INTRODUCTION The total aged population in developing countries is currently as large as the total aged population in the rest

of the world. This segment is growing at a disproportionately faster rate in the developing world and by the year 2000 A.D.. their number is expected to increase by 100 million compared with an increase of 38 million in the developed world (Table 1). Table 1 World Population Projections Year Total Population Population (Million) 65 + years Developing Countries 1980 3284 129 2000 4297 229 Developed Countries 1980 1131 129 2000 1272 167

Percentage 65 + years 3-9 4-7 11-4 13-2

The Western Pacific Regional Office of the World Health Organisation carried out a survey on social and health aspects of the ageing population in four countries of Asia, and Pacific (Malaysia, Philippines, Republic of Korea and Fiji). (Andrews,1987). The demographic characteristics observed were in tune with those of other developing countries in general, but with relatively a smaller percentage of the total population in the older age groups. India ranks second population-wise and seventh area-wise and supports 15% of the world's population. Those aged 60 + (N = 43 millions) currently constituting 6% of the country's population are expected to soar to 75 millions around 2000 A.D. Next year, 1991 is the census year. It is not the percentage of the aged in the population, but it is their number that is formidable in the developing countries. The United Nations 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 presently falling under the category of 'matured' society, will soon reach the status of the 'ageing' society by 2000 A.D. The distribution of population in developed countries, starting with a triangular type has now reached the shape of a rectangle. In India it is at present triangular with lower age groups constituting the bulk of the population. China alone among the Asiatic countries, with its family planning drive is approaching rectangular pattern approximating that of the Western world. The Indian Council of Medical Research identified the aged as the priority area and instituted a single centered Task Force Project in 1981. Initially this project started at the Institute of Psychiatry, Madurai Medical College and later completed

Source: UN Age and Sex Composition by population by country, 1960-2000, New York, 1979. Andrews, G. R. (1987). Annals of Academy of Medicine. Singapore. Ageing in the Developing Countries of Asia and the Pacific-Implications for Health Care pp. 3-10. Accessibility and adequacy Out of 603 subjects, to 191 (32%), PHC was of easy access and to the remaining 412 (68%), the sub-centres could be reached by some method of transport. On enquiry about adequacy of treatment facilities, more than half of those interviewed opined that the treatment facilities to be 'adequate' at the PHC while two-thirds felt inadequate about them at the sub-centres. 56% placed the facilities as 'adequate' at the PHC while a meagre 6% said so at the sub-centres, The figures for the 'non-adequacy' of the treatment facilities at PHC and the sub-centres were 8% and 60% respectively. The remaining pleaded ignorance on the subject. Satisfaction The satisfaction or otherwise with treatment at PHC/ Sub-centre and reasons for not being satisfied are offered in Tables 11, 12. Table 11 Satisfaction with treatment at PHC/Subcentre (among those taking treatment) Satisfaction Treatment At PHC At Sub-centre (N = 134) (N = 68) Satisfied 93 60 Not satisfied 23 3 Non-responders 18 5

About 70% of those taking treatment at the PHC reported' satisfaction while 17% expressed otherwise, Eighteen subjects 'could not assess' whether satisfied or not. Eightyeight per cent reported satisfaction with treatment at the sub-centres. This high figure probably reflects their resorting to facilities for minor ailments. Table 12 Reasons for not being satisfied with the treatment Reason At PHC At Sub% centre %

1. Inadequate drugs 2. Inadequate injections 3. No improvement in health condition even after treatment 4. Poor attention and care 5. Doctors not present

5 (12.2) 12 (41.5) 16 (39.0) 3 (7.3) ---

7 (87.5) 1 (12.5) 5 (62.5) 2 (25.0) 7 (87.5)

MPHWs' visits and services On enquiry about the 'frequency of visits' made by the MPHWs to the villages, 325 (54%) put it as 'once a fortnight' and 176 (29%) as 'once a month'. Ninety-seven (16%) said that the MPHWs visit 'occasionally' while 5 (1%) failed to recall having seen them at all. One of the major functions of the MPHWs was making it known to the geriatric subjects in the PHC area, about the functioning of the 'geriatric clinic' at the PHC/ Sub-centres. An evaluation of this 'awareness' revealed a near total success since 564 (94%) knew of the geriatric clinic at the PHC/ Sub-centres. Some of the services offered by the MPHWs were appreciated by the elderlies, (Table 13) : Table 13 Services rendered by MPHW Dispensing of drugs at doorstep Taking them to PHC/ Sub-centre Maternity Care of the young women Referral to Geriatric clinic Health Education Arranging project research officer to visit to the household Family counselling

1. 2. 3. 4. 5. 6. 7.

N % 337 55.9 309 51.2 258 42.8 225 212 35.2 2 0.3 2 0.3

Three fourths of the subjects (N = 453, 75%) admitted their having been benefited by the MPHWs' services while 76 (13%) felt otherwise. The remaining 74 (12%) were noncommittal. The expectations of the subjects concerned medical (N = 251, 42%), economic (N = 203, 34%), social, recreational, nutritional (N = 45, 8%) and occupational (N = 33, 6%)

rehabilitative measures. However, 71 (12%) entertained none of these or other expectations. Table 16 Suggested Intervention Number % Organising medical camps in the villages for 698 82.8 the elderly (involving specialisation) frequently Motivation of doctors/others by the Govt. to 369 43.8 serve in the rural areas Starting of more rural hospitals to cater to 218 25.9 the needs of the rural people

Family and Social Intervention The intervention measures comprised careful listening to the family and social problems of the subjects and offering appropriate and relevant advice in respect of the problems of ageing. The subjects were also motivated to indulge in such social and religious activities as visiting friends and families, visiting temples and attending to religious discourses and in recreational activities such as visiting cinema theatres, playing indoor games etc., and to avoid remaining 'idle' as much as possible. Excepting for 9 subjects, who found this type of intervention was of no use to them, all the others (N = 386) accepted family and social intervention in some degree or other depending on their liking. The table 17 offers various other intervention measures extended to the geriatric subjects. Table 17 Family/ Social Intervention Intervention Measures Number % Patient listening to family/ social problems 339 85.8 Encouraging talk explaining the problems of 176 44.6 ageing Counselling 49 12.4 Motivating them to indulge in various social 11 2.8 activities (like visiting temples, hearing religious discourses etc.) not to keep themselves idle Satisfaction with intervention Three hundred and eighty subjects (98%) expressed satisfaction over the family and social intervention measures. There were 6 subjects, who could not achieve satisfaction. Three of them stated that the measures were not useful specifically to them, while 3 others stated that family problems could never be solved by such advice. The reasons

advanced by the subjects for being satisfied with these intervention measures are as follows: a patient listening to family/social problems (N = 326, 85%), suitable counselling to cope up with family problems (N = 179, 46%), organising recreational activities (N = 9, 2%). Two destitute women were satisfied on admission into the Old Age Homes. Suggested improvements in family/social intervention When requested to suggest what other social intervention measures they expected, the subjects responded as follows : (Table 18) Table 18 Suggested Improvements Intervention Measures Number % Organisation of recreational activities in a bigger 591 70.1 way (Cinema, games, festivals, drama etc.) Arranging religious discourses by eminent 284 33.7 persons Starting of Old Age Homes in Villages 282 33.4 Occupational rehabilitation 21 25 Nineteen subjects could offer nothing on these measures. The success of these intervention measures on such variables like family jointness, family integration, social integration and living status was reflected by the high percentage of people being satisfied with these and the significant improvement achieved in the areas of family and social integration of the elderlies on followup (as discussed earlier). A NOTE ON MANAGEMENT AND OTHER INTERVENTION MEASURES The intervention measures consisted of medical treatment either at the PHC or through referral to the Govt. Rajaji Hospital, Psycho-social management (counselling and supportive psychotherapy), arranging of nutritional and economic support, offering the principles of health education and organising rehabilitation within the existing facilities. These are incorporated in the Training Programme to the PHC medical personnel and Multi Purpose Health Workers which have been referred to already. Medical It is not to be assumed that all old people are sick. In a study of 1598 subjects aged 60 + living in 200 villages in Tamil Nadu, Krishnan Nair (1980) reported on their health status as measured by mobility, sensory impairment, incapacity, self-perception of health and physician utilisation. Vast majority of the elderly, more than 4 in 5 failed to rate themselves as in good health. Health pessimism appears to be a predominant feature of the elderlies.

The subjects were attending either the main PHC at Kallandiri or its sub-centres. MPHWs made routine visits to the homes of these patients as well as those who did not attend the PHC enquiring about the progress, doling out the drugs and imparting general information on health education. The treatment at the PHC was carried out through the special Geriatric Clinic of the ICMR functioning in the Primary Health Centre. 73% of the subjects were treated at the PHC level, while 18.5% were referred to specialists at the Govt. Rajaji Hospital; 1.1% of the subjects were treated as inpatients in the Govt. Rajaji Hospital for physical illness, while 0.5% as patients for psychiatric ailment. The conjoint treatment namely by the PHC staff and the visiting specialists was offered to 6.9%. The efficacy of the training imparted to the PHC MOs was testified by the fact that almost 3/4ths of the sample were managed at the PHC level. Utilisation of Eye Camp Services Dr. G. Venkatasamy, Director, Aravind Eye Hospital offered services for examination of the subjects and cataract extraction for those who needed. The staff of the Aravind Eye Hospital conducted special Eye camps at Kallandiri PHC, Othakadai and Karupayeeorani sub-centres. The services of the eye camps conducted by Aravind Hospital elsewhere in the PHC area during the intervention period were also utilised by the subjects. Of the 395 subjects utilising the geriatric clinic, 178 subjects (45.1%) availed of the consultation services in these camps, while 54.9% did not (as elicited in sub-sample survey II). In the latter category, the reasons offered were : Consultation helplessness and hopelessness and considers himself as unfit to live. The depressives may frankly express suicidal ideation and reject treatment even for their physical problems like cataract. Out of loss of interest and despair, some of them become tearful. There is a gradual loss of weight due to poor intake of food. Such persons should be identified since treatment is rewarding in these patients. Memory failure is common in the aged. It is generally benign and is associated with ageing, when it is occasional and only for details or for names which later, the individual is able to recall. On the other hand, memory failure may be progressive. The person is unable to recall the major events even. He may fail to identify the place and the persons and likely to lose himself on the streets or even within his house. This memory failure gradually leads to other difficulties and this should be recognised as beginning of a serious brain disease, dementia. Some elderly people suffer from ideas of being persecuted and that their food is poisoned etc. They may have hallucinations of voices or vision. Owing to suspicious nature, they have difficulties in adjustment and may lodge complaints with the police. These disturbances occur in 'late paraphrenia' in the elderly. The delirious states are characterised by incoherent talk, hallucination and disorganised behaviour. Place, people around are identified wrongly. They may not know the time, day or date. Although this is generally due to the brain disease, such episodes can result from the conditions like fever, acute constipation, retention of urine, bronchitis or from taking drugs, starvation, vitamin deficiencies, persistent vomiting. The cataract operation or acute psychological stress can lead to such

delirious states. In many instances, they are reversible by treating the precipitating cause. However, in some they can be the beginning of the dementia. Many elderlies are in the habit of self-medication. They suffer from symptoms from such prolonged administration of drugs. They may be taking medicines for constipation, cough, sleep and for depression both prescribed and unprescribed. This is to be enquired into by the MPHWs. Early detection of cancer carries with it a possibility of complete cure in some cases. Even in advanced cases of cancer, management is possible and in many terminal cases, measures to control pain and to make life tolerable are possible. Patients are to be enquired about the following: Change in bowel or bladder habits, such as persistent constipation, recent onset of diarrhoea and difficulty in voiding urine or urinary incontinence, bleeding or bloody discharge in urine, in motion or in the vomit or while coughing; any ulcer or a sore that fails to heal, especially on the tongue, in the mouth, on the skin; progressive loss of weight and loss of appetite and difficulty in swallowing; a persistent cough or change in the voice; a lump in the breast (in women) or any mass appearing in the body. The women may be advised to periodically examine their breasts for lump and also to report on any bloody discharge per vagina. Research all over the world has proved that certain behaviours predispose to or cause cancer. Cigarette smoking, chewing tobacco cause cancer of the lung and cheeks and tongue respectively. Similarly the excess of chilli powder in the diet can produce cancer. Suitable advice is to be given on stopping smoking, chewing tobacco and use of chilli powders. A family history of cancer also indicates the liability of the person to this disease. The elderly people in view of their physiology are unable to metabolise drugs and to excrete them as efficiently as the youngsters. For example, a drug like Diazepam takes 20 hours to get metabolised and excreted in a twenty year old individual. On Accessibility and adequacy Out of 603 subjects, to 191 (32%), PHC was of easy access and to the remaining 412 (68%), the sub-centres could be reached by some method of transport. On enquiry about adequacy of treatment facilities, more than half of those interviewed opined that the treatment facilities to be 'adequate' at the PHC while two-thirds felt inadequate about them at the sub-centres. 56% placed the facilities as 'adequate' at the PHC while a meagre 6% said so at the sub-centres, The figures for the 'non-adequacy' of the treatment facilities at PHC and the sub-centres were 8% and 60% respectively. The remaining pleaded ignorance on the subject. Satisfaction The satisfaction or otherwise with treatment at PHC/ Sub-centre and reasons for not being satisfied are offered in Tables 11, 12.

Table 11 Satisfaction with treatment at PHC/Subcentre (among those taking treatment) Satisfaction Treatment At PHC At Sub-centre (N = 134) (N = 68) Satisfied 93 60 Not satisfied 23 3 Non-responders 18 5

About 70% of those taking treatment at the PHC reported' satisfaction while 17% expressed otherwise, Eighteen subjects 'could not assess' whether satisfied or not. Eightyeight per cent reported satisfaction with treatment at the sub-centres. This high figure probably reflects their resorting to facilities for minor ailments. Table 12 Reasons for not being satisfied with the treatment Reason At PHC At Sub% centre % Inadequate drugs 5 (12.2) 7 (87.5) Inadequate injections 12 1 (12.5) (41.5) No improvement in health condition 16 5 (62.5) even after treatment (39.0) Poor attention and care 3 (7.3) 2 (25.0) Doctors not present --7 (87.5)

1. 2. 3. 4. 5.

MPHWs' visits and services On enquiry about the 'frequency of visits' made by the MPHWs to the villages, 325 (54%) put it as 'once a fortnight' and 176 (29%) as 'once a month'. Ninety-seven (16%) said that the MPHWs visit 'occasionally' while 5 (1%) failed to recall having seen them at all. One of the major functions of the MPHWs was making it known to the geriatric subjects in the PHC area, about the functioning of the 'geriatric clinic' at the PHC/ Sub-centres. An evaluation of this 'awareness' revealed a near total success since 564 (94%) knew of the geriatric clinic at the PHC/ Sub-centres.

Some of the services offered by the MPHWs were appreciated by the elderlies, (Table 13) : Table 13 Services rendered by MPHW Dispensing of drugs at doorstep Taking them to PHC/ Sub-centre Maternity Care of the young women Referral to Geriatric clinic Health Education Arranging project research officer to visit to the household Family counselling

1. 2. 3. 4. 5. 6. 7.

N % 337 55.9 309 51.2 258 42.8 225 212 35.2 2 0.3 2 0.3

Three fourths of the subjects (N = 453, 75%) admitted their having been benefited by the MPHWs' services while 76 (13%) felt otherwise. The remaining 74 (12%) were noncommittal. The expectations of the subjects concerned medical (N = 251, 42%), economic (N = 203, 34%), social, recreational, nutritional (N = 45, 8%) and occupational (N = 33, 6%) rehabilitative measures. However, 71 (12%) entertained none of these or other expectations. Suggested improvements in family/social intervention When requested to suggest what other social intervention measures they expected, the subjects responded as follows : (Table 18) Table 18 Suggested Improvements Intervention Measures Number % Organisation of recreational activities in a bigger 591 70.1 way (Cinema, games, festivals, drama etc.) Arranging religious discourses by eminent 284 33.7 persons Starting of Old Age Homes in Villages 282 33.4 Occupational rehabilitation 21 25 Nineteen subjects could offer nothing on these measures. The success of these intervention measures on such variables like family jointness, family

integration, social integration and living status was reflected by the high percentage of people being satisfied with these and the significant improvement achieved in the areas of family and social integration of the elderlies on followup (as discussed earlier). A NOTE ON MANAGEMENT AND OTHER INTERVENTION MEASURES The intervention measures consisted of medical treatment either at the PHC or through referral to the Govt. Rajaji Hospital, Psycho-social management (counselling and supportive psychotherapy), arranging of nutritional and economic support, offering the principles of health education and organising rehabilitation within the existing facilities. These are incorporated in the Training Programme to the PHC medical personnel and Multi Purpose Health Workers which have been referred to already. Medical It is not to be assumed that all old people are sick. In a study of 1598 subjects aged 60 + living in 200 villages in Tamil Nadu, Krishnan Nair (1980) reported on their health status as measured by mobility, sensory impairment, incapacity, self-perception of health and physician utilisation. Vast majority of the elderly, more than 4 in 5 failed to rate themselves as in good health. Health pessimism appears to be a predominant feature of the elderlies. The subjects were attending either the main PHC at Kallandiri or its sub-centres. MPHWs made routine visits to the homes of these patients as well as those who did not attend the PHC enquiring about the progress, doling out the drugs and imparting general information on health education. The treatment at the PHC was carried out through the special Geriatric Clinic of the ICMR functioning in the Primary Health Centre. 73% of the subjects were treated at the PHC level, while 18.5% were referred to specialists at the Govt. Rajaji Hospital; 1.1% of the subjects were treated as inpatients in the Govt. Rajaji Hospital for physical illness, while 0.5% as patients for psychiatric ailment. The conjoint treatment namely by the PHC staff and the visiting specialists was offered to 6.9%. The efficacy of the training imparted to the PHC MOs was testified by the fact that almost 3/4ths of the sample were managed at the PHC level. Utilisation of Eye Camp Services Dr. G. Venkatasamy, Director, Aravind Eye Hospital offered services for examination of the subjects and cataract extraction for those who needed. The staff of the Aravind Eye Hospital conducted special Eye camps at Kallandiri PHC, Othakadai and Karupayeeorani sub-centres. The services of the eye camps conducted by Aravind Hospital elsewhere in the PHC area during the intervention period were also utilised by the subjects. Of the 395 subjects utilising the geriatric clinic, 178 subjects (45.1%) availed of the consultation services in these camps, while 54.9% did not (as elicited in

sub-sample survey II). In the latter category, the reasons offered were : Consultation Krishnan Nair, T. (1980) Older people in rural Tamil Nadu, Madras School of Social Work, Madras. was felt to be not necessary (38.7%) and unawareness of such services (30.4%). Nine subjects (4.1%) did not utilise services for fear of surgery and 2 subjects had nobody to look after them and therefore failed to utilise the services. 57 subjects (26.3%) had no specific reasons for non-utilisation of ophthalmic services. Of the 178 subjects who attended the eye camps, 92 (51.7%) were advised surgery. Of these, 66 (71.7%) underwent cataract surgery. Of these who underwent surgery, 82% (N = 54) benefited, while the rest (12) did not. The reason given for not being benefited in spite of surgery was the non-provision of glasses after the surgery. Of the 26, who were advised surgery but who did not undergo the reasons attributed by them for not submitting for surgery were: no one to look after them (50%), fear of surgery (57.7%), no need for a better eye sight in old age-'a stoic attitude' (7.7%). Glasses following cataract surgery we-re supplied to 44 patients (66.7%), while 22 others who were operated could not be supplied with the glasses. Although the subjects with hearing defect were attended to, Hearing Aids could not be supplied owing to the prohibitive cost. Cases requiring Cancer therapy were referred to the Department of Oncology, Govt. Rajaji Hospital and two cases were referred to the Cancer Centre, Adayar, Madras. The Mobile Service Van of the Madurai Medical College visited the PHC twice a week and the subjects were attended to by the visiting hospital staff on referral by the project staff. The services of the ICMR T. B. Clinic, Govt. Rajaji Hospital and District Leprosy Programme at the PHC were utilised for intervention purpose. A weekly Geriatric Clinic was also functioning at the Centre for Advanced Research on 'Health and Behaviour', Govt. Rajaji Hospital, for the subjects to be reviewed by the project staff and for followup purposes. Such of those who were disabled or handicapped by various illnesses were able to pursue their original occupation mainly agriculture following intervention measures. Economic Intervention Among the 1910 registered in the study, 217 subjects (11.4%) were receiving the Old Age Pension (Rs. 351/- per month) and automatically the Noon Meals besides a set of clothes for wearing on Pongal and Independence days and a fixed quantity of paddy. This benefit was received by those, who satisfied the Governmental criteria. At least five subjects were offered guidance to get these benefits. Among the 843 subjects surveyed for subsample survey II, 121 (45%) were receiving the Old Age Pension of the Govt. of Tamil Nadu amongst 269 eligible for that. When interrogated about the measures of improvement of the existing economic support, 694 (82%) suggested modification and the revision of the eligibility criteria for the Od Age pension to cover larger population of

the elderly. Three hundred and forty-nine (41%) suggested that suitable steps undertaken to make the elderly aware of the scheme and 497 (59%) pleaded for an increase In the amount of pension and the quantity of paddy/rice supplied to them. Only 1% of those surveyed subjects suggested that Governmental Loans be sanctioned for some sort of occupation for themselves (self-employment) while 2.5% requested for free shelter for those who needed housing. Rehabilitation measures consisted of supply of walking sticks and provision of spectacles following the cataract operation. Attempts were made to acquire hearing aids to the needy, but were not successful. Quite a number of adentulous subjects were encouraged to procure artificial dentures, but they were not willing. Other intervention measures Recreational measures included visit to the cinema and the temples in the vicinity. The student groups from the schools and colleges visited the villages and provided recreation and snacks for the elderlies. Other recreational measures were already in existenceGathering of the elderly in the local chavadi, where some of them read the news papers and listen to the radio programme, participating in yearly local temple festivals etc. As many as 70% expected increased organisation of recreational activities. In a few instances the subjects who were destitutes and homeless, arrangements were made through the project social workers to admit them into the 'Homes for the Aged'. About one-third of the sample, mainly those with no family and the uncared favoured starting of Old-age homes in rural areas. Among the bereaved subjects, following the death of the spouses, suitable psychological intervention was carried out as a part of rehabilitation. The most significant observation has been that a large number of elderly subjects used to delight themselves in attending the Clinic at the PHC and the Centre, which besides enhancing their morale, gave them a good degree of mobility and social contacts. CONCLUSIONS The project involved a study of 1910 subjects aged 60 + registered in the Geriatric Clinic of the Primary Health Centre, Kallandiri. The Study included, besides sociodemographic details, family composition, family integration, social integration, physical illness and handicaps and mental health assessment. Intervention measures were instituted and the subjects were followed-up for a period of three years. The project involved the training of PHC medical and paramedical staff in detection of physical, mental morbidity and family and other psychosocial factors in the aged and on health education and rehabilitation. The followup covered 97% of the probands. A significant improvement in health status and in family and social integration was noted following intervention. The mortality in the series was 5.7%. Two sub-sample surveys, one involving collection of data on the pattern of utilisation of health services and another on an evaluation of the geriatric services offered were conducted.

