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Health of Elderly

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37
Health of the Elderly

Mohamed Iliyas
Shaheena Manzoor
M. Irfanullah Siddiqui

Objectives
After going through the chapter the student will be able to:
1. Differentiate between Geriatrics and Gerontology
2. Describe physiological and pathological aging
3. Understand the health proglems of elderly
4. Play role in development of professional and community programs for the
community
5. Appreciate changing requirements of elderly
6. Updates himself about current research in elderly issues and conducts
research as well
596
Geriatrics
Geriatrics or geriatric medicine is a sub-specialty of in-
ternal medicine and family medicine that focuses on health
care of elderly people. It aims to promote health by preventing
and treating diseases and disabilities in older adults. There
is no set age at which patients may be under the care of a
geriatrician or geriatric physician, a physician who specializes
in the care of elderly people. Rather, this decision is deter-
mined by the individual patient’s needs, and the availability
of a specialist.
Geriatrics, the care of aged people, differs from gerontol-
ogy, which is the study of the aging process itself. The term
geriatrics comes from the Greek γέρων geron meaning “old
man” and ιατρός iatros meaning “healer”. However, geriatrics
is sometimes called medical gerontology.
Health of the elderly is dealt with under Geriatrics. Ge-
riatrics is the practice of medicine in its preventive, curative
or rehabilitative models, in the elderly.
It may be applied in relation to many health care con-
texts – thus: geriatric nursing, geriatric psychiatry (or psy-
chogeriatrics), geriatric rehabilitation, etc. Gerontology is
the scientific study of the aging process. It can be related
to any discipline in the context of aging - thus: experimental
gerontology, behavioral gerontology, etc.
Goal for the elderly: A WHO scientific group has defined
the goal for the elderly of health and social services as the
“maintenance of a minimum level of autonomy - the ability
to function within a given social setting ...”.
At the very outset it should be recognized that the life of
an individual cannot be isolated from his total life commenc-
ing from birth. Aspects of life indirectly related to health must
therefore receive consideration, not only by those who are
in charge of health care, but by all those who are concerned
with the welfare of the society as a whole. In fact aging should
be considered from the time of conception right upto the
top of the pyramid, the elderly. In practice, however, aging
is regarded as that phase in man’s normal life when body
functions begin to decline. This happens usually at the age
of retirement from active service. This age is commonly 60
years. It has become customary to think of anyone beyond
this age as being classified as “old”. Yet a person of chrono-
Health of the Elderly
logical age 55 could be physiologically older in terms of body
functions and mental activity than another individual of age
75 years if the latter is active and mentally alert. The arbitrary
age of 60+ is accepted in our society as marking off a segment
of Pakistan’s population that has health and health related
needs different from those of other segments.
Chronic disease and the process of aging are not syn-
onymous, because of the simple reason that many of the
elderly are in excellent health. Those who are not seen by a
physician and/or a welfare agency tend to be the overlooked
in the evaluation of the general health of older citizens. Not
less than half the older citizens suffer from some degree of
impairments, that may mean, limited activity. Although the
writers estimate that at least 60% of the elderly of Pakistan’s
population are homebound because of a varying degree of
impairment or unable to be participants in active work and
depend on the family’s financial resources, a good many are
capable of active work.
Pakistan’s Aging Population and
Epidemiology of Geriatrics
It is generally accepted that the age distribution of Paki-
stan’s population is shifting towards the older age group is
general knowledge. The number of people in the nation over
the age of 60 has considerably increased since the time of
partition of India. Today there are not less than 20 million
people in this category, and with the rise in expectation of
life at birth, their number is increasing.
Because of the growing interest of the nation in fam-
ily planning and consequent lowering of the birth rate, the
population pyramid of the future will shrink at the bottom and
grow wider at the top. By the year 2010, the percentage of
the population of 60 years or more is expected to increase
up to 10-15% if the birth rate continues the downward trend.
This population merits an organized community program for
their health and welfare. While in the western world this is
not a new interest, in Pakistan it has not received anyone’s
interest that it deserves.
Health of the Elderly
Aging – A Natural Process
Physiological Aging
Aging is a natural process with physiological changes,
many of them merely a decline in the rate of functioning. A
reduction in the metabolic rate of about 7% occurs every 10
years after the age of 30. There is a retardation of the rate of
cell division, cell growth and cell repair. Tissues with their cells,
tend to dry out. A fatty infiltration usually occurs with cellular
atrophy, and a decrease in the speed of muscular response
and a decline in muscular strength occurs. With a reduc-
tion in the efficiency of circulation, endurance is adversely
affected. Connective tissues suffer a decrease in elasticity,
bones become more brittle as the amount of organic material
becomes reduced, teeth lose their structural integrity, and
functions of the digestive system declines so that digestion
proceeds at a much slower rate than before. Some of the
nutritional deficiency in the elderly can be attributed to poor
digestion and inadequate absorption rather than a poor diet.
