AGING
By 2030, one in six people in the world will be aged 60 years or over.
- World Health Organization
Normal Aging
Getting old is a normal process of life
The Elderly contribute to society as family, workforce or volunteers but also as staunch community members. While most have good health, we, at DEMCARES witness many are at risk of developing reduced mobility, chronic pain, frailty, dementia or other health problems, for which they require some form of long-term care. As people age, they are more likely to experience several conditions at the same time. Many may also experience mental health conditions such as depression and anxiety disorders.
References:
- World Health Organization
Approximately 14% of adults aged 60 and over live with a mental disorder.
Healthy Aging vs Unhealthy Aging
Mental health issues during different phases of life
The geriatric population in India suffers from a variety of problems associated with old age. Physical and mental health problems among the elderly in India are important issues that get ignored. While healthy aging emphasises on taking care of physical and mental health, unhealthy aging refers to establishing maladaptive habits like chain smoking and alcohol abuse with coping mechanisms like high dependency on others to get their work done when they can still do it; these tend to worsen the health of the elderly person.
The most common mental health conditions for older adults are depression and anxiety. Around 14% of adults aged 60 and over live with a mental disorder. According to the Global Health Estimates (GHE) 2019, these conditions account for 10.6% of the total disability among older adults. In a recent Indian geriatric population study, 18.9% of elderly individuals were having depressive symptoms, and 22.6% were having anxiety symptoms. GHE 2019 shows that globally, around a quarter of deaths from suicide (27.2%) are among people aged 60 or over. Some older adults are at greater risk of depression and anxiety, because of dire living conditions, poor physical health or lack of access to quality support and services. This includes older adults living in humanitarian settings and those living with chronic illnesses (such as heart disease, cancer or stroke), neurological conditions (such as dementia), or substance use problems.
References:
- World Health Organization
Loneliness and social isolation are key risk factors for mental health conditions among senior citizens
- World Health Organization
Adjustment to Aging
We are simply levelling up
Mental health conditions among older people are often underrecognized and undertreated, and the stigma surrounding these conditions can make people reluctant to seek help. At older ages, mental health is shaped not only by physical and social environments but also by the cumulative impacts of earlier life experiences and specific stressors related to ageing. Exposure to adversity, significant loss in intrinsic capacity and a decline in functional ability can all result in psychological distress.
Older adults are more likely to experience adverse events such as bereavement, or a drop in income or reduced sense of purpose with retirement. Despite their many contributions to society, many older adults are subject to ageism, which can seriously affect people's mental health. Social isolation and loneliness are key risk factors for mental health conditions in later life. Abuse of older people, which includes any kind of physical, verbal, psychological, sexual or financial abuse, as well as neglect, seem to play a huge rift within caregiving.
References:
- World Health Organization
Mental disorders among older adults account for 10.6% of the total years lived with disability for this age group.
- World Health Organization
Promotion and prevention strategies of Aging
Environments that support well-being
Key mental health promotion and prevention strategies for healthy ageing include:
- measures to reduce financial insecurity and income inequality;
- programmes to ensure safe and accessible housing, public buildings and transport;
- social support for older adults and their carers;
- support for healthy behaviours, especially to eat a balanced diet, be physically active, refrain from tobacco and reduce alcohol use; and
- health and social programmes targeted at vulnerable groups such as those who live alone or in remote areas and those living with a chronic health condition.
For older adults, social connection is particularly important to reduce risk factors such as social isolation and loneliness. At this stage of life, meaningful social activities can significantly improve positive mental health, life satisfaction and quality of life; they can also reduce depressive symptoms. Example interventions include befriending initiatives, community and support groups, social skills training, creative arts groups, leisure and education services and volunteering programmes. Regular screening camps and health awareness meetings with the elderly and their caregivers designed to provide solutions for their day-to-day problems are part of an important large-scale strategy to tackle this issue in India.