A preponderance of females over males in the ratio of 2 : 1 was noted. Almost twothirds belonged to the 'not at all joint' family category (Khatri's scale) and one-fourth of the subjects were living alone. A good integration into the family was noted in 71% and into the community in 93%. Every elderly person had multi-diagnoses and multi-system involvement and the study revealed on an average a minimum of 3-4 symptoms and 2-3 clinical diagnoses simultaneously in any individual. Visual handicap and Degenerative Joint Diseases topped the morbidity list. The psychiatric illness occurred in 8.1% of the subjects. A state of well being was observed in nearly 20% of the subjects in the rural area. The study has offered a feasible model for the total health care of the rural aged within the existing infrastructure with some extra inputs associated with backache, osteoporosis most commonly causes the disease. There is no effusion or synovial thickening. Crepitus is present. Rheumatoid arthritis involves the peripheral joints too in association with the knee and ankle. Early morning stiffness with relief of pain as day advances is characteristic of rheumatoid arthritis. There is synovial thickening and effusion and minimal local tenderness. A classical doughy feeling is elicited. There is atrophy of muscles around the joints of the interossei. Deformities in rheumatoid arthritis as mentioned early are typical, when the knee and ankle are alone involved in rheumatoid in rheu- matoid arthritis. Rest in Cases of osteoporosis, adequate mobilisation and change of occupation as in drivers with cervical spondylosis are simple but important guidelines. -R. Subramaniyan EYE DISEASES Visual handicap is the major physical sensory deficit in the elderly. Cataract, glaucoma, diabetic and hypertensive retinopathy, macular degeneration, corneal degeneration, refractive errors, dacryocystitis and conjunctivitis are some of the common diseases in the old. Arcus senilis is a normal physiological change in this age group. Early intervention prevents blindness, hence early referral is absolutely essential. Cataract Any lenticular opacity is called cataract. Development of cataract is a physiological process in senility. Factors like working in welding, manufacture of gun-powder, genetic predisposition and constant exposure to ultraviolet rays (sunlight) influence the onset of cataract formation. There occurs gradual painless loss of vision. Depending upon the progress of opacity, cataract formation is divided into four stages viz. (i) early (ii) immature (iii) mature and (iv) hypermature. A white opacity in the pupillary area denotes

cataract. In cases of immature cataract, the iris throws a shadow which can be well visualized. Absence of iris shadow signifies a mature cataractous lens. In the hypermature stage, calcified spots are seen in the anterior chamber as a result of which intraocular pressure shoots up. Emergency removal of the cataract is then indicated.ln cases of immature cataract, glasses would suffice. Early surgery can be done for immature cataract-surgical intervention depends upon the visual needs and acuity. If defective vision interferes with the occupation of the person, surgery can be done. Mature cataract always demands surgery. Expulsive haemorrhage is a complication that can be met with during surgery. Post-operatively infections as panophthalmitis, iridocyclitis and endophthalmitis may occur. Iridocyclitis can be cured in few days. Glaucoma Increased intraocular pressure damages the optic tissue. Glaucoma is of two types viz. (i) open angle glaucoma and (ii) closed angle glaucoma. Primary open angle glaucoma is often symptomless.. There is a gradual painless loss of vision along with constriction of field of vision. Headache is occasional. Defective vision with a sluggishly reacting pupil is diagnostic. In advanced stages, there is gross defective vision, increased tension, small and slowly reacting pupil. 2% pilocarpine 2-3 drops instilled every 4-6 hrs is of immense use. In closed angle glaucoma, there is sudden redness of the eye, circumcorneal congestion, haziness of cornea and the pupils are dilated, almost oval and do not react briskly. Patients complain of rainbow haloes around light, headache especially on entering dark, occasionally vomiting, prostration and fever. The attacks are severe at night and hence patients report first in the outpatient department. Acute catarrhal conjunctivitis also presents with redness of the eye and history of haloes around light. When the eye is washed and the discharge washed away, haloes disappear; congestion occurs in the lids too. Careful evaluation is necessary before excluding any case of glaucoma as ACCO. Diabetic retinopathy Development of retinopathy in diabetics depends upon the age of the patient rather than the severity of diabetes. Diabetic retinopathy is of two types viz. (i) simple (ii) proliferative. Haemorrhages and exudates are visualised in the fundus in the simple type. Prothrombin and vasodilators help. In the proliferative type of retinopathy, vitreous haemorrhage and retinal detachment also occur. Photocoagulation, laser therapy and cryosurgery are found to be helpful. It is always important to advise diabetics to have a review every year to know the progress.

Hypertensive retinopathy In hypertension with involu.tionary (senile) arteriosclerosis occurring in older patients, the picture of arteriosclerotic retinopathy appears. There are localised constriction and dilatation of vessels with sheathing of the vessels and the deposition of hard exudates and sometimes of haemorrhages without any oedema. Although the vascular changes are bilateral, the retinopathy is confined to one eye and the ocular prognosis is relatively good. A diastolic blood pressure above 100 mm of Hg can cause changes not unlike diabetes mellitus; if hypertension is controlled the disease process is arrested. Central retinal arterial occlusion, central retinal venous occlusion, vitreous haemorrhage and retinal detachment are causes of sudden loss of vision. Senile macular degeneration may require glasses. Mooren's Ulcer This is a bilateral peripheral corneal degeneration with a gutter like opacity, conjunctival congestion and severe pain. Cornea melts from the periphery. Antibiotic drops along with atropine instillation and padded bandage help. Some cases may need corneal transplantation. Excessive lacrimation or epiphora is due to eversion of the lower punctum from laxity of the lids in old age. If on clinical examination, the punctum is visible when the lower lid opposes the globe, it may be considered to be everted. In mild cases, the eversion may be sufficiently counteracted by burning a deep gutter in the fornix just behind and below the position of the punctum with diathermy. As the cicatrical tissue contracts, the punctum is pulled inwards towards the eye. If this fails and in severe cases the conjunctiva should be slit. This is mostly avoided. Chronic dacryocystitis with acute exacerbations is another ophthalmic condition seen in the elderly. Repeated syringing of the nasolacrimal duct with a view to reducing the swelling of the inflammed mucosa and restoring patency helps in recent cases. In chronic state, dacryocystectomy is the treatment of choice. Arcus senilis Arcus senilis is a lipoid infiltration of the cornea met with in old people. It commences as a crescentric grey line, concentric with the upper and lower margins of the cornea, the extremities of which finally meet so that an opaque line thicker above and below is formed completely round the cornea. It is characterized by being separated from the margin by a narrow line of comparatively clear cornea, being sharply defined on the peripheral side, fading off on the central. It is never more than 1 mm broad and is of no importance either from the point of view of vision or of the vitality of cornea. The most disastrous result of ocular disease, short of relatively rare loss of life is

blindness. The term blindness implies inability to perceive light. But, it is obvious that many people who yet retain some degree of visual capacity are helpless from the economical standpoint. In the elderly, cataract, glaucoma, senile macular degeneration and diabetic retinopathy account for blindness. Early intervention and preventive measures can help prevent blindness. -G. Venkatasamy NEUROLOGICAL DISORDERS The common neurological diseases and complaints in the elderly are (i) cerebral arteriosclerosis (ii) dizziness or vertigo (iii) headache (iv) dementia and (v) peripheral neuropathy. Cerebrovascular disease is the most disabling illness which leads on to stroke. Most of these patients die of myocardial infarction. The management of cerebrovascular disorders like cerebral haemorrhage, embolism and thrombosis is the prerogative of well equipped hospitals. At the PHC, one should pay attention to the symptoms and as far as possible give symptomatic relief. Previous history of strokes, paralysis, epilepsy and ischemic heart disease is important. Family history is elicited by asking about specific illness. Family members must be visited and seen whenever possible. Most often the patient reports with strokes, seizures and dementia. The physical disability and physical problems such as dressing, shaving, climbing stairs etc., sample of speech and writing should be recorded. In general examination, the pulse in all peripheral vessels must be felt. For every cerebral vessel blocked, 2 coronaries and 4 peripheral vessels are blocked. Palpate the skin and scalp, palpate the tongue in all cases of wasting to differentiate from malignancy. Tremors, bradykenesia must be recorded. Respiratory rate is important; hypopnea is often missed. The routine neurological examination is time-consuming. In the crowded out-patient department of the PHC, the neurological patient is to be seen last. A routine methodical testing is essential. Assessment of mental function is very important in the elderly. The level of alertness of the patient must be ascertained, attention and orientation must be assessed. Atleast one verbal and one non-verbal test for memory must be administered. Insight into the illness is enquired for. To test right brain function, spatial orientation must be tested: e.g., the direction of the patient's village, the direction of the nearest city and an important nearby landmark. Left brain function can be assessed by finding out whether propositional speech is present by asking the patient to give an account of himself. Assess for apraxia and agnosia. These are essential to identify early cases of dementia. Cerebrovascular disorder is never diagnosed on the basis of a single symptom. It is observed that transient attacks cause stroke in 50% of individuals within 2 to 3 months. The territories are usually carotid and basilar arteries. Electrocardiography is a must in all

cases. Bruits in the neck generally indicate an arterial disease. However bruits do not signify much in the elderly. The commonest cause of syncope in old age is cardiac and not neurological. Car-diogenic neurological problems are generalised and they recover when blood pressure is reestablished. Syncope never produces focal neurological deficit. In a case of syncope, the blood pressure has to be correlated with fall in blood pressure and cardiac arrest. The patient should be allowed to lie down as lying increases blood pressure, pulse rate and enhances blood supply. Carotid sinus sensitivity can be diagnosed when patient gives history of syncope on shaving, moving the neck etc. Atropine tablet checks the attacks. Micturition syncope, cough syncope and anoxia can cause fits. Headache in the elderly is due to (i) hypertension (ii) vasodilation (iii) tension headache and (iv) collagen diseases. It is said that migraine and bronchial asthma should not be diagnosed first time during one's life in old age. Though collagen disease is rare it is to be remembered that steroid therapy is a fruitful mode of therapy in such cases. Increased intracranial tension slows the pulse. Tumors cause headache, fits and confusion. Acute confusional states can occur in the elderly due to extracerebral causes like chronic bronchitis, hypoxia, congestive cardiac failure, drugs, prolonged hypotension and hypoglycaema. Evaluation of the patient's attention, concentration, orientation, memory, intellect and personality changes must be done. Organic brain syndromes due to cerebral lesions cause acute confusional states. Subdural haematoma The incidence is 2 to 3 patients per year only. There is weakness of one arm and one leg with a fluctuating level of consciousness. There is usually a quick recovery. Late onset seizure disorder Focal fits invariably denote a temporal lobe lesion. Cerebral atherosclerosis is the important cause for late onset seizure disorder. Hypoglycaemia and metabolic defects can lead onto seizures in the elderly. The various neurological signs should be watched for. Mysoline is the drug of choice, gardenal is always to be avoided. Diabetes causes cranial nerve palsy, diabetic 'pseudotabes', gangrene and peripheral neuropathy. The peripheral neuropathy in diabetes mellitus may be motor or autonomic. In the motor type, wasting of thigh muscles occurs. Autonomic neuropathy is characterised by sinus arrhythmia, lack of sweating, postural hypotension and dry skin. In diabetic pseudotabes pupils are not involved. Nutritional neuropathy is another type of peripheral neuropathy occurring in the elderly. -K. Srinivasan

CARDIOVASCULAR SYSTEM Hypertension and Ischemic heart diseases are the commonest cardiovascular illnesses occurring in old age. Very often they occur together and are associated with diabetes and atherosclerosis. I. Hypertension The WHO has defined 'hypertension' as a state in which systolic pressure is 150 mm of Hg or more and diastolic pressure is 95 mm of Hg or more. Normal blood pressure varies according to age. In those aged 60 and above, the normal values are higher than the WHO values for all age groups. Higher readings of BP may be in both systolic and diastolic pressure or in systolic pressure alone. The systoIic hypertension is also to be treated and it has been shown that males with systolic hypertension alone have 2 fold increase in cardiovascular mortality rates, than normal population. Hypertension occurring and detected for the first time in the geriatric population is more likely to be secondary type than in middle aged persons. Pyelonephritis, which may be due to obstructive nephropathies such as enlarged prostate, and tuberculosis of kidney are two common conditions giving rise to secondary hypertension. Other illness giving rise to secondary hypertension include Cushing's syndrome, phaeochromocytoma and primary aldosteronism. Many patients with hypertension have no symptoms referrable to elevation of blood pressure and are identified only in the course of physical examination. When symptoms are present they may be related to (1) elevated pressure itself, (2) the hypertensive vascular disease and (3) the underlying disease in secondary hypertension. Headache, though popularly considered as symptom of elevated pressure, is characteristic only of severe hypertension, it is localized to occipital region and is more severe in the morning. Other complaints include dizziness, palpitation and easy fatiguability. A strong family history of hypertension and intermittent pressure elevation in the past favours the diagnosis of primary hypertension. Presence of symptoms of underlying diseases favours a diagnosis of secondary hypertension. Physical examination should include recording the blood pressure in supine and standing positions. A rise in diastolic pressure from supine to standing positions occurs in essential hypertension and a fall suggests secondary hypertension. A complete cardiovascular examination may reveal other signs of hypertension such as loud second sound in aortic area, ejection systolic murmur. Fundus examination reveals hypertensive retinopathy.

Basic investigations include urine analysis for albumin, sugar and deposits; patients with features suggestive of secondary hypertension should be sent to referral centre for detailed investigation and evaluation. The main complications are atherosclerosis, ischaemic heart disease, congestive cardiac failure and cerebrovascular accident. Uncomplicated primary hypertension may be treated at the Primary Health Centre itself with an appropriate anti-hypertensive drug. The patient is also advised salt restriction, diet restriction, regular mild to moderate exercise and control of other risk factors contributing to the development of complications. Reserpine and alphamethyldopa are avoided in the elderly as they can result in depression with potential danger of suicide. Nifidipine, a calcium channel blocker which reduces the irritability of the myocardium and lowers the preload and the after load of the heart is found to be very effective. II. Ischaemic Heart Diesases Ischaemic Heart Diseases occurring in the elderly are 1. Angina Pectoris and 2. Myocardial infarction. In Angina pectoris there is severe substernal squeezing or vague pain or burning sensation, brought on exertion and relieved by rest, radiating to either side of the sternum, or back, or neck, or left upper limb along the medial border and associated with autonomic symptoms such as sweating, nausea or vomiting. The pain rarely lasts for more than few minutes. An anginal pain lasting for more than half an hour and not relieved by rest is usually due to myocardial infarction, Nocturnal angina occurs due to syphilitic coronary osteal stenosis. Coronary ischaemia in elderly is due to 1. Atherosclerosis, 2. Systemic hypertension, 3. Diabetes with atherosclerosis, 4. Aortic stenosis, 5. Syphilitic aortitis with aortic incompetence and coronary osteal stenosis, 6. Presbicardia. Presbicardia is a condition occurring in the elderly due to senile cardiac degeneration with multiple small areas of ischaemia with fibrosis leading onto left sided failure. There may not be typical anginal pain or ECG changes. Pulmonary microemboli cause acute dyspnoea in the elderly. This condition is called superacute 'corpulmonale'. The diagnosis of bronchial asthma in such cases should not be entertained. Half a tablet of aspirin (acetylsalicylic acid) is of immense help. Thyrocardiosis or a sub clinical hyperthyroid state may cause inappropriate tachycardia.