There is a general decline in the functioning of the nervous
system and organs of special senses. Illness, when it occurs
tends to prolong because of the reduction in body defense
mechanism.
Pathological Aging
Certain factors contribute to premature aging. Patho-
logical aging refers to those factors that affect the body in
hastening the natural process of aging so that the affected
individual becomes or appears prematurely old. Identifying
these factors will enable us to undertake measures of preven-
tion. These factors relate to repeated infections or chronic
infections, environmental pollution, degenerative diseases
such as hypertension, arthritis and rheumatism, tension and
worry, irregularity in the mode of living, nutritional deficiency,
smoking and inactivity. If these are regulated, the process of
pathological aging definitely will advance to a natural aging
process.
Characteristic of Elderly People
Although it is not possible to mention any typical features
to identify an elderly person, one could expect in most, if not
all, older people the following characteristics:
l Loss of status and an increased uncertainty about per-
sonal worth.
l An insecurity associated with a feeling of inability to meet
the demands of life.
l Apprehension about health.
l Difficulty in adjusting from a work routine to one of retire-
ment.
l Inability to find avenues of service that will provide per-
sonal satisfaction.
597
l Difficulty in meeting stress is created by social change
and limited incentive for social participation.
Elderly people are eager to be useful in some capacity.
Women make the transition into retirement more easily than
men, because of their preparation for the later years of life.
Status of the Elderly Person
Retirement provisions in Pakistan, as elsewhere are
still inadequate, in spite of Governmental efforts at improv-
ing them. At least 60% of the elderly depend on the family
resources either inherited or on the revenues of the earning
members of the family working abroad. 60% or more have
adequate physical capacity as well as mental capacity to
take up jobs. But employers seem reluctant to take them,
because of slow work and high frequency of absenteeism.
Nevertheless they work meticulously, produce work of a high
quality, train the younger employees and provide evidence
of high reliability. Employment opportunities therefore need
to be increased for those who are able to contribute toward
the country’s economy. Part-time jobs have their merit with
other community activities. Personal adjustment is the key
to satisfactory retirement.
Old People’s Home versus Family House
In the western world, the usual practice is to shift the
elderly to old people’s home. In the eastern countries, how-
ever, the elderly stay with their children and grand children,
Their word has authority over the young and they are a part
of the family with full participation in the family functions.
The Old People’s Homes are either not available or scarce.
However the young generation is drifting from joint family
system to nuclear families and a tendency to isolate the
elderly appears to be increasing. The Senior Citizens As-
sociation has established day care centres in a few places,
but the utilization rate is small.
There are considerable advantages for the elderly per-
sons in staying with the families but their tendency to hold fast
to the traditions and strict adherence to religious practices
does not seem to appeal to the young.
The result is in no way advantageous to the young as
there is no one to discourage the “social evils” which they
follow, as there is ample evidence of social disintegration
of the society by not following the advice of the elderly and
experienced people.
Health Problems
(1) Loss of confidence, assurance to the elderly that they
are required by family members is a key factor in main-
taining the health status.
(2) Arthritis and Rheumatism, two of the principal causes
of disability in the aged, can usually be treated to relieve
them of much of their pain thus enabling them to extend
their activities.
598
(3) Disorders of vision are common among the aged. Some
degree of correction is possible. When cataract is identi-
fied, surgical intervention should be made available to
them on priority basis.
(4) Loss of hearing in the later years of life is common.
Hearing aids have been developed to relieve this disorder
enabling them to hear adequately.
(5) Accidents. The usual accidents that occur are home ac-
cidents. These can be prevented by creating awareness
and providing some support with a cane or manually.
Inability to walk must be solved by provision of a wheel
chair.
(6) Diabetes mellitus. Management of diet and medication
must not be left to the individual but assistance should
be provided by the family members.
(7) Hypertension. Medication supported by frequent B.P.
recording at the home environment as well as physician’s
advice must be ensured.
(8) Cardiovascular diseases. Management, timely medica-
tion and check up by a physician should be the motive.
Access to cardiologist must be simplified. It is not easy in
the present health system of the country in spite of pay-
ment. Possibly community organization for such services
is the answer.
(9) Prostate enlargement. This is natural. But pathological
changes call for surgical intervention. Condom catheters
are useful for incontinence, without significant enlarge-
ment of prostate.
(10) Depression. Lack of adjustment to the social change
and family circumstances causing insecurity may be a
factor but the family members tendency to isolate them
may also be a cause.
(11) Senile dementia: Slower response and other symptoms
are hardly noticed by the physicians. These deserve
consideration of the medical profession.
