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Journal of the Academy of Hospital Administration

Planning Consideration of Comprehensive Geriatric Care in India

Author(s): Chaubey P. C. *
Vij Aarti **

Vol. 11, No. 2 (1999-07 - 1999-12)

Keywords : Geriatric, Geriatric Care, ageing, population

Historical Perspective

The twentieth century reaped an unprecedented gain in life expectancy at birth; some 25 years throughout the industrialized world and more modest though significant increase in the developing world. Among the less developed regions, it is Asia which has been most successful in reducing the growth rate of population.

Japan has the highest life expectancy at birth of any nation : 77.1 years (1985). This compares with 55 just prior to World War II. The speed of the aging of Japan's population is remarkable. While it took 45 years of its population being elderly (age 65 and older), Sweden required 85 years, and France 115. This world-wide demographic revolution is a stunning social achievement. Yet, the consequences of longevity to family life, individual and social productivity, and the organization, delivery and financing of health care, social services and housing arrangements are not well understood. As the world faces larger number and proportions of older people, each society will have to grapple with longevity issues.

Interdisciplinary geriatrics appeared first in Great Britain in the 1930s, stimulated by Dr. Majorie Warren's efforts to reduce institutionalization of the elderly poor. The term 'geriatrics' was coined in USA by Dr. Ignatz Nascher in 1909. In 1988, American medicine established a certificate of competency for physicians licensed in internal medicine and family practice. Geriatrics is growing as a speciality in Scandinavia and Japan.

Global Scenario

As the twentieth century ends, most of the developed world has at least 10% of its population over 65. By the year 2000, more than 410 million persons will be aged 65 or older, with about 41% living in developed countries. Sweden's population has the highest proportion of elders i.e. 17%. (612 million, forming 10 percent of the total world population). The elderly population is expected to comprise 19 percent of the total world population in the more developed regions and 8 percent in the less developed regions by 2000.

Whole populations are said to 'age' when mortality and fertility rates fall and survival from birth through older ages increases.

Many countries have initiated programmes to tackle the issue of ageing population.

Japan has put in place a health-care financing system that gives essentially free care (only a 5% of copayment is required) for all persons over age. A 'Golden Plan' was announced in 1990 for expanding home and community-based services, particularly rehabilitation and adult day care.

The People's Republic of China having world's largest population has initiated the policy of one child per family, if fully implemented, would alter remarkably the responsibility of the individual to his or her parents and grandparents; potentially, the one child would bear responsibility to two parents and four grandparents.

The United Kingdom has incorporated Geriatric medicine in the postwar National Health Service.

The Union of Soviet Socialist Republics (USSR) has one of the first research institutes on ageing.

Australia has developed an extensive health care policy, including programs for geriatric assessment. Social security benefits are based on need.

Indian Scenario

In India, considering the socio economic situation, age 60, seems an appropriate cut off, against age 65 in many other countries.

Since 1961, a sharp decline in the overall death rate also in mortality levels in the older age groups (age 60 and above) initiated a process of ageing. The elderly population has increased from 12.06 million in 1901 to 60 million currently (in 1990's). According to estimates made by the technical group on Population Projections, the likely number of the elderly by the year 2016 will be around 113 millions (i.e. approx 10-12% of entire population). United Nations has classified societies broadly into 'young' (4% or less of those aged 60+), matured (4-7%) and "ageing" (7% and above). According to this definition India is presently falling under the category of 'matured' society which will soon reach the status of "ageing" society by 2000 AD.

It is therefore apparent, that the Indian population has begun a process of ageing due to recent decline in fertility and sustained improvement in survival.

As of now, not much importance has been given to geriatric care in India. The time has come to plan cost effective, and community friendly approach for comprehensive health care delivery to the large geriatric population.