Acute left ventricular failure may ensue. Hence counting the pulse rate becomes very essential in the clinical examination. On examination, patient with ischaemic heart disease is pale and sweating excessively. The pulse rate may be below 60/ minute. The pulse is feeble and weak in anterior wall ischaemia, which is associated with severe hypertension. In inferior wall ischaemia involving the conduction system, there may be various types of arrhythmias and pulse is irregularly irregular. Ischaemia involving the papillary muscles may give rise to transient musical midsystolic click, and mitral incompetence. Patient may also show evidence of left ventricular failure, such as dyspnoea, and pulmonary oedema. All cases of coronary ischaemia usually need detailed investigation and careful management. They are sent to a referral hospital. -M. Chandramohan RESPIRATORY DISORDERS The Important respiratory diseases occurring in the elderly are pulmonary tuberculosis, chronic bronchitis bronchial asthma, bronchiectasis, tropical eosinophila, pneumonitis, and carcinoma-lung. They present with cough of more than two weeks duration. Chronic bronchitis is otherwise called 'Blue bloaster' syndrome. Dyspnoea is of the expiratory type. Smoking and cotton dust and occupational hazard are important predisposing factors. It should be remembered that antibiotics are administered for a period of 30 to 50 days, with rotation of antibiotics once in ten days so as to combat the lurking residual mixed infection. If signs of congestive cardiac failure appear, the dose of antibiotic should be raised. Emphysema is charterised by dyspnoea without wheeze. It is called 'pink buffees' syndrome. Breathing exercises must be taught to the patient. Infections are avoided by prophylactic long acting penicillin. High fever, dyspnoea, with contraction of alar nasae and features of consolidation are characteristic of pneumonitis. It is found that death rate is increased ten fold due to pneumonitis as pulmonary compliance is low and immune machanisms are less efficacious in the elderly. Amoxycilin and aminoglycocide antibiotics are indicated. Haemoptysis may be due to pulmonary tuberculosis, fungal infections or malignancy of lung. Clubbing of fingers is found in patients, with carcinoma lungs, bronchiectasis and pyothorax. Bronchiectasis is suspected when pneumonitis remains unresolved and when history of foul smelling sputum with change of posture and blood streaks in the sputum are elicited. Suppurative lung disease with brain abscess presents with mental symptoms like acute confusional state. Malignancies of lung are common in smokers and those

exposed to asbestos. Pulmonary tuberculosis occurs more frequently than expected. It may present with haemoptysis. Often no active signs are encountered in the old. E.S.R. is raised and sputum shows acid fast bacilli and x-ray chest reveals fluffy infiltrations. The patient must be educated about the importance of a complete course of therapy for 9 months. The drug regimen is as follows. First 3 months 1. Cap. Rifampicin 450 to 600 mg as single dose early in morning in empty stomach. 2. INH 300 mg as single dose early morning. Second 3 months 1. Pyradzinamide 35 mg/ kg per day in single or divided dose. 2. INH 4-10 mg/ kg per day single dose early in the morning. Third 3 months 1. Ethambutol for 6 weeks 25 mg/ kg/ day in single or divided dose. For next 6 weeks 15 mg/ kg/ day in single or divided dose. 2. INH 4-10 mg/ kg/ day single dose in early morning. DIABETES MELLITUS It is a common illness in the elderly. Polyurea, polydipsia, repeated infections like bronchitis, chronic ulcers over gluteal region, groin, legs are the common presenting complaints. Certain features are characteristic of diabetes mellitus in the elderly. Viz. (i) the maturity onset type of diabetes mellitus may only occur. (ii) Hyperosmolar nonketotic type of coma occurs more commonly than the other types. (iii) Diabetic coma ranks second to cerebrovascular accidents among the causes of death in the elderly. (iv) acute myocardial infarction with failure occurs with no anginal pain. (silent infarction) (v) there is an increase in the renal threshold for excretion of urine sugar due to interglomerular sclerosis and this can be inappropriately rated as improvement during therapy. Family history of diabetes is often present. Urine sugar has to be tested especially with simultaneous blood sugar estimation after full meal with two sweets and two bananas, asking the patient to void urine after one hour. If blood sugar is more than 140 mg diabetes mellitus can be diagnosed. Geriatric patients can be easily controlled with oral hypoglycaemic agents without insulin. These patients are advised to reduce their weight; with diet restriction and weight reduction, good control can be achieved in many patients. A diabetic is asked to avoid

tubers, sugar, sweets, ghee, butter, vanaspathy, coconut oil, fruits (Except tomatoes and apples), Horlicks, 'Viva' and yellow of the eggs. They are allowed rice, wheat, ragi, otta preparations, mutton, chicken, fish etc. in limited quantities. Green vegetables. garlick and onion can be taken in plenty. For patients requiring drug treatment, oral anti-diabetic agents may be added. Initially, Tolbutamide (Rastinon) 0.5 mg 1 bid or tabl. Glybicide (Glynase) 1 bid to 3 bid or tab. Glybandamide (Dionil) 1 bid to 3 bid or Tab. Chloropropamide (Diabenase) 100 to 250 mg. od can be used. If not controlled T. Penformin (DBI) 25 mg. liquid or long acting phenformin (DBI- TD) 50 mg. 1 bid can be added. If diabetes is not controlled, insulin therapy has to be started. To begin, 5 units of plain insulin may be given subscuteneously after each principal meal, increasing suitably every 3rd or 5th day testing the urine sugar. Once good control is achieved, lente insulin can be substituted. In old people, renal threshold for sugar is raised. Hence periodic blood sugar estimation is essential, till stabilization is attained. DERMATOLOGY The skin disorders in the elderly can be broadly classified into (i) skin changes in the elderly due to ageing (ii) physiological changes (iii) disorders peculiar to senility (iv) common skin diseases as in other age groups. (i) Skin changes in the elderly The common changes that occur are (a) dryness of skin (b) Sparse, grey hairs (c) yellowness and thinness (d) diminished sweating and (e) diminished sebaceous gland activity. (ii) The physiological changes (a) Grey hair appear due to decreased MSH activity, decreased melanocytes and due to diminished melanogenesis in the remaining cells (b) Baldness with frontoparietal receding inherited from male members of the maternal side. (c) Seborrhoeic warts: These are asymptomatic brownish black in colour, ranging from few mms to several cms in size occurring in any area of the body. (d) Idiopathic guttate hypomelanosis: Hypopigmented multiple, white spots, less than few mm in size occurring the pretibial area and thigh. This does not require any active treatment but may be associated with diabetes. (e) Actinic elastosis: Lesions occur in areas exposed to the sun mostly in face and limbs. The skin is coarse, dry and accentuated skin markings. (f) Senile comedones: Multiple pigmented papular eruptions. (g) Nail dystrophy in the form of longitudinal striations. (h) Senile angioma or cherry angioma: Multiple erythematous papules in the trunk. (iii) Diseases peculiar to senility

(a) Senile pruritus: This is associated with a dry skin resulting in itching which is generalised or localised to genital, perianal regions and nape of the neck. Repeated scratching leads to thickening, pigmentation and is called neurodermatitis. Diabetes mellitus and obstructive uropathy have to be ruled out. (b) Eczema: This is an asteatotic eczema occurring in the legs due to lack of proper nutrition and oedema of legs. (c) Leg ulcers occur due to .(i) lack of proper care (ii) malnutrition (iii) post-thrombo phlebotic changes (iv) progressive arteriosclerosis. Bullae: Pemphigoid bullae in the form of multiple vesicle or bullae on the skin surfaces, usually asymptomatic, do not rupture and resolve in course of time. No steroid treatment is required. Pemphigoid has to be differentiated from pemphigus characterised by onset in the middle age, bullae which rupture with the fluid emanating cat's urine smell. In pemphigoid, the bullae are tense, do not occur in the mucous membranes, do not rupture and hence secondary infection is less. (d) Dermatitis herpetiformis: Grouped vesicles occurring on the extensor surfaces with intense itching and associated with malabsorption syndrome. Malabsorption syndrome is also associated with extensive psoriasis and chronic eczema of the legs. Dapsone 100 mgs/day and antihistaminics would suffice. Steroids are not required. (iv) Common skin diseases as in other age groups (a) Scabies: Sarcoptes scabii or acarus scabii is the causative organism. The illness is characterised by nocturnal itching and papular eruptions occurring in inter-digital spaces, ulnar border of the hand, axillae and thigh. Secondary infection may lead to impetigo, furunculosis and acute nephritis. Sulphur ointment or 25% Benzyl Benzoate emulsion are the treatment of choice. Benzyl benzoate is applied from neck to feet and the patient is asked to take bath after 12 hours. Anti-bistamines and antibiotics are given orally. (b) Pediculosis: Pediculosis is common in the scalp, trunk and pubic area. It is one of the common conditions for cervical node enlargement. Pediculosis corporis otherwise called 'Vagabond's disease' occur due to poor personal hygiene. Multiple scratch marks are seen on the trunk. In pediculosis pubis, blue lines are seen in the public, suprapubic and inguinal areas. Itching is severe. DDT powder and/ or Benzyl Benzoate emulsion are used. (c) Impetigo, furunculosis and folliculitis: Caused by: staphylococcus. Recurrence is due to carrier stage. Diabetes mellitus has to beruledoutjn cases of recurrence. Impetigo occurs in any part of the body, becomes pustular and crust forms within 2 to 3 days. Furunculosis occurs most commonly with poor nutrition and diminished resistance. Folliculitis of legs is called Bockhart's impetigo. Folliculitis in the face is called sycosis barbae.

Topical antibiotics: Penicillin, sulpha or synthetic penicillin. Recurrence is due to periodic discharge from carrier sites. Antibiotic therapy should be continued till the carrier stage is controlled. (v) Fungal infections These can be divided into superficial and deep fungi. The superficial fungi are either keratinolytic or non-keratinolytic. (a) Taenia versicolar: This is a non-keratinolytic fungus. They are seen as hypopigmented scaly lesions,' called achromic type. Occasionally seen as coloured lesions called chromic type. Occurs in all age groups. It is not contagious. Usually asymptomatic but causes cosmetic disfigurement. Associated with diabetes melltius, Cushings syndrome and steroid therapy. (b) Taenia corporis: It is akeratinolytic fungus annular, scaly lesions with a clear border. There is intense itching. Treatment: Whitfield ointment. 1% Miconazole. Nitrate. Systemic griseofulvin 125 mgms, twice daily infection of the scalp should be for 2 months. Nail. T. Unguinum 500 mgms/day after food for 6 months. Deep fungi (a) Moniliasis: Lesions-Monilial paronychia, granuloma, oral thrush on the dorsal surface of the tongue, cheilitis, monilial balanoposthitis Occur in 99% of diabetics. In female, monilial vulvovaginitis or pruritus vulva Occur. 1% G. V. Paint or 1% Miconazole nitrate. Nystatin tablets oral or vaginal. In resistant cases Ketoconazole 200 mgms 1 tablet daily for 3 to 4 weeks. Ketoconazole can be used in those who are sensitive to griseofulvin in any deep fungal infection. Papulosquamous (a) Psoriasis (b) Lichen planus. Psoriasis: Erythematous scaly lesions in the extensor surface, symmetrical in distribution, recurrent in nature. Exacerbation seen in winter. Itching may be mild or moderate. May occur in the form of exfoliative psoriasis, pustular lesions, psoriasis with arthropathy and psoriasis of the nails. Steroids are used externally or internally. Mostly occur as plaques on the scalp or limbs. Salicylic ointment, Coal tar ointment and antihistaminics. PUV A is now used. Psoralin20 mgs longwave UV rays - This has antimitotic effect.

Lichen planus: It is self-limiting disease, characterised by flat, blue to violet coloured papules occurring on the flexor surface of the forearm and extensor surfaces of the legs. The oral and genital mucosae are also involved. Itching is very severe. Topical salicylic acid ointment or coal tar ointment. Oral antihistaminics. In extensive lesions involving scalp, steroids are useful. Pityriasis roseae: Round or oval lesions occur in the trunk, the upper limbs upto elbow and in the lower limbs upto knee. Lesions disappear on their own within 6 weeks. There is no recurrence. Symptomatic treatment in the form of liquid paraffin for external applications and oral antihistaminics are sufficient. Hansen's disease: Hansen's disease is a chronic, mildly contagious, primarily involving the peripheral nerves, secondarily involving the skin, the mucous membrane! of upper respiratory tract, eyes, bone, testes, reticulo-endothelial system and other organs except brains, spinal cord, gall bladder and ovaries. Infection is disseminated through the blood stream and lymphatics. The Schwann cells act as biological refrigerators and organism remains alive within Schwann cells for years together. In 1960, the mycobacteria leprae were grown in the foot pads of mice. It was seen that human beings are the only natural hosts. With genetic susceptibility in the background, the disease spreads through prolonged direct physical contact, basal secre. tion and breast milk. Hansen's disease is classified into 5 types viz., (i) Tuberculoid (ii) Borderline Tuberculoid (iii) True borderline (iv) Borderline lepromatous and (v) Lepromatous. (i) Tuberculoid Hansen: Solitary or 2 to 3 erythematous coppery patches with flat or raised edges. These show loss of pain, temperature, touch from the beginning of the illness. Peripheral nerves including unnamed cuaneous nerves are thickened. (ii) Borderline Hansen: Consists of multiple, asymmetrical lesions irregular in size and shape associated with thickening of nerves. (iii) Lepromatous Hansen: This is characterised by macules in the early stages, infiltrative lesions and nodules. All the three types of lesions can occur in the same individual. They are usually symmetrical and occur in the cooler areas of the body. The scalp, perineum and axilla are called immune areas for lepromatous Hansen. Sensory loss occurs often in the distal parts of the limbs. The skin, usually of the hand is shiny and oedematous, due to lack of vasomotor tone. There is stuffiness of the nose and ulceration of the oral cavity. Chronic iridocyclitis may lead on to loss of vision. Complications like trophic ulcers due to anaesthesis, claw hand, wrist or foot drop and facial palsy occur. According to WHO, single drug therapy is to be deferred so as to prevent emergence of

resistant strains. In non-lepromatous types, Dapsone 100 mgs/ day, on all 7 days of a week and rifampicin 600 mgs once a month are administered. In lepromatous type, Dapsone 100 mgs/ day, Clofazimine (Lampren) 50 mgs/ day or 100 mgs on alternate days and Rifampicin 600 mgs once a month are the treatment of choice. The advantages of a multiple drug therapy are that such a therapy prevents the emergence of resistant strains of bacteria, the spread of infection is checked rapidly as the bacilli are destroyed in a few months time. 1 capsule of Rifampicin can kill 75 to 80% of the bacilli. Within 3 months time an individual becomes negative for the bacilli with Rifampicin, while Dapsone takes 2 years. Also the duration of treatment can be shortened remarkably, with only 6 months in non-lapromatous type and about 2 years or until smear negative with Dapsone. When all signs have disappeared or when biopsy shows no granuloma in the dermis, the treatment could be stopped. BCG vaccine in Hansen's disease : BCG vaccine administration leads on to a lepromin positive stage in the individual. When a lepromin positive individual is exposed to Hansen, he develops the less harmful types like tuberculoid Hansen while a lepromin negative individual develops the more harmful -A. Kotteeswaran ENT DISEASES Types of hearing loss 1. Presbyacusis of various degrees (i.e.) - high tone loss alone, high and middle tones loss - high, middle and low tones loss 2. Noise induced type and acoustic trauma 3. Advanced otosclerosis-sensorineural/ mixed loss 4. CSOM of Early period of life and hearing loss associated with severe degree of conductive/ mixed/ sensorineural loss 5. Mild to moderate conductive loss due to other ear problems and associated problems. 6. Oto-toxicity producing sensorineural loss, etc. 7. Progressive type of loss due to other systematic diseases. How to detect History 1. Family history 2. Personal and medical history 3. Occupational history 4. Environmental history-urban, rural, noisy surroundings, slums, etc.

Behavioural observations - Using cupped hand behind the ear while listening to others - Repeatedly asking to repeat - Ask the other person to talk louder - Watching the person's face very keenly while talking (i.e.) lip reading - Finding it difficult to answer when the face of speaker is not clearly visible or is turned away - Localisation of head and turning of head close to the sound source - May find it difficult to understand a Radio Talk Loudspeaker etc. Whereas he find it easy while the speaker's face is visible - Speaks in a soft voice irrespective of the surrounding noise level - Speaks in a very loud voice (shouting) with others - Slurring of speech-Misarticulated speech-Loss of certain phonemes or words during speech - Change of general quality of voice - Too suspicious about other's talking - Irritability, distraction etc. as emotional problems - These types of behavioural problems will suggest that the person is having difficulty in hearing. Hearing Tests 1. Conversational voice test: Use common words which are familiar to the patient. Keep the patient at a distance of about 20 feet and ask him to repeat the words said to him by the tester. Each ear to be repeated separately 2. Whisper test: Distance of about 3 feet between the tester and the patient 3. Watch tick test 4. Crumbling sounds-using tissue papers etc. 5. Dropping of a coin or metallic piece without the knowledge of the patient 6. Using various pitch pipes-different frequencies low, middle and high tones and other screening sound (if possible calibrated) 7. Tuning fork tests 8. Communicate with the patient as far as possible without showing your face or lips 9. Audiometry if available. UROLOGICAL PROBLEMS The process of ageing brings on with it several changes in the organ systems. The creatinine clearance falls down, as the glomerular filtration rate of the elderly is Iow, and the capacity for tubular reabsorption is low. The excretory function is impaired, due to decreasing expulsive force of the bladder and an enlarging prostate which causes obstruction to the free voiding of urine. The other problem of the elderly is loss of potency.

Examination of the patient with urinary complaints Micturition problems are elicited using the screening schedule. The complaints often are: (1) increase in frequency especially nocturnal polyuria, (2) hesitancy in passing urine where initiation is impaired. The patient may have urgency, tending to wet his clothes as he walks to the toilet, (3) He may pass a large amount of urine, (4) a major complaint is retention of urine. Leading questions must be asked to elicit whether or not the patient has haematuria, a history of drug intake especially analgesics. tetracyclines, other chemotherapeutic' agents. Past history of diabetes and/ or hypertension must be enquired for. During general examination one must include the presence or absence of pitting oedema feet, puffiness of face, anaemia. Examination of the abdomen should be directed towards, assessing the distention of the bladder. Rectal examination is to be carried out to make out any prostatic hypertrophy. Malignancies of rectum could also be made out. Rectal examination is as important for detection of cancer Prostate as PAP test for cancer cervix. The above examination, supplemented by simple urinary examination should lead to one of these three possibilities. 1. Obstructive urinary pathology 2. Inflammatory process 3. Basic renal failure. The urine is examined for albumin-albuminuria indicating infections most commonly and sugar indicating glycosuria-commonly due to diabetes mellitus. Deposits reveal casts in chronic renal failure and crystals in renal calculus. Patient with retention, irrespective of the cause of obstructive pathology can be managed by catheterisation with a sterile rubber catheter, or if possible a metal catheter. If catheterisation is not possible, a lumbar puncture needle may be passed in the supra pubic area into the bladder and the contents may be aspirated. The patient can then be transported comfortably to the referral hospital for active management. Infection of Urinary Tract The infections are either non-specific or tuberculosis of the urinary tract. The patient presents with fever with rigors, dysuria, increased frequency and supra-pubic pain. Treat with antibiotics or sulpha group of drugs for 2 weeks. Further, continue for two weeks to avoid recurrence. During treatment patient is advised to take plenty of oral fluids-3 litres in summer and 2 litres in winter. A recurrent infection or non-responsive

one is referred to the referral centre for further management. Renal failure Commonest causes in the elderly are diabetes, hypertension, and abuse of drugs. There is either polyuria or anuria. The specific gravity in early cases is very low 10.02. The patient is asked to void 24 hours urine in a container to ascertain quantity. Refer these patients to the hospital. In female patients, owing to fibrosis, urethral caruncles, there may be difficulty in passing urine. An urethral dilatation can help. Malignancy in urinary tract AIl cases of suspected malignancy should be referred. Haematuria, unless otherwise proved is thought to indicate malignancy. A renal mass, bladder tumor, nodule of the prostate may also be present. The absence of these does not exclude malignancy. Tuberculosis of the urinary tract This occurs secondary to bone and joint tuberculosis and involves the epididymis and testis. Sterile acid pyuria is pathognomonic of the disease. In cases of haematuria, other causes must be excluded. The common presenting clinical patterns are those of hydronephrosis and epididymoorchitis. The infection is always chronic. Tuberculosis of the urinary tract is diagnosed by investigations only. 450 mgms/day of Rifampicin, 300 mgms/day of INH and 1000 mgms of Ethambutol are administered for the first four months and the therapy is continued for the next five months with 300mgms of INH, 1000 mgms of Ethambutol with or without pyrazinamide. Surgical intervention is necessary in cases of stricture. The primary care physician can advise the elderly to have a urine analysis once in 6 months and to maintain an intake of 2000 ml and output of 1500 ml of fluid per day. MALIGNANCY Cancer is a dangerous illness. Nevertheless, when detected in early stages, many types of cancer are curable. The beginning of cancer always tends to be painless. When pain is complained of, it is an advanced stage of the illness. The following symptoms should arouse a suspicion especially when there is a family history of cancer. Cancer of the Mouth 1. Tobacco chewing is likely to produce cancer of the mouth 2. White patch in the mouth

3.. Ulcer in the mouth. Cancer of the Food-pipe 1. Difficulty in swallowing of short duration 2. A sensation of food being arrested beneath the chest 3. Change in voice 4. Difficulty in swallowing solids initially and liquids later 5. Regurgitant vomiting 6. Swelling in the neck on either side. Cancer of the Stomach 1. Persistent change in feeding behaviour i.e. quality of food taken and frequency of food intake 2. Heaviness in the abdomen 3. Persistent loss of appetite 4. Progressive loss of weight 5. Tarry stools 6. Vomiting and constipation 7. Vomiting blood. Cancer Rectum 1. History of bleeding per rectum 2. Change in bowel habits 3. Diarrhoea alternating with constipation of long duration 4. Abdominal pain 5. Passing tarry stools 6. Progressive constipation 7. Vomiting. Cancer Prostate 1. Frequency of micturition, hesitancy and precipitancy 2. Swelling of legs 3. Blood in urine. Cancer Breast 1. Painless lump in the breast 2. Bloody discharge through nipple. Advice to Women: Please palpate your breasts and look for any lump. Please approach the

doctor if you detect any such slow growing painless I ump in your breasts. Cancer Cervix 1. White discharge per vaginum 2. Blood and white discharge per vaginum 3. Ulcers in the vulva 4. White patches. Cancer Kidney 1. Passing blood in urine which is painless 2. Pain in the loin with a swelling 3. Spontaneous bone swelling 4. Clot colic. Cancer Lung 1. Persistent cough 2. Blood in the sputum 3. Smoking habit. THE LECTURE LASTED FOR TWO HOURS IN"TWO SESSIONS. A CASE OF CERVICAL CARCINOMA AND CARCINOMA LARYNX AND AN OPERATED CASE OF CARCINOMA BREAST WERE DEMONSTRATED. PSYCHOLOGY AND PSYCHIATRIC DISORDERS Ageing brings with it, attendant changes, in the psychological, family and social life of the individual. Family life undergoes a sea change. The elderly person with his position as the protector being altered to a dependant status, the sense of mastery no longer persists. As a result a lowered self-esteem ensues. Life long companions within the home are lost. Daughters marry and leave the homes. Sons in the pursuit of occupation too leave. The homes of the elderly are rendered lonely by the death of their spouse. This loneliness, added to the lowered esteem, causes intense grief/despair. Studies have found, the recently bereaved elderly are more prone to psychiatric and medical illness especially infarction and cancer. A constricted sphere of activity in the absence of work, leisure activities, sensory handicap and musculo-skeletal disability results in reduced psychological resilience. The outlets that provided relief at an younger age are no longer available. This results in depression.

