India is in a phase of demographic transition. Trends reveal that population of elderly is growing faster than general population. The life expectancy has steadily gone up from 32 years from the time of independence to 67.14 years in 2012. There has been a sharp increase in the number of elderly persons and it has been projected that by the year 2050, the number of elderly people would rise to about 324 million.
India can be called as “an aging nation” with 8.3% of its population being more than 60 years old. With the decline in fertility along with declined mortality rate and increased life expectancy, a significant part of demographic change is the gradual increase in the number of elderly persons. Among the elderly, the so called Old-Old (above 80 years) are growing at a fast pace and these people are usually weaker, insecure, more frail, dependent and suffer more often from age-related diseases. The increasing life span and poor health care add to the degree of disability among the elderly people and compound the problems of care giving.
Elderly persons show lot of variation in age-related physiological decline and medical disorders. The age-related decline in following progress slowly
- Muscle strength
- Immunity and homeostasis
However, the onset of disease may be abrupt, the course of illness varying, complications severe and dreadful. Many chronic diseases increase with age and some elderly are more susceptible to co-occurring problems compared to others. Chronic diseases and disabilities are another area of concern.
Physiological Changes in Old-Old People
The physiological decline refers to the physical changes in an individual because of the decline in the normal functioning of the body which results in poor mobility, hearing, vision, inability to eat and digest food properly, a decline in memory, the inability to control certain physiological functions and various chronic health problems.
Specific Health Issues in Elderly People
In India, the elderly people suffer from dual medical problems, i.e. communicable as well as non-communicable diseases. This is further compounded by impairment of special sensory functions like vision and hearing. A decline in immunity as well as age-related physiologic changes leads to an increased burden of communicable diseases in the elderly. The prevalence of tuberculosis (TB) is higher among the elderly than younger individuals. Elderly people suffer from chronic obstructive pulmonary disease, coronary heart disease, stroke, Alzheimer’s disease, cataracts, prostatic hypertrophy,cancer, macular degeneration, etc. and at the same time, they are vulnerable to infections involving respiratory (including TB), urinary and digestive tract.
According to the Government of India statistics,
- Cardiovascular disorders account for one third of elderly mortality.
- Respiratory disorders account for 10% mortality
- Infections including TB account for another 10%
- Neoplasm accounts for 6%
- Accidents, poisoning and violence constitute less than 4% of elderly mortality
- Nearly 4% for nutritional, metabolic, gastrointestinal (GI) and genitourinary infections.
- Instead of pyrexia and leukocytosis, the acute infections in elderly may present in an atypical way with impaired intellect/memory, incontinence, instability or immobility.
- Malnutrition, occult hypothyroidism, renal failure, depression and sexual problems are also common in the elderly.
The health issues in elderly are several. Following are the important health issues, which are frequently encountered.
Figure 1 depicts the patho-physiological changes in elderly resulting in various geriatric syndromes.
Frailty is defined as dependence on others for activities of daily living (ADLs)—bathing, feeding, dressing, toileting and mobility. Both frailty and disability frequently coexist and the prevalence increases with increasing age. Impaired cognitive function may add to the complexity of the situation.
Normal aging is associated with anorexia, which is more prominent in male than in female. Anorexia in elderly is due to decline in energy demand, due to lower physical activity andlow BMI. Loss of taste sensation, reduced digestive capacity and low testosterone in males, associated with increased leptin are other factors responsible for anorexia in elderly.
Malnutrition is a consequence of anorexia, as the food intake decreases to a level below the energy demand. Monotonous diet, inadequate intake of important micronutrients, lack of sufficient fresh food/fruits and vegetables, contribute to malnutrition. The adverse health consequences of malnutrition are impaired muscle function, immune dysfunction, anemia, reduced cognition,decreased bone mass, delayed recovery from surgery, delayed wound healing, increased risk of falls, disability and mortality.
Anorexia and malnutrition lead to muscle weakness and weight loss in elderly people. Malabsorption, hyper-metabolism, cancers, admission to elderly home, acute illness, depression,hospitalization, dysphagia,various drugs, dental issues, oral infections, endocrine conditions such as thyroid diseases, reduced access to food and dehydration contribute to weight loss.
Awareness in the patients, caregivers and physicians related to this often neglected issue is important. The record of regular weights measurement should be maintained in medical records of all elderly subjects.
- Poor muscle strength
- Hypoglycemia in diabetes
- Cerebellum/basal ganglia involvement
- Postural hypotension (mostly drug induced or autonomic) in hypertension and peripheral neuropathies.
Preventive strategies for falls need comprehensive medical, rehabilitative and environmental interventions.
Aging is associated with progressive bone loss and osteoporosis with increased risk of hip and other fractures. It is more common in postmenopausal women due to cessation of estrogen secretion. The risk factors for osteoporosis are
- Female gender
- Advancing age
- Small build
- Calcium and vitamin D deficiency
- sedentary lifestyle
- Smoking, alcoholism and caffeine excess.
Bone mineral density measurement by dual energy X-ray absorptiometry (DEXA) scan is the modality readily available for the diagnosis of osteoporosis. Also the following will help strengthening bone
- Calcium and vitamin D supplementation
- Regular walking
- Muscle strengthening exercises
- Cessation of smoking
- Moderation of alcohol intake are to be followed meticulously by the elderly.
- Sunlight exposure at least 15 minutes a day for three times a week is a good source of vitamin D.
The involuntary leakage of urine is highly prevalent in elderly, particularly females. The increasing age, multiparity, obesity and associated medical co-morbidities are the risk factors for urinary incontinence (UI) (Table 1).
