’’ Dementia

’’ Confusion

’’ Chronic illness
’’ Use of medications for heart diseases; and
’’ Emotional stress.

A large number of accidents in older people can be avoided. The Medical Officer needs to
identify the risk factors for the accident in the elderly and help them with simple and innovative
measures such as:
’’ Use of walking aids
’’ Optimize the senses:
 Use of visual aids
 Use of colors to enhance the older person’s vision and depth perception
 Use of hearing aids
’’ Exercise regularly to improve gait and power.
’’ Gait and balance training to improve coordination and reduce the risk of falls
’’ Environmental modifications to suit elderly:
 Removal of obstacles and clutter
 Ensure adequate lighting in the household area
 Use of flat shoes
 Availability of stable structures to hold on to in case of an impending fall
 Proper flooring inside the home and the immediate outside environment.
’’ Keep floors free of obstacles and moisture.
’’ Place the non-slippery mats on the floor of the bathroom.

Drug reaction
Older persons require multiple drugs due to the presence of multiple diseases. As a result, there
is a high risk of drug interaction and adverse drug reactions. The behavior of the medications
inside the body and their effects (pharmacokinetics and pharmacodynamics) are changed in
Health Promotion and Counseling in Elderly Care

old age due to alterations in absorption from the gastrointestinal tract, detoxification in the liver,
excretion through the kidney, composition of body fat, muscle mass, and total body water; and
drug-receptor sensitivity.

Common drugs which produce adverse reactions are antibiotics, anti-arrhythmic drugs, digoxin,
diuretics, non-steroidal anti-inflammatory drugs, anti-Parkinsonian drugs, anticholinergic drugs,
sedatives, anti-depressants, anti-hypertensive, anti-coagulants, and psychotropic drugs.

Common adverse drug reactions are confusion, delirium, postural hypotension, falls, anxiety,
depression, sleep disturbances, constipation, diarrhea, urinary incontinence, and urinary
retention.

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 Interventions to reduce adverse drug reactions are
’’ Avoidance of self-medication

’’ Minimizing the number of drugs used

’’ Frequent review of medication

’’ Use of specific medications for specific illnesses

’’ Use with caution the medicines which have significant adverse drug reactions and

’’ Instruct the patient about anticipated side-effects

’’ Limited use of over-the-counter drugs

’’ Community Health Workers providing health education to elderly must keep in

mind the following aspects: the normal physiological changes in ageing; healthy
diet; family support and wellbeing; prevention and control of communicable and
noncommunicable disease through avoiding risk factors such as smoking, harmful
alcohol use, unhealthy diet, sedentary life and so on; cognitive exercises and
counselling support to prevent memory loss and depression; prevention of falls and
utilization of health services.

’’ Health professionals can adopt the 5A approach that includes Ask, Assess, Advice,
Assist and Arrange either in community settings or healthcare settings.
Training Manual on Elderly Care for Medical Officer at Ayushman Bharat – Health and Wellness Centres

’’ Regular screening is essential to detect chronic age-related conditions such as

diabetes, hypertension and cancer for early diagnosis and treatment.

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National Programme for
Health Care of the Elderly 6
The Ministry of Health & Family Welfare had launched the “National Programme for the Health
Care of Elderly” (NPHCE) during 2010-11 to address various health related problems of elderly
people. The National Programme for the Health Care for the Elderly (NPHCE) is an articulation
of the International and national commitments of the Government as envisaged under the
UN Convention on the Rights of Persons with Disabilities (UNCRPD), National Policy on Older
Persons (NPOP) adopted by the Government of India in 1999 & Section 20 of “The Maintenance
and Welfare of Parents and Senior Citizens Act, 2007” dealing with provisions for medical care
of Senior Citizen. The Programme is State oriented and basic thrust of the Programme is to
provide dedicated health care facilities to the senior citizens (>60 year of age) at various level
of primary, secondary and tertiary health care.