To tackle these psychological proble1ns the PHC doctor has to recognise the major contributory factors. Encouragement to be more active, cultivation of leisure time activity (such as visiting temples, panchayat meetings-sharing the wisdom of age with younger companions) are beneficial. To listen compassionately to the grief of the aged assists the process of mourning. The treatment of patient's sensory handicap and musculo-skeletal disability can by itself widen the patient's horizon of activity by removing barriers. Fear of dying may be present, to a disabling extent in some eldery subjects. Probing into the life led by such person and helping him to see it as a life usefully led will help to an extent. If somatic accompaniments of anxiety are associated, anxiolytic drug therapy is of assistance. The process of ageing, with neuronal death, causes memory deficits to appear. The elderly patient may become fastidious and excessively orderly in an attempt to cope with memory lapses by rigidity of habits or may become paranoidal accusing others of medding with, or theft of misplaced articles, a strong suspicion of organic dementia must be aroused. The social life of the elderly is also affected by lowering of economic status, loss of companions of the age and changing social order in our country. The economic hardship can be alleviated by seeing that the economic benefits granted to the elderly accrue to them. The PHC doctor can help to this end by working jointly with revenue officials. Social isolation and lack of social integration can only be managed by increasing the social activity. Medical assistance to treat handicaps that restrict activity is essential. Even in the absence of 'family support' a good social support network can prevent psychiatric morbidity. The role of Multi Purpose Health Workers is crucial in 'identifying such people in the community. These people can be managed both in their homes and at the PHC by a comprehensive approach. Mental health is a state of mental wellbeing. The elderly is afflicted by the process of ageing, which causes a decrease in the functioning of all organ systems in the body. In addition there is a change in their personal and social life. They are unable to persue their occupation, loose their productivity and earn ing capacity. Family life is traumatic with exit of their children and from home and loss of spouse and relatives and friends owing to death. The major psychiatric illnesses in the elderly are affective disorders, organic brain syndromes and paraphrenia. Affective disorders

The commonest psychiatric illness in the elderly is depression. In a community survey it was estimated to be prevalent at 59/ 100. The other affective disorder is Mania. Depression Depressive illness in the elderly is characterised by depressed mood, sleep difficulties, worrying, slowness in thinking and activity. The patient complains of sadness, multiple body complaints and does not pursue his occupation without clear reason. On enquiry the patient reveals sleep difficulties, poor appetite, constipation, sadness, tends to weep, shows constriction in activity and is generally slow or sometimes agitated. Often during home visits it may be revealed that the patient lies in bed most of the time, does not work, does not like to meet others, worries excessively and talks of suicide. Very often a physical examination does not reveal pathology that could cause so much functional disability. A patient hearing of the individual's complaint and encouragement to discuss his personal problems helps. Recent stressful life events such as loss of loved ones or property or status may be forthcoming. An assessment of the suicidal ideation should always be undertaken by gentle emphathetic direct questioning. A depressive with suicidal intent should be referred for active inpatient management at the hospital. A detailed evaluation of the patient's memory and orientation is necessary to exclude organic dementia. He can be managed with antidepressant drugs. Drug treatment may cause retention of urine, constipation, arrhythmias and blurring of vision. The patient is advised not to change his postures suddenly so as to prevent giddiness and falls. Risk of over dosage should always be borne in mind. As far as possible the patient should be allowed to talk freely and the doctor can assist in sorting out any problems in the family. Encouragement and reasssurance form essential part of treatment. ECT is safe in the elderly and is preferred in some cases. Mania It is a relatively less common mental illness. Often the patient is brought to the hospital owing to the sudden and dramatic nature of the illness. The patient is usually excited, appears unduly happy, is over-talkative and may harbour grandiose ideas. History often reveals over activity, excessive spending and lack of judgement in social and personal matters. Testing ..for memory defects and examination for any cause of toxicity is undertaken. When these are not present the patient may be sedated and referred to the referral centre for further inpatient management. Organic Brain Syndromes An organic brain syndrome may be an acute or chronic psychiatric illness resulting from failure of brain function.

An acute organic brain syndrome constitutes a psychiatric emergency with a high risk of mortality, of almost 50%. The patient presents with grossly disorganised behaviour of acute onset. There may be symptoms such as fever, convulsions, other organ failure-renal, hepatic etc. The patient talks incoherently, has florid auditory and visual hallucinations. History reveals inappropriate social behaviour, incontinence of bowel and bladder and excitement. The patient may have displayed impaired memory function. On enquiry he often has a change in level of consciousness, has gross memory deficits and is disoriented. A thorough physical examination is directed towards identifying the cerebral or extracerebral cause for brain failure, with special reference to presence of neurological signs and symptoms, fever, signs of renal or hepatic failure. History of recent drug taking behaviour should be elicited. Symptomatic relief could be provided by use of analgesics to control fever. The patient may be sedated only if necessary to enable immediate transport to referral centre for further management. Dementia The chronic organic brain syndrome, dementia is a common psychiatric illness of the elderly. With increase in life expectancy, dementia, in the United States is the fourth common cause of mortality. In India, the prevalence of dementia is between 6 and 32 per 1000 in geriatric population studies. Dementia is a heterogenous entity comprising of different types such as Senile DementiaAlzheimer's type, Multi infarct Dementia and dementia secondary to other causes. A detailed history reveals a gradual decline in all spheres of the patient's activities- such as an inability to persue his occupation, lack of social behaviour, evidences for defective memory, inability to take care of self etc. Often these are ignored by the family members as part of ageing. The patient seldom has any relevant complaints suggesting dementia. Enquires should be directed to find if the patient had lost his/ her way in the recent past, inability to handle even a small sum of money etc. Detailed assessment by verbal enquiry to assess orientation to time person and place, memory in all aspects-remote, recent and immediate, will reveal serious impairment. Inability to solve simple arithmetic problems quickly establishes the patient's intellectual decline. A detailed physical examination, with a complete neurological evaluation is absolutely essential. Hypertension, atherosclerosis may often be associated. The patient should be referred to the hospital for detailed investigation. Paraphrenia Paraphrenia, is a functional psychiatric illness of the elderly. It is a schizophrenia like illness. The patient has abnormal sensory perceptions in the absence of stimulus hallucinations. These may be voices or visions. The patient often holds false morbid

beliefs, delusions such as people being against him, people trying to kill him or that he has imaginary powers. The patient often has sensory handicaps, he may be hard of hearing or has failing vision. The patient, even prior to the illness is of a suspicious nature, with poor adjustment with relatives and would have had few friends. The patient may be seen muttering or talking to self. However, there is no gross deterioration in personality as found in schizophrenic illness. In a special variety of paraphrenia the patient is deluded that he is infested with parasites especially on the skin. This is known as 'Delusional parasitosis' or 'Ekbom's syndrome'. Physical examination reveals a sensory handicap visual and/or auditory. Patients with paraphrenia usually respond well to antipsychotic drugs and they can usually be treated at the Primary Health Centre itself.

Krishnan Nair, T. (1980) Older people in rural Tamil Nadu, Madras School of Social Work, Madras. Health promotion/disease prevention to the rescue! Tempering the giant geriatric tsunami Feb 1, 2006 By:Marie Bernard, MD Geriatrics In his January editorial, Dr. Sherman noted that we are facing "a giant geriatric tsunami." The sheer number of Baby Boomers in the coming years of this century have the prospect of overwhelming our health care system. With the social and fiscal support bases of younger individuals shrinking relative to the number of Baby Boomers, undoubtedly there will be significant challenges for resource allocation, as Boomers develop disabilities requiring interventions. Dr. Sherman urged that "changes to the health care delivery system must be openly debated with new approaches crafted NOW, before this giant geriatric tsunami overwhelms our capacity to care." Part of that system change must include better focus upon and compensation for health promotion and disease prevention. Unfortunately, health promotion and disease prevention activities do not lead to increased revenue in our acute care-oriented health care system. According to a report in the New York Times (January 11, 2006), diabetes prevention and treatment centers throughout the New York City metropolitan area have closed due to lack of revenue generation. Although the $455 investment for a patient visit with diabetes preventive specialists could prevent the expenditure of $1,499-$11,360 for an amputation due to poorly controlled

diabetes, compensation for many preventive health interventions is often difficult to garner. Our current health care system is better formulated to pay for dialysis, amputations, and other acute care-focused treatments for illness. However, with modifications to recognize the long-term benefits of preventive health care, many resource allocation challenges presaged by Dr. Sherman will be obviated. Focus upon compensation for health promotion and disease prevention can contribute to "'rationally rationed care so that the collective health of the nation improves in a setting of limited funds." An initial investment to prevent illness could save considerable funds that would otherwise be expended to treat the consequences of disease. Thus, GERIATRICS has chosen to launch the 2006 calendar year with a series of updates on preventive health issues, applicable to the current cohort of older adults, and referable to aging Baby Boomers. I am happy to introduce that series and note that despite the challenges for compensation, there are many practices health care professionals can incorporate into routine patient care that can promote health and prevent disease. The first article of the series, published in January, addressed mental health promotion; this month, we tackle the role of lifestyle in metabolic syndrome. In the next several months, articles will address smoking cessation, successful aging, nutrition, exercise for homebound patients, driving, and accidental injuries. These articles are configured to provide good baseline scientific information and practical advice for the direct care of patients. I invite you to apply the concepts in this health promotion series to patient care. The advocated interventions are easily adapted, and do not consume excessive amounts of a practitioner's time and resources. Consistent application of health promotion and disease prevention methodology can provide significant assistance with the coming resource constraints expected as Boomers advance in age. Resources Sherman FT. The good news: It's our 60th birthday. The bad news: A giant, geriatric tsunami! Geriatrics 2006; 61(1):10-11. Urbina I. In the treatment of diabetes, success often does not pay. New York Times, January 11, 2006. Mandelblatt J, Saha S, Teutsch S, et al; Cost Work Group of the U.S. Preventive Services Task Force. The cost-effectiveness of screening mammography beyond age 65 years: A systematic review for the U.S. Preventive Services Task Force. Ann Intern Med. 2003; 139(10):835-42. Messonnier ML, Corso PS, Teutsch SM, Haddix AC, Harris JR. An ounce of prevention...what are the returns? Second edition, 1999. Am J Prev Med 1999; 16(3):248-

63. Pignone M, Saha S, Hoerger T, Mandelblatt J. Cost-effectiveness analyses of colorectal cancer screening: A systematic review for the U.S. Preventive Services Task Force. Ann Intern Med 2002; 137(2):96-104. Disclosure: Dr. Bernard reports no relevant disclosures. Dr. Bernard is Donald W. Reynolds Chair in Geriatric Medicine, professor and chairman, Reynolds Department of Geriatrics, University of Oklahoma College of Medicine; associate chief of staff for geriatrics extended care, Oklahoma City Veterans Affairs Medical Center; and director, Oklahoma Geriatric Education Center. She has served as a member of the Geriatrics Editorial Advisory Board since 1993.
Age and Ageing, Vol 28, 543-550, Copyright 1999 by British Geriatrics Society

ARTICLES

A randomized trial of comprehensive geriatric assessment and home intervention in the care of hospitalized patients
T Nikolaus, N Specht-Leible, M Bach, P Oster and G Schlierf
Department of Geriatric Medicine, University of Ulm and Bethesda Geriatric Clinic, Germany. thorsten.nikolaus@medizin.uni-ulm.de

OBJECTIVE: to prove the effectiveness of geriatric evaluation and management for elderly, hospitalized patients, combined with post- discharge home intervention by an interdisciplinary team. DESIGN: randomized controlled trial with outcome and costs assessed for 12 months after the date of admission. SETTING: university-affiliated geriatric hospital and the homes of elderly patients. SUBJECTS: 545 patients with acute illnesses admitted from home to the geriatric hospital. INTERVENTIONS: patients were randomly assigned to receive either comprehensive geriatric assessment and postdischarge home intervention (intervention), comprehensive geriatric assessment alone (assessment) or usual care. MAIN OUTCOME MEASURES: survival, functional status, rehospitalization, nursing home placement and direct costs over 12 months. RESULTS: the intervention group showed a significant reduction in length of hospital stay (33.49 days vs 40.7 days in the assessment group and 42.7 days in the control group; P < 0.05) and rate of immediate nursing home placement (4.4% vs 7.3% and 8.1%; P < 0.05). There was no difference in survival, acute care hospital readmissions or new admissions to nursing homes but the intervention group had significantly shorter hospital readmissions (22.2 days vs 34.2 days and 35.7 days; P < 0.05) and nursing home placements (114.7 days vs 161.6 days and 170.0 days; P < 0.05). Direct costs were lower in the intervention

group [about DM 7000 (US $4000) per person per year]. Functional capacities were significantly better in the intervention group. CONCLUSIONS: comprehensive geriatric assessment in combination with post-discharge home intervention does not improve survival, but does improve functional status and can reduce the length of the initial hospital stay and of subsequent readmissions. It can reduce the rate of immediate nursing home admissions and delay permanent nursing home placement. It may also substantially reduce direct costs of hospitalized patients. AMERICAN FAMILY PHYSICIAN VOL. 61, NO4

The Geriatric Patient: A Systematic Approach to Maintaining Health

KARL E. MILLER, M.D., ROBERT G. ZYLSTRA, ED.D., L.C.S.W., and JOHN B. STANDRIDGE, M.D. University of Tennessee College of Medicine, Chattanooga, Tennessee
The number of persons 65 years of age and older continues to increase dramatically in the United States. Comprehensive health maintenance screening of this population is becoming an important task for primary care physicians. As outlined by the U.S. Preventive Services Task Force, assessment categories unique to elderly patients include sensory perception and injury prevention. Geriatric patients are at higher risk of falling for a number of reasons, including postural hypotension, balance or gait impairment, polypharmacy (more than three prescription medications) and use of sedative-hypnotic medications. Interventional areas that are common to other age groups but have special implications for older patients include immunizations, diet and exercise, and sexuality. Cognitive ability and mental health issues should also be evaluated within the context of the individual patient's social situation--not by screening all patients but by being alert to the occurrence of any change in mental function. Using an organized approach to the varied aspects of geriatric health, primary care physicians can improve the care that they provide for their older patients. (Am Fam Physician 2000;61:1089-104.)

Current predictions suggest that the number of persons 65 years

of age and older will more than double in the United States during the next 30 years. As a result, the number of elderly Americans could increase from 34 million in 1998 to approximately 69 million in 2030.

This increase, combined with the disproportionate rate at which elderly patients use medical resources, will require that primary care physicians become increasingly knowledgeable about the needs of geriatric patients and increasingly efficient in the evaluation and management of concerns unique to these patients.

TABLE 1 Medications Associated with an Increased Risk of Falls in the Elderly

Antiarrhythmics Antihistamines Antihypertensives Antipsychotics Benzodiazepines and other sedative-hypnotics Digoxin (Lanoxin) Diuretics Laxatives Monoamine oxidase inhibitors Muscle relaxants Narcotics Tricyclic antidepressants and selective serotonin reuptake inhibitors Vasodilators

Adapted with permission from Reuben DB, Grossberg GT, Mion LC, Pacala JT, Potter JF, Semla TP. Geriatrics at your fingertips, 1998/99. Belle Mead, N.J.: Excerpta Medica, 1998.

The value of performing a comprehensive geriatric assessment appears to be equivocal. Simple screening instruments can be helpful in identifying patients at risk for common health problems and in improving the clinical assessment of a disease course.1 However, these screening tools may not be effective in reducing health care utilization or costs.2

The comprehensive geriatric assessment is often described in the literature as a multidisciplinary, time-intensive evaluation of a patient previously identified as being at significant risk for imminent morbidity or mortality.2,3 An evaluation of this type is impractical in most primary care settings and is seldom used by practicing physicians.4 Yet the ongoing, long-term management component of primary care is a key ingredient in the success of outpatient geriatric evaluation.5 Effective primary care management of geriatric health issues, with its goal of caring for healthy and functional elderly patients, may perhaps be better

described as comprehensive health screening. Using simple and easily administered assessment tools, physicians can improve the identification of specific problems that are common in the elderly and also shift their focus from disease-specific intervention to preventive care and proactive medical management.5 In 1996, the U.S. Preventive Services Task Force (USPSTF) published the second edition of its Guide to Clinical Prevention Services.6 In this publication, the USPSTF updated earlier recommendations on preventive services for patients at various stages of life. The recommendations for patients 65 years of age and older include a number of items common to other age groups. The unique assessment categories for older patients are sensory perception (hearing and vision screening) and accident prevention. Assessment areas common to other age groups but with special implications for the elderly include diet and exercise, immunizations and sexuality. Although the USPSTF found little evidence in 1996 to support the value of screening for dementia, recent pharmaceutical advances have resulted in beneficial treatment options that were not available just a few years ago.7 Using the USPSTF recommendations as a guide, this article reviews available standardized assessment tools and techniques that can be used in outpatient settings. The goals are to encourage a systematic assessment of various areas of potential geriatric risk and to develop a database appropriate to the unique concerns of elderly patients. All of the information does not need to be gathered in one office visit. Multiple visits can be used to perform the entire assessment.

Injury Prevention
The USPSTF recommends that primary care Risk factors for falls include physicians ask patients in most age groups environmental hazards, gait about the routine use of safety belts and bike and balance disturbances, use helmets, the availability of smoke detectors, of sedative-hypnotic drugs and the maintenance of hot water heater polypharmacy. temperature at or below 48.8C (120F) and the danger of smoking near bedding or upholstery.6 Fall prevention, however, is an assessment category unique to patients 65 years of age and older. The annual incidence of falls in patients over 65 years of age who live independently is approximately 25 percent but rises to 50 percent in patients over 80 years of age.8 Falls are responsible for a significant number of accidental deaths and traumatic injuries among the elderly. One third of patients with confirmed falls may not recall falling.9

TABLE 2 Risk Factors for Osteoporosis

Increasing age Female gender Early menopause Low body weight Small stature White or Asian race Family history Drug use (e.g., steroids, heparin) Low calcium intake Excessive alcohol intake Smoking Physical inactivity Conditions that impair calcium absorption High caffeine intake

Risk Factors Intrinsic factors that contribute to falls include age-related changes in postural control, gait and visual ability, and the presence of acute and chronic diseases that affect sensory input, the central nervous system and musculoskeletal strength and coordination. Certain medications can also increase the risk of falling

(Table 1).10 Osteoporosis is one notable intrinsic factor that leads to falls. In patients with this condition, a pathologic fracture may precede a fall. In the absence of universally accepted criteria for the assessment of bone mineral density, screening should be directed at a risk assessment for osteoporosis (Table 2). Extrinsic factors that contribute to falls include poor lighting, obtrusive furniture, slippery floors, loose floor coverings and bathrooms without handrails or grab bars. Mobility and Dexterity A comprehensive risk assessment for falls incorporates a review of all potential intrinsic and extrinsic factors, as well as a focused physical examination (Table 3).11 The physical examination can be a simple evaluation of one-leg balance (i.e., the ability to stand unassisted on one leg for five seconds)12 or a more structured evaluation such as the "Get Up and Go" test.13 In the "Get Up and Go" test, the patient is observed as he or she rises from a sitting position, walks 10 ft, turns and returns to the chair to sit. The effectiveness of the test for predicting falls can be enhanced by timing the process, with more than 16 seconds suggesting an increased risk of falling.14 Any observed or reported changes in gait, strength or balance may require further evaluation with a more detailed assessment.

