Geriatric Care

Introduction
Old age is a incurable disease Seneca
You do not heal old age. You protect it; you promote it; you extend it Sir James Sterling Ross

Geriatric care
Geriatrics is the branch of medicine that focuses on health promotion and the prevention and treatment of disease and disability in later life. The term itself can be distinguished from gerentology, which is the study of the aging process itself. The term comes from the Greek geron meaning "old man" and iatros meaning "healer", This was proposed in 1909 by Dr. Ignatz Leo Nascher, former Chief of Clinic in the Mount Sinai Hospital Outpatient Department (New York City) and a "Father" of geriatrics in the United States. "Geriatrics" is cognate with Jara in Sanskrit which also means old.

Need of Geriatric care

India is undergoing demographic changes. with the declining birth rate at 34 per cent and increasing life expectancy the geriatric population, which is at 7 per cent now, is expected to reach 10 per cent by the year 2030. India is only the second country after China to have worlds largest geriatric population.

Need of Geriatric care continue.

According to the 2001 census, India is home to more than 76 million people aged 60 years and over. This age group, currently only 7.4% of the population, is expected to grow dramatically in the next few decades. at present, 10.5% of Kerala's population is older than 60 years while in Dadra and Nagarhaveli, this proportion is only 4%. Regions with more favourable health indicators seem to be aging faster and the demand for specialist services will soon be evident in such places.

Implications of demographic figures

Larger number of elderly requiring care Considerable period of life after 60 or 70 years requiring care No decline in the number or proportion of other vulnerable population requiring care Competition among various group of people for resources.

Challenges of health care of elderly

Health care needs of elderly are different from those of other age groups The structural, functional, mental and emotional status of elderly is not the same as of younger population The manifestation and course of disease can be very unpredictable and may require specialized care. The goal of health interventions is more likely to care than cure. Consequently restoration of functions and improvement in quality of life than eliminating the disease.

Myths related to old age

Most elderly live in developed countries. ( over 60% of elderly live in developing countries i.e 355 million out of 580 millions and by 2020 it will be 700 millions out of 1000 millions) Elderly are all the same ( elderly are diverse group some lead active healthy lives others of much younger may have poor quality of life due to many contributing factors such as Participating in family and community life Eating balanced and healthy diet Maintaining adequate physical activity Avoiding smoking and alcoholism Genetic component Men and women age same way (Men and women age differently. Women live longer than men and having biological advantage until menopause as hormones protect them from ischemic heart diseases for example)

Myths related to old age continued

Elderly are frail ( Far from being frail, the vast majority of elderly remain physically fit and well into later life and able to care for themselves. It is a minority of elderly who are very old and became disabled to the point that they need assistance for the activities of daily living.) Elderly have nothing to contribute. (Elderly make innumerable contribution to their families, society and economies) Elderly are an economic burden on the society. ( most elderly around the world continue to work in both paid and unpaid jobs making a significant contribution to the economic prosperity of their community e.g. in agriculture men and women continue working till very late in life and in developed world there is recognition that let the people work till they can.)

Problems of old age

Economic problems Social problems Mental problems Physical problems

Economic problems
On retirement income reduces to half The working capacity declines with age Provident fund and bank balance is already spent on making houses and settling the children Big sum of money is needed to spend on medical care

Table 1: Percentage of elderly economical dependents in India Compiled from 42nd NSSO, 1986/8

Degree of Male dependence Rural Urban

Not dependent Partially dependent Fully Dependent 51.6 45.71

Female
Rural 8.78 13.71 77.51 Urban 4.84 9.13 86.04

16.20 16.90 32.74 37.39

Social problems
loss of status after retirement might loose spouse, other near and dear ones or good friends sons, daughters and young friends get busy in their own affairs there is a painful feeling of futility and loneliness which is increasing more due to nuclear families the needs of old age such as mixing up with relatives, playing with children, becoming useful to society, feeling of wanted and needed were well taken care in joint families earlier