Objectives
’’ To provide accessible, affordable, and high-quality long-term, comprehensive and
dedicated care services to an Ageing population.
’’ Creating a new “architecture” for Ageing; to build a framework to create an enabling
environment for “a Society for all Ages”
’’ To promote the concept of Active and Healthy Ageing.
National Programme for Health Care of the Elderly

’’ Convergence with National Rural Health Mission, AYUSH and other line departments
like Ministry of Social Justice and Empowerment.

Components of the Program

’’ National Health Mission (NHM) Component: Primary & Secondary care service delivery
through District Hospitals (DH), Community Health Centres (CHC), Primary Health
Centres (PHC), Sub-Centre/Health & Wellness Centres.
’’ Tertiary Component: Renamed as ‘RashtriyaVaristh Jan Swasthya Yojana’ in 2016-17.
These services are being provided though Regional Geriatric Centres (RGCs) located at
19 Medical colleges in 18 states of India and two National Centres of Aging (NCAs) one
in AIIMS, Ansari Nagar, New Delhi and another in Madras Medical College, Chennai.

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 ’’ Research: A Longitudinal Ageing Study in India (LASI) project: The LASI is a
nationally representative survey of older persons in India is being undertaken
through International Institute of Population Sciences (IIPS), Mumbai. LASI wave-1
survey (2017-18) covers all 30 states and 6 Union Territories of India with a panel
sample size of 72,250 older adults aged 45 years including 31464 people above
60 years of age and above and their spouses regardless of age. LASI collects
data on four major subject domains:
1. Health: Disease Burden & Risk Factors (Reported and Measured)
2. Health Care and Health Care Financing
3. Social: Family, Social Network and Social Welfare Programmes for the Elderly
4. Economic: Income, Wealth, Expenditure, Employment, Retirement and Pension

The first wave of LASI has been completed and the final report of LASI wave-I released by
Hon’ble Union Health Minister on 6th January 2021.

Longitudinal Ageing Study in India- LASI Wave-1 Report along with India & States/UTs Fact
Sheets – Web Link- https://www.iipsindia.ac.in/content/lasi-publications

Program Strategies
’’ Community based primary health care approach including domiciliary visits by trained
health care workers.
Training Manual on Elderly Care for Medical Officer at Ayushman Bharat – Health and Wellness Centres

’’ Dedicated services at PHC/CHC level including provision of machinery, equipment,

training, additional human resources (CHC), IEC, etc.
’’ Dedicated facilities at District Hospital with 10 bedded wards, additional human
resources, machinery & equipment, consumables & drugs, training and IEC.
’’ Strengthening of Regional Geriatric Centers to provide dedicated tertiary level medical
facilities for the Elderly, introducing PG courses in Geriatric Medicine, and in-service
training of health personnel at all levels.
’’ Information,Education & Communication (IEC) using mass media, folk media and other
communication channels to reach out to the target community.
’’ Continuous monitoring and independent evaluation of the Programme and research in
Geriatrics and implementation of NPHCE.

Expected Outcomes of NPHCE

’’ Establishment of Department of Geriatric Medicine in selected 19 Medical Colleges
Sanctioned as Regional Geriatric Centres (RGC) with a dedicated Geriatric OPD and 30-
bedded Geriatric ward for management of specific diseases of the elderly, conducting
trainings of health personnel in geriatric health care and pursuing research.
’’ Post-graduation in Geriatric Medicine (two seats) in each of the 19 Regional Geriatric
Centres.
’’ District Geriatric Units with dedicated Geriatric OPD and 10-bedded Geriatric ward
Rehabilitation/Physiotherapy Services in all District Hospitals.
’’ OPD Clinics/Rehabilitation units including domiciliary visits at CHC, PHC & HWC.

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 ’’ Health & Wellness Centres/Sub-centres provided with equipment for community
outreach services for Elderly.
’’ Training of Human Resources of Public Health Care System for provision of quality
Geriatric Care.