TABLE 3 Interventions to Reduce the Risk of Falling in the Elderly

Risk factors Interventions

Postural hypotension: a drop in systolic blood pressure of >=20 mm Hg or to <90 mm Hg on standing

Behavioral recommendations, such as ankle pumps or hand clenching, and elevating the head of the bed Decrease in the dosage of a medication that may contribute to hypotension; if necessary, discontinuation of the drug or substitution of another medication Pressure stockings Fludrocortisone (Florinef), 0.1 mg two or three times daily, if indicated Midodrine (ProAmatine), 2.5 to 5 mg three times daily Use of a benzodiazepine or Education about the appropriate use of sedativeother sedative-hypnotic drug hypnotic drugs Nonpharmacologic treatment of sleep problems, such as sleep restriction Tapering and discontinuation of medication Use of four or more prescription Review of medications medications Environmental hazards for falling Home safety assessment with appropriate changes, or tripping such as removal of hazards, selection of safer furniture (correct height, more stability) and installation of structures such as grab bars or handrails on stairs. Any impairment in gait Gait training Use of an appropriate assistive device Balance or strengthening exercises if indicated Any impairment in balance or Balance exercises and training in transfer skills if transfer skills indicated Environmental alterations, such as installation of grab bars or raised toilet seats Impairment in leg or arm muscle Exercises with resistive bands and putty; resistance strength or impaired range of training two or three times a week, with resistance motion (hip, ankle, knee, increased when the patient is able to complete 10 shoulder, hand or elbow) repetitions through the full range of motion Adapted with permission from Tinetti ME, Baker DI, McAvay G, Claus EB, Garrett P, Gottschalk M, et al. A multifactorial intervention to reduce the risk of falling among elderly people living in the community. N Engl J Med 1994;331:821-7

Sensory Perception
Changes in vision and hearing occur as patients age. Because these changes can have a great impact on well-being, the USPSTF recommends regular vision and hearing screening for patients 65 years of age and older.6

Hearing Handicap Inventory for the ElderlyScreening Vision Version One study found that 72 percent of community-based patients more than 64 The rightsholder did not years of age had impaired vision as tested grant rights to reproduce this with a Snellen eye chart.15 Other studies item in electronic media. For have detected lower percentages of geriatric patients with vision problems, but the missing item, see the the prevalence of visual impairment is still original print version of this publication. quite high. The most common causes of visual impairment in the elderly include FIGURE 1. presbyopia, cataracts, glaucoma, diabetic retinopathy and age-related macular degeneration. Changes in vision can cause a significant number of problems for elderly patients, including an increased risk for falls.16 The Snellen eye chart is an appropriate tool for visual acuity screening in the elderly. Referral to an ophthalmologist should be considered when visual acuity is worse than 20/40 (with normal corrective lenses, if applicable) and visual impairment is interfering with daily activities. The USPSTF found insufficient evidence to recommend for or against screening with ophthalmoscopy performed by primary care physicians in asymptomatic elderly patients. However, patients at high risk for glaucoma (i.e., black patients over 40 years of age, white patients over 65 years of age and patients with diabetes mellitus, myopia, ocular hypertension or a family history of glaucoma) should be referred to an eye care specialist for tonometry, funduscopy and visual field examination. The optimal frequency for glaucoma screening in these patients is uncertain.6 Hearing The prevalence of hearing loss in the geriatric population ranges from 14 to 46 percent,17,18 but only 20 percent of primary care physicians routinely screen elderly patients for hearing loss.18 As a result of psychologic, financial and mechanical impediments, only 32 percent of persons with moderate to marked hearing loss use a hearing aid.17

Presbycusis, a progressive highfrequency hearing loss, is the most common cause of hearing impairment The rightsholder did not grant in geriatric patients.19 This type of rights to reproduce this item in hearing loss decreases the ability to electronic media. For the interpret speech, which can lead to a 20 decreased ability to communicate and missing item, see the original print version of this publication. a subsequent increased risk for social 17 isolation and depression. Hearing loss in the elderly can also adversely affect physical, emotional and cognitive well-being.21 Questionnaires such as the Hearing Handicap Inventory for the ElderlyScreening version (HHIES) have been shown to accurately identify persons with hearing impairment18 (Figure 1).22 The reference standard for establishing hearing impairment, however, remains pure tone audiometry, which can be performed in the physician's office. Combining the HHIES questionnaire with pure tone audiometry has been shown to improve screening effectiveness.20 Appropriate interventions include periodic screening to provide early detection of hearing impairment, cautious use or avoidance of ototoxic drugs, and support for the obtainment and continued use of hearing aids.17 Interventions to be considered, depending on the degree of hearing loss, are provided in Table 4.10

TABLE 4 Interventions Based on the Degree of Hearing Loss in the Elderly

Nutrition
Malnutrition and undernutrition are common yet frequently overlooked problems in the geriatric population. Elderly patients with a compromised nutritional state require longer hospital stays and develop more complications.23 One simple screening device for geriatric nutrition is the Nutritional Health Screen (Figure 2).23 This assessment tool is simple to administer, can be graded by a health care professional or family member, and may help to prevent nutritional problems in at-risk patients. The USPSTF recommendation for encouraging regular tooth brushing, flossing and dental visits gains importance in the elderly.6

Nutritional Health Screen

Read the statements below. Circle the number in the "yes" column for each statement

that applies to you. Add up the circled numbers to get your nutritional score. Yes I have an illness or condition that has made me change the kind and/or amount of food I eat. I eat fewer than two meals a day. I eat few fruits, vegetables or milk products. I have three or more drinks of beer, liquor or wine almost every day. I have tooth or mouth problems that make it hard for me to eat. I do not always have enough money to buy the food I need. I eat alone most of the time. I take three or more different prescribed or over-the-counter drugs a day. Without wanting to, I have lost or gained 10 pounds in the past six months. I am not always physically able to shop, cook and/or feed myself. The scale is scored as follows: 0 to 2 = You have good nutrition. Recheck your nutritional score in 6 months. 3 to 5 = You are at moderate nutritional risk. See what you can do to improve your eating habits and lifestyle. Recheck your nutritional score in 3 months. 6 or more = You are at high nutritional risk. Bring this checklist the next time you see your doctor, dietitian or other qualified health or social service professional. Talk with any of these professionals about the problems you may have. Ask for help to improve your nutritional status. FIGURE 2. Nutritional health screen. Adapted with permission from The clinical and cost-effectiveness of medical nutrition therapies: evidence and estimates of potential medical savings from the use of selected nutritional intervention. June 1966. Summary report prepared for the Nutritional Screening Initiative, a project of the American Academy of Family Physicians, the American Dietetic Association and the National Council on the Aging, Inc., and funded in part by a grant from Ross Products Division, Abbott Laboratories Inc. 2 3 2 2 2 4 1 1 2 2

Immunizations
A 1990 report24 indicated that fewer than 30 percent of adults had received updated tetanus-diphtheria, influenza and pneumococcal immunizations. The poor compliance rate was determined to be secondary to patients' concerns about adverse reactions to immunizations and physicians' overlooking the need for such immunizations. In recent years, however, immunization rates in adults have improved. Data from the Centers for Disease Control and Prevention indicated that the 1997 rates for influenza and pneumococcal vaccinations were 65.5 percent and 45.5 percent, respectively.25

Primary care physicians must be diligent in assessing the immunization status of geriatric The U.S. Preventive Services patients and providing the recommended Task Force recommends 6 vaccines. As suggested by the USPSTF, an annual influenza vaccination annual influenza vaccination in the fall is and at least one pneumococcal recommended for all elderly patients. vaccination for all patients over Patients over 65 years of age should also 65 years of age. receive at least one pneumococcal vaccination in their lifetime, with high-risk patients receiving a second immunization in six years. The tetanusdiphtheria (Td) toxoid should be given every 10 years. The Td toxoid is given again after five (or more) years if the patient suffers a wound that would be classified as "dirty."

Sexuality
Although the tempo and intensity of sexual activity may change over time, problems that relate to a person's ability to have and enjoy sexual relations should not be considered part of the normal aging process. Studies show that 74 percent of married men and 56 percent of married women over 60 years of age remain sexually active.26 Common problems affecting sexual functioning include arthritis, diabetes, fatigue, fear of precipitating a heart attack and side effects from alcohol, prescription drugs and over-the-counter medications.27 Older patients state that they would like their physician to initiate discussions about sexuality, ask open and direct questions, and treat them as normal sexual persons.28

Continence
Incontinence is estimated to occur in 11 to 34 percent of elderly men and 17 to 55 percent of elderly women.29 Although incontinence is common, is frequently reversible30 and has significant social and emotional consequences,31 relatively few patients volunteer that they are having problems or request treatment.32 The first step in screening for urinary incontinence is to ask the patient if he or she is experiencing any problems in this area. Two straightforward questions are "Do you ever lose urine when you don't want to?" and "Have you lost urine on at least six separate days?" Affirmative answers to both questions constitute a positive screen. In this situation, further evaluation is necessary. Evidence of Assessment for urinary incontinence should include evaluation of cognitive function, fluid intake, mobility, medication side effects and previous urologic surgeries.

stress incontinence is elicited by questions such as "Do you ever lose urine when you cough, exercise, lift, sneeze or laugh?" The assessment for urinary incontinence should include an evaluation of cognitive function, fluid intake, mobility, medication side effects and previous urologic surgeries.30 The physical examination should focus on the lower genitourinary tract in women and the prostate gland in men. A rectal examination can determine the presence of fecal impaction, and a simple urinalysis can be used to screen for infection or glycosuria.

Mental Status
Changes in mental status can have a profound impact on elderly patients and their families. Two of the more common changes are cognitive decline and depression. Cognition Dementia is chronic and progressive, and it is characterized by the gradual onset of impaired memory and deficits in two or more areas of cognition, such as anomia, agnosia or apraxia. For the diagnosis of dementia to be established, these deficits must be present with no alteration of consciousness and no underlying medical cause that would better explain the deficits. Two of the more commonly used screening tools for dementia are the Mini-Mental State (Figure 3)33 and the Clock Test.34 An alternative to patient testing is a structured family report using the Informant Questionnaire on Cognitive Decline in the Elderly (IQCDE).35 Although less discriminating than the Mini-Mental State, the IQCDE is not affected by a patient's educational level or premorbid intelligence.36 Combining these tools can increase the sensitivity of the screening process and identify additional patients in the early stages of dementia.37

Mini-Mental State
Write in the points for each correct response. A total of 30 points is possible. Score Points Orientation 1. What is the: Year? Season? Date? Day? Month?

_____ _____ _____ _____ _____

1 1 1 1 1

2. Where are we?

State? Country? Town or city? Hospital?

Floor? Registration 3. Name three objects, taking 1 second to say each. Then ask the patient to repeat all three names after you have said them. (Give one point for each correct answer.) Repeat the answers until the patient learns all three. Attention and calculation Serial sevens. Have the patient count backward from 100 by 7's. (Stop after five answers: 93, 86, 79, 72, 65. Give one point for each correct answer.) Alternatively, have the patient spell WORLD backwards. Recall 5. Ask for the names of the three objects learned in question 3. (Give one point for each correct answer.) Language 6. Point to a pencil and a watch. Have the patient name them as you point. 7. Have the patient repeat "No ifs, ands or buts." 8. Have the patient follow a three-stage command: "Take a paper in your hand. Fold the paper in half. Put the paper on the floor." 9. Have the patient read and obey the following: "CLOSE YOUR EYES." (Write the words in large letters.) 10. Have the patient write a sentence of his or her choice. (The sentence should contain a subject and an object, and it should make sense. Ignore spelling errors when scoring.) 11. Have the patient copy the following design. (Give one point if all sides and angles are preserved and if the intersecting sides form a quadrangle.)

_____ _____ _____ _____ _____

1 1 1 1 1

_____

_____ _____ _____ _____ _____ _____ _____ _____

5 3 2 1 3 1 1 1

Total _____ FIGURE 3. Mini-Mental State. Adapted with permission from Folstein MF, Folstein SE, McHugh PR. "Mini-mental state." A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975;12:189-98.

Depression Depression significantly increases morbidity and mortality.38 As opposed to dementia, depression is usually characterized by a relatively rapid onset, intact but possibly retarded cognitive abilities and a generally time-limited duration. The Geriatric Depression Scale, shown in Figure 4,39 is a good screening tool to use in older patients.40 It avoids issues related to physical symptoms

and asks questions requiring only a "yes" or "no" answer. The onequestion Yale Depression Screen ("Do you often feel sad or depressed?") has also been found to be an effective screening tool41 and may be worth considering when clinical time is at a premium. An assessment for suicide risk is important in geriatric patients who appear depressed. The best way to accomplish this task is to ask direct, yet nonthreatening questions. An effective interview progression might be to begin by asking patients if they are concerned that they are becoming a burden to their family and if they have ever felt that their family might be better off without them. This is followed by questions about active suicidal ideation.42

Geriatric Depression Scale (Short Form)

For each question, choose the best answer for how you felt over the past week. 1. Are you basically satisfied with your life? 2. Have you dropped many of your activities and interests? 3. Do you feel that your life is empty? 4. Do you often get bored? 5. Are you in good spirits most of the time? 6. Are you afraid that something bad is going to happen to you? 7. Do you feel happy most of the time? 8. Do you often feel helpless? 9. Do you prefer to stay at home, rather than going out and doing new things? 10. Do you feel you have more problems with memory than most? 11. Do you think it is wonderful to be alive now? 12. Do you feel pretty worthless the way you are now? 13. Do you feel full of energy? 14. Do you feel that your situation is hopeless? 15. Do you think that most people are better off than you are? Yes / NO YES / No YES / No YES / No Yes / NO YES / No Yes / NO YES / No YES / No YES / No Yes / NO YES / No Yes / NO YES / No YES / No

The scale is scored as follows: 1 point for each response in capital letters. A score of 0 to 5 is normal; a score above 5 suggests depression. FIGURE 4. Mini-Mental State. dapted with permission from Sheikh JI, Yesavage JA. Geriatric Depression Scale (GDS): recent evidence and development of a shorter version. Clin Gerontol 1986;5:165-72.

Social Issues
Because multiple aspects of the social situation can influence functional ability, efficient use of time can be made by asking patients and family members if any recent changes have occurred in living arrangements, finances or activities. Actual or potential caregivers can provide information about a patient's social network and support system, as well as the availability of care.6

Evaluating a caregiver's potential for feeling overwhelmed is important in determining the risk of "burning out." Referral to agencies such as the Alzheimer's Association or a local senior center can provide functional and emotional support for patients and caregivers.6 Other issues that need to be addressed with patients and caregivers include advance directives, the living will and the durable power of attorney. Finally, the USPSTF recommends that all family members of geriatric patients receive training in cardiopulmonary resuscitation.6

The rightsholder did not grant rights to reproduce this item in electronic media. For the missing item, see the original print version of this publication.
FIGURE 5.

Remaining as independent as possible for a long as possible is a primary concern for most elderly patients. The level of supportive assistance that is needed can quickly be determined by asking the patient and/or caregiver about the patient's ability to perform the Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs). An ADL evaluation form is provided in Figure 5,43 and an IADL evaluation form is presented in Figure 6.44 Having the patient complete a structured series of activities, such as the Performance Test of Activities of Daily Living (PADL), provides similar information without reporting bias.45

Instrumental Activities of Daily Living (Self-Rated Version)

For each question, circle the points for the answer that best applies to your situation. 1. Can you use the telephone? Without help With some help Completely unable to use the telephone 2. Can you get to places that are out of walking distance? Without help With some help Completely unable to travel unless special arrangements are made 3. Can you go shopping for groceries? Without help With some help Completely unable to do any shopping 4. Can you prepare your own meals? 3 2 1 3 2 1 3 2 1

Without help With some help Completely unable to prepare any meals 5. Can you do your own housework? Without help With some help Completely unable to do any housework 6. Can you do your own handyman work? Without help With some help Completely unable to do any handyman work 7. Can you do your own laundry? Without help With some help Completely unable to do any laundry at all 8a. Do you take any medicines or use any medications? Yes (If "yes," answer question 8b.) No (If "no," answer question 8c.) 8b. Do you take your own medicine? Without help (in the right doses at the right time) With some help (take medicine if someone prepares it for you and/or reminds you to take it) Completely unable to take own medicine 8c. If you had to take medicine, could you do it? Without help (in the right doses at the right time) With some help (take medicine if someone prepares it for you and/or reminds you to take it) Completely unable to take own medicine 9. Can you manage your own money? Without help With some help Completely unable to handle money FIGURE 6. Instrumental Activities of Daily Living Scale (self-rated version). Adapted with permission from Lawton MP, Brody EM. Assessment of older people: selfmaintaining and instrumental activities of daily living. Gerontologist 1969;9:279-85.

3 2 1 3 2 1 3 2 1 3 2 1 1 2 3 2 1 3 2 1 3 2 1

One recent study indicated that short-term memory and orientation are the domains most closely associated with ADL dependence. The study findings suggested that a shortened version of the Mini-Mental State that included only the recall of three words and the orientation to month, year and address could be a valid and time-efficient assessment tool.46

Checklist of Assessment Areas for Maintaining Healthy Geriatric Patients

Sexuality Review of chronic conditions _____ and medications Injury prevention Initiation of discussion about _____ Use of safety belts or helmets _____ sexuality Smoke detectors (in place and Continence _____ working) Review of chronic conditions _____ Hot water temperature at and medications _____ <=48.8C (120F) Initiation of discussion about _____ Smoking near bed or incontinence _____ upholstery Focused physical examination _____ _____ Poor lighting (pelvis, prostate, rectum) _____ Obtrusive furniture Mental status (consider one of the _____ Slippery floors and loose rugs following) _____ Handrails and grab bars _____ Mini-Mental State _____ One-leg balance (5 seconds) _____ Clock Test _____ "Get Up and Go" test* Informant Questionnaire on _____ Cognitive Decline in the Sensorium Elderly _____ Snellen eye chart _____ Geriatric Depression Scale _____ Ophthalmology examination _____ Yale Depression Screen Hearing Handicapped _____ Questioning about suicide _____ Inventory for the ElderlyScreening version Social issues _____ Pure tone audiometry Changes in living _____ arrangements, finances or Nutrition activities _____ Nutritional Health Screen Tooth brushing, flossing and _____ Caregiver support or burnout _____ _____ Advance directives dental visits Family training in Immunizations _____ cardiopulmonary resuscitation _____ Tetanus and diphtheria toxoid _____ Activities of Daily Living _____ Influenza vaccine Instrumental Activities of _____ Pneumococcal vaccine _____ Daily Living Performance Test of Activities _____ of Daily Living
*--The patient rises from a sitting position, walks 10 feet, turns and returns to the chair to sit. The test is positive if these activities take more than 16 seconds. FIGURE 7. Areas of assessment in a systematic approach to maintaining healthy geriatric patients.

Information from U.S. Preventive Services Task Force. Guide to clinical preventive services: report of the U.S. Preventive Services Task Force. 2d ed. Baltimore: Williams & Wilkins, 1996.

Final Comment
Geriatric patients present multiple challenges to primary care physicians. Using a standard assessment plan, which might include a chart-based checklist of counseling topics (Figure 7),6 as well as a brief screening list (Table 5),47 physicians can prevent or delay some of the major causes of morbidity and mortality in their older patients. The assessment can be performed over time and during multiple visits. By performing comprehensive health screening, physicians can provide appropriate interventions and improve quality of life for their geriatric patients.

TABLE 5 Ten-Minute Screen for Geriatric Conditions

Problem Vision Screening measure Ask this question: "Because of your eyesight, do you have trouble driving a car, watching television, reading or doing any of your daily activities?" If the patient answers "yes," test each eye with the Snellen eye chart while the patient wears corrective lenses (if applicable). Use an audioscope set at 40 dB. Test the patient's hearing using 1,000 and 2,000 Hz. Time the patient after giving these directions: "Rise from the chair. Then walk 20 feet briskly, turn, walk back to the chair and sit down." Ask this question: "In the past year, have you ever lost your urine and gotten wet?" If the patient answers "yes," ask this question: "Have you lost urine on at least 6 separate days?" Positive screen "Yes" to question and inability to read at greater than 20/40 on the Snellen eye chart

Hearing

Inability to hear 1,000 or 2,000 Hz in both ears or inability to hear frequencies in either ear Unable to complete task in 15 seconds

Leg mobility

Urinary incontinence

"Yes" to both questions

Nutrition and weight loss

Ask this question: "Have you lost 10 "Yes" to the question or a pounds over the past 6 months without weight of less than 45.5 kg trying to do so?" (100 lb) If the patient answers "yes," weigh the patient. Three-item recall Unable to remember all

Memory

three items after 1 minute Depression Physical disability Ask this question: "Do you often feel sad or depressed?" Ask the patient these six questions: "Are you able to do strenuous activities, like fast walking or bicycling?" "Are you able to do heavy work around the house, like washing windows, walls or floors?" "Are you able to go shopping for groceries or clothes?" "Are you able to get to places that are out of walking distance?" "Are you able to bathe--sponge bath, tub bath or shower?" "Are you able to dress, like put on a shirt, button and zip your clothes, or put on your shoes?" Adapted with permission from Moore A, Siu AL. Screening for common problems in ambulatory elderly: clinical confirmation of a screen instrument. Am J Med 1996;100:438-43. Copyright 1996, with permission from Excerpta Medica Inc. "Yes" to the question "No" to any of the questions

The Authors
KARL E. MILLER, M.D., is associate professor of family medicine and director of predoctoral education and research at the University of Tennessee College of Medicine, Chattanooga. Dr. Miller earned his medical degree from the Medical College of Ohio, Toledo, and completed a residency in family practice at Flower Memorial Hospital, Sylvania, Ohio. ROBERT G. ZYLSTRA, ED.D., L.C.S.W. is director of behavioral science and instructor in the Department of Family Medicine at the University of Tennessee College of Medicine, Chattanooga. Dr. Zylstra earned a master of social work degree at the University of Michigan, Ann Arbor, and a doctor of education degree at the University of Memphis.