Socio-Economic characteristics of ageing population in India (1991 Census)

  1. 78.1% of the elderly population lives in rural areas of India.
  2. Percent decadal growth rate has increased from 5.75 in year 1901 to 31.31 in the year 1991.
  3. There are 930 females per thousand elderly males in India.
  4. 63.09% of elderly population (aged 60+) is married.
  5. Percentage of widowed males is 15.47% and widowed females is 54.04% in India (population aged 60+).
  6. Litracy rate for persons aged 60+ is 27.15. (Males Litracy rate is 40.62 aned females 12.68)
  7. Work Participation rate for the elderly population aged 60+ is 39.1 (work participation rate is defined on the number of workers as percentage of population.
  8. Expectation of life at birth is 60.3 years, at the age 60 year = 16.2, 65 = 13.2 and at 70 = 10.6.
  9. Total old age dependency ratio in India is 12.19. (old age dependency ratio is defined as the number of persons aged 60+ as a percentage of persons aged 15-59).

Existing facilities in geriatric care - India

1. Helpage India

2. Societies

  1. Association of Gerontology (India), started in 1978, at Banaras Hindu University. Members of this association are clinicians, basic scientists, sociologist, psychologist and clinical gerontologist. This has 250 members.
  2. Geriatric society of India affliated to Association of Physicians of India started in 1982. It has about 500 members. It is Delhi based.
  3. Alzeihmer's diseases and related disorders society.

3. Government of India has formulated a National Policy for aged under the Ministry of Social Justice and Empowerment.

4. National Blindness control programme.

5. Deafness programme run by Delhi government.

6. Existing medical facilities

  1. Only one medical college in the country is running a M.D. course in Geriatric Medicine.
  2. Geriatrics out-patient clinics are being run at BHU, AIIMS, Maulana Azad Medical College, LTMN College at Madurai.
  3. Some states as running old age homes.

7. Government of India has undertaken a programme to develop training modules for medical colleges Teachers in Medicine and P.S.M. (as Trainer's) who will in turn train the doctors in primary and secondary health care setup.

Goals of Geriatric Care

  1. Provide a safe and supportive environment for chronically ill and dependent people.
  2. Restore and maintain the highest possible level of functional independence.
  3. Preserve individual autonomy.
  4. Maximize quality of life, perceived well-being, and life satisfaction.
  5. Provide comfort and dignity for terminally ill patients and their loved ones.
  6. Stabilize and delay progression, whenever possible, of chronic medical conditions.
  7. Prevent acute medical and iatrogenic illnesses and identify and treat them rapidly when they do occur.

Elements of comprehensive geriatric health care in India

As the issue of providing care to the elderly population is of recent origin due considerations are not being given to the comprehensive geriatric health care which comprises of home care and institutional care.

In Indian socio economic situation the elderly population in majority of cases (upto 70%) are living in a joint family set up and members of the family provide them care and comfort. But the situation is changing because of industrialisation and post liberalisation economic scenario resulting in migration of younger population in search of better future.

In India there is a great need for development of health care facilities for geriatric patients which should be comparatively cheaper and cost effective so that they are easily accessible to vast majority of population who otherwise are unable to afford the services offered by various expensive institutions. Certain Non-Government Organisation, Charity-Welfare Organisations and Public Sector Undertakings etc. could contribute in this direction.

Comprehensive geriatric health care comprises of physical, psychiatric, social, family, economic, nutritional and rehabilitation aspects.

Acute Hospitals

In India there are approx. 12000 hospitals comprising of about 7 lakhs hospital beds. Most of the hospital beds are under government sector. There has been tremendous growth in recent years in hospitals under private sector. The elderly population approaches hospitals mostly during acute illness depending upon physical and financial accessibility. A fractured hip, pneumonia stoke or heart attack may necessitate immediate professional attention.

Problems in these hospital are that most of these hospitals have no geriatric wards fulfilling the specific requirements and needs of geriatric patients. Also these hospitals are not designed to provide long term care so as soon as the patient's condition improves he or she is sent home.

Keeping in view the delay in convalescence of the geriatric patient, once a patients is admitted, beds are occupied for a long time and thus hospital are also hesistant to admit such patients. As a

economically inaccessible. After discharge patients are looked after by relations. There is a need for low-cost convalescence homes atleast in all districts of country i.e. approx. 550. In this area, N.G.O.'s and International agencies can contribute.

