HEALTH PROBLEMS IN ELDERLY
 Pravin Pisudde
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
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.
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
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.
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.
 Family is still considered the mainstay of social support for the
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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).
Percentage share of person 60 years and above in the
total population by sex, India 1901-2001(3)
9
8
7
6
5
Total
4
Males
3
females
2
1
0
1901 1911 1921 1931 1941 1951 1961 1971 1981 1991 2001
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.
Comparative percentage distribution of
population in India & Maharashtra
8
7
6
5
4
India
3
Maharashtra
2
1
0
1971
1981
1991
2001
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)
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 ↑
 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 ↓
 Muscle strength
 Muscle mass ↓
 Muscle diameter ↓
 Speed of contraction ↓
 Max. voluntary strength ↓
 Control of movements ↓
 Thermoregulation
 Tolerance to heat ↓
 Sweating ↓
 Vasodilation ↓
 Skinfold thickness ↑
 Excretory system
 Renal mass(70%) & perfusion(50%) decrease
 Digestive system
 Loss of teeth
 Salivary & gastric secretion
 Special senses
 Reaction speed ↓
 Acuity ↑
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
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
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
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
 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.
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.
Distribution of Old age death by system(60+) in rural India (Top 5 causes)(4)
Disorders of the RS
33.7%
Disorders of the CVS
21.6%
Other clear symptoms
18.1%
Disorders of the CNS
9.6%
Fever
6.6%
Distribution of Old age death by disease (60+) in rural India (Top 5 causes)(4)
Bronchitis-Asthma
25.8%
Heart Attack
13.2%
Paralysis
8.4%
Cancer
7.1%
TB of lungs
5.8%
Cause of Death(5)
65-69 years
70+
Male
Female
Male
Female
Infectious and parasitic disease
13.2
9.6
9.3
6.5
Neoplasms
5.3
6.9
4.1
3.8
Endocrine system
4.9
6.5
4.1
4.5
Disease of haematopoetic system
1.5
1.8
1.4
1.9
Mental disorder
0.2
0.1
0.1
0.1
Disease CNS
1.9
2.3
1.9
1.9
Disease of the CVS
38.3
36.3
36.9
36.9
Disease of the RS
8.2
7.1
9.7
10.2
Disease of the GIT
5.1
3.5
3.2
2.4
Disease of the GUT
1.8
1.7
1.7
1.2
Ds of the skin & subcutaneous
tissues
Ill defined conditions
0.2
0.3
0.2
0.2
15.7
19.5
24.1
27.3
Injury and poisoning
3.5
3.3
2.9
2.6
Other causes
0.1
0.5
0.3
0.4
All causes
100
100
100
100
System
CVS
RS
CNS
Endocrine
Genitor-urinary
Nutritional
Locomotor
GIT
Psychiatry
Institutionalized
Males
Females
16.39
22.31
32.78
33.1
14.76
17.27
11.47
10.79
19.67
10.79
24.59
23.74
26.24
36.69
24.6
34.54
18.03
17.27
Non Institutionalized
Males
females
26.09
18.52
34.78
25.92
15.21
5.56
15.22
3.7
10.86
9.25
26.09
33.34
36.95
50
19.57
38.88
21.74
29.63
Magnitude of health problem
Percentage distribution of physically immobile elderly by Age,
Gender and Residence
Rural
Urban
Age
Male
Female
Total
Male
Female
total
60-64
22.71
19.93
21.3
19.1
18.07
18.59
65-69
20.88
19.88
20.37
24.66
19.83
22.34
70+
56.41
60.19
58.13
56.24
62.1
59.17
Percentage distribution of Type of chronic Disease
among the Indian Elderly by the age and Residence
(A)Rural
Age
Cough
Piles
pain
Joints
BP
60-64
65-69
60+
70+
35.6
33.8
34.37
33.69
3.37
2.98
3.25
33.35
46.07
48.5
46.96
46.65
6.47
6.22
6.42
6.52
Heart Urinary diabetes
disease problem
3.26
3.53
3.74
4.33
3.2
3.21
3.53
4.33
2.04
1.78
1.73
1.41
(A)Urban
Age
Cough
Piles
pain
Joints
BP
60-64
65-69
60+
70+
24.16
24.25
24.95
24.52
3.65
3.8
3.58
3.58
38.37
38.70
39.16
38.79
18.53
17.65
16.6
17.48
Heart Urinary diabetes
disease problem
6.44
6.88
5.93
6.34
3.2
3.1
5.23
4.02
5.65
5.62
4.76
5.27
Mental health
 Over 10% of India’s 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
 Another dimension of mental health that has been
neglected so far has been the gender dimension.
 Alzheimer’s 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.
Percentage Distribution of Elderly According to Impairments
Age
Vision
Hearing
Walking
60-64
28.9
7.8
11.9
65-69
32.8
8.9
15.7
70-74
35.6
12
19.9
75-79
45.3
19.8
29.7
80-84
54.5
31.2
44.2
85-90
66.7
33.3
43.3
90+
60
66.7
73.3
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
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
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 multisectoral and multidisciplinary approach is required
Intervention to modify risk factors
 Population strategy
 Health protection
 Health promotion
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Health education
Environmental facilitation
Life style and behavioural change
Nutritional intervention
 Specific protection
 High risk strategy
Screening for disease in Old age
Breast cancer
Mammography
Cataract
Clinical examination of eyes
Cervical cancer
Pap smear
Colo-rectal cancer
Stool occult blood
Coronary heart disease
Risk analysis, ECG, stress ECG
Deafness
Clinical evaluation and audiometry
Dementia
Mental state examination(MMSE)
Diabetes mellitus
Blood glucose estimation
Diabetic retinopathy
Fundoscopic examination and fluorescin angiography
Dyslipidemia
Lipid profile
Glaucoma
IOP by tonometery
Hypertension
Periodic BP recording
Lung cancer
Chest Radiograph
Osteoporosis
Bone densitometer after risk assessment
Prostate cancer
Rectal examination, blood PSA level
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 noncontributary, 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.
 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).
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.
 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.
 Government of India has also introduced another
Insurance scheme for the benefit of agricultural
worker called Khetihar Mazdoor Bima Yojna on
18th 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.
 Varistha Pension Bima Yojna:
 Its is a government’s 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.
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
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.
 UTI’s 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.
References
 Sharma SP, Xenos P; Ageing in India: Demographic Background and
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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
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