JOHN B. STANDRIDGE, M.D., is assistant professor of family medicine at the University of Tennessee College of Medicine, Chattanooga, and medical director of Alexian Health Care Center, Signal Mountain, Tenn. He earned his medical degree at the University of Tennessee College of Medicine, Memphis, and completed a family practice residency at Roanoke (Va.) Memorial Hospital. Dr. Standridge also earned a Certificate of Added Qualification in Geriatric Medicine.
Address correspondence to Karl E. Miller, M.D., Department of Family Medicine, University of Tennessee, Chattanooga Unit, 1100 East Third St., Chattanooga, TN 37403. Reprints are not available from the authors.

REFERENCES 1. Maly RC, Hirsch SH, Reuben DB. The performance of simple instruments in
detecting geriatric conditions and selecting community-dwelling older people for geriatric assessment. Age Ageing 1997;26: 223-31. 2. Toseland RW, O'Donnell JC, Engelhardt JB, Hendler SA, Richie JT, Jue D. Outpatient geriatric evaluation and management. Results of a randomized trial. Med Care 1996;34:624-40. 3. Reuben DB, Frank JC, Hirsch SH, McGuigan KA, Maly RC. A randomized clinical trial of outpatient comprehensive geriatric assessment coupled with an intervention to increase adherence to recommendations. J Am Geriatr Soc 1999;47:269-76. 4. Tryon AF, Mayfield GK, Bross MH. Use of comprehensive geriatric assessment techniques by community physicians. Fam Med 1992;42:453-6. 5. Reuben DB, Maly RC, Hirsch SH, Frank JC, Oakes AM, Siu AL, et al. Physician implementation of and patient adherence to recommendations from comprehensive geriatric assessment. Am J Med 1996; 100:444-51. 6. U.S. Preventive Services Task Force. Guide to clinical preventive services: report of the U.S. Preventive Services Task Force. 2d ed. Baltimore: Williams & Wilkins, 1996. 7. Shadlen MF, Larson EB. What's new in Alzheimer's disease treatment? Reasons for optimism about future pharmacologic options. Postgrad Med 1999;105:10918. 8. Tinetti MD. Falls. In: Cassel CK, et al., eds. Geriatric medicine. 2d ed. New York: Springer-Verlag, 1990: 528-34. 9. Cummings SR, Nevitt MC, Kidd S. Forgetting falls. The limited accuracy of recall of falls in the elderly. J Am Geriatr Soc 1988;36:613-6. 10. Reuben DB, Grossberg GT, Mion LC, Pacala JT, Potter JF, Semla TP. Geriatrics at your fingertips, 1998/99. Belle Mead, N.J.: Excerpta Medica, 1998. 11. Tinetti ME, Baker DI, McAvay G, Claus EB, Garrett P, Gottschalk M, et al. A multifactorial intervention to reduce the risk of falling among elderly people living in the community. N Engl J Med 1994;331:821-7. 12. Vellas BJ, Wayne SJ, Romero L, Baumgartner RN, Rubenstein LZ, Garry PJ. One-leg balance is an important predictor of injurious falls in older persons. J Am Geriatr Soc 1997;45:735-8. 13. Mathias S, Nayak US, Isaacs B. Balance in elderly patients: the "get up and go" test. Arch Phys Med Rehabil 1986;67:387-9.

14. Okumiya K, Matsubayashi K, Nakamura T, Fujisawa M, Osaki Y, Doi Y, et al.

The timed "up and go" test is a useful predictor of falls in community-dwelling older people [Letter]. J Am Geriatr Soc 1998;46:928-9. 15. Wun YT, Lam CC, Shum WK. Impaired vision in the elderly: a preventable condition. Fam Pract 1997; 14:289-92. 16. Carter TL. Age-related vision changes: a primary care guide. Geriatrics 1994;49:37-42,45. 17. Popelka MM, Cruickshanks KJ, Wiley TL, Tweed TS, Klein BE, Klein R. Low prevalence of hearing aid use among older adults with hearing loss: the Epidemiology of Hearing Loss Study. J Am Geriatr Soc 1998;46:1075-8. 18. Reuben DB, Walsh K, Moore AA, Damesyn M, Greendale GA. Hearing loss in community-dwelling older persons: national prevalence data and identification using simple questions. J Am Geriatr Soc 1998;46:1008-11. 19. Maggi S, Minicuci N, Martini A, Langlois J, Siviero P, Pavan M, et al. Prevalence rates of hearing impairment and comorbid conditions in older people: the Veneto Study. J Am Geriatr Soc 1998;46:1069-74. 20. Lichtenstein MJ, Bess FH, Logan SA. Validation of screening tools for identifying hearing-impaired elderly in primary care. JAMA 1988;259:2875-8 [Published erratum in JAMA 1990;264:38]. 21. Jerger J, Chmiel R, Wilson N, Luchi R. Hearing impairment in older adults: new concepts. J Am Geriatr Soc 1995;43:928-35. 22. Ventry IM, Weinstein BE. Identification of elderly people with hearing problems. ASHA 1983;25:37-42. 23. The clinical and cost-effectiveness of medical nutrition therapies: evidence and estimates of potential medical savings from the use of selected nutritional intervention. June 1966. Summary report prepared for the Nutritional Screening Initiative. A project of the American Academy of Family Physicians, the American Dietetic Association and the National Council on the Aging, Inc., and funded in part by a grant from Ross Products Division, Abbott Laboratories Inc. 24. Douglas KC, Rush DR, O'Dell M, Monroe A, Ausmus M. Adult immunization in a network of family practice residency programs. J Fam Pract 1990;31: 51320. 25. Influenza and pneumococcal vaccination levels among adults aged > or = 65 years--United States, 1997. MMWR Morb Mortal Wkly Rep 1998;47: 797-802. 26. Diokno AC, Brown MB, Herzog AR. Sexual function in the elderly. Arch Intern Med 1990;150:197-200. 27. Kaiser FE. Sexuality in the elderly. Urol Clin North Am 1996;23:99-109. 28. Johnson B. Older adults' suggestions for health care providers regarding discussions of sex. Geriatr Nurs 1997;18:65-6. 29. Thom D. Variation in estimates of urinary incontinence prevalence in the community: effects of differences in definition, population characteristics, and study type. J Am Geriatr Soc 1998;46:473-80. 30. Brandeis GH, Baumann MM, Hossain M, Morris JN, Resnick NM. The prevalence of potentially remedial urinary incontinence in frail older people: a study using the Minimum Data Set. J Am Geriatr Soc 1997;45:179-84. 31. DuBeau CE, Levy B, Mangione CM, Resnick NM. The impact of urge urinary incontinence on quality of life: importance of patients' perspective and explanatory style. J Am Geriatr Soc 1998;46:683-92. 32. Roberts RO, Jacobsen SJ, Rhodes T, Reilly WT, Girman CJ, Talley NJ, et al. Urinary incontinence in a community-based cohort: prevalence and healthcareseeking. J Am Geriatr Soc 1998;46:467-72.

33. Folstein MF, Folstein SE, McHugh PR. "Mini-mental state." A practical method 34. 35. 36. 37. 38. 39. 40. 41. 42. 43. 44. 45. 46. 47.
for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975;12:189-98. Tuokko H, Hadjistavropoulos T, Miller JA, Beattie BL. The Clock Test: a sensitive measure to differentiate normal elderly from those with Alzheimer's disease. J Am Geriatr Soc 1992;40:579-84. Jorm AF, Jacomb PA. The Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE): socio-demographic correlates, reliability, validity and some norms. Psychol Med 1989;19:1015-20. Mulligan R, Mackinnon A, Jorm AF, Giannakopoulos P, Michel JP. A comparison of alternative methods of screening for dementia in clinical settings. Arch Neurol 1996;53:532-6. Mackinnon A, Mulligan R. Combining cognitive testing and informant report to increase accuracy of screening for dementia. Am J Psychiatry 1998; 155:152935. Gallo JJ, Rabins PV, Lyketsos CG, Tien AY, Anthony JC. Depression without sadness: functional outcomes of nondysphoric depression in later life. J Am Geriatr Soc 1997;45:570-8. Sheikh JI, Yesavage JA. Geriatric Depression Scale (GDS): recent evidence and development of a shorter version. Clin Gerontol 1986;5:165-72. Yesavage JA, Brink TL, Rose TL, Lum O, Huang V, Adey M, et al. Development and validation of a geriatric depression screening scale: a preliminary report. J Psychiatr Res 1982-83;17:37-49. Mahoney J, Drinka TJ, Abler R, Gunter-Hunt G, Matthews C, Gravenstein S, et al. Screening for depression: single question versus GDS. J Am Geriatr Soc 1994;42:1006-8. Devons CA. Suicide in the elderly: how to identify and treat patients at risk. Geriatrics 1996;51:67-72. Katz S. Assessing self-maintenance: activities of daily living, mobility, and instrumental activities of daily living. J Am Geriatr Soc 1983;31:721-7. Lawton MP, Brody EM. Assessment of older people: self-maintaining and instrumental activities of daily living. Gerontologist 1969;9:179-85. Kruiansky J, Gurland B. The performance test of activities of daily living. Int J Aging Hum Dev 1976; 7:343-52. Gill TM, Williams CS, Richardson ED, Berkman LF, Tinetti ME. A predictive model for ADL dependence in community-living older adults based on a reduced set of cognitive status items. J Am Geriatr Soc 1997;45:441-5. Moore A, Siu AL. Screening for common problems in ambulatory elderly: clinical confirmation of a screen instrument. Am J Med 1996;100:438-43.

Volume 21 - Issue 19, Sept. 11 - 24, 2004

India's National Magazine from the publishers of THE HINDU

MEDICINE

The old and the ignored

ASHA KRISHNAKUMAR With the population of elderly people rising, their health care has become a matter of concern especially since the family support system is crumbling and there is no comprehensive geriatric care system. THE rising life expectancy at birth is one of the major achievements of the 20th century. But instead of rejoicing over the favourable demographic indicator, the world is caught in an "age-quake". For, the proportion of people aged 60 plus is rising and is expected to accelerate in the next 50 years. This "demographic time bomb" is nearing explosion in developed nations, and Asia, including India, is not far behind.
R.RAGHU

Two-thirds of the world's elderly live in developing countries. The rise in the proportion of the ageing population represents one of the most significant demographic shifts in history. In 1950, there were 205 million people who were over 60; in 2000, there were 606 million; and by 2050, there will be two billion. The number of the elderly trebled over the last 50 years and an encore is expected in the next 50 years. As a proportion of the total world population, the number of the elderly will double in the next 50 years. This demographic change is fast turning the hair of policy-makers prematurely grey throughout the world, especially in developing countries, where the growth of the aged population is happening at a more rapid pace. Though developed countries have a relatively high proportion of the elderly, the older population is concentrated in the developing world and growing at a much faster rate. Two-thirds of the elderly live in developing countries. Women comprise a greater number and proportion of the elderly in almost all societies. This disparity rises as people grow older - women comprise 55 per cent of the 60-plus population; in the 80-plus set, they are 65 per cent; and in the 100-plus, 77 per cent. The last century saw rapid industrialisation and urbanisation the world over. In India, these developments brought about major changes in the social structure. The centuriesold joint-family system disintegrated, and with it collapsed the safety net of parents and grandparents. Since the welfare of the elderly has been a low priority with the state, they have nowhere to turn, and are left disillusioned, shattered and lonely. In India, the elderly population has grown manifold. While only 19 million people were 60-plus in 1947, today the figure has risen to nearly 80 million, an increase of 285 per cent in the last five decades. The figure is expected to double in the next 25 years. Nearly 90 per cent of the elderly have no form of official social security, and over 40 per cent

live below the poverty line. Close to 75 per cent are from the rural areas and over 73 per cent are illiterate. Some 55 per cent of the women over 60 years (over 20 million) are widows. If achieving longevity was the triumph of the 20th century, care of the elderly will be the challenge of the 21st century. While research on ageing is well-developed and documented in developed countries, it hardly happens in countries such as India. According to Dhar Chakraborti (The Greying of India, Sage Publications, 2004), this is primarily because of the belief that the family support system is and will continue to be an adequate insurance against all problems related to old age. No doubt family has so far been the most effective provider of old-age support in India in the absence of institutional support. But with social and economic developments undermining traditional values, and with the number of the elderly growing rapidly vis-avis those expected to provide them support, it is becoming a major problem. Experts argue that the increasing proportion of the elderly will make the latter's own conditions pitiable as they would draw heavily from the limited resources of most families. They would take away large shares of the national income, burdening future generations of taxpayers, and savings and investments would decline. Simultaneously, national productivity will also fall with a rise in the median age of workers. The problem of the rising proportion of the aged has been compounded, in most populations, by a steady decline in the proportion of children, with a decline in fertility mortality transition always precedes fertility transition. From 34 per cent in 1950, the proportion of children below 15 declined to 30 per cent in 2000 and is projected to fall to 21 per cent by 2050. At around this time the proportion of the elderly population will equal the population below 15 years. The dependency ratio (the number of over-65 dependent on every person in the 15-64 age group) would zoom to 23; it had risen from eight in 1950 to 10 in 2000. This would mean that every parent would have fewer children to take care of them during old age. With the cost of parent care rising per child, and in the face of the continuing financial crisis, most children do not have adequate resources to take care of their elderly parents. Where resources are not scarce, psychological barriers against caring for parents have emerged. Pressured by high unemployment levels and job insecurity, youth migrate in search of work. This also puts tremendous strain on the elderly. THE elderly require special care. Most hospitals in the country do not have a special geriatric facility and if there is one, it is prohibitively expensive. Yet, on an average, 1015 per cent of hospital beds are occupied by the elderly. According to the principles of health economics, the elderly requiring treatment for longer periods are best kept at home for better resource utilisation. But with increasing female participation in the labour force, caring of the elderly at home has come down sharply. Housing shortages and the consequent reduction in space are increasingly eroding the rights of the elderly to privacy.

The elderly are the major casualties of the break-up of the joint family system. Studies conducted recently among old people show that over 35 per cent of the elderly in urban areas and 32 per cent in rural areas live alone. There is nobody to look after them - and financial constraints and lack of security add to their troubles. Thus dependence - mental and physical - becomes unavoidable. An increasing number of the elderly are now looking for employment, mostly for low wages, and under insecure and unhealthy working conditions. Among the poorest and the most vulnerable are the elderly living in rural areas.
S.R.RAGHUNATHAN

At an old age home on October 1, 2003, International Elders' Day. In India, there has been a 285 per cent increase in the population of the aged in the past 50 years. There are significant socio-economic differences between the urban and rural elderly. More than 80 per cent of those over 60 years live in rural areas. The rural elderly are older than the urban elderly, but have little access to tertiary care. In rural areas over 6 per cent of the women are elderly, while in urban areas it is 5.1 per cent. While over 78 per cent of the elderly men have the support of their spouses, 64 per cent of elderly women are widowed, most of them dependent on someone else for their care. A large workforce among the elderly exists in the rural informal sector - over 70 per cent of the rural elderly men work, as against 48 per cent of the urban elderly men. Health care services also differ significantly in rural and urban areas, with emphasis on primary health care in the rural areas and tertiary care in the urban areas. Recent Indian Council of Medical Research (ICMR) studies in Chennai, Lucknow, Delhi and Mumbai have revealed that out of the surveyed older population, 52 per cent did not have any income. The studies show that it is the women who suffer most and in greater numbers as they live longer than their spouses. Widows form a large number of the elderly, particularly with Indian women married to men 10-15 years older than they are, and who, therefore, have to endure longer periods of widowhood. Their conditions are worse as they, more often than not, cannot fend for themselves after the death of their husbands. Studies also show that they are abused severely - verbally, psychologically and physically. According to Dr. Shilu Srinivasan, Editor of Dignity Dialogue, average life expectancy in India, which was 42 years in 1947, has increased to 65 years today. But geriatric care continues to be one of the most neglected sectors in hospitals. According to the ICMR, the special problems of the elderly are best dealt with within a geriatric unit with trained geriatricians and nursing staff, putting special emphasis on early rehabilitation, remedial exercise and occupational and psychiatric therapy. In India, hospitals merely provide outpatient geriatric service. According to Dr. C.A.K. Yesudian, Professor and Head of the Department of Health Services Studies, Tata Institute of Social Sciences, Mumbai, private hospitals do not like venturing into geriatric care as hospital stay of these patients is longer. These patients do not require intensive care, owing to which the infrastructure is poorly utilised.

Geriatric care is also capital intensive, but non-profitable. According to Dr. D.M. Gamadia, medical adviser, Masina Hospital, Mumbai, to have a separate geriatric unit would be ideal, but no one wants to invest in a full-fledged geriatric unit as the returns are poor. (Masina Hospital has a geriatric home, which is open only for the Parsi community.) Though government hospitals provide geriatric care, it is not a speciality, says Neha Dalal, a social worker with Dignity Foundation. Most doctors in India have not specialised in geriatrics. There is only one hospital in Chennai that gives post-graduate (M.D.) education in geriatric medicine. Yesudian suggests having geriatric departments in teaching hospitals. Medically, early diagnosis is difficult in elderly people. They mostly ignore the symptoms, considering them as part of the ageing process. This means it is often too late when a disease is diagnosed. In some cases they suffer in silence, in some others the family ignores their complaints. Youngsters are hesitant to spend money and time for the aged. Communication barriers also contribute to the problems. Thus, when the examination of the patient becomes difficult, only a "specially trained" medical practitioner (geriatrician) can diagnose the silent atypical symptoms of the aged patient. THE medical problems of the elderly are mainly chronic. Coronary heart disease is the leading cause of death in the elderly. Visual impairment and locomotive disabilities are widely reported. In a recent rural survey by the ICMR, only 20 per cent of those interviewed said they had no major medical problems. Many reported five or six symptoms and were presented with two or three diagnoses. The problems reported related to vision (65 per cent), movement (36 per cent), respiration (10 per cent), skin (8.5 per cent), the central nervous system (7.4 per cent), cardiovascular ailments (6.3 per cent), and hearing (5.8 per cent). According to the ICMR study, geriatric clinics can be set up successfully at the rural primary health centres with the existing infrastructure. The paramedical staff can be trained to recognise major physical illnesses and find appropriate medical, community or social interventions. The study showed that sleeplessness, vague body pain and backache responded well to intervention by health workers, while other symptoms such as a visual handicap, giddiness and pain in the joints showed marginal improvement. Counselling proved very useful in cases where lack of family and social integration led to depression, which was the most common problem. Such patients responded well to intervention. Among those living with their families, many reported lack of integration. Screening and referrals greatly decrease the load on tertiary care services for the elderly. Some hospitals do have geriatric outpatient services, but very few have in-patient facilities, especially for the aged. This may be because the elderly are mostly in the "young elderly" group (60-75 years), in which case there is little demand for long-term health care.