Mental problems
Mental changes are inevitable in old age A certain degree of cerebral atrophy in universal in elderly and is associated with loss of memory and slowing of reflexes Sexual changes aggravate mental tension Senile dementia is well known entity Depression associated with social isolation Suicidal tendencies may increase

 A comparative study to assess emotional well being of senior citizen staying in old age home verses senior citizens staying in families revealed that 90% of senior citizens in old age home were in border line emotional well being(61-80 score), 5% were having positive emotional well being (81-100 score) and another 5% were having negative emotional well being (40-60 score). Whereas 92% of senior citizens living with families were having positive emotional well being (81-100 score) and only 8% were having border line emotional well being(61-80 score). This difference was statistically significant. Naik Nisha

 A comparative study on quality of life among senior citizens living in home for aged and family setup in Erode district showed that majority of senior citizens living in home for aged had moderate quality of life but none of senior citizens reported high quality of life. Similarly in family set up majority of senior citizens moderate quality of life. But overall mean score was higher among senior citizens living at family set up than living in home for aged. Kavitha AK

Physical problems
There are physical changes in the body with the aging process such as
loss of elasticity of skin thinning and loss of hair brittleness of bone weakness of muscles slowness of movements unsteadiness of gait sluggishness of reflexes immune system of body decline metabolism begins to slow down kidney loose 50% of its efficiency lungs loose 30-50% of their breathing capacity

Physical problems continues..

Taste and smell sense decline that may give rise to lack of appetite Pupil shrink reducing the amount of light reaching the retina Lens becomes hard and clouded leading to cataract organ functions deteriorate can cause
o o o o o o o o o o o impairment of special senses especially hearing and sight deterioration of heat regulating mechanism of body hypertension and coronary diseases Obesity osteoporosis and osteoarthritis prostate enlargement Diabetes Cancer cardiac and respiratory problems Accidents disability

A study to assess the health complains and related self care abilities among the geriatric population highlights that among 117 elderly subjects dental problems (93.1%) headed the topmost rank and the skin problems (20.5%) the last. The other health complaints reported were vision (80.3%), general weakness (80.3%), musculoskeletal (65.8%), falling memory (51.2%), chest and lung problem (50.4%), digestive (39.3%), addiction (48.7%), neurological (46.1%), urinary (27.3%), hearing (27.3%), blood pressure (24.9%). In musculoskeletal system females had more problems (80.7%) than males (53.8%) Similarly in failing memory, urinary complains and hearing impairment females had higher problems than males . In chest lung problems, addiction males had more problems than females. Bhutia TK.

On assessing health problems 100 elderly at old age home it was observed that most residents had cataract (52%), anemia (38%),osteoarthritis (37%), gastroesophageal reflux disease (32%), hypertension (28%), diabetes (24%), constipation (15%), sensorineural hearing loss (14%), coronary artery disease (13%), chronic obstructive airway disease (11%), upper respiratory tract infection (7%), depression (6%), glaucoma (6%), benign prostatic hypertrophy (6%), optic nerve atrophy (4%), low backache (4%), constipation (4%), hypothyroidism (3%), rheumatoid arthritis (3%), corneal opacity (3%), conjunctivitis (3%), blindness (3%), anorexia (3%), knee joint pain (3%), fracture (2%),pulmonary tuberculosis (2%), arrythmias (2%), carpal tunnel syndrome (2%),hydrocele (2%), dementia (3%), sciatica (2%), eczema (2%), senile tremors (2%), chronic fatigue syndrome (2%), and obesity (2%). Besides, chronic alcoholic liver disease, Parkinson's Disease, piles, prolapsed intervertebral disc, schizophrenia, hiatus hernia, dermatitis, diabetes, fibroid uterus, lumbar spondylosis, ascites,dysentry, herpes Zoster, migraine, urinary incontinence, lymphadenopathy,deviated nasal septum, vertigo, pyorrhoea and corneal opacity were also seen.
Government of India WHO India Country Office Collaborative Programme