Hospice

In recent years a new movement for terminal care has developed. Beginning in England, the hospice philosophy spread to the United States and has become in important aspect of terminal patient care. The philosophy is based on a belief that death is a normal process which should neither be hastened or delayed.

Growing numbers of people concerned about protecting the dignity and comfort of the terminally ill have developed units within hospitals and medical centers or have founded specific care facilities.

The goal of hospice care is to control pain so that the individual can remain an active participant in life until death. Psychological, spiritual and social support, as well as legal and financial counselling, should be available to both family and patient. Personal physical care for the patient is assured. A geriatric nursing assistant or home health aide can provide most of the care under the direction of a professional hospice nurse.

Hospice care can meet the needs of terminal oncology patients (those with incurable malignant tumors), and can also be extended to include others with a life expectancy of six months or less. Support groups can by formed to visit terminal patients in conjuction with hospice teams. Many volunteers serve as "special friends," making regular visits and working on a one-to-one basis with the patient and family.

In India, there are very few hospices, and most of them are only located in metropolitans. Organisation like Mother Teresa has done lot of work in this direction to give dignity to dyeing poor. First in Calcutta, later on other parts of country. Such facilities could also exist in district level. Charitable and welfare organisation can play an active role.

Death and Dying

Postmortem Care

Postmortem care is the care given after death is pronounced. Death, like life, must be handled with dignity and caring. Immediately following death, hospitals should make sure that the body is positioned with the limbs straight and that the bedding is clean and neat. Equipment should be moved out of the unit. Family members may wish to view the deceased and attention to these details makes the experience easier.

Day care/Day Hospital

One big advantage of day care is the cost, which is usually less than the cost of care in a nursing home. In addition to providing treatment for the patient, the day care center can assist families in making adjustments and finding aid. A day care facility can often make it possible to avoid or delay institutionalization.

Day hospitals attempt to dissociate the investigational and therapeutic aspect of hospital treatment from the hotel aspect which often requires patients to be looked after at night and throughout the weekend when no investigation or treatment is carried out. The day hospital also helps in a close and prolonged supervision of patients suffering from chronic disease who, if isolated completely from hospital care, would almost certainly deteriorate and require readmission.

Day care centres could also be business investments incorporating social as well as health benefits, where health examination and health screening can be routinly carried through agencies such as local health department, doctors, nurses, dieticians and social workers visiting the centre. Doctors and nurses could use their visits to do the health screening and referals. Special programmes on nutrition and general preventive health measures could be conducted on monthly basis.

Variants in day hospitals could have provisions for a travelling day hospital in which a group of staff move between different centres on each day in the week for management of psychogeriatric need for patients.

Rehabilitation Centres and Teams

Rehabilitative services are offered through centres, some of which specialize in specific types of rehabilitation. Such units are frequently part of large metropolitan hospitals or are associated with independent agencies.

Rehabilitation services can be directed by a team of professional people, working together to establish and reach realistic goals. At times, the team will consist of medicine, recreational therapy, occupational therapy, psychotherapy, physiotherapy, social service and nursing. The nurse can serve as coordinator for the combined effort. At other times, the nurse, doctor, and a few specialists make up the team. With team approach, each team member sees the patient from a slightly different viewpoint. From the consensus, a specific rehabilitation plan is devised and recorded on the patient care plan.

Patients hospitalized in institutions with rehabilitation units can take advantage of these services. Many other patients utilize them on out-patient basis. Outside of the centres, rehabilitative planning and services are provided by the physician, family, and public health nurse. The home health aide/geriatric nursing assistant/health workers can play an important role in the rehabilitation of the home patient, supplying encouragement and assisting in therapy as directed.

Home Care

In India because of close social links, families and also because of economic compulsion, geriatric population has to entirely depend upon near and dear ones. Lack of health education and awareness of geriatric needs, certain practices may actually harm the health of geriatric patient. Therefore, there is need for development of reading material for home care of geriatic patients. Audiovisual media (T.V., Radio etc.) could greatly help in this regard.

Safety considerations for elderly (institutional as well as home care)

Safety is the concern both of the elderly person and of those responsible for the elder's health care.