Package of Services
The program has two components for provision of geriatric health care services i.e.: district &
sub-district level component and tertiary level component. The package of services provided
to elderly people at both levels is as given below.
’’ Sub/HWC Centre:
 Health Education related to healthy ageing, environmental modifications, nutritional
requirements, lifestyles and behavioral changes.
 Special attention to home bound / bedridden elderly persons and provide
training to the family health care providers in looking after the disabled elderly
persons.
’’ Primary Health Centre:
 A weekly geriatric clinic at PHC level by trained Medical Officer, Conducting
Health assessment of the elderly persons and simple investigation including
blood sugar, etc.
’’ Community Health Centre:
 Biweekly geriatric Clinic and Rehabilitation services to be arranged by trained
staff and rehabilitation worker at CHCs.
 Domiciliary visits by the rehabilitation worker will be undertaken for bed-ridden
elderly and counseling to family members for care such patients.
’’ District Hospitals:
 Dedicated Geriatric OPD services, In-door admissions through 10 bedded
geriatric ward, laboratory investigations and rehabilitation services.
 Provide services for the elderly patients referred by the CHCs/PHCs etc. and refer
severe cases to tertiary level hospitals
’’ Regional Geriatric Centers:
 Provide tertiary level services for complicated/serious Geriatric Cases referred
National Programme for Health Care of the Elderly

from Medical Colleges, District Hospitals and below.

 Conduct post graduate courses in Geriatric Medicine. Each RGC to produce 2
postgraduates (MD geriatrics) every year.
 Providing training to the trainers of identified District hospitals and medical
colleges
 Developing/and updating Training modules, guidelines and IEC materials.
 Research on specific elderly diseases.
’’ National center for Ageing:
 High level tertiary care with multidisciplinary clinical services involving medical
and surgical disciplines.

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  Specialized OPD care in various clinical disciplines. Special clinics like memory
clinic, fall and syncope clinic, frail elderly clinic, aids and appliances clinic, implants
and cosmetic clinic.
 Day care center for: Investigations, rehabilitation, respite care, dementia care,
continence care
 In patient care for: Intensive care, acute rehabilitation, diagnostic and therapeutic
services, long term rehabilitation service.
 Human resources development in all sub-specialties of Geriatric Medicine
 Developing evidence-based treatment protocols for Geriatric diseases prevalent
in the country.
 Special focus on care for 75+ aged population
Training Manual on Elderly Care for Medical Officer at Ayushman Bharat – Health and Wellness Centres

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Service Delivery Framework
& Continuum of Care 7
Elderly individuals have distinct physical, emotional, social and economic needs that demand
greater attention and prefer to have services closer to their homes. With empathetic, age-friendly
and holistic primary health care services, much can be done at the community level, which is
cost effective for the providers as well as the beneficiaries. In addition, the multi-morbidity
status consequent to chronic disease conditions can be minimized through promotive and
preventive care including screening, early detection, supportive and consistent follow up care
for those undergoing treatment or with advanced disease conditions. Thus, Comprehensive
Primary Health Care for elderly is needed not only to improve the access and affordability, but
also to emotionally enable the elderly in the community. The Primary Health Care Team has the
responsibility for providing care for the elderly starting from the community level to the SHC-
HWC and PHC-HWC level.

At the community level: ASHA, MPW(M/F) will identify elderly individuals in the community
including mapping of elderly population under HWC in the category of bedbound, restricted
and mobile elderly, undertake risk assessment of the elderly, provide counseling and
support to the elderly for various health conditions, including basic nursing care, provide
support to the caregivers, identify and report medical conditions suspected to be elderly
abuse cases to the HWC, enable formation of support groups for the elderly and caregivers,
identify and medical conditions and refer to the CHO for further management and provide
follow up care.
Service Delivery Framework & Continuum of Care

At the SHC-HWC level: CHO will carry out comprehensive geriatric assessment of elderly
individuals, manage common geriatric ailments and/or refer to appropriate higher centres,
arrange for suitable assistive devices from higher centres to the elderly /disabled persons to
make them ambulatory, provide counselling and support to elderly and their caregivers.