Protection from ageism and abuse is also critical. Key interventions include anti-discrimination policies and laws, educational interventions and intergenerational activities. A range of carer interventions – including respite care, advice, education, financial support and psychological interventions – can support carers to maintain a good and healthy caring relationship that avoids abuse of older people.
References:
- World Health Organization
Mental disorders among older adults account for 10.6% of the total years lived with disability for this age group.
- World Health Organization
Treatment and care
Prompt recognition and treatment of mental health conditions (and associated neurological and substance use conditions) in older adults is essential. This should follow standards for integrated care for older people, which is community-based and focused on both the long-term care of older adults living with mental health conditions and declines in intrinsic capacity, as well as the education, training and support of carers. A mix of mental health interventions are usually recommended, alongside other supports to address the health, personal care and social needs of individuals.
Services range from acute care management to long-term care.
- Acute care is provided mostly in hospital settings.
- Specialized clinics that offer clinical assessment, support, information, and advice to persons with memory problems concentrated in the urban and rural settings
- Day care centers; residential care facilities, which may be long term care or short-respite care.
- Training Domiciliary care services at the residence, such as caregiver training, formal nursing care provided by geriatric home nurses, or other trained personnel.
- Support groups for caregivers and families.
- Mental Health helpline (phone lines handled by trained personnel to address the queries).
References:
- World Health Organization
One in six older adults experience abuse, often by their own carers.
- World Health Organization
Laws and Policies for the Elderly
The geriatric population in India suffers from a variety of problems associated with old age, which are increasingly drawing attention of policy planners, social scientists, and medical and mental health professionals in the country.
| Sl No. | Laws/Policies/Programs | Year | Objectives/Provisions for Geriatric Care and/or Geriatric Mental Health (GMH) |
|---|---|---|---|
| 1. | National Mental Health Program (NMHP) District Mental Health Program (DMHP) | 1982 1995 | Goals include setting up quality MHC services for persons across the living space in cross-cutting issues the elder population is recognized as a vulnerable segment requiring specialized services. Envisions integration of care into primary health care. Implementation serviced for the specific care of the elderly is yet to carried out universally. |
| 2. | National Policy on Older Persons | 1999 | Elders are accorded higher priority in accessing health care resources. The emphasis on ensuring affordability via specific insurance schemes. Encouraging support for NGOs to function in elder health care. Mandates establishment of separate geriatric wards alongside the development of specializations and courses in geriatric medicine and geriatric nursing. **Elder mental health does not find great mention except in a provision mandating appropriate referrals for counseling. |
| 3. | Maintenance and Welfare of Parents and Senior Citizens Act | 2007 | Accords importance to the health of elderly persons and mandates periodic reviews of their health care status. Stipulates provision of elder sensitive and specific medical services that are to be staffed by those experienced in geriatric health care services. Helpline establishment for elderly persons to access help in contexts of abuse that are also linked to health care. **No specific mention of elder-specific or elder-sensitive mental health care services is noted. |
| 4. | National Program for Healthcare of Elderly (NPHC) | 2011 | Aims to provide "easy access to promotional, preventive, curative, and rehabilitative services through community-based primary health care approaches." Setting up daycare centers for the elderly have been stipulated which would cater to elders with mental health issues as well. |
| 5. | National Policy of Senior Citizens | 2011 | Provisions are similar to the NPHCE with emphasis on accessible affordable care via the primary and community health centers with special provisions for elderly persons. Envisions setting up separate elder insurance schemes. Setting up of program for raising awareness about dementia. Emphasis on early identification and management of persons with dementias. |
| 6. | Rights of Persons With Disabilities Act (RPWD) | 2016 | Conditions that are more prevalent in the elderly such as Parkinson's disease, dementia, are included in the Act. Empowers elderly persons with disabilities with rights under the RPWD Act Chapter 2. Cognitive disabilities aside from dementia's do not find specific mention. Disability due to mental illness comes under the purview of the Act, no specific mention of elderly with mental health issues. |