 A quasi experimental study on lacrimation and associated symptoms of mild dry eyeby application of warm compress among geriatric population at village Dhanas UT Chandigarh revealed that 42% of geriatric population was suffering from mild dry eye warm compress was applied on the eyelids of 36 subjects of experimental group for seven days and tear level of experimental group and control group was assessed on first and seven days, It was observed that tear level and symptoms improved significantly in experimental group on seventh day. Madhu Malini

 Study on intensity of knee joint pain by Application of moist heat among geriatric population found that 48% of geriatric population was suffering from Knee joint pain. Moist heat was applied at knee joint twice a day on 43 subjects of experimental group. Intensity of pain was assessed in experimental as well as control group on first and 8th day. It was observed that intensity of knee joint pain and intake of pain killers reduced significantly in the experimental group. Parminder Kaur

Elder abuse
Elder abuse is often defined as a single, or repeated act, or lack of appropriate action, occurring within any relationship where there is an expectation of trust which causes harm or distress to an older person (WHO)

Elder abuse
There are several types of abuse of older people that are universally recognised as being elder abuse and these include: Physical: e.g. hitting, punching, slapping, burning, pushing, kicking, restraining, false imprisonment/confinement, or giving too much medication or the wrong medication; Psychological: e.g. shouting, swearing, frightening, blaming, ridiculing, constantly criticizing, ignoring or humiliating a person. A common theme is a perpetrator who identifies something that matters to an older person and then uses it to coerce an older person into a particular action;

Elder abuse
Financial: e.g. illegal or unauthorized use of a persons property, money, pension book or other valuables (including changing the person's will to name the abuser as heir), often fraudulently obtaining Power of attorney followed by deprivation of money or other property, or by eviction from own home; Sexual: e.g. forcing a person to take part in any sexual activity without his or her consent, including forcing them to participate in conversations of a sexual nature against their will; Neglect: e.g. depriving a person of food, heat, clothing or comfort or essential medication. In addition some countries also recognise the following as elder abuse: Rights abuse: denying the civil and constitutional rights of a person who is old, but not declared by court to be mentally incapacitated. This is an aspect of elder abuse that is increasingly being recognised and adopted by nations Self-neglect: elderly persons neglecting themselves by not caring about their own health or safety.

Management of geriatrics
Prevention and management of illness or disability Maintenances of general health and nutrition Prevention of accidents Combating ageism

 Periodical medical check ups, usually annually to rule out the chronic diseases at the beginning itself Immunization Acceptance and adaptation to the demands of chronic disease Continuity of care Monitoring drug usage Maintaining family and neighbour support system Management of crises Financing the health care Planning for the old age

Prevention and management of illness or disability

Maintenance of general health and nutrition

Physical activity Regular contact with family and friends Participating in political, social or civic concerns Satat udyog Shant man means be busy be calm Keeping too busy to be ill and too healthy to be old Keeping busy in
social work religion pursuits Loneliness has to be decreased by suitable hobbies, social service etc. Joining the clubs or groups of senior citizens

Maintenance of general health and nutrition

Adequate nutrition Use of dentures if needed Adequate fluid intake, fresh fruits, vegetables to alleviate constipation Having good sleep as sleep is very important for mental health Self health monitoring and self care

Prevention of accidents
Developing safe environment and habits to compensate sensory loss and slowed or unsteady reactions to danger Limiting driving Wearing comfortable and suitable clothes and shoes Good house keeping Using stick for support

Management of Elderly abuse

Educate individual about occurrence of elderly abuse Implement safety plan ( Placement in safe home, court protection order, hospital admission) Refer patient or family members (counseling services, legal assistance) Follow up

Government Policies
Old age pension Traveling concession Reservation of seats for elderly Separate queue for senior citizens Special reservation in housing schemes for pensioners Old age homes

Management Continued
Kerala government has already announced a policy for health care of elderly in 1997 and draft bill is already ready in 2004. Older person living alone should be encouraged to register with the police stations and a separate cell should be set up at police stations to keep a vigil on such older persons in their jurisdiction.

