderly work for longer time as agriculture labourers, while urban elderly seek re-employment. In a country with high unemployment rate, this may not be easy. At times poor health may act .as an obstacle for reemployment.

STATUS OF THE OLD IN INDIA
75 per cent suffer from physical disability.
60 per cent face a great sense of alienation. ·
48 per cent are extremely lonely. ·
46 per cent face economic problems.
MAJOR FACTORS RESPONSIBLE FOR THE SENSE OF DEPRIVATION
40 per cent feel unwanted by their children.
35 per cent feel no one helps them or speaks consolatory words. ·
35 per cent are unhappy due to disrespect in the family. ·
33 per cent are worried about bad health.
52 per cent aged of both sexes do all their work themselves, including cooking their meals, and feel a sense of loss about daughters-in-law not helping out. Only 1 per cent enjoy this facility.

PROBLEMS DUE TO ECONOMIC INSUFFICIENCY
67 per cent feel the family treats them with contempt as they are no longer working.
25 per cent suffer from depression.
12 per cent have no hope of economic support from any source.
10 per cent suffer from a sense of economic alienation.
(Source: UGC-sponsored research project on “Sociology of ageing among the senior citizens” in urban UP).

3. The Elderly Women

Ageing is universal, both men and women age. Yet, ageing issues of women merit special attention. Gender makes a difference to the ageing experience. Gender is a very important variable influencing quality of life at any age, especially in old age. Ageing has become a ‘gender issue’ because due to demographic changes, there will he 604 million older women in the world by 2025. 70% of these will be in developing countries and 70% of them will be living in rural poverty. In most advanced countries women outsurvive men by four to 8 years. India is one of the few countries where sex ratio is biased in favour of men. The reason for this trend has to be sought in the sociocultural practices of our country and the general low status of women. Life expectancy of women is gradually rising in India too, and in older age group, women tend to have longer life expectancy. Biological advantage females have over male asserts itself in the 70+ age group and percentage of old women will be 50.9 and that of men 49.1 beyond the seventh decade. Older women in India face ‘triple jeopardy’- that of being female in patriarchal culture, of being old in a fast changing society, and of being poor.
Poverty: Women tend to be poorer as they are likely to work in domestic, agricultural, informal settings. This work is hardly monetised. There is considerable difference between older men and women in work force partiipation rates.
Illiteracy (only 8% of older women were literate in 1981) and unemployment make women dependent on others.
Widowhood: The main social effect of extension of life in later years for women is the extended period of Widowhood. Percentage of widows is disproportionately larger in India than that of widowers. Much lower proportion of men were widowed compared to women in extreme age. Main reasons that can be attributed to this phenomena are longer life of women compared to men; usual practice of young women to get married to older men and widowed men permitted to remarry which is prohibited for widowed women. NSS data shows that 60, 65 and 70 years, percentage of widows was around 56, 58 and 78 percent. In the same age group, percentage of widowers was around 14,17 and 27%. Widowhood makes an important difference to health, socioeconomic status, morbidity and even mortality.
Health: Older women’s health is affected by a life time of poor nutrition, multiple pregnancies, poor reproductive health care apart from other causes. Women have considerably more morbidity than men. A higher percentage of women are physically immobile due to illness. If they live longer, they may become victims of more disabling disorders such as cancer, osteoporosis, arthritis and AD.
Women as a group are more depressed. Most studies report lower life satisfaction· and poor psychological well being in women. More than any other problem, mental health of women is conditioned by social and cultural factors. Depression arises out of widowhood, loneliness, unpleasant life circumstances, lack of social support and poverty.
Some statistics about Older Women: There are 974 women per 1000 men in India. There were 33 million widows in 1991. Only about 10% of older women are literate. 60% of older women are chronically ill. 80% are totally economically dependent. Women are the primary care givers for elderly .