A recent study on those attending a geriatric clinic in a rural primary health centre found that 58 per cent required referrals for medical care, 5.3 per cent for psychiatric help, and only 2.3 per cent for in-patient admission. In a recent countrywide survey by the National Sample Survey Organisation (NSSO), only 5.4 per cent of those above 60 years reported being immobile. General hospitals and departments of medicine continue to cater to terminally ill patients. Several forums have discussed the need for more emphasis on geriatric medicine and management in India. The public health system needs more centres and specialists in this field. The elderly are not easily moved to seek hospital care. According to the ICMR, on an average the time between needing institutionalisation and accepting it is 9.8 years. Health insurance and other support measures for the terminally ill are available only for some 10 per cent of the elderly, who have worked in the organised sector. In the latest Census, 65 per cent of the country's elderly men and 14 per cent of elderly women are listed as workers. Thus, a large proportion of the elderly remain economically active. Of the non-working elderly, only 23 per cent of the men are retired pensioners; 69.4 per cent of the men and 52 per cent of the women are dependents. In India, the position and the status of the elderly and the care and protection they traditionally enjoyed have been undermined by several factors - urbanisation, migration, break-up of the joint family system, growing individualism, change in the role of women from being full-time carers to earners, and increased dependency status of the elderly. There is also a generation gap in terms of education, aspirations and values, and the allocation of resources to different members of the family. Often the family is unable to meet the financial, social, psychological, medical and welfare needs of the elderly, and seeks help from supporting services. The government, instead of dealing with the problem of the elderly by itself, is implementing schemes to assist voluntary organisations to help senior citizens. These organisations are provided financial assistance - grants up to 90 per cent of the project expenditure - to set up day-care centres, old-age homes and mobile medicare units for the elderly. There are 186 old-age homes, 223 day-care centres and 28 mobile medicare units under these projects. The Centre's direct contribution for the elderly comes in the form of tax rebates and travel concessions. The responsibility of the state for its senior citizens is enshrined in Article 41 of the Constitution. While the welfare of the aged is a State subject, the nodal responsibility for the aged is vested with the Centre. The public policies of old-age income support takes three forms: retirement benefits for those in the formal sector, voluntary insurance schemes encouraged through tax exemptions, and direct government programmes to help the needy elderly. The eligibility rules are often complicated and the pension amount varies across States - from Rs.55 to Rs.300 a month. The National Old Age Pension scheme offers a mere Rs.75 a month for those over 65. And even these inadequate

schemes together cover only 10 per cent of the elderly. An NSS survey (52 Round, 199596) shows that 79 per cent of the elderly in the rural areas (who were engaged in wage/salaried jobs or were casual labourers) and 35 per cent in the urban areas did not receive any benefit after retirement. With such a rapid increase in the proportion of the elderly, this is hardly the way for the government to respond. It should, as Dr. Koshy Eapen, a researcher on geriatric care in the University of London, points out, put in place a comprehensive geriatric care system. WWW.SENIOR JOURNAL.COM Elder Care News

Home Intervention Program Makes Life Better for Low-Income Elderly

GRACE program developed to improve quality of care for low-income seniors Dec. 12, 2007 - A home-based geriatric care program for low-income seniors resulted in higher-quality medical care, improvement in quality of life and fewer emergency department visits, but did not appear to prevent decline in physical functioning, according to a study in the December 12 issue of the Journal of the American Medical Association (JAMA). Low-income seniors frequently have chronic medical conditions and limited access to health care. Older adults in general, and especially the poor, often do not receive the recommended standard of care for preventive services and management of chronic diseases. These patient groups have been understudied in previous trials and represent a complex and high-cost population that might especially benefit from improved coordination and integration of their health care, according to the article. The Geriatric Resources for Assessment and Care of Elders (GRACE) model of primary care was developed specifically to improve the quality of care for low-income seniors. Features of the GRACE intervention include in-home assessment and care management provided by a nurse practitioner and social worker team; extensive use of specific care protocols for evaluation and management of common geriatric conditions; utilization of an integrated electronic medical record and a Web-based care management tracking tool; and integration with affiliated pharmacy, mental health, home health, community-based and inpatient geriatric care services. Steven R. Counsell, M.D., of the Indiana University School of Medicine, Indianapolis, and colleagues conducted a study to test the effectiveness of the GRACE intervention on health outcomes for 951 low-income adults 65 years or older.

The participants primary care physicians were randomized from January 2002 through August 2004 to participate in the intervention (474 patients) or usual care (477 patients) in community-based health centers. Patients received two years of home-based care management by a nurse practitioner and social worker who collaborated with the primary care physician and a geriatrics interdisciplinary team and were guided by 12 care protocols for common geriatric conditions. Analysis of the results indicated significant improvements for intervention patients compared with usual care at 24 months in several measurements, including general health, vitality, social functioning and mental health. No group differences were found for physical function outcomes or death. The two-year emergency department visit rate was lower in the intervention group, but hospital admission rates were not significantly different between groups. In a pre-defined group at high risk of hospitalization (consisting of 112 intervention and 114 usual-care patients), emergency department visit and hospital admission rates were lower for intervention patients in the second year. Future studies should compare potential cost savings from less acute care utilization with program costs to determine feasibility. Under current fee-for-service Medicare, most of the services provided by the GRACE intervention are not reimbursed. Medicare managed care, however, presents a financial vehicle under which the GRACE intervention could currently be supported, the researchers write. We hope the GRACE model will prove to be a practical health system innovation that will contribute to improved geriatric care and outcomes while reducing high-cost acute care utilization in low-income seniors. Editorial: Better care for older people with chronic diseases an emerging vision In an accompanying editorial, David B. Reuben, M.D., of the University of California, Los Angeles, writes that research has indicated what is important to deliver optimal health care for older persons with chronic diseases. First, care must be personalized to meet each patients goals, values, and resources. Second, care should be provided in accordance with best practices. Third, physicians cannot do the job alone. Team care, which has been a hallmark of geriatrics, is essential for providing high-quality care for patients of all ages who have chronic diseases. Dr. Reuben adds that other important points include coordinating care among those caring for patients; care must consider the resources and environment of the person; and older persons must be included as active partners in their care except when they are too frail, mentally or physically.

These principles fit well within the chronic care model, a construct that espouses better health care linked to community-based services. If the chronic care model is followed, patients become more informed and activated and practice teams are more prepared to be proactive, which should result in improved clinical and functional outcomes. Implementing this type of care requires staff, support systems, and a payment mechanism. GRACE, short for Geriatric Resources for Assessment and Care of Elders, was developed by researchers from IU Geriatrics of the Indiana University School of Medicine, the Indiana University Center for Aging Research and the Regenstrief Institute, Inc.

Central Council for Research in Ayurveda and Siddha

Dept. of AYUSH, Ministry of Health & Family Welfare, Govt. of India ,New Delhi

NATIONAL CAMPAIGN ON ROLE OF AYURVEDA AND SIDDHA IN GERIATRIC CARE

GERIATRIC CLINICAL RECORD FORM

BACKGROUND
Twentieth century has seen gradual decline in the growth rate of population but with increase in life expectancy. As a result society is grappling with longevity issues. Though worldwide demographic revolution is a social achievement, yet the consequences of longevity inter alia are larger number and proportions of older people that influence financing of health care. The elderly population over the age of 65 years in most of the developed world is estimated at least 10%. In India, considering the socio-economic situation age of 60 is the cut off for elderly people. About 75% of the older people live in rural India.

According to an estimate the likely number of elderly people in India by 2016 will be around 113 millions i.e. approximately 10-12% of the entire population, out of which 51% would be elderly women. This demographic transition necessitates old-age specific health management to address the age-linked health problems like osteoarthritis, osteoporosis, diabetes, joint pain, cardiovascular diseases, and hypertension, Parkinsons disease etc.

CURRENT STATUS
National Policy for aged under the Ministry of Social Justice and Empowerment seeks health security of older people and it recognizes special health needs of the older persons to be met through strengthening and reorienting of public health services at Primary Health Care level and creation of health facilities. A few Societies and NGOs viz. Association of Gerontology, Geriatric Society of India, Parkinsons & Ageing Research Foundation, Helpage India, Age well Foundation etc. are engaged in support activities related to Geriatric Care. Geriatrics clinics and M.D. course in Geriatric are functioning at BHU, AIIMS, and Maulana Azad Medical College etc. Promotion of time-tested AYUSH practices for holistic health care viz. Rasayana therapy of Ayurveda in particular for Geriatric Care. PROFILE AND STRENGTH Jara Chikitsa or Rasayana, provides numerous single/compound herbal and herbo-mineral preparations having diversified affects on body systems indicated for the promotion of health as well as treatment varied problems. Multiple actions of Rasayana therapy includes immunomodulation, antioxidant action( prevents bio-oxidation there by checking age related disorders, auto immune disorders, degenerative disorders), adaptogenic affects and so on. Time-tested Holistic and comprehensive remedies for on Natures Laws can address the gaps in health care of old people.

Lifestyle modulation remains integral to the treatment. Most cost effective; affordable by all sections of People Well tolerated; no Adverse Drug Reactions AYUSH systems have specialized therapeutic procedures for rejuvenation, health promotion and prevention & management of degenerative health problems. Panchakarma & Yoga are proven to be efficacious in neuro-muscular, musculo-skeletal, psychosomatic and other chronic health problems of elderly people. NEED FOR NATIONAL CAMPAIGN The factors leading to vulnerability of the aging population include Inadequate public awareness on the role of AYUSH and Rasayana concept of Ayurveda for slowing down ageing process. Huge AYUSH infrastructure mainstreamed in health delivery. and manpower not

Elderly people, medical fraternity and policy makers are not well informed about the simple, holistic, cost-effective options for geriatric health care available in AYUSH systems Huge gap exists in demand and supply position of geriatric care facilities. Noncomprehensive conventional prevalent in the health care system. medical approach

Increasing number of elderly people with age above 80. Nuclear family system and isolated/ lonely living add to the challenge of geriatric care.

SCIENTIFIC INSIGHT Numerous scientific studies on single and compound herbal and herbo-mineral Ayurveda and Siddha formulations revealed the safety and efficacy in the management of age related and improvement of quality of life.
AIM Mainstreaming of the time tested potentials of Ayurveda Siddha in Geriatrics Care. Creating awareness and knowledge sharing on the Ayurveda and Siddha for Geriatric Health Care. strengths of

OBJECTIVES AND FOCUS

PRIMARY OBJECTIVES To generate awareness among public and stakeholders including policy makers, Health care providers, NGOs etc. about the role of Ayurveda and Siddha in geriatric care. To provide a platform for exchange and orientation of knowledge, merit and scope of Ayurveda and Siddha for geriatric care among Ayurveda, Siddha and Allopathic practitioners. To motivate State Governments, voluntary and private organizations for setting up Ayurveda/ Siddha geriatric care facilities in AYUSH and allopathic hospitals, medical college hospitals, PHCs, CHCs and District Hospitals.

SECONDARY OBJECTIVES
To Establish linkage among the Educational/Research Institutions, N.G.Os and the clinicians to disseminate the efficacy of Ayurveda and Siddha for Geriatric Health Care in addressing the health issues pertaining to old age problems

Promote greater awareness among Ayurveda, Siddha, Allopathic and other practitioners in dealing with issues related to Ayurveda and Siddha for Geriatric Health Care Involve practitioners of other systems of medicine to convey strengths of Ayurveda and Siddha for Geriatric Health Care , so that they can advise their patients to avail of the services of Ayurveda and Siddha in the conditions where their therapy is contra-indicated or has limitations. Determine the applicability of community-for participatory approaches for the future development and implementation of a comprehensive Ayurveda and Siddha for Geriatric Health Care program

TARGETED GROUP
Policy makers: Related to Health and Family Welfare (Central Government/ State Government) Department of AYUSH (Central Government) Department of AYUSH (State Governments) Ministry of Social Justice and empowerment Ministry of women and child development Ministry of Panchayati Raj Ministry of Rural development Ministry of Information and Broadcasting Department of Telecommunications (linking villages) Planning commission National Institute of Health and Family Welfare (NIH &FW)

Parliamentarians (different committees) Professionals: Allopathic Physicians Ayurveda/ Siddha Physicians Physicians from other Traditional Systems of Medicine Eminent scientists People (Masses) NGOs * Help age India * Public health foundation North East council of India Opinion makers/ thinkers

Social Scientists Community Groups

STRATEGY /METHODOLOGY
A National Workshop organized by the Department of AYUSH Central Council for Research in Ayurveda & Siddha (CCRAS) , New Delhi

State Level Workshops will be organized through NRHM as nodal body. Two CCRAS institutes each in large states and one institute each in smaller states would be involved. District Level combined workshops for Ayurveda, Siddha will be organized by the State AYUSH/ Health

Directorates in coordination with District Authorities.

EXPECTED OUTCOME
Build capacity and skills among Ayurveda/ Siddha practitioners/educators and provide orientation to practitioners/educators of allopathic and other traditional systems of medicine to implement the programs related to main streaming of Ayurveda and Siddha geriatric practices through systematic delivery mechanisms which can be replicated throughout India. Increase in awareness & skills of the participants in dealing with Ayurveda and Siddha for geriatric care. Identification of a group of most efficacious medicines for the diseases of geriatric age group. To establish specialized Geriatrics OPDs at primary healthcare centres, taluka hospital up to district, state and at national level hospitals. An increase in level of coordination among Ayurveda/ Siddha/ Allopathic and other physicians on issues related to Ayurveda and Siddha for geriatric care. Practitioners of other systems would be acquainted with strengths of Ayurveda & Siddha and refer such patients for treatment for conditions in which they have limitations. Non-professionals/ Masses will be sensitized about potential benefits and limitations of different systems and will be encouraged to avail of Ayurveda and Siddha for geriatric care as first line of treatment.

INITIATIVES
National Workshop: CCRAS & Dept. of AYUSH, Ministry of Health & Family Welfare, Govt. of India in collaboration with AIIMS are conducting a National Work shop on Role of Ayurveda and Siddha in

Geriatric Care Date: 23th and 24th January 2008 Venue: India habitat

Details Contact:
DR. G.S.LAVEKAR,DIRECTOR CENTRAL COUNCIL FOR RESEARCH IN AYURVEDA AND SIDDHA Jawahar Lal Nehru Bhartiya Chikitsa Avum Homeopathy Anusandhan Bhavan No.61-65, Institutional area, Janakpuri New DELHI 110038 Telephone : 91-011-28525852/83/97/31/01 Fax : 91-011-28520748/5959 E mail : ccras_dir1@nic.in. geriatrics_ccras@yahoo.co.in

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 1559). 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. 2. 3. 4. 5. 6. Care at home Health education. Institutional care - facility planning for elderly population. Human resource development for creation of medical and pare-medical expertise. Sensitisation and involvement of NGO's and voluntary organisation. 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.
Issue dtd. 1st to 15th June 2003

Geriatric care continues to be neglected by hospitals Chetna Rathod - Mumbai India is undergoing demographic changes, with the declining birth rate at 34 per cent and 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. According to Dr Shilu Srinivasan, editor of Dignity Dialogue, Today people are not only living longer but are also living a richer life. The life expectancy which was 42 years in 1947 has increased to 65 years today. But sadly, geriatric care continues to be one of the neglected sectors in hospitals. Reports state that special problems of the elderly are best dealt within a geriatric unit, a unit comprising high proportion of trained and interested geriatricians and nursing staff giving intensive care for a short period of time, with special emphasis on early rehabilitation and adequate accommodation, equipment and staff for physical medicine, remedial exercise, occupational therapy, diversional therapy and recreation. While other countries are rapidly moving ahead in providing these services, India seems to be rather slow with the hospitals being mere OPD geriatric service providers. The service is open to in-patients as well as out-patients once or twice a week and run by a medical unit (seniors and resident doctors). According to Dr C A K Yesudian, professor and head, department of Health Services Studies, Tata Institute of Social Sciences (TISS), Private hospitals do not like venturing

into geriatric care as the hospital stay of these patients is longer. These patients do not require intensive care due to which the infrastructure goes waste. Geriatric care is also capital intensive, but non-profitable. According to Dr D M Gamadia, medical advisor, Masina Hospital, Mumbai, To have a separate geriatric unit would be ideal. But there is no money. Masina Hospital has a Geriatric Home which is open only for the Parsee community. And for government hospitals, though most of them provide geriatric care service, patients find it difficult to locate these unit, says Neha Dalal, a social worker with Dignity Foundation. Experts say India stands far behind other countries in this respect. In European countries and Japan, the hospitals have a separate geriatric unit. They also have Geriatric Special Care Hospitals. Hospitals in Japan are equipped with latest technology instruments and they have specialised doctors in the geriatric field,informs Yesudian. According to reports, Heritage Medical Centre, a healthcare institute based in Hyderabad, is trying to help the elderly to face lifes troubles. The centre offers many facilities for the elderly sick including skilled nursing care, physical rehabilitation, speech therapy, clinical psychology, a day hospital, surgical and post-operative care, a non-ambulatory unit and an intensive care unit. It also has a senior citizen forum, with a membership of Rs 50, which holds meetings and dinners, and offers a social situation for the elderly. It is said that though the Centre is inspired by institutions in the US, the longterm goal is home-nursing and not providing high-tech facilities. Fighting all constraints is KEM Hospital which has been providing the geriatric care service since 1986. The hospital has a Geriatric Functional Assessment (GFA) team of inhouse doctors working for the OPD geriatric service. The team comprises physician, dieticians, medical social workers (MSWs), psychiatrists, physiotherapists, orthopaedic surgeons, nurses, caretakers, occupation therapists, geroorthopaedicians and gero-gynaecologists. However, for these doctors, this is an additional duty as they have not done geriatric schooling. There are no separate wards or beds for these patients. When patients need hospitalisation, they are admitted along with other patients. There is limited interest on the part of doctors. Doctors find it difficult to stretch the working hours. These doctors are not specialised in geriatric care and they do not work specially for geriatric care, informs Dr Yogini V Meisheri, professor of Medicine, Unit head, Seth GS Medical College and KEM Hospital who has been heading the KEM Geriatric service since 1991.

LTMG Hospital also provides referral geriatric service backed by the dean and resident doctors. Patients above 60 years of age are given priority, explains Dr Nitin Karnik, associate professor, Department of Medicines, LTMG Hospital. The various tests are done free of cost for individuals. We have the poor box charity funds and social workers who help with the medicines. And if the patient is a pensioner, he can pay whatever he can afford and the rest is taken care of, adds Dr Karnik. The drugs which are provided free are generally taken from hospital dispensaries, doctors donations and `Drug Banks formed by collecting drugs which pharma companies leave behind as samples. ``We are requesting pharmaceutical companies to come forward and provide drugs, says Dr Meisheri. We also have social organisations sponsoring the drugs for them, says Dr Karnik. He further adds that that drugs should be sponsored on a continuous basis as most of the times the drugs are not available. What is happening now is that all these hospitals as well as social organisations are working individually. If a common body is formed, then it might help to improve the working of these services and streamline the work and help cater to the correct need jointly. Also, so far, there is no law that every hospital must have a geriatric unit. If such a law is enacted than the working of our services will become systematic, suggests Dr Meisheri. This apart, another major problem faced is lack of funds due to which most of the times the doctors end up paying from their pockets. These hospitals are highly dependent on donations. Funds have always been a problem. We should have the backing of special funds in the form of relief funds, avers Dr Karnik. Experts say India needs specialised medical education in geriatric care. As of now there is only one hospital, in Chennai, which gives post-graduate (MD) education in geriatrics medicines. Doctors who are trained abroad should be introduced here who can in turn teach other doctors. We should have geriatric departments in teaching hospitals, suggests Yesudian. According to Dr Sandhya A Kamat, professor of medicine, TN Medical College and BYL Nair Hospital, Most of the time, these patients being old have locomotive problems and they find it difficult to come to the hospital. If transport was arranged, things would have been easier and convenient for both the patients and the serviceproviders.

Ideally, a Geriatric Care Unit should have Patient Care

Out-patient consultancy 3 clinics and follow-ups Therapeutic Workshops Health Education (professional as well as nonmedical) Physical fitness programme Obesity Clinic Drug Bank Memory Clinic Menopausal consultancy Blood Investigation Supervised Health Education Programme Quarterly Bulletin Professional Geriatric Education Programmes Library Health camps/ check-ups/ educative exhibitions and lectures Clinical Geriatrics Social Geriatrics Psycho Geriatrics Aging Syndrome

Education

Community Services

Research

Source: KEM Hospital which is the only hospital providing the above services

Journal of the Academy of Hospital Administration Study on the Need to Establish a Geriatric Set Up in a Teaching Hospital
Author(s): Sunita Saldanha*, Libert Anil Gomes**, Sanjeev Rai*** Vol. 15, No. 2 (2003-07 - 2003-12)

Abstract:
Eighty Five geriatric inpatients aged 60 years and above were interviewed to know the adequacy of physical structure, organization and medical care in a teaching hospital

where significant number (17%) of geriatric population is utilizing the services provided by the hospital. Majority (61%) of the geriatric patients felt the need for a separate set up. They felt the need of facilities such as, telephone, television, music, prayer hall, dining hall for their social and spiritual needs. Most of them (78%) were satisfied with clinical and supportive service, Majority (90%) of them did not face any problem in the physical facilities provided except non-slippery floor and cot adjustments. There is a need for a separate geriatric unit in a teaching hospital utilized by significant number of geriatric population. However modification of the existing facility would at least result in a better care being provided to geriatric population.

Key Messages:

Geriatric population is at high risk of disease and high risk of utilizing medical services. There is a need to provide adequate physical facilities, if possible a separate set up to support their special needs.

Keywords: Geriatrics, health need, health care, service utilisation.