The first line of treatment for urinary incontinence is bladder training associated with pelvic muscle exercise, sometimes with electrical stimulation. Treatment of cause of UI, treatment of urinary tract infections (UTIs), omission of culprit drug/s, sometimes surgical correction are to be planned in elderly subjects with UI.
The lesions due to skin breakdown occur in elderly quite frequently. The weak elderly, whose body parts goes through pressure,shearing, friction, and drenching, develop bed sores on skin, subcutaneous tissue, muscles and also in bones and joints. Prolonged immobilization, inactivity in/ outside bed, fecal/Urinary Inconsistency, malnutrition are the risk factors for development of sores in elderly. The factors prolonging the healing of ulcers are anemia, infection, diabetes, peripheral vascular diseases, edema, paralysis, dementia, alcoholism, fractures and malignancy.
Frequent change of patient’s position, avoiding head end elevation beyond 30°, use of special beds like water/air beds, keeping skin and body folds clean and dry, are the basic steps in preventing the decubitus ulcers. Regular nursing care, control of infection and debridement of wound whenever indicated are mainstay in the management.
Sleep disorders are common in elderly with difficulty in onset of sleep, frequently leading to excessive daytime sleepiness. In most of the cases, it is secondary to some medication or medical or psychiatric illness. Detailed history is crucial in diagnosis.
The primary sleep disorders are restless leg syndrome, periodic limb movement disorders, rapid eye movement (REM), sleep apnea. If diagnosis of primary sleep disorder is established, specific treatment should be started. In patients with obstructive sleep apnea or long term continuous-positive airway pressure (C-PAP) has proven to be useful in reducing cardiovascular mortality.
Delirium is an acute disorder of disturbed attention that fluctuates with time. It is associated with high in-hospital mortality and sometimes with permanent brain damage. The clinical features of delirium include:
- Rapid decline in the level of consciousness with difficulty in focusing, shifting or sustaining attention
- Cognitive change (mumbling, memory gaps, incoherent speech, hallucinations, disorientation)
- Medical history suggestive of pre-existing cognitive impairment, frailty and co-morbidity (Table 2).
The diagnosis of delirium can be done in a hospital by simple tool like confusion assessment method (CAM). Prompt and early identification and treatment, withdrawal of culprit drug and supportive care are the focus areas in the treatment.
Cognition Impairment (Dementia)
Dementia is decline in cognitive, intellectual and memory function due to affection of central nervous system without loss of consciousness. Dementia occurs in Alzheimer’s disease, multi-infarct state, subdural hematoma, normal pressure hydrocephalus, hypothyroidism, head injury, alcoholism, brain space occupying lesions (SOLs) and vitamin B12 deficiency.
Clinical features include slow onset of forgetfulness, loss of interest in surroundings, impairment in social skills and personality. Depression is an early feature of this disease. Disorientation in time and space, followed by language impairment, aphasia and paralysis are common features. Vegetative state followed by death are frequent end results.
Neuro-imaging helps in supporting the diagnosis of dementia. Unless a treatable cause is found, the treatment is mostly supportive. Neuro-protective agents are claimed to have beneficial effects on cognitive functions.
Screening For Elderly People
- Osteoporosis: Bone mineral density (BMD) at least once after the age of 65 years, once in every 2–3 years.
- Hypertension: Blood pressure at least once a year, more often in patients with hypertension.
- Diabetes: Serum glucose and hemoglobin A1C every 3 years, more often in patients who are obese or hypertensive.
- Lipid disorders: Lipid profile every 5 years, more often in patients who are diabetics or any cardiovascular disease.
- Colorectal cancer: Stool occult blood test, sigmoidoscopy or colonoscopy, regularly up to age of 75 years. Breast cancer: Mammography every 2 years between ages 50 and 74 years.
- Cervical cancer: Pap smear every 3 years up to age of 65 years.
Preventive Plan for Elderly People
- Vaccinations: Influenza immunization annually, Pneumococcal immunization once at the age of 65 years.
- Myocardial infarction: Daily aspirin in patients with prior history or with cardiovascular risks factors.
- Osteoporosis: Calcium 1,200 mg daily and vitamin D at least 800 IU daily.
- Exercise: In older adults, increased physical activity improves physical function, muscle strength, mood, sleep and metabolic risk profile. Regular, moderate intensity supervised exercise can reduce the rate of age associated decline in physical function. 150 minutes/week of moderate intensity aerobic activity such as brisk walking and muscle strengthening exercises are recommended for elderly.
- Nutrition: Basic principles of healthy diet are also valid for older people, such as :
- Consumption of fruits, vegetables, whole grains
- Good hydration, at least 1,000 mL of fluids/day
- Fat-free and low-fat free dairy products, legumes, poultry
- Fish, at least once a week
- Supervised medications and ensuring the drug compliance in elderly
At present, most of the geriatric outpatient department (OPD) services are available at tertiary care hospitals in India. Since 75% of the elderly people live in rural areas, geriatric health care services should be a part of the primary health care services.
The elderly population has longevity on one side and compromised quality-of-life on the other. A probable solution is a multidimensional approach that comprises of both curative as well as preventive, rehabilitative and terminal and respite care. The medical/health and social service institutions in the country need to prepare for the demands of care of the frail/disabled senior citizens to minimize the gap between the longevity and associated poorer quality-of-life.
Increased life expectancy, rapid urbanization, and lifestyle changes have led to varied problems for the elderly in India. Complete health care to the elderly is possible only by the comprehensive and multidisciplinary approach.
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