4. Morbidity in the Elderly

Indians above sixty years of age display considerable morbidity. The number of blind persons among the elderly was estimated to be around 11 million in 1996. The prevalence of blindness is ten times higher in older age group than the prevalence in total population. 60% of elderly have hearing impairment (about 38 million in 1996). Hypertension is twice as common among urban than rural, and twenty times higher when compared to prevalence rate in total population. Nearly five million elderly were diagnosed as hypertensive in 1996. There will be considerable under reporting as in rural areas adequate diagnostic facilities are not available. An estimated 9 million in 64 + age category were diagnosed as having coronary heart disease (CHD). Prevalence rate of CHD was 244 and 237 per 1000 male and female persons. There were around 5 million diabetic persons in higher age group in 1996, prevalence being highest among urban females. Based on population based cancer registries, an estimated 0.35 million elderly had diagnosed cancer. Prevalence rate of peptic ulcer was similar to that of total population around 0.2 million in 1996.
It has been repeatedly pointed out that the progress India has made in extending the life-span of its citizens has not been carried over to providing healthy and disability-free old age. About 5% of older people in urban and rural area are said to be physically immobile. Nearly 60 per cent of those immobile were from 70 + age group.
Difficulties with Activities of Daily Living (ADL) a good measure of functional competence, increase with age. In India, the percent of those chronically ill rises from 39 in 60—64 to 45 in 65-69 and 55 in 70+ age groups. In rural areas, impairment of vision and difficultly in mobility are common in old age. Vision and mobility are two important factors determining independence in later years. In the absence of availability of corrective surgery, medical facilities and prosthetic aides, rural elderly will be more vulnerable. Another common geriatric problem is acute confusional state which is almost as non-specific as vomiting in children! Common causes are infection, cerebral hypoxia, cerebral ischaemia (stroke, MI, etc.), Metabolic (hypoglycaemia, uremia), iatrogenic (barbiturates, L-Dopa), depression, abrupt changes in the environment, social stresses. Pressure sores are one of the special hazards facing patients who are old, ill and immobile. They may be superficial or deep, but require vigilant nursing care. Instability leading to falls and immobility are also common in older people. Age related changes in flexibility, reduction in visual and sensory acuity, neurological diseases, cardio vascular diseases, environmental factors (poor lighting, slippery floors, steep stairs, uneven mats), and certain type of medicines cause falls in elderly. Arthritis is a common and often chronic condition among the aged. A major consequence of this is the limitation of abilities and negative impact on ADL and IADL (Instrumental Activities of Daily Living). This is due to age related changes in cartilage of the joints. Ageing, obesity, trauma are some of the predisposing factors. Pain is the symptom, which leads to stiffness and restriction of joint movement.
Nutritional deficiency is also common among aged. It does not occur as a result of ageing alone. It occurs as a result of reduced intake (may be due to teeth problem), impaired absorption and excessive utilisation. Apart from. this economic and environmental factors play a role. Widespread chronic infection, poor environment, unsanitary conditions, lack of personal hygiene, ignorance about nutrition, etc. cause malnutrition.
The elderly are considered high risk group for multiple morbidity - physical, mental and social. The prevalence rate of mental morbidity among those aged 60+ was estimated at 89/1000 which projected onto the population yielded a figure of nearly 4 million. Affective disorders, particularly depression is the most common diagnosis in this age group. Neurotic disorders are relatively infrequent. Affective disorders, particularly depression, later paraphrenia and dementias form the bulk of morbidity in higher age group. The risk of psychiatric illness increases pari passu with age. The overall prevalence of psychiatric morbidity rises from 71.5 percent of those over 60 (but below 70) to 124 in the 70s to 122 in those over 80. Nearly 43% of psychiatric outpatients in 60+ age group are said to suffer from geriatric depression.
Not only is depression more common in older age groups, the elderly also form a high risk group for self destructive behaviour . Suicide rates increase sharply and is around 12/100,000 while it is 7/100,000 for general population. The ratio of ‘completers’ to ‘attempters’ is around 1.7, while it is 1.15 in younger age group. Women have higher rate of depression. Psychological factors, chronic diseases, social problems, isolation and losses combine to push elderly into depression. Recent studies show that depressive disorders are aggravated by physical iIIness. A significant feature of late life illness is that )psychiatric disorder is seldom an ‘isolated event’. Comorbidity is common with patients displaying a minimum of 6 to 12 symptoms and having two or three clinical diagnosis. Psychiatric disorders are associated with opthalmalogical,. degenerative, arthritis, neurological, cardiovascular, dermatological, hearing, urinary, nutritional and neoplastic disorders, in that order of frequency. Dementia is being called the ‘disease of our century’.The prevalence rate of dementia in those aged 65 + is around 27/1000 in urban and 35/1000 in rural areas. Around 35-40% of these is diagnosed as Alzheimer’s Disease (AD). As the number of elderly increases in the population, a concomitant rise in proportion of dementia is also expected. In a majority of cases dementia does not begin till age 65 and over. However, an estimated 5-10% develops the symptoms in middle age. Though dementia is less common than depression in Indian elders, it causes severe stress to family care givers. Persons with Alzheimer’s (pronounced Altz-Hi-Merz) exhibit only minor symptoms in the beginning that are often attributed to other illness. Gradually, the person becomes more forgetful. As memory loss increases, changes also appear in judgement, concentration, behaviour and personality. AD is not a normal part of ageing, it is a disease. The distinctive changes caused in the brain confirm the diagnosis on autopsy. These changes are not caused by hardening of arteries, nor is it contagious.
As yet, prevention and cure of the disease is not known, though several approaches are described. The level at which a dementing person is able to function is affected by other factors. This is often referred to as ‘excess disability’. These are secondary psychiatric symptoms, presence of other illness or reactions to medication, sensory impairments, or stressors.
Drugs are not the answer to all problems of elderly patients. Loneliness, loss of affection and support often complicate their ill health. Sometimes drug treatment may produce adverse effects that are worse than disease itself. Drug interaction, higher incidence of side effects and effect of multiple prescription should be kept in mind while treating an older person.