Introduction
Population aging has immense implications for all countries. In the 21st century one of the biggest challenges will be how best to prevent and postpone disease and disability and to maintain the health independence and mobility of an aging population.1 There are more than 76 million elderly people in the country who constitute 7.7% of India's population. By the year 2020, the estimated population of the elderly will be 142 million or about 11% of the country's population.2 There are predictions of an increase in geriatric population especially in Asia in the coming decades. Hospital utilization by geriatric patients will also increase.3 The health care in India today is incapable of responding to the needs of the elderly males and females even at the primary level and even doctors are not aware of the special needs of the elderly. So while providing health care to geriatric population under general institutional set-up it is very important to provide adequate physical facilities which will support their special needs and will help to overcome their physical disabilities.4 It is high time nursing care of the elderly to be considered as specialty where the physical, emotional, spiritual needs of an elderly individual can be met in a highly dedicated manner.5

This study was undertaken in a teaching hospital, where significant number of geriatric population are utilizing the services provided, to know the adequacy of physical structure and medical support given to them and thereby the requirement of separate specialty.

Materials and Measurements

85 geriatric in-patients aged 60 years and above were selected by purposive sampling method and interviewed by giving a questionnaire, which included adequacy of the physical structure, organisation structure and type of medical care rendered. The obtained data was analysed. Patients who were re-admitted during the study period, who were not able to communicate because of their disability and who were not willing to participate in the study were excluded. Utilization of the existing facilities was studied by retrospective study from in-patient statistics.

Results:
In patient Admissions of Different Age Groups

This figure shows that significant number of geriatric patients are utilizing the services provide by the hospital. Table 1: Clinical and Supportive Services S. No. Items Satisfied Not Satisfied Undecided Mean Total No. % 22 1.4 15 1.6 17 1.7 40 1.4 17 1.3 70 80 85 70 65 % Mean

Total Total % % No. No. 1 2 3 4 5 Opinion regarding admission / discharge Procedures 51 60 16 74 9 77 5 49 9 55 24

18 18 11 13 6 15

Opinion regarding Nursing 63 Care Opinion regarding Doctors Care Opinion regarding ward Boys / ayahs Opinion regarding diet provided 65 42 47

11 34 28 14

Total

54

63 13

15 18

22 1.5

75

Table 1 reveals that the majority of the patients were satisfied with the clinical and supportive services provided (mean score 75%). Table 2: Location S. No. Items No Difficulty Total % No. 1 2 Difficulty in Locating the 64 wards after Admission Difficulty in going around various dept.'s for 75 investigations Average 70 Minimum Difficulty Total No. % 19 5 9 2 Maximum difficulty Total No. % 6 3 5 1.7 1.9 1.8 85 95 90 Mean % mean

75 16 88 8 82 12

14 4

Table 2 reveals that majority of the patients (i.e. 82%) did not face any difficulty in locating the wards as well as going around the various department after admission. Table 3: Physical Facilities S. No. 1 2 3 4 5 6 7 8 Items difficulty in climbing steps Sufficient space around the bed Difficulty in walking over the ward floor Convenience of bedside stool provided Comfortability of wheelchair and stretchers provided Adequacy of wheelchairs and sretchers in number Requirement of cot adjustments Mean Score Positive Negative % % Response Response 55 60 34 52 82 49 65 55 65 30 71 25 40 51 61 33 97 3 58 36 77 20 48 44 65 30 35 29 60 39 9 42 23 52 45

Requirement of curtains beside the bed for privacy 41

Table 3 reveals that the majority of the patients were happy with the physical facilities provided. 77 % felt the need of cot adjustments and 60% faced difficulty in walking over the ward floor. Table 4: Physical Environment S. No. 1 2 Item Positive Negative % % Response Response 91 8 65 30 78 19 9 35 22

Adequacy of lighting Provided 77 Noise surrounding the stay area 55 Mean Response 66

Table 4 reveals that the majority of the patients were happy with the physical environment Table 5: Emotional Support S. No. 1 2 Item Positive Negative % % Response Response 42 56 Mean Response 49 49 43 66 29 57 36 51 34 43

57% of the patients felt the need of a emotional support by social worker/ relative. Table 6: Other Facilities Items a) Need of telephone service b) Need of reading room c) Need of prayer hall e) Need of dining room Hot water facility for bathing 62 20 60 52 83 Yes 73 23 24 65 70 25 58 35 61 33 98 2 No 27 76 30 42 39 2

Total No. % Total No. %

d) Need of television and music 50

From the table it can be seen that many of the patients felt the need of telephone service, a prayer hall, television and music and dining room facilities attached to their ward.

Conclusion
There is a large number of geriatric population utilizing the existing services and facilities provided by this teaching hospital. While studying the need of the elderly it was found that the majority of the geriatric patients were satisfied with the clinical and supportive services and the physical facilities. But they felt the need of cot adjustments and non-slippery flooring, social and emotional needs. The number of geriatric patients visiting and utilizing the existing services shows that separate geriatric unit will be well utilized and would result in better care being provided to the geriatric population. Since this hospital is already well established, it may not be feasible to plan a new department. However, modification in the existing facilities and fulfilling their social and emotional needs would result in better care to the geriatric population.

References
1. World Health Report, 1998 2. Manju Nandi. Need for speciality nursing care for senior citizens. Geriatric Update by O.P. Sharma 1999:122-123 3. Tan Poo Chang. Implication of changing family structure on old age support in the ESCAP region. Asia Pacific Population journal 1992,Vol.7,No:2:49-66 4. Dr Kalyan Bagchi. Understanding the elderly. Health action:April1999,Vol.12,no:4:16-17 5. D.J.Doheshry. Unmet needs in support services. Hospital Management International 1994:314

* Dept. of Hospital Administration, Fr. Muller Medical College, Mangalore - 575002 ** Asst. Professor, Dept. of Hospital Administration Fr. Muller Medical College, Mangalore - 575002 *** Professor and H.O.D. Dept. of Pediatrics, Fr. Muller Medical College, Mangalore 575002 Policies / Schemes Maintaineance and welfare of parents and senior citizens act 2007 Over the years, the government has launched various schemes and policies for older persons. These schemes and policies are meant to promote the health, well-being and independence of senior citizens around the country. Some of these programmes have been enumerated below. The central government came out with the National Policy for Older Persons in 1999 to promote the health and welfare of senior citizens in India. This policy aims to encourage individuals to make provision for their own as well as their

spouses old age. It also strives to encourage families to take care of their older family members. The policy enables and supports voluntary and non-governmental organizations to supplement the care provided by the family and provide care and protection to vulnerable elderly people. Health care, research, creation of awareness and training facilities to geriatric caregivers have also been enumerated under this policy. The main objective of this policy is to make older people fully independent citizens. This policy has resulted in the launch of new schemes such as 1. 2. 3. 4. 5. 6. Strengthening of primary health care system to enable it to meet the health care needs of older persons Training and orientation to medical and paramedical personnel in health care of the elderly. Promotion of the concept of healthy ageing. Assistance to societies for production and distribution of material on geriatric care. Provision of separate queues and reservation of beds for elderly patients in hospitals. Extended coverage under the Antyodaya Scheme with emphasis on provision of food at subsidized rates for the benefit of older persons especially the destitute and marginalized sections.

The Integrated Programme for Older Persons is a scheme that provides financial assistance up to 90 per cent of the project cost to non-governmental organizations or NGOs as on March 31, 2007. This money is used to establish and maintain old age homes, day care centres, mobile Medicare units and to provide non-institutional services to older persons. The scheme also works towards other needs of older persons such as reinforcing and strengthening the family, generation of awareness on related issues and facilitating productive ageing. Another programme of the government is the Scheme of Assistance to Panchayati Raj Institutions voluntary organisations and self help groups for the construction of old age homes and multi service centres for older persons This scheme provides a one time construction grant. Central Government Health Scheme provides pensioners of central government offices the facility to obtain medicines for chronic ailments up to three months at a stretch. For more details, click here. The National Mental Health Programme focuses on the needs of senior citizens who are affected with Alzheimers and other dementias, Parkinsons disease, depression and psycho geriatric disorders. New Schemes Well, the journey towards financial security does not end here. The Central Government is in the process of developing newer plans and schemes to benefit senior citizens. In the 2007-08 Budget, the Finance Minister has proposed to provide monthly income to seniors and develop new health insurance schemes. For the benefit of senior citizens it has been proposed that

The National Housing Bank will introduce a 'reverse mortgage' scheme under which a senior citizen who owns a house can avail of a monthly stream of income against mortgage of the house. The senior citizen remains the owner and occupies the house throughout his or her lifetime, without repayment or servicing of the loan. Regulations are to be put in place to allow creation of mortgage guarantee companies. An exclusive health insurance scheme for senior citizens is to be offered by the National Insurance Company.

Three other public sector insurance companies as mentioned in the Medical Insurance section, are to offer a similar product to senior citizens. The Maintenance of Parents and Senior Citizens Bill of 2007 This bill has been recently introduced in Parliament. It provides for the maintenance of parents, establishment of old homes, provision of medical care and protection of life and property of senior citizens.

These new developments for senior citizens are meant to get them on the path to a better, peaceful and financially sound life.

CONCESSIONS AND FACILITIES GIVEN TO SENIOR CITIZENS BY DIFFERENT MINISTRIES/DEPARTMENTS OF THE GOVT. Sl. No. 1 Name of the Min./Department Ministry of Social Justice & Empowerment Facilities/Benefits given to Senior Citizens Ministry of Social Justice & Empowerment is the nodal Ministry responsible for welfare of the Senior Citizens. It has announced the National Policy on Older Persons covering all concerns pertaining to the welfare of older persons. The National Policy on Older Persons recognizes a person aged 60 years and above as a senior citizen. 2. The Ministry is also implementing following schemes for the benefit of Senior Citizens: (a) An Integrated Programme for Older Persons (Plan Scheme) This Scheme has been formulated by revising the earlier scheme of Assistance to Voluntary Organisations for Programmes relating to the Welfare of the Aged. Under this Scheme, financial assistance upto 90% of the project cost is provided to NGOs for establishing and maintaining Old Age Homes, Day Care Centres, Mobile Medicare Units and to provide non-institutional services to older persons. (b) The Scheme of Assistance to Panchayati Raj Institutions/ Voluntary Organizations/Self Help Groups for Construction of Old Age Homes/Multi-Service Centres for older persons (Non Plan Scheme) - Under this Scheme, one time construction grant for Old Age Homes/Multi-Service Centre is provided to non-governmental organizations on the recommendation of the State Governments/ UT Administrations. Income tax rebate upto an income of Rs. 1.85 lakh p.a. Higher rates of interest on saving schemes of senior citizens. A Senior Citizens Savings Scheme offering an interest rate is 9% per annum on the deposits made by the senior citizens in post offices has been introduced by the Government through Post Offices in India doing savings bank work.

Ministry of Finance

Ministry of Road Transport and Highways

4 5.

Ministry of Health & Family Welfare Department of Telecommunications

Ministry of Railways

i) Reservation of two seats for senior citizens in front row of the buses of the State Road Transport Undertakings. ii) Some State Governments are giving fare concession to senior citizens in the State Road Transport Undertaking buses and are introducing Bus Models, which are convenient to the elderly. Separate queues for older persons in hospitals for registration and clinical examination. i) Faults/complaints of senior citizens are given priority by registering them under senior citizens category with VIP flag, which is a priority category. ii) Senior citizens are allowed to register telephone connection under N-OYT Special Category, which is a priority category. a) Indian Railways provide 30% fare concession in all Mail/Express including Rajdhani/Shatabadi/Jan Shatabadi trains for senior citizens aged 60 years and above. b) Indian Railways also have the facility of separate counters for Senior Citizens for purchase/booking/cancellation of tickets. c) Wheel Chairs for use of older persons are available at all junctions, District Headquarters and other important stations for the convenience of needy persons including the older persons. d) Ramps for wheel chairs movement are available at the entry to important stations. d) Specially designed coaches with provisions of space for wheel chairs, hand rail and specially designed toilet for handicapped persons have been introduced. 1. Indian Airlines is providing 50 per cent Senior Citizen Discount on Normal Economy Class fare for all domestic flights to Indian senior citizens who have completed the age of 65 years in the case of male senior citizens and 63 years in the case of female senior citizens subject to certain conditions. 2. Air India is offering discount to senior citizens of 60 plus on flights to USA , UK and Europe . Further, Air India has now decided to reduce the age of 60 plus for discount on their domestic routes as well with immediate effect. 3. Sahara Airlines is offering 50% discount on basic fare for travel on its domestic flights only to senior citizens who have attained the age of 62 years. Discount is applicable in economy class only. i) Under the Antyodaya Scheme, the Below Poverty Line (BPL) families which also include older persons are provided food grains at the rate of 35 kgs. per family per month. The food grains are issued @ Rs.3/- per kg. for rice and Rs.2/- per kg. for wheat. The persons aged 60 years above from the BPL category were given priority for identification. (ii) Under the Annapoorna Scheme being implemented by the States/UT Administration, 10 kgs. of food grains per beneficiary per month are provided free of cost to those senior citizens who remain

Ministry of Civil Aviation

Ministry of Consumer Affairs, Food and Public Distribution

uncovered under the old age pension scheme. iii) Instructions to State Governments for giving priority to the Ration Card holders who are over 60 years of age in Fair Price Shops for issue of rations. (i)MCD, Delhi , has opened a separate counter to facilitate the senior citizens for submission of property tax bills. (ii) A rebate of 30% of the property tax due on the covered space of a building up to one hundred sq. mtrs. of the covered space has been allowed by the corporation in the case of any self-occupied residential building singly owned by a man who is 65 years or more in age. (i) Courts in the country accord priority to cases involving older persons and ensures their expeditious disposal. (ii) Under the Old Age Pension Scheme, monthly pension is given at variable rates to the destitute old by various State Governments/UT Administrations.

9.

MCD, Delhi

10

Miscellaneous

11. Apart from the measures/action taken by the Ministry of Social Justice & Empowerment as well as by the different Departments/Ministries in regard to the welfare/care of the Senior Citizens (as indicated at Para 1-10 above), Government has already made sufficient and strong provisions at Chapter III of the Personal Law (Hindu) and at Chapter IX of the Code of Criminal Procedure(extracts at page 77/cr and 78-80/cr respectively) as indicated below:Part IX Personal Law (Hindu) (Chapter III Maintenance) Section 20(1):-------a Hindu is bound during his or her life-time, to maintain his or her legitimate/illegitimate children and his or her aged or infirm parents. Section 20(3):- The obligation of a person to maintain his or her aged infirm parent or a daughter who is unmarried extends in so far as the parent or the unmarried daughter, as the case may be, is unable to maintain himself or herself out of his or her own earnings or others property. Code of Criminal Procedure Chapter IX Order for maintenance of wives, children and parents Section 125(1) (d): If any person having sufficient means neglects or refuses to maintain his father or mother, unable to maintain himself or herself, a Magistrate of the first class may, upon proof of such neglect or refusal, order such person to make a monthly allowance for the maintenance of his wife or such child, father or mother, at such monthly rate not exceeding five hundred rupees in the whole, as such Magistrate thinks fit, and to pay the same to such person as the Magistrate may from time to time direct. Section 125(3): If any person so ordered fails without sufficient cause to comply with the order, any such Magistrate may, for every breach of the order, issue a warrant for levying the amount due in the manner provided for levying fines, and may sentence such person, for the whole or any part of each months allowance remaining unpaid after the execution of the warrant, to imprisonment for a term which may extend to one month or until payment if sooner made:...

PROGRAMMES FOR CARE OF OLDER PERSONS Demographic ageing is a global phenomenon. With a comparatively young population, India is still poised to become home to the second largest number of older persons in the world. Projection studies indicate that the number of 60+ in India will increase to 100 million in 2013 and to 198 million in 2030. The special features of the elderly population in India are :- (a) a majority (80%) of them are in the rural areas, thus making service delivery a challenge, (b) feminization of the elderly population ( 51% of the elderly population would be women by the year 2016) , (c) increase in the number of the older-old ( persons above 80 years) and (d) a large percentage (30%) of the elderly are below poverty line.

Social Defence Division provides for the need of older persons through its various programmes and initiatives.

National Policy for Older Persons (NPOP) (Complete Policy details) Steps Already Taken For Implementation of NPOP List of Members of the National Council for Older Persons (NCOP) List of Ministries/ Departments of Inter-Ministerial Committee implementing National Policy on Older Persons. Concessions and facilities given to Senior Citizens by different Ministries/ Departments Inter-Ministerial Committee Annual Plan of Action 2005-06 for implementation by various Ministries/ Departments concerned with the welfare of Older Persons Schemes An Integrated Programme for Older Persons. Scheme of Assistance to Panchayati Raj Institutions/Voluntary Organisations/Self Help Groups for Construction of Old age homes/multi service centers for older persons. Important Documents and Downloadable Formats TOP

National Policy for Older Persons

2. The National Policy for Older Persons (NPOP) was announced in January, 1999, with the primary objective viz. 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; and to create awareness regarding elderly persons to develop themselves into fully independent citizens. TOP

Steps already taken for implementation of NPOP 3. The Government has constituted a National Council for Older Persons (NCOP) under the Chairmanship of Honble Minister for Social Justice and Empowerment to advise and aid the Government on policies and programmes for older persons and also to provide feedback to the Government on the implementation of the National Policy on Older Persons as well as on specific programme initiatives for older persons. The NCOP is the highest body to advice and coordinate with the Government in the formulation and implementation of policy and programmes for the welfare of the aged.

3. The National Council for Older Persons has been re-constituted in 2005. Presently, it has 37 members.The given areas of concern have been emphasized which include:a. Uniform age of 60+ for extending facilities/ benefits to senior citizens; b. Financial security to the elderly population by: (1) Proposing tax benefits and higher interest rates for senior citizens (2) Promotion of long term savings in both rural and urban areas (3) Increased coverage and revision of old age pension schemes for the destitute elderly and (4) Prompt settlement of pension, provident fund, gratuity and other retirement benefits;

c. Health care and nutritional needs of the elderly populations by: (1) Strengthening of primary health care system to enable
it to meet the health care needs of older persons; (2) Training and orientation to medical and para medical personnel in health care of the elderly. (3) Promotion of the concept of healthy ageing. (4) Assistance to societies for production and distribution of material on geriatric care. (5) Provision of separate queues and reservation of beds for elderly patients. d. Food security and shelter by : (1) Coverage under the Antyodaya Scheme to be increased with emphasis on provisions for the benefit of older persons especially the destitute and marginalized sections. (2) Earmarking ten percent of houses/house sites for allotment to older persons. (3) Barrier-free environment for the disabled and elderly persons etc.

e. Meeting the education, training and information needs of older persons. f. Identification of the most vulnerable among the older persons and working for their welfare. g. Realizing the crucial role by the media in highlighting the situation of older persons and emphasising their continued role

in Society h. Protection of life and property of the elderly population. TOP

Inter-Ministrial Committee The Ministry has also set up Inter-Ministerial Committee (IMC) headed by Secretary (SJ & E) for ensuring speedy implementation of the decisions taken in the meeting of the National Council for Older Persons and also to review the progress of plan of action for implementation by the concerned Ministries/Departments as in many cases, the activities have to be initiated by the other Ministries/ Departments and, therefore, a combined effort by all the Ministries/ Departments is required to implement the National Policy on Older Persons. The Inter-Ministerial Committee comprises of twenty -two Ministries/Departments and representatives of State Governments and UT Administrations. The Inter-Ministerial Committee is responsible for the implementation of the action points as described. TOP

SCHEMES : An Integrated Programme for Older Persons Scheme of Assistance to Panchayati Raj Institutions/ Voluntary Organisations/ Self Help Groups for Construction of old age homes/multi service centres for older persons TOP

9. An Integrated Programme for Older Persons Under this Scheme financial assistance up to 90% of the project cost is
provided to NGOs for establishing and maintaining old age homes, day care centres, mobile medicare units and to provide non-institutional services to older persons. The scheme has been made flexible so as to meet the diverse needs of older persons including reinforcement and strengthening of the family, awareness generation on issues pertaining to older persons, popularisation of the concept of life long preparation for old age, facilitating productive ageing, etc. The budget allocation during 2005-2006 was Rs.19.80 crores which was revised and the RE was Rs. 14.00 crores, against which the expenditure was Rs.14.00 crores. The budget allocation for the year 2006-07 is kept at Rs.28 crore.

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10. Scheme of Assistance to Panchayati Raj Institutions/Voluntary Organisations/Self Help Groups for Construction
of old age homes/multi service centres for older persons This scheme provides for one time construction grant for old age homes/multi service centers. The registered societies, public trust, Charitable Companies or registered Self-help Groups of Older Persons in addition to Panchayati Raj Institutions are eligible to get the assistance under this scheme. Against the budget allocation during 2005-06 of Rs.67 laskh, the expenditure was Rs. 47 lakh.