12) Alzheimer’s Disease: A genetic disorder with cerebral
atrophy, occurs more commonly in the elderly, resulting
in loss of memory for recent events, while recalling past
events of young age. While investigating the problems
of the elderly, Lubna Ansari Baig and Ilyas, came across
five cases, 3 females and two males, suffering from this
disease. All were above the age of 68 years. Two of
these females could not even recognize their sons and
daughters, and of them one had urinary incontinence,
whereas the other female had lost the sensation of
faecal excrement. Similar symptoms were recorded in
one male. The families had no manpower resources to
manage these cases and relatives made scarce visits
to such families.
A situation of this sort calls for organized community ef-
forts for providing management assistance to such families,
in the absence of institutions for such patients, for which the
attention of the government should be drawn.
Health of the Elderly
Development of Human Resources for
Health Care
Professional Programs
The need for health workers to be trained to provide high
quality care to the elderly is an urgent need. Population aging
should be taken into account in all health care policies, plan-
ning and health program activities. Training for health care of
the elderly should be conducted at both undergraduate and
postgraduate level.
Emphasis needs to be given to building up a core group
of people able to act as local resources in the development
of human resources for health care of the elderly.
Mid-level health professionals including community nurs-
ing personnel need to be trained as local supervisors and
team leaders. Attention should also be given to traditional
health care providers and nonprofessional categories of
health workers who contribute significantly to the provision
of services.
Community Programs
Functional programs must be formulated at the commu-
nity level, because at higher levels the programs will fail to
touch individual elderly citizens and their families.
In this field the problem of a community is basically three
fold:
l Public education in the field of health.
l Integration of all services and forces in the community
that can have a service to offer elderly persons, and
l The acquisition and provision of appropriate services
that the community does not have. A health committee
can be constituted by the Senior Citizens Association if
not so far constituted. This committee may serve as an
information centre and liaison with the Pakistan Health/
Medical Association. A community health program under-
taken without the full approval and support of the local
medical profession is non-likely to flourish.
Primary emphasis in the community program must be
placed on public health education. The public needs to un-
derstand the nature of aging and the phenomena associated
with advancing years. The public should understand what
can be done to prevent some of the premature deterioration
of age and should have an understanding of measures for
the prevention of diseases and disabilities of the advancing
years. The public needs to be informed of the importance of
medical supervision and the contribution various individuals
and agencies have to make to the elderly.
A community program to promote the health of elderly
people must include attempts to provide the various services
required for the treatment, hospitalization, and rehabilitation
Health of the Elderly
of those elderly people who have some disability. It must
include provisions for activities that elderly people can enjoy
through participation. For those who are unable to pay for
professional services, which is the case with many, the pro-
gram should provide some means through which they may
receive the required services.
Perhaps the greatest contribution such a program can
make is to give the elderly a feeling that someone is con-
cerned with their problems and that there is an agency in
the community to which they can turn for guidance and as-
sistance. The individuals who will greatly benefit from the
program are those who do not have anyone in the family to
look after their interest and support.
Routine for the Elderly Persons
Mostly elderly people follow a normal course of living.
The particular routine adopted by each should however be
adjusted to his/her capacity, past mode of living, present
needs, and life interests. Certain factors are virtually com-
mon to all.
Nutrition: While the quantity of food required by the
person in the later years of life is less than earlier years,
the qualitative needs are important. Diversity of proteins, a
sufficiency of vitamins, and adequate minerals should be
included in daily life. Foods should be attractive. In the later
years of life, the output of enzymes is reduced and the rate
of digestion is much slower. For this reason, many elderly
people find that eating less at each meal and more frequent
is a highly satisfactory practice.
Activity: Unless a physician advises otherwise, moder-
ate activity is highly desirable for the normal elderly persons.
Some degree of fatigue during the day is normal, excessive
fatigue is harmful. Activity can be purposeful, such as gar-
dening or performing simple tasks and can be productive.
Moderate paced exertion, can be rewarding physically,
emotionally and socially.
Rest and sleep: A midmorning, noon and night rest
period will normally be adequate, but others may need more
rest. Some do very well without any rest period during the
day. Generally, as people get older they tend to sleep longer
each day. The tendency is for the elderly person to go to bed
earlier and to rise earlier than the adult population. Some
seem to require less sleep than they did in earlier years.
Each person in the old age group adjusts sleep adopted to
individual needs.
Safety: Physical injury and accidental death are high
among people in the old age groups. Slow reaction time,
poor vision, and the inability to adjust readily to changing
situations make the old persons more accident prone than
younger individuals. Conditions in the home should be made
safe. Living on the ground floor is an effective safety mea-
sure, because of falls from stairs. Well lighted rooms and
hallways and even dim light through the night are effective
safety measures.