| 7. | National Program for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke | 2017 | Focus on screening, diagnosis, treatment, and rehabilitation of the Non-Communicable Diseases (NCDs) under the purview of the Program. |
| 8. | Law Mental Health Care Act (MHCA) | 2017 | Right to access to mental health services close to the place they reside. Section 18—Promotes specialized clinical services for the elderly in Mental Health Establishments (MHE). Free legal aid service. The government should provide for the care of the mentally ill individual in case of being abandoned/ rejected by family and rehabilitation services. |
| 9. | Allied Healthcare Bill | 2021 | Emphasis is given on providing all-around care for the geriatric population with allyship of different cadres such as occupational therapists, physiotherapists, and clinical psychologists. |
References:
19. Government of India Ministry of Health and Family Welfare
20. National Mental Health Program Guidelines
21. National Policy on Older Persons, 1999
22. The Maintenance and Welfare of Parents and Senior Citizens Act, 2007
23. Rights of Persons With Disabilities Act, 2016
24. National Program for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke, 2017
25. Mental Health Care Act, 2017
26. Allied Healthcare Bill, 2021
Geriatric Depression & Anxiety
Geriatric Depression & Anxiety
Depression and anxiety are common geriatric disorders that have a negative effect on a person's balance (clumsy, unsteady), movement (involuntary movements like tremors can occur), and speech (racing thoughts and faster speech). Other aging issues, such as loss of taste, hearing, or smell, can be problematic, especially for seniors living alone. Deterioration in these vital senses makes older people increase the chances of accidents leading to more injuries. Depression is one of the risk factors for CVS disease, and it has been related to higher mortality rates. In addition, successful care of the main problem, who should undertake efforts to improve patients' psychological and social function, and more efforts should be put into improving issues related to the mental and emotional state of the person and relation to society's function.
There are several warning signs and symptoms of depression, such as persistent sadness, anxiety, or sorrow, undiagnosed aches and pains that don't go away with medication, sudden appetite loss or weight loss, low motivation or energy, trouble falling asleep or staying awake, suicidal thoughts or prior suicide attempts, memory problems, forgetfulness, or difficulty making decisions.
DEMENTIA
Understanding Dementia
What is Dementia?
The most common cognitive health issue facing the elderly is Dementia in India. Globally, 47.5 million people have dementia, and this number is predicted to nearly triple by 2050. Chronic health conditions and substance abuse, such as diabetes, hypertension, depression, HIV, and smoking, increase the risk of developing dementia. Dementia as a term refers to a variety of symptoms resulting from damage to brain cells, which alters the ability of the brain to perform its regular activities. Different illnesses cause this damage to occur in different patterns, which in turn produce unique symptoms.These patterns correspond to the different types of dementia, for e.g Alzheimer's disease, dementia in Lewy bodies etc.
Common signs of Dementia
Dementia usually occurs among the elderly population (aged 65 and above). If an individual younger than 65 is diagnosed with dementia, it is called 'early-onset' dementia and is quite rare.
- Memory loss and thinking difficulties
- Difficulty coping with daily tasks and functioning independently
- Language & communication difficulties
- Changes in mood, judgment or personality
Though memory loss generally occurs in dementia, memory loss alone doesn't mean you have dementia. For a diagnosis of dementia, at least one more of the following core mental functions must also be significantly impaired to be considered dementia:
- Communication and language
- Ability to focus and pay attention
- Reasoning and judgment
- Visual perception
- Orientation and comprehension
Early vs Advanced Symptoms of Dementia
Early Symptoms
Memory difficulties: Misplacing important items like keys, wallets, official documents etc.; forgetting day/date/year/month or important events like festivals and birthdays; making lists to remember things; forgetting recipes if they regularly cook and so on
Subtle language and communication difficulties: Such as searching for words during conversations; forgetting or mixing up names of people, objects or places; using the wrong word during conversation; making minor grammatical errors and so on
Difficulty planning, making decisions, solving problems: Being unable to carry out tasks involving many steps which they otherwise usually can; unable to pay attention to many things simultaneously; giving up responsibilities to others and refraining from being involved in planning events like weddings or festivals and so on.