At the PHC-HWC level: Medical Officer will undertake an advanced comprehensive health
care of the elderly referred from the SHC-HWC or coming directly to the PHC. He/she will
make diagnosis of diseases and disorders based on clinical examination and investigations and
prescribe treatment. Complicated cases will be referred to specialists at higher centres.

At the referral center level: Diagnosis and treatment of complicated conditions, surgical
care, rehabilitation and counselling will be provided for the elderly by Medical Officer or
specialists.

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 The Elderly care at Health and Wellness Centers will be based on mobility-based classification
of elderly with three main categories - Mobile Elderly, Restricted elderly and Bedbound / Home
bound elderly for any reason. Such categories would be used in the assessment of high-risk
elderly who would be prioritized accordingly for service delivery.

Service Delivery Framework

Human Responsibilities
Resources
ASHA ƒƒ Undertake household visits for community mobilization, risk assessment,
counselling improved care seeking and increasing supportive environment in
families and community.
ƒƒ Generate awareness in the community about healthy lifestyle in the elderly to
promote active and healthy ageing.
ƒƒ Identify elderly individuals in need of care in the community including mapping of
elderly population
ƒƒ Provide support in family counselling and redressal of medical issues
ƒƒ Identify caregivers within or outside the family and link them to the nearest health
care facility.
ƒƒ Facilitate environmental modification, nutritional intervention and physical activities
including yoga, lifestyle and behavior changes at the family and individual level.
ƒƒ Would work with Gram Sabha, ULB, SHG, VHSNC/MAS, JAS, RWA and local NGO
to enable creation of facilitatory environment for elderly.
Training Manual on Elderly Care for Medical Officer at Ayushman Bharat – Health and Wellness Centres

ƒƒ Support caregivers in learning a range of practical skills like transferring a bed

bound elderly within house, support in daily routine activities like eating, bathing etc.
ƒƒ Facilitate services available for elderly at HWCs and referral centres.
ƒƒ Home based follow-up care for elderly discharged from higher facilities.
ASHA ƒƒ All elements of ASHA (as above)
Facilitator ƒƒ Deliver passive physiotherapy services to bed bound elderly acting as a lay
rehabilitation worker under the guidance of CHO & MRW from CHC.
ƒƒ Supportive supervision to ASHA
MPW-F/ ƒƒ Undertake initial screening using preliminary Comprehensive Geriatric Assessment
MPW-M for all elderly twice in a year.
ƒƒ Facilitate formation of Elderly support groups named ‘Sanjeevini’ and elderly care
giver support groups
ƒƒ Reinforce healthy ageing via adequate nutrition, physical activity, regular checkups
and rehabilitative care.
ƒƒ Undertake weekly visits to home bound/bed bound elderly
CHO ƒƒ Undertake comprehensive geriatric assessment twice a year
ƒƒ Providing immediate/primary management of common ailments of elderly and
referring to MO at PHC or conducting teleconsultation services and manage as per
MO-PHC instructions.
ƒƒ Develop and administer a personalized care plan for each elderly identified in the
community in consultation with MO-PHC.
ƒƒ Facilitate identification and provide guidance to care givers regarding care given
to bed bound elderly.
ƒƒ Develop elderly support groups named “Sanjeevini”
ƒƒ Conduct periodic home visit to bedbound elderly, sick elderly and restricted
mobile elderly
ƒƒ Undertake preliminary assessment for the need of assistive devices. - Support for
rehabilitative services for the elderly

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 Human Responsibilities
Resources
Medical ƒƒ Conduct weekly fixed day geriatric clinics
Officer ƒƒ In-depth person-centered assessment of elderly; Undertake Advanced
comprehensive geriatric assessment of the elderly.
ƒƒ Primary management of all common diseases of the elderly and basics of
counselling and physiotherapy
ƒƒ Referral and linkages
ƒƒ Assure public awareness on promotional, preventive and rehabilitative aspects of
geriatrics and village
ƒƒ Conduct home visit for bed bound elderly at-least on quarterly basis.
ƒƒ Facilitate provision of assistive devices for the needy elderly and also train them
to use it
ƒƒ Enable skills and competencies of the caregivers