599
Bathing: A well established living routine that includes
bathing is a health asset for the elderly person. Because the
old person’s sensitivity to heat is reduced, it is sometimes
desirable that a young person test the temperature of water
before the bath. Some elderly persons have been scalded by
bath water that they were unable to recognize as too hot until
they had been badly burnt. Bathing contributes to a general
feeling of wellbeing.
Clothing: Clean clothing adapted to the season and
needs perhaps represents a factor in mental health. Ex-
tremely important for the elderly is a feeling of pride, status,
or worth. Dress can be used to advantage as personal ap-
pearance can do much to give him enjoyable living.
Living practices of the elderly should be directed as much
toward their mental and emotional needs as their physiologi-
cal needs. Through such practices, it is possible to create
in elderly persons the feeling that they are still very much a
part of the community.
Sex: The elderly enjoy sex as much as the young, al-
though the frequency is much less than the latter. Erection
takes longer and the hardness of the penis lessens. The non-
cooperative female partners create an inhibitive influence on
the desire for sex. Males have a greater desire for sex than
the females. Not infrequently the elderly resort to extra-marital
practices. Some elderly are known to have oro-genital sex
outside their home environment. Others marry young ladies
who not infrequently ends up with unpleasant consequences
of rejection or divorce.
Females generally feel relieved to end up with meno-
pause. Sex desire lessens and their interest diverts toward
their grand children in preference to the poor husband. In
the traditional families and those of the lower socioeconomic
strata including religious families, the female gets equally
interested if not more with the husband.
Medical Services
The elderly persons in Pakistan do not enjoy the privi-
leges as in technologically advanced countries. Except in
some provincial health departments there are no special
services for the elderly. They are not in a position to take
their turn for physician’s services or check ups in a general
hospital. Appointment with consultants, when required by
them seems difficult. The families are therefore compelled to
pay for the service. In serious cases they have to part with a
large portion of their modest property. Welfare agency such
as Edhi Trust comes to their rescue for transportation but
the provision of professional services is beyond the scope
of the agency.
It is now justified to have special Geriatric Clinics estab-
lished in the country with a view to offer coordinated medical
and social services to the elderly group. Every individual of
this group needs an annual checkup plus emergency care.
This cannot be provided at the public hospitals and institutions
which are already facing a heavy patient load.
600
Rehabilitation
The ill or disabled elderly person needs more  than routine
care. When hospitalization is necessary for an aged person,
the general hospital can provide all the services necessary for
the care and treatment of the patient. But rehabilitation must
be a part of the hospital. Both nursing and social services
are necessary before the transfer of the patient to his home.
Even after reaching home, these services may have to be
continued for some time.
Religious Activities
These activities are necessary for the elderly and many
of them participate in religious functions. Some take a pride
in being active participants in these activities.
Leisure-Time Activity
The elderly need activities that will occupy them profitably
and enjoyably. Most of them enjoy the company of others.
They can take up arts and craft, music, dramatics, poetry
and creative work when the groups are small. Large groups
focus on lectures, parties, excursions and outings. Indoor
games such as contract bridge, chess and table tennis are
popular games.
Mental Health in Elderly
Mental health in elderly is closely linked with quality of life,
Many family caregivers in our communities are themselves
elderly, usually a spouse and sometimes an aging parent of a
disabled son or daughter. The care of people with disabilities
is shifting more and more to the community caregivers, at
least in the western world.
The development of health promotion programs, for the
elderly needs to be based on plans that measure health
status of the elderly groups, ensuring that the programs are
judged on the capacity to change the health status of people,
an important indicator of health status would be quality of life
and change in quality of life after the intervention.
Research into Aging
The need for research into the problems of aging needs
no further emphasis. Many of the problems seen in the West
in caring for the elderly, such as the loosening of family ties,
the decline of traditional obligations towards older people
and the increasing relative number of older people were also
found to be occurring in Asian and Oceanic countries.
Research carried out in the Western Pacific Region of
WHO indicates that 80% of males were able to do all activities
of daily living at 60 years but this percentage drops to nearly
50 above the age of 79 in the Republic of Korea.
View publication stats
Health of the Elderly
Dental and visual problems in Korea were the most com-
mon ones reported. 17% reported hearing problems and 20%
had some problem of incontinence. Mental health problems
such as sleep difficulties, worry and anxiety, loss of interest,
tiredness and forgetfulness were reported by 30-50% of the
population studied.
Successive cohorts of 70-year old Swedes, only 5 years
apart, have been shown to be healthier than their predeces-
sors while surveys in Japan show a higher proportion of
healthy old people than in Western countries. One study in
the U.K. found that the recent gains in life expectancy have
not been at the expense of any substantial increase in the
time spent in hospital in the final years of life.
Studies and points such as those mentioned in the forego-
ing paragraphs as well as other problems of the old people
have yet to be studied in Pakistan to the best of our knowl-
edge and belief. Research therefore into these problems is
an urgent need for community action.
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