National Policy for Older Persons

Announced in January, 1999. Objectives: to encourage individuals to make provision for their own as well as their spouses old age; to encourage families to take care of their older family members; to enable and support voluntary and non-governmental organizations to supplement the care provided by the family; to provide care and protection to the vulnerable elderly people, to provide health care facility to the elderly; to promote research and training facilities to train geriatric care givers and organizers of services for the elderly; to create awareness regarding elderly persons to develop themselves into fully independent citizens.

World Elder Abuse Awareness Day (WEAAD)

In 2006 the United Nations designated June 15th as World Elder Abuse Awareness Day (WEAAD) and an increasing number of events are held across the globe on this day to raise awareness of elder abuse, and highlight ways to challenge such abuse.

Specialized education for geriatric care

Post Graduate Diploma in Geriatric Medicine for MBBS doctors Six Month Certificate Course in Geriatric Care 1-year Post Graduate Diploma in Integrated Geriatric Care 3-Month Certificate Course, the NGO trainees are exposed to different techniques and tools relevant for geriatric care

Organizations working for elderly

Help age India Servants of people society Geriatric society of India

Geriatric care in Chandigarh

Geriatric friendly low door buses Separate queue for senior citizens Pavements for walking on the road sides Parks Free once a weak medical check up and medication by help age India in low socio income colonies Old age homes

References
1. Naik Nisha. A comparative study to assess emotional well being of senior citizen staying in old age home verses senior citizens staying in families. Nightingale Nursing Times 2007; 2;10;January:37-38. 2. Kavitha AK. A comparative study on quality of life among senior citizens living in home for aged and family setup in Erode district. Nightingale Nursing Times 2007; 3;4;July:47. 3. WHO. Aging exploding the myths. Ageing and health programme. WHO publication 1999. cited by Nightingale Nursing Times 2005; 1;8;Oct:36-40. 4. Bhutia TK. A study to assess the health complains and related self care abilities among the geriatric population. Unpublished MSc Nursing thesis, Cllege of nursing, PGIMER, Chandigarh 1997. 5. Dey AB. Health care of older people. A manual for trainers of nurses. WHO publication. Ministry of health and family welfare 2003. 6. Mahajan BK, Gupta MC. Textbook of preventive and social medicine. 2nd edition 1995. Japee brothers medical publishers (P) LTD. 7. Malini M, Walia I, Kaur Sukhwinder. A quasi experimental study on lacrimation and associated symptoms of mild dry eye by application of warm compress among geriatric population at village Dhanas UT Chandigarh. Nursing and Midwifery Research Journal 2007;3(4):152-161. 8. Kaur Parminder, Walia I, Saini SK. Study on intensity of knee joint pain by Application of moist heat among geriatric population. Nursing and Midwifery Research Journal 2007;3(4):162-171. 9. NICE training resources. Ministry of social Justice and empowerment, government of India. trainingresourcemht!http://nic.nisd.gov.in

10. PIB Press release. Programme for care of older person. mh!http//socialjustice.nic.in 11. Elder abuse. Wikipedia, the free encyclopedia. 12. WHO. Evaluation of health status and health needs of old age home residents and establishment of minimum standards of health services in long stay institutions in India.Final report. Government of India World Health Organization India Country Office Collaborative Programme 2006-2007. 13. Park K. Parks textbook of preventive and social medicine. 17th edition. Jabalpur:M/s Banarsidas Bhanot Publishers 2000. 14. Mahajan BK, Gupta MC. Textbook of preventive and social medicine. 2nd edition. New Delhi: Jaypee Brothers Medical publishers (p) Ltd 1995 15. Tandan Lavanya. Elder Abuse. Nightingale Nursing Times 2005; 1;6;June:2428.