Being moody: Being easily irritable, low frustration tolerance, crying spells, temperamental or aggressive – more than usual
Becoming inactive and being disinterested in any activity: (losing interest in activities they usually took part in, being withdrawn, less sociable and so on.
Needing help with some of the activities that they were able to do independently previously: Such as starting to get overly dependent on other family members for complex tasks that involve a lot of thinking; struggling with tasks that are new and involve learning; struggling with managing finances as well as they used to and so on
In the later stages of the diseases, a Person with dementia may experience –
- Decline in independent day to day functioning – bathing, dressing, eating, shavingand so on
- Further memory decline – Beginning to forget name of spouse, name of children, misrecognizing familiar people, forgetting their address, phone number or familiar places, being repetitive in conversations
- Wandering – getting lost, leaving the home unexpectedly despite being asked not to
- Will most likely need care provided by others for all day to day activities
- May be unable to recognize people (including close family and friends), or familiar places (their own home or neighborhood)
- May experience bladder and bowel incontinence
- May display little to no communication or language abilities
- May be mostly bed bound
Common difficulties with dementia
Each person is unique and experiences dementia in their own way. The way people experience dementia depends on many factors, including physical make-up, emotional resilience and the support available to them. On a general note, people with dementia may have problems with short-term memory (or remembering things that have happened in the recent past), keeping track of personal items and belongings, paying bills, preparing meals or carrying out other household activities, finding their way around familiar places, planning and remembering appointments- which can be quite frustrating for them. As the illness progresses the person may loose their ability to perform self-care functions such as bathing, brushing one's teeth, changing clothes and recognize family and friends.
The illness affects each person differently. It is important to remember what is true of one Person with Dementia (PwD) may not necessarily be true of another PwD.
Types of dementia
In India it was estimated that in 2010 there were 37,00,000 people with dementia and this number will grow to almost 80,00,000 in 2030. That is 5 in 100 people about the age of 65 may have dementia
Common types of Dementia:
- Alzheimer's disease
- Vascular Dementia
- Dementia in Lewy bodies
- Fronto- temporal dementia
These types of dementia are among the most commonly occurring and account for at least 90% of all cases of the illness. However, it is important to note that the distinctions between these sub-types are not clear in some cases and symptoms may overlap resulting in mixed dementias. Mixed Dementia is observed when more than one cause of dementia can occur simultaneously in a person.
Apart from the above, there are some types of dementia caused by conditions that are often treatable or reversible by timely medical and/or surgical intervention. These include –
- Depression: causes a 'pseudo-dementia' which can get better with antidepressants and talking therapies.
- Toxic reactions, like excessive alcohol or drug use
- Nutritional deficiencies, like vitamin B12 and folate deficiency
- Endocrine disorders such as thyroid hormone problems can cause memory problems
It is important to be vigilant of delirium which occurs commonly among the elderly. Delirium occurs when a person due to may have periods of transient confusion or memory loss due to infection and many other physical health problems including constipation or dehydration. Behaviour like this must immediately be referred to a doctor and can be reversed by initiating appropriate treatments.
Cure vs Prevention of Dementia
Diagnosis of dementia as early as possible is crucial!
An early dementia diagnosis is beneficial for not just the PwD but also for those will take care of them.For practical purposes, it is important for dementia to be diagnosed in the early stages so that doctors can assess the PwD's medical situation as accurately as possible and subsequently administer the right treatment to improve their prospects. Apart from this, an early diagnosis means the PwD has the capacity to plan and make appropriate decisions for the future. These could be medical, financial, family-related or even in terms of the kind or support they want to receive during their illness. Also, an earlier assessment and treatment may completely cure some of the other conditions associated with dementia, such as thyroid problems or depression. Psychological interventions can also be provided to extend their current level of functioning as long as possible and reduce the acceleration of their decline or even stabilize them.