Referral Pathway for Elderly Care across all levels:

Service Delivery Framework & Continuum of Care

Community-Elderly mobilized by ASHA/MPW/

volunteers and Elderly Support Groups

Home bound/Bed bound elderly

SHC HWC (Screening for disease
Screening for disease and disability
and disability
by the CHO

Quarterly visit
by MO to bed/
Primary health centre Weekly home bound
fixed day geriatric clinic
Managing through
teleconsultation services at
PHC
Outpatient/rehabilitative
services and/secondary
level care (CHC/UCHC/SDH
hospitals)
Service Delivery Framework & Continuum of Care

Tertiary level care at DH or

Regional geriatric centres/PMJAY
empanelled hospitals

Key roles of Medical Officer in elderly care

Your role in elderly care would be providing primary level care at the PHC-HWC level as well
as supervision of the activities of the PHC-HWC team. You will also supervise the SHC-HWCs
under your area for providing elderly care services. Broadly, your roles will encompass clinical,
public health and managerial aspects.

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 Clinical roles
’’ Comprehensive assessment and examination of elderly people attending OPD, relevant
investigation and confirming diagnosis. This will also include all those individuals who
are referred to you by the CHO. You will use the Advanced Comprehensive Geriatric
Assessment tool for individuals with more than 3 red flags.
’’ Treatment of elderly people for diagnosed conditions and preparing a treatment and
follow up plan. You will follow-up all such elderly individuals in whom you have initiated
treatment at regular intervals to monitor progression of disease, dose regulation of
medicines and any need for referral to higher centres. If you refer any elderly individual
to higher centres, you will follow up such patients at regular intervals and re-refer if
required.
’’ You will counsel elderly individuals and their caregivers/family about healthy ageing and
ways to maintain good health in old age. You will provide health education regarding
healthy lifestyle including avoiding tobacco and alcohol use, taking a balanced diet and
practicing regular physical activity.

Public health roles

’’ You will undertake planning and conduct of awareness generation activities to sensitize
elderly and caregivers in identifying common elderly problems and orienting them
to home-based care, undertake modifications within the physical home environment
to help reduce hazards that cause falls and fractures in the elderly, counsel against
malnutrition and neglect of care which is very common in elderly through identifying
Training Manual on Elderly Care for Medical Officer at Ayushman Bharat – Health and Wellness Centres

and providing advice for geriatric friendly home settings, sensitize them to the various
needs of the elderly and providing support to the elderly.
’’ You will ensure implementation of the various components of the National Programme
for Health Care of the Elderly.
’’ In order to provide elderly care services, it is important to establish linkages with –
a) NGOs for support group meetings and health promotional activities; b) government
departments, such as Department of Empowerment of Persons with Disability Social
Justice and Empowerment, District Legal Services Authority, Panchayati Raj Institutions
(PRIs), Urban Local Bodies (ULB) etc. to facilitate access to entitlements/schemes/
programs for the benefit of the elderly; c) referral and integrated/coordinated care
linkages with other programs (elderly and palliative care, communicable diseases and
NCDs program etc.)
’’ You will also support the formation of support groups for elderly and elderly caregivers
to improve motivation and share the challenges and success related to elder abuse,
lifestyle changes, reduction in substance abuse and adherence to treatment for chronic
diseases.

Managerial roles
’’ Supervision of elderly care activities at linked SHC-HWCs.
’’ Maintaining relevant records of elderly care services provided at the PHC-HWC including
OPD/ geriatric clinic attendance, screening camps, IEC activities and referrals.
’’ Inventory control including indenting and supply of assistive devices for the elderly
people as per requirement.

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