5. Shelter needs of the Elderly

Families are in continuous process of change, and that patterns observed at any given time represent ongoing negotiation between family values and social change. From an agrarian joint family system, families are becoming, urban, nuclear and individualistic. Families are rarely self-sufficient and are often subjected to tremendous pressure and adjustments as a result of rapid socioeconomic change.

For a very long time Planners and Policy makers ignored the problems of older people, complacent that ‘our traditional’ joint family system would take care of the elderly. With industrialisation, youngsters started migrating to cities. Increased urbanisation brought in nuclear families. Physical distance and financial independence severed ties with natal household. When cities drew young ablebodied working force from rural areas, it created pockets of poverty with old and infirm unable to keep alive the rural economy. The force of customs, traditions and control of caste and kinship diluted in urban areas. As women entered the workforce, old people lost their traditional carers. While people live longer, require long-term care, there are not enough people around to meet such demands. All this has repercussions on care giving and caring for elders as well as living arrangements.

A host of factors such as gender, health status, presence of disability, socioeconomic status and cultural tradition influence living arrangement of older people. Family, still appears to be the natural habitat of older Indians. Living with spouse and children, followed by living with a married son (and his family) is the preferred living arrangement. Living with a married daughter is less preferred. Least preferred is living in an old age home. While ordinarily the elderly persons live with their family, circumstances are developing in such a way that many of them have had to live independently or under institutional care. NSS (1986-87) reports that 8% of urban and 5.9% of rural elderly live alone. Sometimes the health condition of the persons may be such that the concerned families may not be able to provide the necessary care. In some cases there may be no family at all. At the worst, the families might have abandoned them and the elderly persons need to seek institutional care.

Living alone is often due to widowhood, migration of children and due to adjustmental problems. In urban areas, there is a trend for older women to live alone. There is another pattern of living arrangement - an older person usually a widow is shunted from the house of one child to another, as no one child is willing to provide continuous care.

INSTITUTIONALISATION
The idea of institutionalisation of the aged has been largely borrowed from the western societies, whose values and norms are quite different from that of India. The requirements of institutionalisation cannot be denied for those aged people who are neither able to manage their own affairs nor do they have any person to look after them. Usually living in an old age home evokes a picture of apathy, dependence and sadness. The inmates often confront problems due to highly ipstitutionalised, depersonalised and bureaucratic atmosphere in OAHs. They face problems with adjustment with tight and rigid schedule, total or near total separation from the family/social milieu, anxiety over entrusting oneself to a new environment, diminished physical capacity and very close and frequent encounters with death and ailments in the institution.
Old Age homes are, generally, the last resort for the aged. In the absence of joint family system, nuclearisation of families, the old parents are left with no other alternative than joining the old age homes. According to a study conducted in the old age homes of Maharashtra (Dandekar, 1996) almost 64 per cent of inmates had nobody to take care of them, and among them 45 per cent had no money. Economic consideration is one of the main reasons for choosing old age homes and even if there is family to support, the domestic environment and poor interpersonal relationships also push the aged to old age homes.

There were around 354 old age homes in 1997. By 2001 the number of old age homes in the country has grown to 969. Many such homes are run on charity and inmates are poor. In major cities, relatively well to do people are opting to live in condominiums built for the elderly. Expensive but well maintained old age homes are also appearing. Construction companies are promoting senior housing projects with medical and recreational facilities. It is important to realise that where a person lives in old age will make a significant difference to availability of care, nature and amount of care, emergency help, social interactions and well being in general .