For the carer, an early diagnosis of dementia can be very valuable. It will give them time to cope with the news that their loved one will soon start to change. They can have conversations with their loved one about their future and get familiar with their preferences for care. They can also resolve any feelings that might be provoked by the news along with their loved ones. They also have the time to prepare for their eventual role as the care-giver – which can be extremely stressful and demanding (physically, emotionally and socially). They can extend the period of independence of their loved ones which would subsequently reduce a lot of care-giver burden. An early diagnosis also means that the carer doesn't have to make all important decisions alone; they can involve their loved one as long as they are able to.
Importantly, both the PwD and the carer require time to understand the illness and seek out the best advice and medical care so that they can prepare to face it together.
Risk factors for Dementia
- Increasing age: The risk goes up with advanced age. The older you are the more at risk you are for developing dementia.
- Hardening and narrowing of arteries: The accumulation of fats and cholesterol in the lining of arteries can hinder blood from getting to the brain, which can lead to stroke or another brain injury.
- Diabetes: People with diabetes appear to have a higher risk for dementia, as it is a well-proven risk factor for stroke and cardiovascular disease-related events, which in turn increase the risk for vascular dementia.
- Hypertension: High blood pressure has been linked to cognitive decline, stroke, and types of dementia that affect the white matter regions of the brain.
- Down syndrome: Many people with Down syndrome develop early- onset AD, with signs of dementia by the time they reach middle age.
- Genetics: When more than one family member has the disorder, risk increases. Very early onset frontotemporal dementia is found to be genetic.
- Mental illness: Depression has been associated with mild mental impairment and cognitive function decline.
- Substance use: Smokers are prone to diseases that slow or stop blood from getting to the brain.Excessive consumption of alcohol also increases risk of developing dementia.
(Diabetes and Hypertension has been known to be quite prevalant in India hence it is paramount to keep it under control as one gets older)
Management of Dementia
Dementia is a progressive disease. Unfortunately, there is no curative treatment. However, a lot can be done to improve the quality of life of the PwD and their carers if the diagnosis is made early and appropriate measures are put in place to plan for the future, thus avoiding many a crisis.
Medicines currently available for the treatment of some types of dementia can help in slowing down the disease process. They also can help in managing some of the common behavioural challenges such as restlessness, aggression, sleep disturbance, etc. They are best chosen and monitored by physicians who are experienced in managing persons with dementia. Also, it is important to note that some medicines may not be appropriate for certain types of dementia.
Best outcomes for persons with dementia and their carers are achieved with multi-disciplinary, person centred approach involving the family members as well as professionals like dementia trained nurse, psychologists, home care assistants, occupational therapists, physiotherapists etc. Understanding the uniqueness of the person with dementia and exploring the meaning of some of their symptoms often help in identifying right interventions. Good nursing interventions will be necessary in those with more severe condition.
Treatment for Dementia
Some non-drug interventions for dementia include:
Cognitive Stimulation
Participating in activities and exercises designed to improve memory, problem-solving skills and language ability especially in group settings that facilitate communication and social interaction
Reminiscence
Using the PwD's past information and stories from their child and young adulthood (which in most cases remain intact) to relate to the present.
Validation therapy
Using empathy and listening as the key tools to facilitate well-being in conjunction with talking therapies
Functional Analysis
Using rehabilitative techniques to manage aggression, anxiety, delusions and hallucinations, wandering behaviours by understanding the motivation driving the behaviour and tackling it at that level
Other therapies used with people with dementia include Cognitive behavioral therapy to help reduce their day to day distress, Supportive psychotherapy and family therapy to help the family understand and resolve conflicts in a manner that aids the patient and the family as a whole.
To read more about the treatment and support options DEMCARES offers:
https://www.dementiaindia.org/demcaremedia/booklets/environment-digest-final.pdf
https://www.dementiaindia.org/demcaremedia/booklets/healthproblems-final.pdf