Persons aged sixty and above account for approx. 20 percent of all accidental death and 13 percent of all hospitalized accident victims. Therefore constant vigilance is needed to safeguard the elderly both at home and in patient care facilities.

Causes of Accidents

  1. Intrinsic Factors
    1. Cerebral ischemia or temporary hypoglycemia
    2. Tremors
    3. Postural changes
    4. Decreased visual acuity
    5. Confusion and forgetfulness
  2. Extrinsic Factors
  3. Locations without warning
  4. Unlighted hallways
  5. Inadequately identified medicines
  6. Accumulated trash

Stairs should have railings and well lit (lights should be operable both from top and bottom of stairs). The top and bottom steps can be painted to alert the elderly persons.

Raised toilet seats are convenient and make toileting safer for the older person. Getting on and off a low toilet can cause an elderly person to lose balance and fall. Bath rooms and toilets should be provided with handrails/and grab bars are both convenient and an important safety factor.

Beds chairs and couches of the proper height are important if accidents are to be avoided. Furniture should be low enough so that the feet are flat when sitting but high enough so that rising to stand is not difficult. Arms on chairs are helpful, and there should be room enough under the chair to put one foot back while rising.

Bed rails should be up in the locked position and beds in lowest height position in night. Call bells should be provided close to the bed.

Manpower Development

Medical Manpower

Undergraduate and post graduate courses should have curriculum for geriatric medicine. In service training for doctors at all levels of health car (primary, secondary, tertiary) should be imparted.

Nursing Manpower

Geriatric nursing care should be part of curriculum for nursing courses or a special post graduate course could be designed for geriatric nursing.

Geriatric Health Care Assistant/Home Health Assistant

This category of workers should be trained in gereotology and basic nursing skills. Geriatric health care Assistant may function as home health aids or may be employed in a nursing facility.

At the peripheral level, male and female health workers should be imarted this training to help the chunk of elderly population living in rural areas and dependent on primary health care centres.

The curriculum for this category could be developed, Paramedical vocational education at 10+2 level. (Such courses are being developed in the field of Dental Technician, hygenist, Radio-grapher, Hospital housekeeper, Record keeping etc. by Pandit Sunderlal Sharma Central Institute of Vocational Education, Bhopal under NCERT, Ministry of HRD.) This is going on as per the recommendation of Bajaj Committee.

Conclusion

The percentage of elderly population is continously increasing in India due to decline in overall death rate, decline in fertility and sustained improvement in survival. There is also revolutionary change in health care delivery system in the country as a result of privatisation and globalisation. To evolve a comprehensive health care for elderly population we have to think in terms of all the elements of comprehensive health care such as :

  1. Care at home
  2. Health education.
  3. Institutional care - facility planning for elderly population.
  4. Human resource development for creation of medical and pare-medical expertise.
  5. Sensitisation and involvement of NGO's and voluntary organisation.
  6. Health insurance programme.

References

  1. Geriatrics - A study of Maturity, Authors Esther Cald well, Barbara R. Hegner.
  2. Torrey B B, Kinsella K, Taeuber C 1987 An aging world, US Census Bureau, International Population Reports Series P-9578. Government Printing Office, Washington, DC.
  3. Oriol WE 1982 Aging in all nations : A special report on the United Nations World Assembly on Aging. The National Council on Aging, Washington, DC. Included is the text of the International Action Program on Aging.
  4. Health Care of the Rural Aged - A Venkoba Rao, A study by ICMR - New Delhi.
  5. Report of the Expert Committee Meeting on Development of Training Modules for Health Care of the Elderly People.
  6. Year Book 1996-1997 - Family Welfare Programme in India, Deptt. of Family Welfare Programme in India, Deptt. of Family Welfare, Ministry of Health and Family Welfare, Govt. of India.
  7. Parkes C M 1985 Terminal care : home, hospital or hospice - Lancet i : 155-157.

* Additional Professor, Deptt. of Hosp. Admn., AIIMS, New Delhi.

** Senior Resident Administrator, Deptt. of Hosp. Admn., AIIMS, New Delhi.

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